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A TREATISE 
 
 ON COMMON FORMS OF 
 
 Functional Nervous Diseases 
 
 BY 
 
 L. PUTZEL, M.D., 
 
 PUysician to the Clinic for Nervous Diseases, Belletue Hospital Out-Door Department ; 
 Visiting Physician for Nervoxis Diseases, RandalTs Island Hospital ; 
 Pathologist to the Lunatic Asylum, B. I. ; Curator 
 to Charity Hospital, etc. 
 
 NEW YORK: 
 WILLIAM WOOD & COMPANY^ 
 
 27 Geeat Jones Street. 
 1880. 
 
COPYEIGHT, 1880, BT 
 
 •WILLIAM WOOB & COMPANY. 
 
 Trow's 
 
 Printing and Bookbinding Company, 
 
 20X-2I3 East \7.tk Street, 
 
 NEW YORK. 
 
PROF. E. G. JANEWAY, M.D., 
 
 IN APPRECIATION OF HIS UNSURPASSED ABILITY AS A DIAGNOSTICIAN AND CLINICAL 
 
 TEACHER, AJTD AS A SLIGHT TOKEN OF GRATITUDE FOR THE INSTRUCTION 
 
 RECEIVED DURING A NUMBER OF TEARS OF PROFESSIONAL 
 
 INTERCOURSE, THIS BOOK IS RESPECTFULLY 
 
 BY THE AUTHOR. 
 
PEEFAOE. 
 
 Pathological anatomy has exercised such an enormous influence 
 upon the advances made in practical medicine within the last twenty- 
 five years that many pathologists sneer at the term " functional " dis- 
 ease and deny its very existence. 
 
 While we fully agree that there can be no morbid manifestations 
 without a change in the material structure of the organs involved, we 
 are nevertheless fully convinced, in view of the fruitless search of 
 pathological anatomists, that the diseases which we have considered in 
 this work present no primary anatomical changes which are visible to 
 the naked eye or to the microscope — in other words, that the changes 
 in structure are of a molecular nature. 
 
 Perhaps in the reviving growth of physiological chemistry, the ba- 
 lance of the chemist will determine the presence of subtle changes in 
 the constitution of the diseased organs, and will afford us some insight 
 into the true pathogeny of these affections. 
 
 The tendency to the disbelief in the actual existence of functional 
 nervous diseases led to the inconvenience that their clinical study has 
 been neglected. 
 
 If we glance through the most widely known text-books on ner- 
 vous diseases which have appeared in the English language, we will 
 find that due attention is not paid to functional affections, although 
 practically they are by far the most important, and are much more 
 frequently encountered by physicians than diseases due to organic 
 lesions. A change is now, however, becoming noticeable in this re- 
 spect, especially in foreign literature. 
 
 In the present work special attention has been paid to the sections 
 on clinical history and diagnosis, as it is especially in the latter respect 
 that mistakes are made. I have entered into the pathology of the 
 affections merely with the view of giving the present status of our ac- 
 tual knowledge of the subject, and not for the discussion of disputed 
 questions. 
 
 The consideration of hysteria has been omitted because this dis- 
 
VI PREFACE. 
 
 ease has been described in sufficient detail in numerous works which 
 are now in the hands of the medical public. It is true that the 
 French school have recently revealed some startling and hitherto 
 undescribed manifestations of hysteria, which they have included 
 under the term hystero-epilepsy, and which have excited a great deal 
 of interest in scientific circles. In our own country, however, these 
 symptoms are observed so rarely that I have not considered myself 
 justified in entering into the subject in a work of this character. 
 
 Some of the forms of peripheral paralysis which have been con- 
 sidered in the final article cannot be regarded, properly speaking, as 
 functional, but I have discussed them under that heading in accord- 
 ance with long-established custom and for the sake of completeness. 
 
 In conclusion, I desire to acknowledge my great indebtedness to 
 my friends Drs. V. P. Gibney, R. Yan Santvoord, and S. Heming- 
 way, for much valuable assistance received in the preparation of this 
 work. 
 
 L. PUTZEL. 
 
 252 East Fokty-eighth Street, 
 New York, July 20, 1880. 
 
C H O EE A. 
 
 CHAPTER L 
 
 CLINICAL HISTORY. 
 
 Chorea is essentially a disease of childhood, though it occasionally 
 begins in adult life, and, in rare instances, makes its appearance in old 
 ao-e. Its first beginnings in children are frequently misinterpreted as the 
 results of wilfulness. A child, while attending school, is noticed to become 
 restless and frequently move from side to side in his seat. Twitchings 
 of the muscles of the hands also develop and are evidenced by irregularity 
 in writing, in the manner of holding a pen or pencil, and by the fact that 
 the patient will drop his slate or some other light object more frequently 
 than his fellows. In addition, certain slight manifestations of mental dis- 
 order make their appearance at the same time as the development of 
 the muscular phenomena, or may even precede the latter. These symp- 
 toms consist of slight loss of memory, and inability of the patients to 
 apply themselves to their studies as well and continuously as formerly. 
 Children who were previously of an obedient and mild disposition become 
 irritable, obstinate and perverse. They become insubordinate, lose their 
 love of play, and are not so affectionate as was their wont. These phe- 
 nomena are naturally looked upon as indubitable evidences of wilfulness 
 and are punished accordingly, thus frequently precipitating and aggra- 
 vating the course of the disease. The muscular symptoms gradually 
 spread in intensity and extent, and usually attain their maximum severity 
 in the course of a couple of weeks to a month. At the height of the dis- 
 ease, all the voluntary muscles in the body, especially those of the 
 arms and face, may be affected by the choreic movements. The eyelids 
 twitch irregularly, the ocular muscles proper undergo similar involuntary 
 contractions, and those inserted into the angles of the mouth twitch in 
 an irregular manner, imparting to the face a peculiar expression, some- 
 times bordering on the ludicrous, sometimes of a stern character. At 
 times the mouth is thrown widely open and the tongue is rapidly pro- 
 truded, to be as quickly withdrawn. The muscles of the neck, especially 
 the sterno-cleido-mastoids, are also involved, causing the head to bend 
 rapidly upon the chest, to be thrown backward, or to be tossed from side 
 to side. In rare instances, the affection is confined to the muscles of the 
 neck, and the head is continually engaged in a series of nodding move- 
 ments, constituting the so-called chorea nutans of Marshall Hall. It is 
 doubtful, however, whether this is a form of true chorea. The muscles 
 of respiration and phonation are not exempt from the convulsive phe- 
 1 
 
2 FUNCTIONAL NERVOUS DISEASES. 
 
 iiomena. If the chest is bared, it will be found that inspiration is 
 frequently interrupted, before the act is complete, by a sudden expira- 
 tory movement. The speech of the patient is often interrupted, owing' 
 to the irregularity in the respiratory rhythm. This disturbance is some- 
 times so marked that the patients must take a deep inspiration between 
 the utterance of individual words, and become greatly fatigued after 
 speaking a few sentences. According to Ziemssen,' an affection of the 
 laryngeal muscles usually accompanies severe cases of chorea. By means 
 of the laryngoscope, Ziemssen was able to detect the irregular contractions 
 of the different muscles which are engaged in varying the tension of the 
 vocal cords. In some cases, this is shown by the loxo pitch and monotony 
 of the voice; as improvement progresses, these phenomena gradually dis- 
 appear. In many instances the hands are chiefly affected. Even when 
 the child is perfectly quiescent and without any voluntary effort on his 
 part, the hands will suddenly become forcibly flexed or extended, the fin- 
 gers Avill be separated from one another, and the hand will be drawn 
 away from the body, or vice versa. If the patient attempts to drink 
 a glass of water, he experiences great difficulty in grasping the glass, 
 and is unable to carry it directly to his mouth. A considerable portion 
 of its contents is spilled in the endeavor to drink, and the patient may 
 strike the vessel against his cheek or nose. The legs are also usually 
 affected, though not, as a rule, to such an extreme degree as the hands. 
 In walking, the knees frequently bend under, the patient trips and stum- 
 bles on account of the ill-timed contractions of the extensors or flexors of 
 the foot, and the legs often become entangled in one another; sometimes, 
 however, a shuffling gait is the only evidence of the affection of the legs. 
 In severe forms of the disease, the patient is in a truly deplorable condi^ 
 tion. The movements of the hands may be so intense that he is unable 
 to feed himself, and when the muscles of mastication and deglutition are 
 implicated to an extreme degree, the sufferer must be fed through the 
 stomach-tube or by means of nutritive enemata. Sometimes the patient 
 is unable to maintain his seat, but is continually jumping up and down 
 or falling from his chair. Even in cases of moderate severity', locomotion 
 is often rendered difficult, if not impossible, by the irregular contractions 
 occurring in the legs. As a rule, the movements cease almost entirely 
 during sleep (although rest is often disturbed by frequent fits and starts); 
 but, in cases of extreme severity, sleep is rendered impossible by tiie vio- 
 lence of the movements, and the latter continue even when the patient 
 does finally fall into a light slumber. Ulcerations of the prominent por- 
 tions of the body, from the continued friction against surrounding objects, 
 supervene in these cases, and inanition and exhaustion rapidly develop 
 from the lack of nutrition consequent on the inability to eat, from the 
 continuous violence of the choreiform movements, and from the loss of 
 sleep. 
 
 In light cases, the choreic contractions usually occur when the patient 
 endeavors to perform a voluntary act, and the bizarre movements are 
 then due to associated contractions of antagonistic rpuscles. In the 
 more severe forms, the movements develop irrespective of any voluntary 
 effort on the part of the patient, and, as we have previously mentioned, 
 may even continue uninterruptedly during sleep. But these statements 
 will not hold good in all cases and under all circumstances. Gowers ' 
 
 ' Handb. d. spec. Path. u. Therap. Bd. XII. p. 415. 
 « Brit. Med. Journ., Mar. 30, 187«. 
 
CHOREA. 3 
 
 found, that, in chorea, inco-ordination of voluntary movement bears no 
 relation to the spontaneous movements, but varies independently of the 
 latter. Thus, a patient in whom the spontaneous movements were very 
 marked, could perform voluntary actions with great ease and steadiness, 
 while, on the other hand, in a patient with scarcely noticeable spontane- 
 ous movements, the inco-ordination became extreme when he tried to exe- 
 cute a voluntary effort. The independent variation in these two elements 
 in chorea suggests that they may depend on an affection of distinct and 
 separate regions of the nerve-centres. 
 
 This state of affairs appears, however, to be decidedly exceptional. 
 The majority of authors do not appear to have had a similar experience, 
 and I do not recollect a single case in which the statements of Gowers 
 will hold good, although I have carefully examined in this particular all 
 the patients wlio have come under my observation since reading Gowers's 
 article. 
 
 The movements are not always bilateral, but may only involve one 
 half of the body, and tlien constitute a variety of the affection usually 
 known as hemichorea. The disease not infrequently begins as a hemi- 
 chorea, but spreads to the other side of the body as the affection pro- 
 gresses. The following statistics vrill serve to show the relative frequency 
 of tills variety of the disease: 
 
 No. of cases. Hemichorea. 
 
 S6e 154 97 
 
 Pye-Smith 150 33 
 
 Russell 97 29 - 
 
 Author 82 16 
 
 Among Pye-Smith's 33 cases of hemichorea, 15 affected the right and 
 18 the left side of the body. Althaus reported 22 cases of hemichorea, 
 of which 16 involved the left and 6 the right side of the body; Ogle, 24 
 right, 20 left hemichorea; Russell, 18 right, 11 left. These facts possess 
 considerable importance and we shall refer to them hereafter in discussing 
 the pathology of this affection. In rare instances, the choreiform move- 
 ments are even more limited in their distribution and may be confined to 
 the face or arm. Jn one case of vertebral caries in the lower lumbar re- 
 gion, which Avas under my observation, the patient, a boy a;t. 16 years, 
 began to suffer from well developed choreic movements of the left forearm 
 and hand, and the left side of the face, these phenomena suddenly mak- 
 ing their appearance upon the day after he had seen a severe case of 
 general chorea in a young friend. 
 
 It is a curious and interesting fact that the patients do not complain 
 much of fatigue, even although the movements are quite violent and con- 
 tinuous. As a rule, also, there is little or no loss of power in the affected 
 limbs, though in some cases considerable paresis may develop, especially 
 in hemichorea. The intensity of the paresis does not appear to present 
 any definite relation to the severity of the choreiform movements. A 
 better idea of the loss of power can be obtained by allowing the patient 
 to squeeze the hand of the observer than by using the dynamometer, 
 since the manipulation of the latter requires more delicate muscular co- 
 ordination than the former procedure, and is therefore more interfered 
 with by the choreic movements. In rare instances the muscles become 
 completely paralyzed. I shall report in full the following case of general 
 paralysis due to chorea, as it is very interesting from several points of 
 view. 
 
4 FUNCTIONAL NEEVOUS DISEASES. 
 
 Case I. — The patient, Peter K., ret. of years, first came under my ob- 
 servation at the clinic for Nervous Diseases in the Bellevue Out-door De- 
 partment, on April ;22, 1878. The family histor}- is unimportant; neither of 
 the parents or other members of the family have ever suffered from rheuma- 
 tism. The patient was always in excellent health until seven weeks pre- 
 viously, when he suddenly developed considerable fever, followed in three 
 days b}^ swelling of the knees and ankles, the joints also becoming ex- 
 ceedingly painful to the touch. This condition lasted three weeks, and 
 was diagnosed as acute articular rheumatism by the physician in attend- 
 ance. Very shortly after the termination of the rheumatic attack (about 
 April 1st), and while the patient was apparently doing very well, he 
 began to suffer from irregular choreiform twitchings in the limbs, which 
 did not, however, attain any considerable severity. A few days after this 
 symptom appeared, the child awoke one morning in a condition of great 
 muscular weakness, and was unable to articulate, although speech had 
 hitherto been perfect. The paresis gradually grew worse until a week 
 ago (April 15th), since which time it has remained in statu quo. The 
 twitchings of the muscles continued up to the present, but were not very 
 marked. 
 
 Present condition (April 22, 1878). — The patient is a large child, ap- 
 parently well nourished. He has left convergent strabismus, which came 
 on after a slight attack of diarrhoea, that occurred last July, and has per- 
 sisted ever since. Physical exam.ination: lungs normal; the apex-beat of 
 the heart is felt at the nipple; a loud, blowing systolic murmur is present, 
 which is heard most distinctly at the apex and is also conveyed into the 
 left axillary space, but could not be traced into the scapular region; the 
 second cardiac sound is heard sharply and distinctlj', and is not accom- 
 panied by any adventitious sounds. 
 
 The patient is unable to swallow solid food, and this condition has 
 lasted since the beginning of the paralysis. There is considerable weak- 
 ness of the upper limbs; the grasp is feeble, and the patient is unable to 
 raise his hands above the shoulders. The lower limbs are even weaker 
 than the upper. There is almost complete paralysis of the anterior mus- 
 cles of the legs, the feet hanging in the position of talipes equinus, and 
 the toes are only movable to a very slight extent. The patient is barely 
 able to flex the thighs on the abdomen. When placed in a sitting posture 
 the child immediately topples over to one or the other side, apparently 
 from paralysis of the dorsal muscles. The muscles throughout the entire 
 body feel soft and flabby. It is impossible to get accurate data with 
 regard to sensation, on account of the age of the patient; reflex action 
 and the electro-muscular reactions are normal throughout the body. 
 The patient is unable to speak, except to say "yes " and " no," the for- 
 mer word being uttered in a very indistinct manner. Sleep is very much 
 disturbed. The natural folds of the face are almost completely effaced and 
 the facial muscles appear to be paretic, if not entirely payalyzed; the fea- 
 tures present a dull mask-like appearance. The patient is, however, able 
 to close the eyes in a normal manner. There is very little power of mo- 
 tion in the tongue, the organ being protruded very slowly and tremu- 
 lously, and only to a slight extent. The choreiform movements are scarcely 
 noticeable, come on only at long intervals, and are ^'ery moderate in in- 
 tensity. I ordered milk diet, ol. morrhuas, and a mixture composed of 
 tinct. ferri chlorid. 3 ij., potass, chlorat. 3 j-, and syr. simp, f iv., one tea- 
 spoonful being given three times a day. The child began to mend very 
 rapidly, and on May 22d the following notes were taken: the patient is 
 
CHOEEA. O 
 
 able to walk almost as well as ever, and the power in the upper extremi- 
 ties is apparently entirely restored; slig-ht choreiform movements still 
 continue from time to time. Speech is almost perfect. The mother states 
 that during the last two weeks the child has been almost demented, and 
 has not appeared to comprehend the simplest ideas. At times he has 
 apparently had hallucinations of sight. On one occasion, while playing 
 with some toys on a sofa, he began to talk with imaginary playmates, 
 saving "that he was better than they." At other times, he is said to 
 have had hallucinations of various kinds. To-day, however, the patient 
 appears quite bright and intelligent. 
 
 June 5th. — The patient was again brought to me and was entirely 
 well in every particular, except that the heart-murmur was still distinctly 
 audible, though not so loud as formerly. 
 
 This case is unlike those in which the muscles become paretic during 
 the course of very intense choreic movements; in fact, the latter were so 
 slight at times that prolonged observation was necessary in order to 
 detect them. 
 
 Cliiford Albutt ' also published the notes of an attack of acute chorea 
 followed by a state of general paralysis. 
 
 C. Handheld Jones ' narrates the case of a girl suffering from chorea, 
 attended with extreme paresis of the limbs and trunk, and also of the 
 tongue and pharynx; no rheumatism or heart-murmur discoverable. The 
 patient recovered completely. The cases in which an attack of chorea 
 precedes hemiplegia (pr^ehemiplegic chorea), and those in which it follows 
 the latter (post-hemiplegic chorea), together with the allied affection known 
 as athetosis, will be discussed in a subsequent section of this article. 
 Trousseau, in his " Lectures on Clinical Medicine," mentions the case of a 
 girl set. 18 5'ears, who, after an attack of right hemiplegia, manifested 
 symptoms of hemichorea upon the paralyzed side. Trousseau regarded 
 this case as one of ordinary chorea, but there is very little doubt that it 
 belongs to the category of post-hemiplegic chorea, which is of an entirely 
 different nature, and the patholoo-ical sio-nificance of which was unknown 
 at the period during which this observation was made. 
 
 Very few investigations have been made with regard to the electrical 
 reactions of the nerves and muscles in chorea. Rosenthal ' resorted to 
 electrical exploration in three cases of hemichorea observed soon after the 
 onset of the disease (for obvious reasons it is useless to make examina- 
 tions of this nature in cases in which the choreic movements occur upon 
 both sides of the body). He found a marked increase of electro-muscular 
 contractility in the affected muscles. Rosenthal observed very marked 
 excitability to the galvanic current, which was manifested by contractions 
 upon closure at the negative pole, by galvano-tonic contractions with 
 weak currents, and by contractions upon opening at the cathode. In- 
 creased irritability of the sensory nerves was also manifested. Gowers * 
 states that a few weeks after the onset of the affection there is observed 
 in most, though not in all cases, a distinct increase in the irritability of 
 the nerves and muscles of the affected side, both to the faradic and the 
 galvanic currents. The difference varied from 1 — 2 centimetres of the 
 
 ' Medical Times and Gazette for 1878. 
 
 ' Practitioner, vol. xxi. , 1878. 
 
 2 A Clinical Treatise on Diseases of the Nervous System, 1878. 
 
 4 Brit. Med. Journ., March 80, 1878. 
 
6 FUNCTIONAL NERVOUS DISEASES. 
 
 secondary coil of Stoehrer's larger induction apparatus, and from 2 — 5 
 cells of Stoehrer's or Leclanche's galvanic battery. The increased irrita- 
 bility diminished with the subsidence of the chorea. 
 
 Mv experience disproves the applicability of these statements to all 
 cases of chorea. In one case of hemichorea the faradic excitability of the 
 muscles of the affected side was notably increased, but the reactions of 
 the muscles and nerves to the galvanic current were equal on the two 
 sides. In six other cases of hemichorea, which I examined with refer- 
 ence to these points, the electrical reactions were similar on both sides of 
 the bodv. In only three of these patients, however, was I able to make 
 the examination during the first period of the disease; in the others the 
 chorea had lasted upward of a month. 
 
 Not infrequently heart-murmurs are heard, which — in the absence of 
 previous rheumatism or other causes of valvular lesions, of hypertrophy 
 or dilatation of the heart, and of other symptoms indicative of organic 
 disease of this organ — should be regarded as merely dynamic in charac- 
 ter. Some authorities consider such murmurs as purely ansemic, while 
 others suppose that they are due to irregular choreiform contractions of 
 the papillary muscles of the heart, which thus prevent the proper closure 
 of the leaflets of the various valves at certain intervals. But this view 
 is strongly contradicted by the fact that it is very doubtful whether 
 choreic movements occur in the heart. As we shall see later, some 
 authorities think that these choreiform movements of the papillary mus- 
 cles are capable of giving rise to endocarditis, and explain in this manner 
 the frequent occurrence of vegetations upon the mitral valves in fatal 
 cases of chorea. At times, indeed, I have observed irregularity of 
 the heart's action in patients suffering from chorea, but this has only 
 been noticed in very anaemic patients, and therefore due to the condition 
 of the blood, or it has occurred during violent choreiform movements of 
 the respiratory muscles. In the latter cases it appears to me to be due 
 to the irregular character of the respirations, the rhythm of which, as 
 physiologists have taught ^s, exerts considerable influence upon the 
 action of the heart. 
 
 The existence of chorea of the bladder is also a disputed point. The 
 majority of neurologists deny that the involuntary muscular fibres are 
 ever the seat of choreiform contractions. Van Buren and Keyes ' men- 
 tion three cases of chorea of the bladder which came under their notice, 
 only one of which, however, is entirely conclusive, and which we copy in 
 full 
 
 Case II. — "Aged eight, is a fat, healthy, lymphatic boy; one of a 
 large family of children, of whom nearly ever}' male has distinct chorea, 
 either generalized or affecting special muscles. Some of the older chil- 
 dren have outgrown the tendency. The patient is troubled occasionally 
 with slight general choreic twitchings, w^hen from any cause his appetite 
 is low, or his general health poor. Under such circumstances he has fre- 
 quent paroxysms of intermitting, uncontrollable contraction of the blad- 
 der, forcing him to frequent micturition and attempts at emptying the 
 bladder every few moments. Sometimes the call comes so suddenly that 
 he wets his clothing, and he also is unfortunate at night. When the boy 
 is enjoying good general health, neither his general chorea nor his fre- 
 
 * Genito-iirinary Diseases with Syphilis, 1874, p. 231. 
 
CHOREA. 7 
 
 quent calls to urinate disturb him. lie improves under arsenic, quinine, 
 or any general tonic or country air." 
 
 I have also observed a case of chorea in which the patient, although 
 previously able to retain his urine, was frequently seized with inconti- 
 nence which came on suddenly, and which I could only explain on the 
 hypothesis that the symptom was due to sudden, choreiform contractions 
 of the detrusor urinjB. After the chorea subsided, the patient was again 
 able to retain his urine as usual. 
 
 As a general rule, both pupils are considerably dilated in this disease, 
 and do not respond readily to light. I have not observed any noteworthy 
 difference in their condition in hemichorea. The appearance of the pupils 
 is not, however, characteristic of this affection, and is frequently ob- 
 served in children whose health is below par. Rosenthal reports one case 
 in which, at the height of the paroxysm, he observed very marked dilata- 
 tion of both pupils, which was not modified by exposure to a bright light 
 or by introducing a small electrode between the sclerotic and conjunctiva. 
 The pupillary dilatation disappeared spontaneously at the termination of 
 the disease. 
 
 Dr. H. R. Swanzy ' reports a case in which an ophthalmoscopic ex- 
 amination in a choreic girl (whose choreiform movements developed simul- 
 taneously with blindness of the left eye) showed the appearances indicative 
 of embolism of the central artery of the retina. After the lapse of five 
 weeks, the retinal circulation was restored, and the chorea likewise ceased 
 about the same time. Three months later, this patient was suddenly 
 seized with complete paralysis of the seventh nerve on the right side. Five 
 days afterward, violent and persistent vomiting occurred, which continued 
 all night and the following morning, and appeared to be of a cerebral 
 character. The sense of taste on the right half of the tongue was some- 
 what impaired. Three months after the beginning of the paralysis the 
 child was growing stronger and the paralysis had improved considerably. 
 Dr. Swanzy regarded the paralytic affection as indicative of an organic 
 cerebral lesion. It is unfortunate that no note was made of the electrical 
 reactions of the affected nerve and muscles; but from the fact that the 
 paralysis was said to be complete, and that the sense of taste was im- 
 paired, we should regard the former as more probably peripheral in its 
 origin. 
 
 Some authors state that sensory disturbances are quite common in 
 chorea, while others barely mention their occurrence. The French writers 
 especially maintain that hemianfesthesia is a frequent concomitant of 
 hemichorea, and that in some cases the special senses are affected. Although 
 my attention has been directed to this point for several years, I have not 
 been able to verify the observation. It is more than probable that many 
 of the cases of chorea in which hemian:esthesia has been a prominent 
 symptom, have been really examples of post-hemiplegic chorea, and there- 
 fore belong to another category. At other times, general hyperffis- 
 thesia of the surface has been noticed, or vague, wandering pains in 
 the muscles and joints. Especial importance has been attached to ten- 
 derness upon pressure over the spinal column, particularly in the cer- 
 vical and upper dorsal regions. Stiebel, Rosenbach, and Seifert have laid 
 great stress upon the value of this symptom from a pathological and 
 
 ' Ophthalm. Hosp. Rep., Sept., 1875, 
 
8 FUNCTIOTTAL NEEVOUS DISEASES. 
 
 therapeutic standpoint. Rosenbach showed (and I have verified his state- 
 ment on several occasions) that the passage of a constant galvanic current 
 through the spinal column will reveal the presence of tender points, at 
 times when they are not appreciable upon pressure with the finger. But 
 these tender points are not, by any means, invariably present in chorea, 
 and some writers have been unable to detect them. If we bear in mind 
 the great frequency of this symptom in hysteria, spinal irritation and 
 general nervous prostration, we will not be tempted to lay much weight 
 upon its appearance in chorea. I know, from personal observations, 
 that physicians will sometimes regard this symptom as present when 
 more careful examination shows that the position of the tenderness varies 
 from time to time during the course of a single examinatioUj is absent 
 when attention is diverted, etc. 
 
 Mental disturbances are rarely absent in chorea. As we have men- 
 tioned in the beginning of this article, the children usually become peevish, 
 irritable, and obstinate, at the onset of the affection. We desire to call at- 
 tention emphatically to these symptoms, since they are almost invariably 
 present, whether the disease be mild or severe, and because, in our judg- 
 ment, they furnish important indications of the position of the lesion in 
 the affection under consideration. But in rarer instances, true insanity 
 develops during the course of chorea. Arndt,' who called attention to 
 the close relationship which exists between the two diseases, states that 
 many cases of insanity merely represent the transmission of the chorea 
 from the motor to the intellectual centres of the brain. Insanity de- 
 velops more frequently during chorea than is usually supposed. Krafft- 
 Ebing ^ divides this form into three classes, viz., mania, melancholia, 
 and a variety characterized by delusions of demonomaniac persecution. 
 He regards them as "inanition-psychoses," caused by exhaustion induced 
 by the violent character of the muscular movements, and by the dimin- 
 ished sleep. It is more than doubtful, however, whether these views will 
 hold good with regard to all cases of this character, and one of my cases, at 
 least, can not be included in this category. The insanity commonly oc- 
 curs at the height of the choreic affection and the mental manifestations 
 present a disjointed character, furnishing an analogue, as Arndt pointed 
 out, to the phenomena observed in the muscles. Chorea sometimes simu- 
 lates insanity although the mental powers are intact. Thus, the patients 
 may appear to be incoherent in their speech, owing to the fact that articu- 
 lation is interrupted by choreic movements of the muscles of phonation, 
 giving rise to the involuntary utterance of words or disjointed sentences, 
 foreign to the matter under discussion. This apparent incoherence of 
 ideas, together with the destructive tendencies manifested by the patient 
 on account of his lack of control over the muscles, has led physicians, in 
 several instances, to make a diagnosis of insanity although the intellec- 
 tual manifestations were entirely normal. A.n English alienist, whose 
 name escapes me, has reported two cases of this nature which had been 
 committed to an insane asylum. The ordinary course of choreic mania is 
 exemplified by the history of the following patient under my charge. 
 
 Case HI. — Fanny M., jet. 17^ years; family history is entirely negative 
 as regards any neuropathic tendencies. The patient always enjoyed 
 
 'Arch. f. Psych. Bd. I. 
 
 2 Handb. f. Psychiatrie. Bd. I., 1879. 
 
CHOREA. y 
 
 g-ood health until the beginning of the present ailment. Last August 
 (1878). the patient caught cold while menstruating, causing a sudden arrest 
 of the menstrual discharge. A week later, she began to have choreiform 
 twitchings upon the right side of the body, and these soon increased in 
 severity. After the lapse of a month, the left side also became involved, 
 but the movements have never been so violent as upon the right side of 
 the body. Toward the end of September, the patient had a bad attack 
 of " nightmare," and during the next five or six weeks, gave marked indi- 
 cations of insanity. For some time she refused to eat, stating that her 
 food was poisoned, and that she was being persecuted by strangers. She 
 evinced hostile feelings toward her family, especially toward the mother, 
 whom she called vile names, etc. At times she was unable to recognize 
 her relatives and acquaintances, and thought that her female relations 
 were men dressed in women's clothes. The patient was also vicious and 
 violent, destroying her clothes and articles of furniture. During this time 
 the choreic movements became extremely severe and continued even dur- 
 ing sleep, so that the patient's limbs had to be tied down in bed. The 
 muscular twitchings then rapidly improved and the symptoms of insanity 
 disappeared at the same time. Tlie chorea did not, however, stop en- 
 tirely and was present to a moderate degree when the patient first came 
 under my observation. I then prescribed Fowler's solution, beginning 
 with five-drop doses three times daily, and increasing rapidly until twelve- 
 drop doses were taken. Within a week after beginning this plan of treat- 
 ment, the menses, which had been suppressed since last August, returned, 
 and within a month the choreiform movements were no longer noticeable. 
 June 19, 1879, the patient returned, stating that the choreiform move- 
 ments were returning on the right side of the body. She was again put 
 on the use of Fowler's solution, gtt. viij. t. i. d., and rapidly improved. 
 Apart from a certain amount of fretfulness and slight loss of memory, 
 there were no mental disturbances during this attack; the muscular 
 twitchings were also of a comparatively mild character. 
 
 In this case the mental aberration was most marked during the height 
 of the affection, when the choreic movements were so violent that they 
 did not even cease during- sleep, and necessitated the application of stout 
 bandages to the patient's trunk and limbs in order to prevent her doing 
 injury to herself. As in the case just reported, the prognosis of this form 
 of choreal mania is good. In the majority of instances the mental dis- 
 turbances disappear as soon as the other symptoms have subsided, or 
 within a couple of months afterward. Cases of maniacal chorea furnish, 
 however, a large contingent of the mortality in this disease, not so much 
 on account of the complication with insanity, but beoause the choreic 
 movements are so severe that they interfere with sleep and nutrition. In 
 other individuals, also, the manifestations of insanity persist, despite the 
 disappearance of the choreiform movements and a return of the patient, 
 in other respects, to a state of health. The following observation fur- 
 nishes a good example of this nature: 
 
 Case IV. — Wm. K., set. 8 years; patient's great-gran daunt was in- 
 sane; grandfather died of apoplexy; a granduncle was an inebriate; a 
 brother suffers from epilepsy; the mother is nervous and hysterical, but 
 states that this condition has only developed in late years from worry and 
 distress connected with the health of her children ; no member of the family 
 has ever suffered from rheumatism. The patient had measles and whooping- 
 
10 FUNCTIONAL NERVOUS DISEASES. 
 
 cough during infancy; when three weeks old, he suffered from pneumonia 
 and had a number of convulsions during his illness; also had two convul- 
 sions at the beginning of the attack of measles. At the age of 3 years 
 and 5 years he had acute articular rheumatism. He also had another at- 
 tack of rheumatism about 18 or 19 months ago, which lasted a week. 
 Two years ago he began to have choreiform twitchings, which grew 
 worse in the spring and almost entirely disappeared after the lapse of a 
 year. But even at the present time considerable muscular twitching be- 
 comes apparent if the patient is very much excited; when he is calm the 
 choreiform movements are not noticeable. 
 
 Last summer (18T8) the patient began to act strangely. ^Yhile at 
 school he became extremely insubordinate, and displayed evidences of 
 very bad temper. Upon one occasion he cut a playmate with a knife 
 on account of a trifling dispute. During last September he began to en- 
 tertain the delusion that objects around him were placed crooked. While 
 sitting at table, he would carefully smooth out the wrinkles in the table- 
 cloth, was continually moving the dishes in order to make them straight, 
 and stated that the chairs and pictures were crooked. Finally, he ate 
 from a low bench placed upon his knees, " on account of his inability to get 
 the table straight." About the same time, he began to manifest an aver- 
 sion to his mother, to whom he had been fondly attached. During the 
 summer he was continually finding fault with his clothes — at one time the 
 sleeves were too short, and then too long. Finally, he began to tear off his 
 clothes and would run around naked, stating that the garments hurt him. 
 The patient also had delusions of sight and hearing. Sleep was very much 
 disturbed unless hydrate of chloral was administered. The appetite was 
 very capricious, so that at times he would eat gluttonously and then again 
 would lose all desire for food. The patient would wake up very tired in the 
 morning; he has never had any epileptic fits during the day, nor have any 
 been noticed at night (slept with his father who is a very light sleeper). 
 He has gone to the window several times and threatened to jump out; 
 also threatened to commit suicide by catting himself with a knife. Has 
 stated that he would rather be dead than alive, and remai-ked to his 
 mother " that she would also prefer death if she felt like him, though he 
 does not suffer from headache." Upon, being questioned he is either un- 
 willing or unable to state the character of his suffering. His insane con- 
 dition is not constant, but alternates with lucid intervals which are more 
 frequent and longer than they were last year. 
 
 May 15, 1880. — The patient has been under my observation since the 
 summer of 1878, and, although the mental symptoms appeared to im- 
 prove for a time, they have presented a relapse during the last six months, 
 so that his condition is almost the same now that it was two years ago. 
 The chorea, which had -entirely disappeared, has begun to develop again 
 since the beginning of this month. 
 
 Chorea is also associated at times with other convulsive affections, es- 
 pecially epilepsy. More frequently, however, we find that epilepsy devel- 
 ops in other members of the family. In rarer instances, a child who was 
 choreic in early life, becomes epileptic in early manhood and finally pre- 
 sents evidences of insanity. Such a condition is almost invariably indica- 
 tive of a severe hereditary neuropathic tendency. Among the cases un- 
 der my observation, only four were complicated with epilepsy. The 
 chorea may follow the epileptoid seizures, or may precede them by a vari- 
 able period. Epileptiform seizures may also occur during the progress 
 
CHOREA. 11 
 
 oi the chorea, as occurred in one of my patients, who presented the fol- 
 lowing history: 
 
 J Case V, — Ellen D , jet. 17 years, family history entirely neq-a- 
 
 tive as regards any hereditary tendencies. During childhood the patient 
 had whooping-cough and measles, and passed through an attack of 
 scarlatina at the age of 9. The menses appeared at the age of 1.3 and 
 have been regular and normal up to the present time. The patient has 
 suffered from left hemichorea for the past five or six years; the dis- 
 ease developed gradually and without any known cause. Upon repeated 
 inquiry, it is found that the patient has masturbated almost daily since 
 she was four years of age. The choreiform movements present a mode- 
 rate intetisity and are exclusively confined to the left side of the face and 
 body. They have continued uninterruptedly since the beginning of the 
 disease, disappearing during sleep. The muscular reactions to the fara- 
 dic current are equal on both sides of the body. The measurements of 
 the arms are alike and there is no loss of power upon the affected side; 
 sensation is also normal. About four years ago, the patient began to 
 have "weak spells" {petlt-77ial), during which she became dizzy, weak, 
 and unconscious. She sometimes wakes up in the morning feeling tired 
 and worn out (possibility of nocturnal epilepsy). She has on an average 
 about one epileptic attack per month, but its development does not ap- 
 pear to be related in any manner to the period of menstruation. During 
 the last six months the patient's memory has become somewhat im- 
 paired, and during the past two months she has become quite cross 
 and irritable. At times, she experiences a sharp pain in the pras- 
 cordial region, and is forced to stand still' and hold her breath until the 
 pain subsides. These attacks are not accompanied by a feeling of terror 
 or by pain or numbness in the left arm. Upon physical examination, the 
 apex of the heart is found a little to the left of the nipple and a slight 
 thrill is felt. The valvular sounds are, however, perfectly sharp and 
 distinct. 
 
 In this case, although the choreiform movements have continued for 
 a number of years and were always confined to one side of the body, 
 the absence of headache, eye-trouble, disorders of the cerebral nerves, 
 and of paralysis of motion or sensation in the limbs, precludes the 
 idea of an organic lesion as the cause of the chorea and epilepsy. It 
 is much more probable that both affections are simply functional, and 
 that the more severe neurosis (epilepsy) is due, in the absence of any 
 hereditary taint, to the long continuance of the habit of masturbation, 
 added to a primary (perhaps congenital) increased irritability of the nerve 
 centres. 
 
 It is probable, also, from the history of the other cases of this nature 
 ■which have come under my observation that they were due, in part at 
 least, to excessive masturbation. Three cases occurred in unmarried 
 females, and one in a young widow, all of whom confessed to the frequent 
 performance of self-pollution. As we shall see later on, however, it is 
 not an easy matter to determine the influence of the secret vice in the 
 production of functional nervous diseases. 
 
 The chorea of pregnancy (chorea gravidarum) demands a few special 
 remarks, on account of certain peculiarities connected with it. Perhaps 
 the larger proportion of cases of chorea occurring in adult life belong to 
 this category, though even in pregnant women the disease is of infrequent 
 
12 FU]SrCTTO]S"AL NEEVOUS DISEASES. 
 
 occurrence, Barnes/ who made a very careful analysis of the literature 
 of the subject, was only able to collect 56 cases. Bodo Wenzel" collected 
 the histories of ten additional cases which had been reported in the jour- 
 nals from 1869—1874. 
 
 I have had no personal experience with regard to this complication of 
 pregnancy, and shall, therefore, merely give an abstract of the conclusions 
 arrived at by Barnes and Bodo Wenzel. I may state that, with the ex- 
 ception of the statistics compiled by these writers, very few cases have been 
 reported. 
 
 The majority of cases occur in primiparae between the ages of 20 — 25 
 years. Among 57 cases, 22 occurred in the first three months of preg- 
 nancy, and 23 from the fourth to sixth months. In very rare instances, 
 the chorea makes its first appearance after delivery has been accomplished. 
 In 14 cases out of 06, the patients had previously suffered from one or 
 more attacks of chorea. The chorea of pregnancy is especially remarka- 
 ble for its fatality. Thus, there were 18 fatal cases among the 66 col- 
 lected by Barnes and Wenzel, or more than 27 per cent. In the fatal 
 cases, the disease usually begins suddenly with great intensity and is 
 often accompanied by considerable febrile disturbance, or by maniacal 
 attacks. Death is generally due to exhaustion produced by the violence 
 of the choreic movements and the loss of sleep and deprivation of nutri- 
 tion attendant upon the maniacal excitement. The disease appears to 
 have little or no effect upon the termination of pregnancy. As a rule, 
 however, the choreiform movements rapidly disappear after the delivery 
 of the child. In 7 cases the onset of the affection was attributed to 
 fright; in 7 other cases, also, the disease was preceded by rheumatism 
 and endocarditis. 
 
 The occurrence of chorea in one pregnancy appears to predispose to 
 its recurrence in succeeding ones. We shall refer to the therapeutics of 
 this variety of the disease under the general head of treatment. 
 
 POST-HEMIPLEGIC ChOKEA. 
 
 In concluding the clinical history of chorea we shall give a short de- 
 scription of the allied affections, known as post-hemiplegic and pras-hemi- 
 plegic chorea, and athetosis. Weir Mitchell ^ was the first to call especial 
 attention to the form which he aptly termed post-hemiplegic chorea, 
 though Trousseau,* in his article on chorea stated that " in some still 
 rarer instances paralysis (I do not mean a mere diminution of muscular 
 strength,. but true paralysis), precedes the manifestation of convulsive 
 phenomena." Although some advances have been made in the pathology 
 of post-hemiplegic chorea, very little has been added to our knowledge 
 of the clinical history of the affection since the publication of Mitchell's 
 article. My own experience has been entirely confirmatory of the views 
 advanced by this author. 
 
 Clinical history. — This affection is a hemichorea occurring at a longer 
 or shorter interval, after the development of a cerebral hemiplegia, and 
 always occupying the same side as the motor paralysis. The period of 
 
 ' Obstetrical Transactions, vol. x., 1869. 
 « Schmidt's Jahrb., 1874. 
 ' Amer. Journ. Med. Sciences, 1874. 
 * Lectures on Clinical Medicine. 
 
CHOREA. 13 
 
 its development varies (usually from a month to a year after the onset of 
 the paralysis), and the choreiform movements generally make their appear- 
 ance after the power of motion in the limbs has been considerably re- 
 stored. It has also been found that the affection is almost invariably at- 
 tended with a slight amount of contracture in the paralyzed limbs. The 
 character of the movements does not differ from that of ordinary chorea, 
 except that they are more apt to be absent while the patient keeps the 
 limb quiet, and, like choreic twitchings, they cease during sleep. It is a 
 carious fact that, while the affection is comparatively rare after the hemi- 
 plegia of adults, it is very common in the cerebral hemiplegia of infancy 
 and cliildhood, as had been noticed by Weir Mitchell. I may remark 
 here as an interesting circumstance, that cerebral hemiplegia of infancy 
 and early childhood, when not followed by post-hemiplegic chorea, almost 
 always becomes complicated with epilepsy or hystero-epileptiform seizures. 
 To this rule I liave found very few exceptions. 
 
 In the large majority of cases post-hemiplegic chorea follows cerebral 
 hemorrhage, although it may also occur in the course of hemiplegia due 
 to embolism, thrombosis, tumors, cerebral atrophy of childhood, or abscess 
 of the brain. 
 
 According to French authors, especially Charcot' and Raymond,' the 
 motor disturbances of post-hemiplegic chorea are frequently combined 
 with sensory disorders. Thus, among 30 cases of this affection collected 
 by Raymond (chiefly from the wards of La Salpotriere), 10 were compli- 
 cated with hemianfesthesia. The anaesthesia not alone affects the gene- 
 ral sensibility, but may also involve all of the special senses. Among my 
 own cases I have been unable to dffecover any disorders of sensation. I 
 should, however, state that I have chiefly observed this affection in young 
 children, in whom it is very difficult to obtain any accurate data with re- 
 gard to sensation. 
 
 Among 10 cases analyzed by Gowers' hemianfesthesia was only ob- 
 served four times. Hemiopia was present in two of these cases, but in 
 one of them it was on the side opposite to the hemiplegia, and was evi- 
 dently due to a distinct lesion. 
 
 Pre-hemiplegic chorea is similar in its clinical characters to the post- 
 hemiplegic variety, varying only with regard to the date of its appear- 
 ance. It usually occurs from a few hours to several days before the full 
 development of paralysis, ?md subsides as soon as the hemiplegia becomes 
 well marked or complete. 
 
 After the paralysis has improved, the choreiform movements may 
 again return and run the same course as the post-hemiplegic variety. 
 Pre-hemiplegic chorea is much more infrequent than the kindred affec- 
 tion. 
 
 Charcot and his followers insist very strongly that the motor affection 
 under consideration is characteristic of a lesion situated in a well-defined 
 portion of the brain, viz.: the posterior part of the internal capsule and 
 of the optic thalamus and caudate nucleus. Although Raymond has shown 
 that this is very generally the case, investigations by other authors have 
 disproven the universal application of this statement. 
 
 Thus, Weir Mitchell found a lesion of the corpus striatum in two cases 
 of post-hemiplegic chorea, and Gowers observed a cicatricial induration 
 At . 
 
 ' Lemons sur les maladies du sysleme nerveux, 1877. 
 * Etude anatomique sur I'hcmichoree, etc., 1876. 
 *Med.-chir. Trans., 1876. 
 
14 FUNCTIONAL NERVOUS DISEASES. 
 
 of the optic thalamus, extending' across its centre beneath the upper sur- 
 face and approaching at its outer part, but not involving, the ascending 
 white fibres from the crus cerebri. In a case reported by Magnan * a 
 heinorrhacric extravasation as laro-e as a small hazel-nut was found in the 
 left cerebral peduncle, at its insertion into the optic thalamus. 
 
 The prognosis in these affections is very poor indeed. Gowers reports 
 a case of complete recovery after the employment of the constant galvanic 
 current for a number of months. I have been less fortunate in my expe- 
 rience with this agent, as a slight amount of improvement has been the 
 utmost which 1 have been able to obtain. 
 
 Charcot regards the prognosis as absolutely unfavorable, and states 
 that the choreiform movements only terminate with the patient's life. 
 
 Athetosis. ^ 
 
 Closely allied, and by many considered as identical, with these affec- 
 tions is the disease which was first described by Hammond under the title 
 of athetosis. 
 
 The main features of this affection consist of slow and involuntary 
 muscular contractions, occurring especially in the hands and feet, and 
 producing rhythmical alternations of flexion and extension in the fingers 
 and toes. The disease is usually unilateral in character (the right side 
 has been involved in most cases), but in some instances, both sides of the 
 body have been affected. The majority of cases have been associated 
 with other cerebral diseases, such as %pilepsy, dementia paralytica, loco- 
 motor ataxia, idiocy, etc. 
 
 The following is the history of an interesting case of this affection, 
 •which is probably unique from the fact that the athetotic symptoms are 
 the sole evidences of disease, there being absolutely no other manifesta- 
 tions of a cerebral affection. 
 
 Case VI. — G. W. L , ret. 18 years, no occupation. The patient's 
 
 mother died of phthisis, the father and other mem.bers of the family are 
 living and healthy. According to the father's statement, the delivery of 
 the patient was effected normally, though it occupied a somewhat longer 
 period than that of the other children; no resort was had to the use of 
 the forceps. The father noticed a peculiarity about the fingers of the 
 right hand (he was unable to open them as readily as upon the opposite 
 side) within two or three days after birth. 
 
 Present condition. — The patient is a very well nourished and bright lad. 
 His education has been neglected on account of his infirmity, but his 
 mental powers are active and fully equal to the average of boys in his 
 station of life. The special senses are perfectly normal. The right side 
 of the face appears, perhaps, to be slightly atrophied, and the mouth droops 
 a trifle on this side. When the patient is watched and when he talks 
 or smiles, the facial muscles upon the right side, especially those inserted 
 into the angle of the mouth, are in an almost continual state of clonic and 
 rather slow contraction. 
 
 Upon measurement, it is found that the length of the arms from the 
 acromion process to the end <R the radius is equal on both sides. The 
 right arm measures 8f inches i<i. circumference, the left arm, 9^ inches; 
 
 ^ Gaz. med. de Paris, 1870. 
 
ciionEA. 15 
 
 the right forearm measures 8-J inches; tlie left, 9^} inches. Tn the usual 
 position of tlie limb, the forearm is somewhat flexed, and the hand and 
 fingers are also forcibly flexed. During rest the muscles of the arm are 
 quite flaccid, but as soon as the patient attempts to move the arm in any 
 direction, the muscles become as rigid as wood. The patient usually 
 grasps the affected hand with the other in order to keep it quiet. 
 
 If lie sets the hand free, the deltoid of the affected arm immediately con- 
 tracts, drawing the limb away from the chest, and the fingers begin to twitch 
 slowly, the most common form of movement being toward more marked 
 flexion, alternating sometimes with slow extension, especially of the 2d 
 and od phalanges. 
 
 If the patient is directed to pick up anything with the right hand, he 
 must first extend the fingers somewhat with the left and then, as he makes 
 the attempt, the fingers become hyperextended and widely divergent, so 
 that it is impossible for him to grasp an object. 
 
 The arm can be moved quite freely at the shoulder-joint, though not as 
 forcibly as on the sound side; passive motion at this joint meets with slight 
 resistance, which is unattended with pain. After a great deal of effort, the 
 patient becomes able to flex the forearm on the arm after it has been ex- 
 tended; when extended the triceps is exceedingly firm and contracted, 
 the biceps not to the same degree. While the patient is flexing the fore- 
 arm the biceps becomes flabby, and when it is completely flexed, this mus- 
 cle is entirely flaccid. The forearm cannot be voluntarily extended after 
 it is flexed, nor can the hand be flexed after it has been extended. It re- 
 quires a considerable exertion of muscular power on my part in order to 
 vary the position of the hand from any in which it may be at the time of 
 the experiment. The continuous movements of the fingers, when not sup^ 
 ported by the other hand, prevent the patient from employing it for any 
 purpose whatever, and render even dressing inconvenient and trouble- 
 some. 
 
 The lower limb is not affected to the same extent as the upper. The 
 right thigh measures 16^ inches, the left 18 inches; the right calf meas- 
 ures 12 inches, the left 12|- inches. The first phalanges of the foot are 
 flexed, the second and third are hyperextended. When the patient at- 
 tempts to walk, the gastrocnemii and solei become contracted and very 
 rigid, pulling up the heel so that he is forced to walk on the front part of 
 the sole of the foot; at the same time, the tibialis anticus contracts, draw- 
 ing up the inside of the foot. When the patient is directed to move his 
 toes, slow movements of extension and flexion, similar to those observed 
 in the fingers, though of course not so marked, become evident. Walk- 
 ing is not very much interfered with, as the involuntary movements of 
 the toes are partially restrained by the shoe. 
 
 Cutaneous sensibility and the electrical reactions of the ipuscles are nor- 
 mal throughout the entire body. The movements of the muscles continue 
 unabated during sleep. The patient is perfectly healthy in all other re- 
 spects. The treatment consisted in the application of the faradic current 
 to the muscles of the arm (this was merely done to retain the patient un- 
 der observation), my galvanic battery not being in working order. To 
 my great surprise, the abnormal facial movements disappeared almost en- 
 tirely in the course of 5 to 6 weeks (the current had never been applied to 
 the face), and the violence of the movements of the fingers was also 
 slightly diminished. I then applied the constant galvanic current for a 
 couple of months, but without producing any further improvement. The 
 patient then passeU out of my observation. 
 
16 FUNCTIONAL NERVOUS DISEASES. 
 
 Very few opportunities liave been afforded for investigating the path- 
 ological anatomy of this affection, and I have only been able to obtain re- 
 cords of five post-mortems upon patients suffering from athetosis. In one, 
 the brain was found normal; in the second, two small spots of softening 
 were discovered in the first temporal convolution; in the third case, the 
 patient also suffered from dementia paralytica, and the brain presented no 
 evidences of a localized lesion; in the fourth case, the athetosis occurred 
 as a complication of locomotor ataxia, and a small spot of softening was 
 found at the posterior, inferior, and outer extremity of the right lenti- 
 cular nucleus. There was probably, however, no connection between 
 this lesion and the athetosis, since the latter occurred upon both sides of 
 the bod}-. The fifth case is of great interest with regard to the light 
 thrown upon the relations of the affection to post-hemiplegic chorea, and 
 I shall, therefore, present a short abstract of the case as reported by Dr. 
 Sturges.* 
 
 Case VIL— H. B , aet. 33 years; when three years old. the patient 
 
 had whooping-cough, and shortly afterward had two fits, which left him 
 paralyzed on the left side. He gradually gained power, however, in the 
 limb, and, at the age of ten could run about as well as other boys. The 
 athetosis appeared soon after the fits, and gradually increased in severity 
 as the muscular power was restored. 
 
 The movements were almost exclusively confined to the left upper 
 limb, and were continuous and involuntary. When the hand was ex- 
 tended with the palm downward, the index and middle fingers were slowly 
 and gradually flexed. The thumb was also adducted, the hand was then 
 supinated, the fingers again extended, and the thumb abducted; prona- 
 tion of the hand com]Dleted the cycle. The patient could slightly control 
 the movements by a great effort of the will; the hand was only quiet 
 during sleep. The left leg occasionally exhibited a somewhat similar 
 condition, but only when the patient was tired out after a long walk. 
 Death occurred from diarrhoea and exhaustion. 
 
 Autojysy. — Brain: right hemisphere distinctly smaller than the left; 
 the posterior half of the middle and inferior frontal convolutions, and, to 
 a slighter extent, the superior and ascending frontal were distinctly 
 smaller on the right side than on the left; the parietal convolutions were 
 also smaller on the right side. There was a depression on the anterior 
 portion of the temporo-sphenoidal lobe, about one inch long; there was 
 also a deep depression extending backward into the lobe, about three- 
 fourths of an inch deep. A deep excavation was found between the anterior 
 extremity of the perforated spot and the convolutions of the island of Reil, 
 extending backward to the level of the corpora albicantia and forward to 
 the anterior surface of the hemisphere. The sides of the fissure seemed 
 to have been in apposition, except outside the perforated spot, where the 
 cavity was about one-fourth inch wide; its roof was formed by radiating 
 fibres spreading upward from the pons. Upon opening the ventricles, 
 almost the whole of that portion of the rig-ht corpus striatum lying in 
 front of the thalamus appeared to be destroyed; the posterior portion of 
 the nucleus caudatus was unaffected. A small portion of the inner part 
 of the corpus striatum near the middle appeared intact, but the whole 
 of the gray substance was destroyed. The optic thalamus seemed to 
 be quite healthy, 
 
 * Lancet, March 15, 1879. 
 
CHOREA. 1 7 
 
 These post-mortem investigations, especially the one last mentioned, 
 appear to me to disprove conclusively Hammond's assumption that athe- 
 tosis is a distinct disease.' The latter case demonstrates that, in some 
 instances at least, the disease merely constitutes a peculiar variety of post- 
 hemiplegic chorea (this should more properly be called symptomatic 
 chorea). 1 have also distinct recollection of a case of post-hemiplegic 
 chorea in a girl, xt. 9 years, in wliich the movements of the fingers were 
 exactly similar to those described by Hammond as characteristic of athe- 
 tosis. In this case, the patient, while suffering from intermittent fever 
 three years ago, was suddenly seized with a convulsion which took the 
 place of a cliill. The child was found to be hemiplegic on the right side 
 on the following morning. As the power began to return to the affected 
 arm, the athetoid movements made their appearance and have continued 
 ever since. 
 
 ' Leube (Deutsch. Arch. f. klin. Med., Bd. XXV., p. 242, 1880) reports a case 
 which also appears to show that athetosis may, in some instances, be a mere variety 
 of ordinary chorea. The patient in question, after prolonged exposure to wet. devel- 
 oped athetoid movements throughout the entire body, which persisted steadily for 
 four years. At the end of this time the symptoms changed to those of ordinary severe 
 chorea, and continued as such during the entire period in which the patient remaiaed 
 under Leube's observation. 
 
CHAPTEE n. 
 
 ETIOLOGY. 
 
 Almost all writers are unanimous in the opinion that sex constitutes 
 one of the chief predisposing causes of chorea, the female sex presenting 
 by far the larger proportion of cases of this affection. In the following 
 statistics, which include a very large number of cases, the proportion of 
 males to females is 382 to 1,053, or nearly 1 to 3: 
 
 Females. Males. Total. 
 
 See 393 138 531 
 
 Rufz 138 51 189 
 
 Hughes 240 69 309 
 
 Steiner 40 12 52 
 
 Pye-Smith 106 42 148 
 
 Peacock 86 37 123 
 
 Author 50 33 83 
 
 1,053 382 1,435 
 
 The majority of cases of chorea occur from the fifth to fifteenth years 
 of life, as is shown by a glance at the following tables: 
 
 Below 5 yrs. 5 — 10 yrs. 10 — 15 yrs. 15 — 20 yrs. Above 20 yrs. 
 
 See 11 94 57 17 12 
 
 Steiner 4 46 6 
 
 Pye-Smith.. 5 62 44 19 6 
 
 Peacock ". . 22 51 14 5 
 
 Author 2 27 28 9 5 
 
 22 251 186 59 28 
 
 In very rare instances, chorea occurs from birth. After careful ex- 
 amination of the literature of the question, I have only been able to find 
 the histories of 8 cases of congenital chorea, reported by Heller,* Mayo,* 
 Monod, Spamer,^ Althaus,'' Fox,^ and Richter (2).° In Mayo's case the 
 mother had been extremely nervous for a period of two months after a 
 disgusting object had been thrown upon her bosom (while she was four 
 months advanced in pregnancy). In Richter's two cases, the mothers had 
 been very much frightened shortly before confinement. Spamer men- 
 
 ' Wien. med. Wschr. 19. 1876. = Outlines of Human Pathology, p. 170. 
 
 2 Wien. med. Wschr. 52. 1876. * Diseases of the Nervous System, 1878. 
 
 ^ Brit. Med. Joum., 1873, No. 653. 
 
 * Sitzb. d. Dresden Ges. f. Nat. u. Heilk. Jan. 5, 1867. 
 
CHOREA. 19 
 
 tions, with regard to his case, that the mother had been very nervous and 
 depressed during the entire period of pregnancy, on account of the death 
 of one of her children. No reference is made in the reports of the re- 
 maining four with regard to the probable exciting cause of the disease. 
 
 Chorea is very infrequent during adult life, and becomes extremely 
 rare in old age. When it occurs after the age of fifty, it is usually at- 
 tended with some mental derangement, especially dementia. Five cases 
 have come under my observation which developed after the age of thirty- 
 five years, one of which was complicated with insanity. In the Lancet for 
 1878. Dr. R. T. Wright reports the history of a case of chorea of three 
 years' standing in a man seventy-eight years of age. 
 
 Heredity exercisesbut little influence upon the development of chorea, 
 and among upward of ninety cases which have come under my observation, 
 I have not been able to obtain a single instance of the transmissibility 
 of the predisposition to the affection from parent to child. Not infre- 
 quently, however, it is found that one of the parents, usually the mother, 
 suffers from nervousness or hysteria, and, in a considerable number of 
 instances, I have observed that one or more of the brothers or sisters of 
 a choreic patient were subject to epilepsy or hysteria. 
 
 Although I have not collected any comparative statistics on this ques- 
 tion, I am nevertheless convinced that chorea develops in those families 
 in whom the neuropathic tendency has not taken strong root, while in 
 those which are more severely affected, more serious nervous diseases, 
 such as obstinate neuralgias, epilepsy, insanity, etc., make their appear- 
 ance. In not a few cases, however, chorea is combined with epilepsy, 
 especially when the former affection has become chronic. 
 
 Antemia also exerts considerable influence as a predisposing cause of 
 chorea, but its importance as a pathogenic factor must not be overesti- 
 mated. It is true that the majority of patients who have suffered from 
 chorea for any length of time present symptoms of anaemia (pallor of 
 face, conjunctivae, and lips, irritable heart, shortness of breath, rapidly 
 developing sense of fatigue), but this condition is then secondary to the 
 disturbed sleep, the insufficient supply of nutriment, and the continual 
 muscular effort to which the patients are subjected. Nevertheless, we 
 not infrequently meet with patients of a very nervous temperament who 
 manifest slight choreiform symptoms as soon as the general health, for 
 any reason, sinks below the normal standard. 
 
 Onanism is also looked upon as an active predisposing cause of chorea, 
 as it is of so many other nervous affections. I have, however, only been 
 able to obtain evidence in a few cases of the sufficiency of this cause as an 
 agent in the production of the disease. In fact, I am of the opinion that 
 the baneful effects of the "secret vice" have been greatly overestimated 
 by the profession at large as well as by the laity. The habit is undoubt- 
 edly practised to an enormous extent among children of both sexes, and 
 if its potency as a disease-producing factor were as great as it is claimed 
 to be by so many physicians, chorea, as well as other functional neuroses, 
 would be much more common than they really are. While I therefore 
 believe that excessive onanism, by lowering the healthful tone of the 
 nervous system, may prepare the way for the more ready development of 
 nervous affections, I doubt whether it is often the principal agent in their 
 production. 
 
 The exciting causes of chorea are very numerous. Peacock' gives the 
 
 1 St. Thomas' Hosp. Rep., 1877. 
 
20 FUNCTIONAL NERVOUS DISEASES. 
 
 following analysis of ninety-two cases, coming under his own observation, 
 with regard to causation: 
 
 Not ascertainable 23 
 
 Fright 25 
 
 Excitement 8 
 
 Blows on head 5 
 
 Driving a van in very hot Aveather 1 
 
 Prolonged lactation 1 or 2 
 
 Pregnancy 3 
 
 Suppression of the catamenia 2 or 3 
 
 Scarlatina 2 
 
 Rheumatism 8 or 9 
 
 Worms 3 
 
 Among the ascertainable causes, therefore, fright holds the chief 
 place. As a rule, the development of the chorea follows this exciting 
 cause after the lapse of from six to forty-eight hours. In four cases under 
 my observation, the patients, who had been frightened during the night 
 by an alarm of fire or by burglars, awoke the following morning with well- 
 developed choreiform twitchings of the entire body. In one instance, the 
 chorea developed immediately after the exciting cause. The patient, an 
 anemic and extremely nervous girl of ten, was suddenly startled last Au- 
 gust by a terrible clap of thunder, which was so severe that it was the 
 subject of town talk for several days. The guardian of the patient, a 
 very intelligent young lady, assured me that the choreic movements de- 
 veloped immediately after the thunder-clap, and that they were very vio- 
 lent from the beginning. When I saw the girl on the following day, the 
 movements were so violent that the little patient M^as unable to maintain 
 her seat, and could only walk with difficulty. Violent fits of anger, or 
 other causes of excitement, will sometimes act in the same manner as a 
 severe fright. When the chorea develops one or two weeks after pro- 
 found mental excitement, it is extremely doubtful whether this can, with 
 propriety, be looked upon as the exciting cause. We must remember 
 that the friends of the patient are usually anxious to aid us in our search 
 for the origin of the disease, and that their zeal often leads them to mention, 
 as causes, occurrences which long antedated the development of the mus- 
 cular twitchings. It is, therefore, always well, when told that the chorea 
 came on after a fright, fall, etc., to enter somewhat into the details of the 
 case, and judge for ourselves whether there is really any connection be- 
 tween the two occurrences. Inattention to this simple rule has led me 
 astray in not a few cases of this as well as of other diseases. 
 
 Among the other exciting causes of a mental nature we must mention 
 imitation. This, however, is exceedingly rare, and has only occurred 
 once in the cases which have come under my observation (I have previ- 
 ously referred to this case on page 3). Bricheteau reports a very inter- 
 esting example of an " epidemic " of chorea which developed in his wards 
 at the Hopital Necker. Within a week after the admission of a choreic 
 patient into the hospital, eight other patients (females) occupying the 
 same ward became affected with the disease. Its further spread was only 
 prevented by isolating the choreic patients. 
 
 Rheumatism constitutes one of the most interesting causes of chorea, 
 both on account of the differences of opinion with regard to its importance 
 and also on account of its relations to the pathology of the affection. 
 
CHOREA. 21 
 
 The opinions of different authorities vary diametrically with regard to 
 this question. The theory of its intimate relations to chorea has been 
 especially promulgated by English and French writers. M. See ' states 
 that one-half of the entire number of cases of chorea are caused by the 
 rheumatic poison. Roger'' is even more pronounced in his views concern- 
 ing the relations of rheumatism and chorea than the preceding author, and 
 thinks that the coincidence of these two affections is as much evidence of 
 a pathological law as the so frequent coexistence of endocarditis and rheu- 
 matism. Among 104 cases which were reported in Hughes' and Brown's 
 paper on chorea in the Gicy^s Hospital Reports, for 1855, and which were 
 carefully investigated with regard to the previous existence of rheumatism, 
 only fifteen cases were found in which the latter affection had not been 
 present,or in which a cardiac murmur was not audible. Trousseau also be- 
 lieves that rheumatism is one of the most common causes of chorea. But 
 numerous statements to the contrary have been made by various au- 
 thorities. Steiner ' found that among 252 cases under his observa- 
 tion, a history of previous rheumatism could be obtained in only four. 
 Octavius Sturges * saw only five positive cases of acute rheumatism, among 
 seventy-one cases of chorea. Among forty personal cases which I examined 
 with great care in this respect, only three gave a history of previous 
 rheumatism. Among these three patients, two presented a well-marked 
 mitral systolic murmur, and in the third, the heart-sounds were normal. 
 
 It must be remembered, in estimating the importance of rheumatism 
 as an etiolosrical factor in chorea, that a diaarnosis of the former disease is 
 frequently made on insufficient data. The cases of acute rheumatism in 
 children which have come under my observation, have presented exactly 
 similar symptoms to those occurring in acute rheumatism in the adult. 
 Not infrequently, however, neuralgic pains in the joints, muscular rheu- 
 matism in the neighborhood of the joints or hyperaesthesia of the skin, 
 are regarded, in children, as sufficient evidence of rheumatism. In like 
 manner many physicians look upon a basic heart-murmur, even when un- 
 attended with hypertrophy of the organ or with the subjective symptoms 
 of valvular lesion of the heart, as sufficient evidence of endocarditis, and 
 presumably, therefore, of antecedent rheumatism. In such cases, the his- 
 tory of previous pains in the limbs is regarded as ample testimony oi the 
 rheumatic origin of the endocarditis. 
 
 Rilliet has also referred to the fact that chorea rarely appears in cer- 
 tain localities in which acute articular rheumatism is of frequent occur- 
 rence, as, for instance, in Geneva. 
 
 As a rule, chorea, when connected with rheumatism, develops in the 
 latter stages of this affection or at a varying interval after recovery. In 
 rare instances, however, the chorea precedes the attack of rheumatism in 
 point of time. Roger * mentions an extremely interesting case occurring 
 in a girl set. 11^ years who suffered, within less than five years, from six 
 attacks of acute articular rheumatism and five of chorea, hemiplegia and 
 endocarditis also developing during two of the relapses. 
 
 Chorea is also said to be sometimes caused by reflex irritation, such 
 as the presence of worms in the intestinal canal, toothache from carious 
 teeth, amenorrhcea, pregnancy, irritation of cicatrices in various parts of 
 the body. There is no doubt that these causes may sometimes give rise 
 
 ' Mem. de TAcad. Nat. de Med. , t. xv. ' Gaz. med. de Paxis, Mar. 7, 1868. 
 
 3 Prag. Vjschr. 1868. ■* Lancet, p. 283, 1878. 
 
 * Arch, gener. , vol. ii. , p. 658. 
 
22 FUNCTION' AL NERVOUS DISEASES. 
 
 to the disease, although the existence of reflex chorea has been denied by 
 some authorities. Eulenburg states that he has, on several occasions, found 
 the disease, when due to dental disorders, disappear after the extraction 
 of the carious teeth, and again make its appearance upon the development 
 of fresh trouble in the teeth. The case of Fann\^ M., which we described 
 upon page 8, seems to show that chorea is sometimes dependent on the 
 sudden abolition of the menstrual discharge, as the chorea appeared soon 
 after the development of the amenorrhceic condition, and no other cause 
 could be ascertained. 
 
 It is doubtful whether pregnancy produces chorea from the reflex irri- 
 tation due to the presence of the foetus in utero, or from the aucemia and 
 hydrsemia which usually exist in this condition. Judging, however, from 
 the action of pregnancy in the development of other neuroses, I should 
 think it probable that chorea gravidarum is attributable to reflex irrita- 
 tion. 
 
 Finally, we must consider the effects of syphilis upon the development 
 of chorea. Although this affection is such a frequent cause of various 
 nervous diseases, there are extremely few examples on record of cases of 
 chorea which may be attributed to its agency. I have only been able to 
 obtain records of seven cases,^ one of which, however, was really post-hemi- 
 plegic chorea, a consideration of which has been previously entered upon. 
 
 Of these seven cases, four occurred in females and three in males. Two 
 developed at the age of seven years, one at the age of twelve, and the 
 remainder between the ag'es of twentv and thirtv-three years. Five 
 recovered completely under the use of anti-syphilitic remedies, one was 
 unimproved, and one proved fatak 
 
 It is extremely difficult to determine in what manner the syphilitic 
 virus produces the choreiform movements. In all probability they may 
 be attributed to disturbances in the nutrition either of the cortical 
 motor centres or of the basal ganglia caused by the changes in the walls 
 of the vessels which are now recognized as the frequent origin of syphili- 
 tic cerebral disturbances. 
 
 In very rare instances, chorea appears to be due to malarial influences, 
 as in the following personal case. 
 
 Case VIII. — Mrs. Eliza G., set. 26 years, married six months; her pater- 
 nal uncle and father's first cousin were insane; the patient was in fair health 
 until marriage (six months ago), but since then very marked hj-sterical man- 
 ifestations have developed. Upon vaginal examination the hymen is found 
 to be intact, and the patient, on inquiry, states that sexual intercourse 
 has never been satisfactorily consummated. The hysterical symptoms 
 were undoubtedly due to this condition of the genital organs, and to the 
 nervous irritability produced by the ungratified sexual desire. For the 
 past three months the patient has been suffering from muscular twitchings 
 which were chiefly confined to the right side (face, arm, and leg), but were 
 also manifested to a slighter degree on the left side. The patient and 
 her mother are positive in their statement that the choreiform movements 
 only appeared every other day during the first two months. Within the 
 last month, the twitching was noticeable every day, but was very slight 
 on the alternate days, so that distinct periodicity is marked even at the 
 
 ' Zambaco : Des affections nerveuses sj'philitiques, Paris, 1862. PhUa. Med. Times, 
 April 14, 1877. Alison: Amer. Joum. of Med. Sciences, vol. ii., 1877. Raymond: 
 Etude, etc., sur rhenaichoree, etc., Paris, 1876. 
 
cnoREA. 23 
 
 present time. Upon examination, the spleen was found to be enlarged, 
 but there were no other evidences of malaria. Acting on the theory that 
 the chorea was of a malarial nature, I placed the patient on thirty-grain 
 doses of quinine daily (November 19th), vphich was sufficient to produce 
 marked cinchonisra. On November 27th the choreiform movements had en- 
 tirely disappeared, and did not return while the patient remained under 
 observation (six to eight weeks). There was also marked improvement as 
 regards the severity of the hysterical symptoms, but I attributed this 
 change to the fact that the patient, at my advice, lived separately from 
 her husband, thus removing, in part at least, the cause of the disorder. 
 
CHAPTEK ni. 
 
 PATHOLOGICAL ANATOMY. 
 
 Although a great deal of attention has been devoted to this branch 
 of our topic within the last twenty years, especially by English patholo- 
 gists, there is still considerable room for further investigation. The au- 
 topsies which were made in the early part of this century are almost 
 entirely valueless, as they were performed before the modern improved 
 methods of pathological and histological research had come into general 
 vogue. But this criticism will also hold, to a certain extent, with regard 
 to the autopsical investigations made at the present day. Numerous 
 cases are reported in the journals in which the writer has felt himself 
 justified in declaring the nervous centres intact, although microscopical 
 examination has been entirely omitted. 
 
 The opportunities for post-mortem examinations in this affection are 
 comparatively rare on account of the infrequency of a fatal termination 
 (among upward of ninety cases which have come under my observation, in 
 only one did a fatal result follow), and it is therefore to be hoped that 
 those observers who are enabled to make such investigations, will resort 
 to a careful nlicroscopical and macroscopical examination of the central 
 nervous system, as well as of the peripheral nerves. 
 
 Aitken examined the specific gravity of the basal ganglia of the brain 
 in a case of chorea, and found that that of the corpus striatum and optic 
 thalamus on the right side was 1-025, and on the left side I'OSl. These 
 figures vary considerably from those furnished by Bucknill for these 
 ganglia in healthy brains (1"036). 
 
 Kirkes * reported several cases of fatal chorea in which he found endo- 
 carditis present upon autopsy. Small, fine granulations were present upon 
 the valves of the heart, especially upon the mitrals. Numerous observa- 
 tions of a similar character have been made by other observers, and even 
 in cases in which no symptoms of rheumatism had been presented by the 
 patient during life. 
 
 Broadbent ° mentions the following case. The patient was a young 
 woman, twenty-three years of age, who began to manifest a change in dis- 
 position two years previously. Her general health soon became impaired, 
 and of late it was noticed that the patient's skin was assuming a browner 
 hue. She was confined to her bed for a period of two weeks with what 
 was called a "low fever," and upon her recovery from this condition it 
 was found that she had lost the perfect control over the movements of the 
 left arm. Well-marked choreiform twitchings soon appeared in this 
 member, then spread to the left leg, and finally to the limbs on the oppo- 
 site side of the body. When admitted to the hospital, the patient was 
 very feeble and presented general choreiform movements, which were 
 
 ' Med. Gazette, 1850, and Med. Times and Gazette, 1863. 
 '^ Traus. Lond. Path. Soc, vol. xiii., IbGl. 
 
CHOREA. 25 
 
 most marked upon the left side. The chorea continued until death, 
 which occurred ten days after admission. 
 
 Post-mortem. — We will merely mention the appearances presented in 
 the nervous system, the other lesions having no relation to the chorea. 
 The brain was perfectly healthy in appearance and consistence. The 
 spinal cord was firm and healthy except at the posterior surface of the 
 dorsal region, two inches above the lumbar enlargement. In this sit- 
 uation a small tumor was noticed, which was at first supposed to spring 
 from the surface of the cord, but, upon section, was found to originate 
 from the interior. 
 
 Tuckwell ' gives the following results of the post-mortem examination 
 in a boy aet. 17 years, who suffered from acute chorea, which had become 
 complicated with mania and proved rapidly fatal. Autopsy. — Upon the 
 middle of the upper surface of the right cerebral hemisphere was a spot 
 of softening which appeared to be limited strictly to the cortical layers. 
 A similar spot was found upon the under and outer aspect of the posterior 
 lobe of the same hemisphere, but in this situation the lesion also ex- 
 tended a certain distance into the white matter. Upon carefully tracing 
 up the posterior cerebral artery, an embolus with a secondary thrombus 
 was found in one of the branches which led in the direction of the softened 
 spot. A spot of softening of considerable size was also found in the 
 dorsal region of the spinal cord, together with a small embolus in one 
 of the vessels within the affected district. The heart appeared healthy 
 with the exception of the auricular aspect of the mitral valves, which 
 presented a row of small, delicate vegetations of recent origin. 
 
 In the " Saint Bartholomew's Hospital Reports," vol. v., Tuckwell men- 
 tions the following interesting post-mortem results in a fatal case of cho- 
 rea: The brain was well developed and presented nothing abnormal in the 
 meninges or upon the surface. Upon tracing out the posterior cerebral 
 artery, and thereby displacing the middle cerebral lobe, the inferior por- 
 tion of this lobe on the right side was found softened. The softening 
 involved the deeper layers of the cortex, and more especially the subja- 
 cent white substance; it also extended upward into the neighborhood of 
 the corpus striatum and optic thalamus. The basal ganglia, however, ap- 
 j>eared to be normal. The corresponding portions of the left hemisphere 
 were also softened, but to a less extent than on the right side. The re- 
 maining portions of the brain presented a remarkably firm and healthy 
 appearance. 
 
 The spinal cord appeared to be normal in all respects. 
 
 Heart. — The auricular aspect of the mitral valves showed the following 
 changes: a line of numerous bright, clustering, warty vegetations, some 
 as large as a pin's head, others barely visible, extended in a sinuous course 
 all along the free margin of each leaflet. In two or three places, the lit- 
 tle growths hung only by a fine pedicle to their line of attachment. 
 
 Wilson Fox ^ also reports a case of chorea with cerebral embolism. 
 During the course of the disease the patient had presented a mitral mur- 
 mur, but no history of previous rheumatism could be obtained. Upon 
 autopsy, the heart was healthy, except that the free borders of both flaps 
 of the mitral valves were thickly covered with rough granulations, which 
 were apparently of recent origin. The brain appeared perfectly healthy 
 to the naked eye, but Bastian, who made a microscopical examination of 
 
 ' Brit, and For. Med.-Chir. Rev., 1867. 
 "^ Trans. Lond. Path. Soc, xx., 1869. 
 
26 FUNCTIONAL KERVOUS DISEASES. 
 
 this organ, observed plugging of some of the blood-vessels in the medulla 
 oblongata. 
 
 Magnan ' reports the follovring case: C. J., aet. 73 years; previous his- 
 tory unknown, presents choreiform movements of the right arm and leg; 
 talks incoherently. After great difficulty, it is found that this condition 
 has only lasted three or four days. No accurate data can be obtained 
 with regard to sensation. 
 
 Upon the day after admission to hospital, the movements were inces- 
 sant; they extended to the neck and face, but only involved the right side. 
 They increased during excitement, and ceased during sleep. Upon the 
 following day the choreic movements had increased in severity, the face 
 was grimacing (to the right) and the arm and leg were in constant mo- 
 tion. At 1 p. M. the patient became pale and then cyanosed, the move- 
 ments ceased, and death occurred suddenly in syncope. 
 
 Autopsy. — The cerebral meninges were thickened, opaline in places, 
 and were readily detached from the convolutions. The convolutions were 
 yellowish and diminished in size. The vessels at the base were athero- 
 matous; the ependyma of the lateral ventricles was thickened. The ^tat 
 crible was visible in both hemispheres, especially in the corpora striata 
 and optic thalami. 
 
 An incision through the left cerebral peduncle, at its insertion into the 
 optic thalamus, showed a hemorrhagic foyer as large as a small hazel-nut, 
 composed of soft, reddish clots of recent date; the adjacent nerve-tissue 
 was torn and infiltrated with fluid. The pons and medulla presented no 
 appreciable change. A yellowish patch of old softening was found upon 
 the inferior surface of the left lobe of the cerebellum. 
 
 W. Howship Dickinson * gives the results of autopsical examination 
 in seven fatal cases of chorea, the appearances in which may be briefly 
 summed up as follows: 
 
 Case T. — Injection of all the vessels of the brain and cord, especially 
 in the corpora striata and dorsal region of the cord. Hemorrhage into 
 the central canal of the spinal cord, which was distended by serum. 
 
 Case II. — Similar injection of the brain, superficial hemorrhages and 
 exudation around the arteries of the corpus striatum. Injection of the 
 spinal cord. 
 
 Case III. — Injection of cerebral vessels, especially around the optic 
 thalamus. Injection of the cord and hemorrhages into the gray matter of 
 the dorsal and lumbar regions. 
 
 Case IV. — Injection of the brain, chiefly venous, and of the corpora 
 striata. Injection of the cord, with large hemorrhage into the cervical 
 gray matter. 
 
 Case V. — Venous injection of the brain, especially of the corpora 
 striata; arteries in the convolutions near the Sylvian fissure surrounded 
 by blood crystals. Injection of spinal cord. 
 
 Case VI. — Recent injection of the structures at the floor of the lateral 
 ventricles, and of the spinal cord. 
 
 Case VII. — Spots of " sclerosis " (simple atrophic degeneration) in 
 the substantia perforata and in the gray matter of the corpora striata. 
 Extensive exudations into the cord. 
 
 The heart was examined in six of these seven cases. Vegetations 
 
 ' Gaz. med., Paris, 1870. * Med.-chir. Trans., vol. lix. 
 
CHOREA. 27 
 
 upon the mitral valves were only found absent in one case (a widow, jet. 
 54 years). 
 
 Elisclier ' found anatomical changes in all parts of the nervous system 
 in a patient suffering from chorea gravidarum, who died of puerperal 
 endometritis; the median and sciatic nerves (which were the only peri- 
 pheral nerves examined) were flattened and smaller than normal, and had, 
 at the same time, assumed a firmer consistence. Microscopical examina- 
 tion showed that the amount of interfibrillary connective tissue was greatly 
 increased, and that it contained a large number of spindle-shaped nuclei. 
 Numerous small extravasations of blood were visible between the nerve- 
 bundles. In some of the nerve-fibres the sheath of Schwann appeared 
 cloudy, in others it presented a vitreous appearance; in these fibres, the 
 axis-cylinders could only be detected with difficulty. 
 
 Spinal cord. — The walls of the blood-vessels, especially the tunica ad- 
 ventitia, were thickened and contained numerous nuclei. The central 
 canal contained considerable serum, and the surrounding connective tissue 
 was firmer and more abundant than usual. The four principal collections 
 of ganglion cells in the gray matter were separated from one another by 
 well-marked bundles of newly formed fibrous tissue, which, in the sub- 
 stantia gelatinosa, contained large numbers of nuclei. The ganglion 
 cells were misshapen and did not stain well with carmine. The nuclei of 
 these cells were no longer visible. 
 
 Brain. — The vessels of the basal ganglia presented the appearance of 
 fatty, amyloid, and pigment degeneration. The vessels were covered, in 
 certain places, with granular cells. Especially in the corpus striatum. 
 Elischer attaches no importance, however, to this appearance, as he ob- 
 served similar lesions in two patients who had died of tuberculosis and in- 
 ternal hemorrhage. The small vessels, especially in the convolutions, con- 
 tained numerous emboli, composed of red and white globules. The 
 neuroglia of the brain was increased in amount and firmness, and was 
 strewn with large, coarsely granular nuclei. The vessels of the corpus 
 striatum were surrounded by numerous minute deposits of a rusty-brown 
 pigment. The ganglion cells contained such a large amount of pigment 
 that the protoplasm appeared to be entirely destroyed and displaced; some 
 cells contained no nuclei, and were filled with fat granules. The changes 
 in the ganglion cells were only visible in the basal ganglia, the cerebellum 
 and cerebral convolutions being normal. 
 
 The following autopsy, for an account of which I am indebted to the 
 kindness of Dr. E. A. Maxwell, Curator to Charity Hospital, was held 
 upon a patient whom I had observed from time to time, for a period cov- 
 ering several years. The patient was an inmate of the Epileptic and 
 Paralytic Hospital on Blackwell's Island. 
 
 Case IX. — Catherine Eppersault, aet. 78 years, admitted 1869, died 
 November 8, 1878. Patient has been choreic for more than twenty years. 
 Nothing is known about her previous history as she had no friends and 
 her speech was so much impaired that it was impossible to get a history 
 from her. Such language that^he used, and which could be understood, was 
 vile and profane. The choreic movements affected the face, tongue, trunk, 
 and extremities, and were extremely violent in character. The body and 
 limbs underwent the most grotesque and hideous contortions, the facial 
 
 » Virch. Arch. Bd. 61, p. 485, and Bd. 63, p. 104. 
 
28 FUNCTIONAL NERVOUS DISEASES. 
 
 muscles were in continual activity, and the tongue was protruded and re- 
 tracted with considerable force. The movements were very much in- 
 creased in violence when the patient was watched. She was unable to 
 use a knife or fork, and her food was cut up for her. The patient was, 
 however, able to eat with a spoon, though with considerable difficulty. 
 She was able to drink from a tumbler by holding it with both hands, but 
 was unable to wash her face or dress herself. She never spoke about 
 friends or relations. She would only eat at meal times, and if food were 
 presented to her between meals, she would throw it at the head of the 
 person offering it. She would not permit the clergyman or visiting ladies 
 to converse with her, and would attempt to throw things at them or 
 curse them. The patient could walk without assistance by taking a step, 
 resting for a short time, and then taking another. As a rule, however, 
 she helped herself by holding on to the beds. Upon several occasions, 
 however, I have seen her walk rapidly through the wards with an irregular 
 gait, the arms swinging violently in all directions, and the head tossed from 
 side to side by the violence of the choreiform movements in the muscles 
 of the neck. She would rarely leave her chair except to go to the closet. 
 Even while sitting in her chair, the body and limbs underwent violent 
 contortions so that she retained her position with some difficulty. Dur- 
 ing sleep the movements ceased entirely. The patient would never take 
 medicine and would not allow anybody to go near her except another 
 patient in the same ward. During the last month she had been gradually 
 failing, becoming weak and anasmic. Upon several occasions she fell to 
 the floor, and, about a month ago, sustained a severe contusion of the 
 right side, face and eye. She never complained since her admission to the 
 hospital, but groaned occasionally during the last week. The patient has 
 been failing very rapidly for the last two or three days, but would not 
 take to her bed; was found dead in her chair, November 8, 1878. 
 
 Autopsy. — Atrophy of the ascending frontal and parietal convolutions 
 upon either side; sclerosis of the medullary substance of both hemispheres 
 (middle third) ; descending degeneration of the crura, pons, medulla, and 
 cord; cardiac hypertrophy; cirrhosis of the liver; chronic diffuse nephritis. 
 
 The post-mortem was held forty-six hours after death. Body of medium 
 size, emaciated, rigor mortis present; contusion over right frontal bone, 
 slight oedema of the eyelids. 
 
 Head. — Calvarium thin and the bones easily cut with a knife. Dura 
 mater shows a pachymeningitis of the falx cerebri; the sinuses normal. 
 Pia mater normal with the exception of marked oedema, which is especi- 
 ally evident over the paracentral lobule on each side, corresponding to the 
 atrophy of the underlying convolutions. The vessels at the base of the 
 brain show thickening of their walls (in places) from atheroma and a de- 
 posit of calcareous plates. The lumen of the affected vessels is moder- 
 ately narrowed, but all are pervious, so far as examined. 
 
 The pia mater can be everywhere normally stripped from the convo- 
 lutions. Convolutions. — The ascending frontal and parietal convolutions 
 upon either side are moderately atrophied from their lower third up to 
 the longitudinal fissure. The atrophy is most marked on the right side, 
 at the situation of the paracentral lobule. Externally, the color of the 
 atrophied gyri shows nothing different from that of the unaffected convo- 
 lutions, but, upon vertical section their outer third presents a bluish gela- 
 tinous appearance, and the inner two-thirds are of a deeper yellow and 
 more granular appearance than elsewhere. The affected convolutions are 
 not abnormally softened. 
 
CHOEEA. 29 
 
 Lateral ventricles. — The epend yma is thickened and presents granula- 
 tions upon its surface; upon the right side over the corpus striatum this 
 thickening is most marked and corresponds to evident atrophy of the 
 interventricular nucleus. The third and fourth ventricles show nothing 
 abnormal. There is no marked dilatation of, or increase of fluid in the 
 ventricles. On section of the brain substance, the white matter is found 
 to be sclerosed in the middle third of each hemisphere and extending 
 somewhat beyond this boundary anteriorly. The sclerotic portions are 
 tough and leathery to the feel, and have a pinkish blue or mother-of-pearl 
 color. There is a symmetrical spot of white softening in the middle of 
 the outer segment of each lenticular nucleus. With the exception of 
 this softening, and of the previously mentioned atrophy of the right in- 
 terventricular nucleus, the basal ganglia are normal. The crura cerebri 
 are about equal in size; upon transverse section, each shows central 
 atrophy, which is most marked on the right side, with slightly yellowish 
 discoloration of the white fibres bordering on the locus niger, and trans- 
 formation of the normal black pigmentation of the latter to a dull yellow- 
 ish brown. 
 
 Pons varolii. — Upon inspection, the lateral halves appear to be of 
 equal size, but on transverse section the bundles of longitudinal fibres of 
 the right side are scarcely more than half the size of those on the left. 
 
 Medulla oblongata. — There are no marked changes to the naked eye. 
 
 Spinal cord.- — This exhibits a descending degeneration which, to gross 
 appearances, disappears in the lumbar region, and is throughout most 
 marked in the left half of the cord. The meninges of the cord are nor- 
 mal. 
 
 Thorax. — The sternum fractures upon the application of the slightest 
 force. Several ribs are fractured and, at the corresponding portions of 
 the costal pleura there are evidences of localized pleurisy and subpleural 
 hemorrhages. Lungs exhibit emphysema and bronchitis. 
 
 Heart. — Hypertrophied, especially the left ventricle. 
 
 Aorta. — Dilated and atheromatous, with calcareous plates. 
 
 Abdomen. — Liver, markedly cirrhotic. I^idneys. — Atrophied, the cor- 
 tex fatty and filled with cysts (chronic diffuse nephritis). 
 
 The above mentioned cases will suffice to furnish an idea of the variety 
 of anatomical lesions which have been found present in chorea. 
 
 "We must not forget, however, that a considerable number of cases 
 have been reported by competent and careful observers, in which no 
 material lesions of the nervous system were found either upon macrosco- 
 pical or microscopical examination. 
 
CHAPTEE ly. 
 
 PATHOLOGY. 
 
 Even at the present day, opinions vary as to the cerebral or spinal 
 origin of chorea. The chief arguments in favor of the spinal charac- 
 ter of the affection have been advanced by French physiologists, espe- 
 cially Chauveau, Longet, Carville and Bert, Legros and Onimus. 
 
 Chauveau ' experimented upon dogs who were suffering from general 
 choreiform movements, by dividing the spinal cord immediately below the 
 medulla oblongata. He found that the chorea nevertheless persisted until 
 the death of the animal with the same degree of severity. If the spinal 
 cord was divided, however, through the dorsal region, the choreiform 
 movements immediately ceased in the tail and posterior limbs, but re- 
 mained unaffected in the anterior limbs. 
 
 The experiments of Longet, Carville and Bert, were merely confirma- 
 tory of the results obtained by Chauveau. 
 
 Legros and Onimus^ made more extended investigations concerning 
 this question. Like the authors previously mentioned, they also found 
 that section of the spinal cord immediately below the medulla oblongata 
 did not diminish the violence of the choreiform movements, if artificial 
 respiration were maintained. If the spinal cord was laid bare by remov- 
 ing the vertebral arches, and the posterior columns of the cord were irri- 
 tated with the end of a scalpel, the choreiform movements were exagge- 
 rated to an enormous extent. If the cord were cooled by means of a cur- 
 rent of air, the movements disappeared when the previous temperature 
 of the cord was restored by pouring warm water upon it. The move- 
 ments were uninfluenced by excision of the posterior roots of the spinal 
 nerves, but were diminished by a partial incision through the posterior 
 white columns and posterior horns of gray matter. When a deep incision 
 was made through these regions, the choreiform movements were entirely 
 abolished. 
 
 Legros and Onimus think they are justified in concluding from these 
 experiments that the morbid process in chorea is situated in the cells of 
 the posterior gray horns, or in the fibres wliich connect these cells with 
 the large motor-cells of the anterior horns. 
 
 These experiments appear to us neither to prove nor disprove the spi- 
 nal character of chorea in the human subject. Apart from the general 
 suspicion which justly attaches to the drawing of conclusions concerning 
 functional disorders in man from the results of experiments in animals, it 
 is quite positive that the chorea of dogs is an entirely different disease 
 from the similar affection in man. This, of course, invalidates all con- 
 clusions which are drawn concerning the latter from the morbid appear- 
 ances presented in the former. 
 
 A review of the pathological anatomy of the affection, as described in 
 
 ' Arch. gen. de med., 1866. = Comptes rend., LX., 1870. 
 
CHOREA. 31 
 
 the last chapter, teaches us that the lesions of chorea have been found 
 both in the brain and spinal cord, and, as Elischer's results appear to in- 
 dicate, in the peripheral nervous system as well. In numerous cases, on 
 the other hand, the entire nervous system has been found intact. It is 
 evident, therefore, that pathological anatomy cannot thoroughly explain 
 the pathology of the affection, and we must resort for further light to the 
 clinical history of the disease. In fact, it appears to us that undue im- 
 portance has been hitherto attached to anatomical investigations in the 
 study of the pathology of functional diseases of the nervous system, and 
 too little to the clinical symptoms of these diseases and to their etiologi- 
 cal relations. 
 
 The rapid and brilliant development of pathological anatomy within 
 the last twenty-five years has laid such a strong hold upon the minds of 
 medical men and upon their habits of thought, that they are apt to rusli 
 to the conclusion that the presence of a certain anatomical lesion in any 
 disease is conclusive evidence that such lesion constitutes the real cause 
 of the affection, and to draw a hasty generalization from very meagre data. 
 In no department of medicine is this more marked than in diseases of the 
 nervous system, and not a small proportion of the investigations now 
 being carried on in this field will result in overturning certain of the theo- 
 ries to which credence has been hastily and incautiously given. 
 
 In the first place, the weight of evidence appears to us to be over- 
 whelmingly in favor of the cerebral character of the affection. The fact 
 that hemichorea is sometimes combined with hemianesthesia, and that the 
 latter symptom is always observed upon the same side as the choreiform 
 movements, is proof positive that the lesion is cerebral in its origin. If 
 it were of a spinal nature, the decussation of the sensory fibres in the 
 cord would cause the appearance of the sensory symptoms upon the side 
 opposite to the motor disturbances. 
 
 Another important argument in this particular is the fact that mental 
 disturbances are so common in the affection under consideration. In all 
 the cases which have come under my observation, there was at least some 
 change in the disposition of the patient, consisting of irritability, defi- 
 cient memory, or obstinacy. As we have further shown in the chapter 
 on the clinical history of the disease, more marked mental disturbances, 
 advancing even to insanity, are not very infrequent. 
 
 Chorea, also, may occur in one member of a family, others of whom 
 present epilepsy or insanity, or the chorea may alternate in the same pa- 
 tient with either of these affections, i. e., the hereditary neuropathic ten- 
 dency may, in one case, involve one portion of the brain, giving rise to 
 insanity, in a second, affect another part causing epilepsy, and, in a third, 
 produce chorea. 
 
 Furthermore, chorea may develop during the course of well-defined 
 cerebral diseases, such as hemorrhages, tumors, meningitis. In the rare 
 cases of praehemiplegic chorea, the choreiform movements appear as the 
 precursors of the cerebral affection, and are undoubtedly due to the initial 
 development of the cerebral lesion. 
 
 Finally, movements of the facial muscles, which are supplied by cra- 
 nial nerves, are noticed in the vast majority of cases of chorea, a symp- 
 tom which is inexplicable on the theory of the spinal origin of the disease. 
 
 But, although there is good ground for the belief that chorea is a cer- 
 ebral affection, the theories with regard to the nature and position, of the 
 lesion are extremely various. 
 
 See, struck by the frequent coincidence of chorea and rheumatism or 
 
32 FUNCTIONAL NERVOUS DISEASES. 
 
 endocarditis, regarded both processes as very closely related, but gave no 
 very satisfactory account of the connection between them. 
 
 Some years later, Roger advocated the doctrine that chorea, rheuma- 
 tism, and endocarditis are so many manifestations of one diathesis, the 
 difference in the clinical history of the three affections depending merely 
 upon the organ affected. But this sweeping statement is amply dis- 
 proved by the results of the statistics which we have collected in the 
 chapter on etiology, and also by our own experience. Thus, in upward 
 of ninety cases which have come under my observation, in only three were 
 there any evidences of rheumatism. 
 
 Nevertheless, the results of autopsical examinations have at least 
 proven the frequent coexistence of chorea and endocarditis. Kirkes first 
 propounded the " embolismic " theory of the connection existing between 
 these two affections. He considered the theory of a rheumatic dia- 
 thesis as the causal factor of rheumatic arthritis, endocarditis, and chorea 
 unsatisfactory, because the two latter diseases are often associated, 
 although no trace of previous rheumatism can be' discovered. He regards 
 it as very probable that chorea is due to removal of some of the fibrinous 
 particles from the valves of the heart and to the disturbances created in 
 the nerve-centres by the impaction of such particles in the cerebral ves- 
 sels. At a later period Broadbent, in an article read before the London 
 Medical Society, narrowed down the doctrine more closely, by stating 
 that the chief cause of chorea is capillary embolism of the basal ganglia 
 (corpus striatum and optic thalamus) and of the structures in their im- 
 mediate vicinity. This theory was also strengthened by the investi- 
 gations of numerous English observers, notably Hughlings Jackson, 
 Tuckwell, and Ogle. 
 
 W. Howship Dickinson, although he acknowledges the close relation- 
 ship of chorea and endocarditis, thinks that the latter affection is a sec- 
 ondary process, due to the choreiform movements of the papillary mus- 
 cles of the heart. As we have previously stated in our remarks on the 
 clinical history of the affection, it is extremely problematical whether the 
 muscular tissue of the heart is ever the seat of choreiform contractions. 
 But, even if this condition could be proven, we are unable to understand 
 in what manner it would lead to inflammation of the endocardium. 
 
 Although the embolismic theory of chorea is very plausible and fasci- 
 nating, there are, in our opinion, weighty objections to be urged against 
 its acceptance. 
 
 In the first place, in ordinary cerebral embolism, the embolismic par- 
 ticles, from causes which it is not necessary to enter into in this place, are 
 usually distributed to the vessels on the left side of the brain. 
 
 Ottomar Gelpke * denies the truth of this statement to the extent to 
 which it is generally believed, and finds from an analysis of 131 cases of 
 cerebral embolism that sixty-four occurred upon the left side, fifty-four 
 on the right, and thirteen on both sides, thus rendering the proportion 
 on the two sides almost equal. Bertin,^ however, found thirty-six cases 
 of ebmolism on the left side of the brain, and only nine on the right side. 
 Gerhardt ' observed the embolus thirty-five times in the left middle cere- 
 bral artery, and sixteen times in the right. Although I have been una- 
 ble to obtain any statistics on the subject, I am positive that, among a 
 
 ' Arch. d. Heilk. 1875. - fitude critique de Tembolie. 
 
 » Wuerzb. med. Zschr. 186a. 
 
CHOREA. 83 
 
 large number of cases of cerebral embolism which I have had the oppor- 
 tunity of observing post-mortem in the dead-house of Bellevue Hospital, 
 very few cases have occurred upon the right side of the brain. Dr. Jane- 
 way has also called my attention to the fact that the ordinary statistics 
 with regard to the relative frequency of right and left cerebral embolism 
 are unreliable, because, from the comparative rarity of right-sided embo- 
 lism cases of this nature are apt to be published, while left-sided embolism 
 is not considered, as a rule, worthy of publication. 
 
 In the second place, the clinical history of chorea differs from that of 
 cerebral embolism. The paralyses which occur in the former, almost in- 
 variably recover very rapidly, and do not come on as suddenly as those 
 dependent upon embolism. While a choreal paralysis may recover com- 
 pletely within a couple of weeks, a case of equally severe paralysis from 
 cerebral embolism will occupy several months in recovery, and even then, 
 as a rule, some paresis of the affected limbs is still perceptible. 
 
 Furthermore, while true aphasia not infrequently occurs in cerebral 
 embolism, this symptom does not develop in chorea. The disorder of 
 speech which occurs so frequently in the latter disease is due to an exten- 
 sion of the affection to the muscles of phonation, and is not of a cere- 
 bral nature, properly speaking, in the same sense that aphasia is. 
 
 Finally, the chief argument, perhaps, against the acceptance of the 
 embolismic theory of chorea lies in the fact that the lesion is found so 
 seldom by pathologists although search has been carefully made. 
 
 The tlieory of capillary embolism restricts the lesion of chorea to the 
 basal ganglia^ since the collateral circulation is so free in the cortex of 
 the brain that plugging of a few capillaries would produce no evil effects 
 upon the nutrition of the nerve-structures in that locality. But a lesion 
 of the motor and sensory basal ganglia will not produce the mental dis- 
 turbances which, as we again insist, form such an integral part of the 
 clinical history of the affection. 
 
 Somewhat similar to the embolismic theory of chorea is Bastian's 
 theory of capillary thrombosis, which he formulates as follows: chorea is 
 due to an altered and often antemic state of the blood which chiefly acts 
 upon the corpora striata and surrounding parts, causing the tissue ele- 
 ments to become "irritated;" congestion then develops as a neces- 
 sary consequence. If the irritation continues for a certain length of time, 
 the disturbed action outside of the vessels is communicated to the tissue 
 elements within them, the white corpuscles therefore begin to adhere to 
 the walls of the small vessels, so that partial obstructions may be pro- 
 duced, which are, perhaps, afterward rendered complete by the separation 
 of fibrine or allied products. In exceptional cases (observed by Aitken 
 and Tuckvvell), small foci of softening result from these processes. 
 
 Apart from the slight amount of support which this theory receives 
 from post-mortem investigations, the same objections apply to it as were 
 advanced in opposition to the doctrine of the embolismic origin of chorea. 
 Furthermore, neither of these theories is capable of explaining^ the 
 numerous class of cases in which the disease evidently results from fright, 
 from reflex causes, or from imitation. 
 
 It seems to us that very little aid can be derived from pathological 
 anatomy in determining the situation of the lesion in chorea. The vast 
 majority of patients recover from this disease without presenting any 
 severe symptoms, and it is therefore highly improbable that a serious an- 
 atomical brain lesion was present. As shown in the chapter on patho- 
 logical anatomv, chorea may accompanv various cerebral lesions, but these 
 3" 
 
34 FUNCTIONAL KEEVOFS DISEASES. 
 
 should then be regarded rather as complications than as essential features 
 of the disease. 
 
 The symptomatology of chorea may be broadly considered as consist- 
 ing of mental disturbances (irritability, loss of memory, perhaps mania, 
 etc.), and motor disorders (muscular twitchings, certain amount of paresis). 
 
 These symptoms could be readily explained by a lesion of the cerebral 
 cortex in the neighborhood of Hitzig's motor centres and the adjacent 
 parts of the frontal convolutions. Like all the functional neuroses, chorea 
 is an evidence of low tone of the nervous system, and we may accordingly 
 regard the cortical disturbance either as the result of anaemia in the parts 
 affected, or of malnutrition or exhaustion of the ganglion cells in the 
 convolutions. As a matter of course we can offer no demonstrable proof 
 of the correctness of this view, but it appears to tally best with the re- 
 sults of clinical observation. 
 
 To our thinking, no theory can be correct which does not explain the 
 general run of cases, and not alone those which are attended with excep- 
 tional symptoms or terminate fatally. The theory of malnutrition of the 
 cortical ganglion cells, either as the result of anaemia or of a direct effect 
 upon the nerve-cells, such as is known to occur at times as the result of 
 fright, appears to us to be capable of explaining the large majority of 
 cases of the disease. 
 
 In this connection we desire to call attention to the views expressed 
 by Sturges ' who has written some admirable articles on the disease 
 under consideration. This author believes, " that the pathology of an 
 affection like chorea is to be sought in the natural endowments of the in- 
 dividual; that it comes to be a child's disease because those elements out 
 of which it is evolved are especially prominent in early life; that child- 
 hood not only p7'edisposes to chorea, but has also the material which is 
 efficient to produce it." He points out the identity of the movements 
 of restlessness in a shy child when embarrassed, with those observed in 
 chorea, and believes that the latter may grow directly out of the former 
 as the result of fright, pain, etc. 
 
 ' Med. Times and Gazette, April 28, 1877. 
 
CHAPTER y. 
 
 DIAGNOSIS AND PROGNOSIS. 
 
 The clinical history of chorea minor is so sharply defined that it is very 
 rarely mistaken for other diseases. In children, as well as in adults, 
 care must be taken to differentiate it from post-hemiplegic chorea. An 
 inquiry into the previous history of the patient will soon dispel any 
 doubts which may exist with regard to the diagnosis. The post-hemi- 
 plegic affection is unilateral, and, as a rule, when the movements have 
 begun in the first five or six years of life, the limbs of the affected side are 
 atrophied in all directions; this does not hold good, however, with regard to 
 post-hemiplegic chorea of adult life. The movements in the post-hemiplegic 
 affection generally subside entirely, when the patient is not performing 
 any voluntary movements, and are usually not so rapid or sudden as those 
 of ordinary chorea. After the disease has lasted for a long time, a mere 
 examination of the patient may be insufficient to determine the true 
 nature of the affection, as the original loss of power in the limbs may have 
 disappeared, leaving only the choreic movements. 
 
 The nature of pre-hemiplegic chorea (which is an extremely rare 
 affection) will only be cleared up by the further history of the case, unless 
 apoplectic symptoms develop from the onset and accompany the chorei- 
 form movements. These movements may continue, however, for several 
 days before the development of hemiplegia, etc., warns us of the true 
 character of the affection with which we have to deal. 
 
 In rare instances, it will become necessary to differentiate chorea from 
 cerebro-spinal sclerosis. As a rule this can be readily done from a con- 
 sideration of the clinical history. In multiple sclerosis, the patients suf- 
 fer usually from marked sensory disturbances (pain, anaesthesia in the 
 limbs), from paresis or contracture of muscles, bladder symptoms, pupil- 
 lary phenomena, cerebral disturbances. Occasionally, however, the motor 
 disorders constitute the chief symptom (perhaps for a certain length of 
 time the only discoverable one), and we must therefore directly compare 
 the motor phenomena of chorea and sclerosis. 
 
 As a rule, the movements of chorea develop independently of any 
 voluntary effort on the part of the patient; the latter may be sitting per- 
 fectly quiet when suddenly the fingers twitch, the muscles of the face con- 
 tract, or the tongue is protruded from the mouth. In cerebro-spinal 
 sclerosis, however, the irregular movements are not evident unless the 
 patient makes a voluntary effort ^ and the greater the will-power 
 
 ' Charcot was the first to call attention to this point, and lays it down as an ab- 
 solute rule. That exceptions do occur, is proven by a case which I observed in Dr. 
 Janeway's practice, and in which the autopsy showed the nature of the aflEection. 
 
36 FUISrCTIOI^AL NERVOUS DISEASES. 
 
 exerted the more violent do the movements become. Another point 
 of contrast between the two affections consists in the fact that, in 
 cerebro-spinal sclerosis, the general direction of the intended movement is 
 maintained throughout, while in correspondingly severe cases of chorea, 
 the patient deviates in all directions from his intended course. Thus, a 
 patient suffering from multiple sclerosis will be able to carry a spoon or 
 glass to his mouth (though some of the contents will be spilled), but in a 
 severe case of chorea, the individual will strike the object against his ear 
 or nose; as soon as the spoon is about to enter his mouth, a sudden jerk 
 of the arm will draw it forcibly away. The difference between the two 
 classes of movements appears to me to be best formulated by the state- 
 ment that, in chorea, volition is disordered at the time of its development 
 in the cerebral cortex (in which I presume the lesion is situated), while in 
 cerebro-spinal sclerosis, the nerve-force becomes interfered with, as Char- 
 cot expresses it, in its passage through the affected portions of the spinal 
 cord. 
 
 Only the grossest carelessness could give rise to the mistake of re- 
 garding the movements of paralysis agitans as choreiform in their na- 
 ture. The former consist of tremor of a limb, as a whole, the excursions 
 of the muscles being very short and following one another with great 
 regularity. Until the disease has lasted for a very long time, the move- 
 ments can always be quieted by a strong effort of the will, thus differing 
 at the same time from the twitchings of chorea and of multiple cerebro- 
 spinal sclerosis, for which this affection is also sometimes mistaken. The 
 clinical history of paralysis agitans and chorea is entirely different. Tiie 
 former is a disease of old age (exceptionally it occurs in middle life); it is 
 almost impossible to check the disease, the movements rarely involve the 
 head (the movements of the head are communicated from the trunk), 
 and the affected muscles usually present a certain amount of rigidi- 
 ty — phenomena which are all entirely distinct from those observed in 
 chorea. 
 
 The prognosis of chorea, as regards recovery from any single attack, 
 is ordinarily good. As a rule, the disease, after it has reached its culmin- 
 ation, begins slowly to decline, and most cases have run their course in a 
 period varying from two to four months. But a considerable percentage 
 of the cases suffer from relapses, and we not infrequently find, upon in- 
 quiring into this point, that the patient has had an attack every spring 
 for several years in succession, or perhaps, in alternate years. 
 
 Sometimes the patients have two attacks in one year, each lasting 
 several months. In these cases, as well as in all others in which the dis- 
 ease has lasted over six months, there is danger that the chorea may con- 
 tinue for years, and even until the end of life. I have at present a case 
 of this kind under observation, in which the choreic movements have con- 
 tinued with undiminished severity for nearly a year, and in which the 
 mental faculties are gradually failing, so that I apprehend the develop- 
 ment of complete dementia. 
 
 The prognosis, as regards a fatal termination, is very good, and not a 
 single case of death (with the exception of the patient mentioned on page 
 27, in whom cerebral sclerosis was found after death) has come under 
 my notice. Cases are reported, however, in which exhaustion and death 
 supervened on account of the extreme violence of the muscular twitch- 
 ings, the loss of sleep caused thereby, the lack of nutrition, and some- 
 times exhaustion from mania. Such instances are, however, quite infre- 
 quent, especially in this country. As a rule, death is due to the pres- 
 
CHOREA. 37 
 
 ence of some intercurrent afEection, such as cerebral hemorrhage, endo- 
 carditis, etc. 
 
 The psychical complications of chorea present a very favorable proo-no- 
 sis as regards recovery from the mental affection, though we must admit 
 that not an inconsiderable proportion of the fatal cases have been attend- 
 ed with mania. As a rule, however, the patient entirely recovers from 
 the maniacal disorder, and the improvement keeps pace with the diminu- 
 tion in the choreic movements, although the mental disturbance may 
 sometimes last several months after the former have disappeared. 
 
CHAPTER YI. 
 
 TREATMENT. 
 
 The first step in the treatment of chorea is to take the children (the 
 disease, as we have seen, generally occurs in childhood) away from school. 
 This is beneficial in several ways. In the first place, the memory is usu- 
 ally impaired to a greater or less extent in this affection, and the little 
 patients are not so bright and intelligent as in their normal condition. 
 The consequence is that they must make unusual efforts to retain their 
 standing in the class, and this strain, reacting upon an already irritable 
 brain, serves to aggravate the existing functional disorder. Furthermore, 
 the patient's classmates, with the well-known inconsiderateness of child- 
 hood, are apt to deride and jeer the little sufferer on account of the gro- 
 tesque character of the muscular movements to which he is subject, and 
 the shame and anger which are produced in this manner will give rise to 
 the same bad effects as those due to mental overwork. 
 
 Shall the patient be allowed to run at will in the open air ? We are 
 aware that this is the usual advice given by the physician, but we are not 
 by any means convinced of its utility. Children are apt to engage in 
 sports with all the earnestness of a serious pursuit, and usually become 
 thoroughly tired out in consequence. This is especially true with regard 
 to choreic children, whose muscular energy always becomes diminished dur- 
 ing the course of the disease. It is a well-known fact, however, that rest 
 tends to diminish the violence of choreic twitchings, and for this reason, 
 although I favor out-of-door life for the patient, I discountenance any 
 rough sports, and prefer that he should take short walks, carriage-rides, 
 etc. 
 
 For a similar reason, also, the patient should be allowed to indulge in 
 sufficient sleep. Although the choreic movements usually begin as soon 
 as the patients wake, or within a few minutes afterward, they are not so 
 severe as they are after the lapse of an hour or two. Sleep is frequently 
 disturbed in this affection, and as this is sometimes due to the fact that 
 the patients are worn out from the constant muscular movements, it is 
 advisable to give the patients a small quantity of ale or porter before re- 
 tiring. When this simple measure proves unsuccessful in procuring a 
 sound sleep, we are warranted in giving from five to ten grain doses of 
 hydrate of chloral at night. We will often find that after several nights' 
 good rest has been secured in this manner, the twitchings rapidly dimin- 
 ish in severity. It is not advisable, however, to continue the use of 
 chloral for any length of time, for we find that in children especially it is 
 apt to give rise to bad after-effects, and is a very potent factor in pro- 
 ducing and maintaining an aiiEemic condition. 
 
 Some of the recommendations presented by Dr. Sturges with regard to 
 the treatment of chorea are so excellent that we shall make a short ab- 
 stract from one of his lectures. 
 
 " Chorea is aggravated by emotion and close inspection; it ameliorates 
 
CHOREA. 39 
 
 with mental and bodily repose and preoccupation; it ceases altogether 
 in sleep and during intervals of musing. Any method of treatment 
 which places the child under obvious surveillance, and thus makes it at- 
 tentive to itself, must tend to aggravate the complaint and aid in its de- 
 velopment To rest the overworked and tired limbs, to 
 
 secure a large measure of sleep; to make the time pass evenly, yet with- 
 out the weariness of monotony; to save the voluntary muscles the morti- 
 fication of failui-e by anticipating the child's wants; these, as I believe, 
 are the most serviceable duties which can be rendered at the outset of 
 chorea. Yet they must be done without ostentation, and without the 
 child perceiving that he is being tended and watched and treated as one 
 sick." 
 
 The patients should be allowed a free, generous diet, and no restriction 
 need be made with regard to the character of the food, except under 
 special circumstances. As in all neuroses, which are evidence of a low 
 condition of nervous tone, it is well to introduce as much fat as possible 
 into the food, and with this end in view we may administer milk and cod- 
 liver oil. In the majority of cases the appetite is poor and usually capri- 
 cious, and we may then prescribe some of the simple bitters (calumba, 
 quassia, gentian). 
 
 A considerable number of the patients are anaemic from the beginning, 
 while a much larger number become so in consequence of the character 
 of the disease. In these cases, mild ferruginous tonics are indicated, such 
 as dialyzed iron or carbonate of iron, or the tincture of the chloride of 
 iron, which is preferable when the digestive organs are in good condition. 
 It is unnecessary, however, to administer iron as a routine matter of 
 treatment, as is so frequently done, under the impression that iron pos- 
 sesses a certain specific influence in the treatment of the disease. 
 
 The medicinal treatment of chorea is extremely unsatisfactory. Gray 
 and Tuckwell found that the average duration of thirty-eight cases, which 
 were treated on the expectant plan, was nine weeks and six days. The 
 average duration when treated with arsenic in gradually increasing doses, 
 according to Begbie's plan, was ten to eleven weeks. See gave sixty- 
 nine days as the average duration of 117 cases treated with various medi- 
 cines, and it is a curious coincidence that this agrees exactly with the 
 duration of Gray's and Tuckwell's cases. The majority of observers 
 agree that recovery within two to three months constitutes a good result. 
 My usual plan of treatment is to put the patient on three to five drop 
 doses of Fowler's solution (three times a day, immediately after meals, in 
 a little water), and increase this amount by one drop at a dose until some 
 of the toxic effects become evident (nausea, sometimes vomiting or loose- 
 ness of the bowels, slight oedema of the eyelids, perhaps pitting over the 
 tibice). The drug is then discontinued for a few days until these symp- 
 toms have subsided (an alkaline drink such as Vichy water will accelerate 
 their disappearance), and it is then again administered in doses slightly 
 smaller than those which sufficed to produce the above-mentioned toxic 
 effects. If it produces any good results, the remedy may be continued 
 in this manner for a period of six or eight weeks. I have found that al- 
 though this plan of treatment will not cut short the disease, the move- 
 ments will become very much milder within ten days or two weeks, but 
 that some amount of motor disturbance will persist until the disease has 
 rvin its natural course (two to three months). 
 
 When the muscular twitchings are of an extremely violent character, 
 interfere with sleep, and threaten to produce serious prostration, I have 
 
40 FUlirCTIONAL NEKYOUS DISEASES. 
 
 obtained good results from the use of a mixture of bromide of potassium 
 and hydrate of chloral. The dosage depends upon the severity of the in- 
 dividual case, but the largest amount should be given at night. Pro- 
 longed warm baths (fifteen minutes to half an hour), are also useful under 
 these circumstances. The movements are sometimes so violent that it 
 becomes necessary to tie the patient in bed in order to prevent him from 
 doing injury to himself. It is well in all cases of such severity to keep 
 the patient in bed continuously until the excessive violence of the move- 
 ments subside. The condition of the integument should be carefully ex- 
 amined from day to day in order to detect the development of excori- 
 ations, which are liable to be produced from the violent friction of the 
 parts against surrounding objects. 
 
 During the past year I have made quite extensive use of inhalations 
 of nitrite of amyl, beginning with two-drop doses three times a day and 
 gradually increasing to six or seven drop doses. It has seemed to me that 
 its effects may be compared with those of Fowler's solution, i. e., it pro- 
 duces considerable improvement within one or two weeks, but the disease 
 then runs its usual course. 
 
 It is well to bear in mind, in treating chorea, that the patients rarely 
 fall into our hands until the disease has lasted for a longer or shorter 
 period, and that part of the effect, which we attribute to our remedies, 
 may be due to Dame Nature. 
 
 Strychnia has been highly recommended by many writers. We must 
 exercise caution in its administration to children, as they not infrequently 
 present a peculiar susceptibility to its influence. A child of eight or nine 
 years should not receive more than one one-hundredth of a grain at a 
 dose in the beginning, and this quantity may then be gradually and 
 cautiously increased. In my hands the drug has proven almost useless 
 except as a nerve-tonic. 
 
 Within the last few years Bouchut has introduced eserine as a remedy 
 in this disease, and claims truly wonderful results in a very large number 
 of cases. It was administered in doses of about one-sixtieth of a grain, 
 either by the mouth or as a hypodermic injection, and Bouchut claims 
 that the majority of cases recovered within two weeks. These remarka- 
 ble results have, however, not been obtained by other observers, and its 
 administration is sometimes attended with such disagreeable effects (vom- 
 iting, prostration, etc.) that I have entirely refrained from using it. 
 
 Curare has been successfully employed in a few cases of chorea of old 
 age, which is usually regarded as incurable. This is given in doses of 
 one-tenth of a grain in the beginning, and of course by means of hypo- 
 dermic injection, since it is well known that when this drug is adminis- 
 tered by the mouth, it is eliminated so rapidly by the kidneys that no 
 effects upon the nervous system are produced. If good results are not 
 obtained within a week after beginning its use, it would be unwise to 
 continue its administration. 
 
 Numerous other drugs have been employed in the treatment of this 
 disease, but it is unnecessary to refer to them, as none of them have stood 
 the test of experience. 
 
 Ottomar Rosenbach has advised the employment of the constant gal- 
 vanic current and of counter-irritation applied to the tender spots which 
 are found along the spinal column. I resorted to this plan of treatment 
 in three cases, but without obtaining the slightest improvement. Nu- 
 merous observers have employed the constant current (to the spine) in 
 treating chorea, but the large majority concur in the opinion that it is 
 
CHOEEA. 41 
 
 either entirely useless, or that its temporary musculo-sedative effects soon 
 disappear. 
 
 In the severe cases which are attended with maniacal excitement and 
 extremely violent muscular contortions, it is advisable to put the patient 
 in a straight jacket/ administer large doses of bromide of potassium and 
 chloral, and endeavor, by every means in our power, to feed the patient. 
 When this cannot be done by the mouth or through the stomach-tube, 
 nutritious enemata should be at once resorted to. In administering hy- 
 drate of chloral in such cases, we should bear in mind that the continual 
 movements of the body tend to antagonize the effects of the druo-^ and 
 that large doses (ten to thirty grains, or even more) sliould be given. 
 "When the choreic twitchings can be controlled in no other manner, we 
 may be compelled to resort to inhalations of chloroform. 
 
 ' This is advisable, not on account of the mania, but merely to moderate the exces- 
 sive muscular twitchings, the production of which is a source of fresh contortions. 
 
EPILEPSY. 
 
 CHAPTER I. 
 
 CLINICAL HISTORY. 
 
 This dread disease has been known since the earliest periods in the 
 history of medicine, and has always attracted the attention alike of the 
 profession and of the laity. The peculiar character of the symptoms, and 
 the usually incurable nature of the malady, caused it to be looked upon 
 as an evidence of demoniac possession. The terms applied to it by the 
 lower classes, in some countries, indicate that this view obtains even at 
 the present. The conception which was formed of the disease remained 
 unchanged for centuries, and it is only within comparatively recent times 
 that our views concerning the scope and boundaries of this affection have 
 undergone a radical change and amplification. It was formerly regarded 
 as a paroxysmal disease, in which the paroxysms consisted essentially of 
 unconsciousness and general convulsive movements, but, at the present time 
 this combination of symptoms is only looked upon as characteristic of one 
 form of epilepsy, viz., the grand mal. In addition to this variety there 
 are cases in which the loss of consciousness is the only symptom, the 
 convulsive movements being entirely absent. These two varieties are 
 not, however, sharply separated from one another, and there are forms 
 which are intermediate between the two, i. e., there are cases in which 
 the unconsciousness is combined with partial convulsions. There is an- 
 other variety in which the attacks are characterized by peculiar groups 
 of actions performed while the patient is in an unconscious or partly un- 
 conscious condition. Finally, a new group has been placed under this 
 head by Griesinger, who applied the term " epileptoid states " to the 
 manifestations in question. 
 
 Grand Mal. 
 
 We shall first enter upon the consideration of epilepsia gravior, 
 or the grcuid inal. The history of the affection embraces two parts, 
 viz., the paroxysm itself and the interparoxysmal period. The attack 
 frequently begins without any warning. The patient, while engaged 
 in his ordinary occupations, suddenly loses consciousness, his face grows 
 pale, and at times he utters a peculiar inarticulate cry. He then falls as 
 if struck by a heavy blow, and the convulsive phenomena immediately be- 
 come apparent. The stage of tonic convulsions now begins. The spasms 
 
44 FUIJ^CTIONAL NERVOUS DISEASES. 
 
 appear first in the muscles of the face or the small muscles of the hand, 
 and then rapidly spread throughout the entire body. Slight twitchings 
 are observed in the muscles inserted into the angles of the mouth; the 
 eyes become fixed and are usually drawn to one side; the muscles of the 
 neck contract, and frequently draw it to the side toward which the eyes 
 are turned; the muscles of the hand contract, and draw the thumb firmly 
 into the palm, and the fingers are clenched. At the same time the mus- 
 cles of respiration, including the diaphragm, are similarly affected and im- 
 pede the act of breathing; this is immediately followed by powerful tonic 
 contractions throughout all the muscles of the body. During the entire 
 stage, which only lasts from a few seconds to a couple of minutes, the 
 body does not move from the position in which it has fallen. These con- 
 tractions may be so powerful that the head is drawn forcibly backward, 
 and the entire body is in a condition of slight opisthotonos, or, if the con- 
 tractions are stronger on one side, as they frequently are, in a condition 
 of emprosthotonos. The tonic sj^asm of the muscles then begins to relax, 
 and clonic convulsions make their appearance, at first mild and local- 
 ized and then growing more diffuse and violent, until, in a very short 
 time, the whole body is in a continual state of violent muscular contrac- 
 tion and relaxation. The face, which had begun to grow dark during the 
 latter part of the tonic stage, now becomes dusky and turgid, the eyes 
 stare, and the features are disfigured by terrible grimaces and contortions. 
 During this period, the tongue, which has been protruded by the violence 
 of the muscular action, is frequently caught between the rapidly closing 
 jaws. After a variable period (usually from two to five minutes) this 
 condition subsides. The clonic contractions sometimes cease quite sud- 
 denly, but usually they grow milder gradually, the dusky hue of the face 
 and body begins to disappear, and the patient then lays perfectly quiet. 
 In some cases, he immediately rouses from his comatose condition, opens 
 his eyes, and looks around him with a stupid, frightened air, mutters, 
 perhaps, some inarticulate words, and then rapidly lapses into his prev- 
 ious condition. Generally, however, he falls into a deep, lethargic sleep, 
 from which he may be roused into consciousness, and wakes up after a 
 period varying from a few minutes to several hours; the epileptic coma 
 has even been known to continue forty-eight hours. The patient usu- 
 ally wakes feeling dull and heavy, complains of headache, and has a tired 
 aching feeling in the muscles, as if he had been engaged in some very 
 heavy work. 
 
 The attacks do not always begin as suddenly as we have described, 
 but in some cases prodromata are experienced, so that the patients can 
 always foretell the occurrence of a convulsion. Opinions vary with re- 
 gard to the frequency of these symptoms. Some authorities, including 
 Romberg and Sieveking, state that they have met them in one-half of all 
 their cases, others have observed them with much less frequency. 
 
 The character of these prodromic symptoms is manifold; they are usu- 
 ally classified into the remote and immediate. The former may last for 
 one, two, or even three days, and are often manifested by a change in the 
 disposition of the patient. If he has previously been in his usual condi- 
 tion of cheerfulness, he now becomes gloomy and irritable, and is liable 
 to causeless attacks of anger; or, perhaps, a sullen state gives way to a 
 more cheerful demeanor. If those surrounding the patient are attentive 
 and observant, they are generally able to tell, from this change of dispo- 
 sition, that a convulsion is impending. Reynolds has also noticed a pecu- 
 liar remote prodroma, consisting of a duskiness of the skin, especially 
 
EPILEPSY. 45 
 
 affecting the face and neck, this symptom being observed from four to 
 twelve hours before the onset of the attack. 
 
 In one case under my observation, the patient, for twenty-four to tliirty- 
 six hours before the fit, has prodromata wliich consist of palpitation of 
 the heart, and a feeling of heat arising from the prnecordium, together 
 with pain and a feeling of distention in the abdomen; she, also, has a 
 flushed face and headache during this period. 
 
 In another case, the patient feels dull, and complains of pain in the 
 frontal reo-ion for about a day before the fit; during this time she also 
 has a watery diarrhoea (ten to twelve passages) although the bowels are 
 perfectly regular at other times. I also have under my care a patient 
 in whom these abdominal prodromata are very well marked (I may men- 
 tion here that these three patients are females). The patient in question 
 is fortv-eight j^ears old, and has had epileptic attacks during the last ten 
 vears. For twentj'-four hours before the attack begins, she suffers from un- 
 controllable vomiting and diarrhoea, so that she is compelled to keep to her 
 bed. At times this is accompanied by intense pain in either forehead, or 
 by exquisite hvpertesthesia in localized spots in various parts of the limbs. 
 Immediately before the convulsion begins, the patient has a sensation as 
 if a large ball were situated in the anus, this appears to move up the 
 rectum, and then passes to the lumbar region of the spine, along which it 
 mounts; she then loses consciousness and has a severe convulsion. 
 
 An extremely rare prodromal symptom was observed by Kuethe.' 
 He found that the individual in question manifested agraphia prior to one 
 of his attacks. The patient, who was a book-keeper, was attacked with 
 a convulsion while engaged in writing in his account books. An exami- 
 nation of these books showed that before the attack began, the patient 
 made wrong entries, repeated certain syllables several times in succession, 
 and introduced words which had no bearing on the accounts. 
 
 The immediate prodromata are usually known under the term aura, 
 and are much more variable in their appearance. They may be classified 
 as psychical, motor, sensory, and vaso-motor. 
 
 At times the patients feel giddy immediately before the attack, and 
 this feeling sometimes lasts sufficiently long to allow them to secure 
 a safe position before the convulsion occurs. At other times they expe- 
 rience a peculiar feeling in the head, which only lasts for a few seconds, 
 and which very intelligent patients have told nie is perfectly indescrib- 
 able. Or, the patient may be in a peculiar state of excitement, and 
 evince great loquacity for a few seconds or minutes before the fit. 
 
 The sensory aura are more variable than the psychical ones. Some- 
 times the convulsion is preceded by peculiar hallucinations. Watson re- 
 lates that Dr. Gregory, of Edinburgh, was assured by a patient of un- 
 doubted veracity, " that always when he had a fit of epilepsy approaching 
 he fancied that he saw a little old woman in a red cloak, who came up to 
 him and struck him a blow on the head, and then he immediately lost all 
 recollection and fell down." 
 
 The visual prodromata may also merely consist of sensations of light, 
 in which the red color appears to predominate. An affection of the 
 acoustic, olfactory and gustatory nerves is also sometimes met with. 
 Thus, the patient may hear a buzzing or roaring noise in the ears, ringing 
 of bells, may smell a peculiar stench, or have a curious taste in the mouth. 
 In one case, a patient of mine, before having the fits thought he heard a 
 
 ' Arch. f. Psych. 1879, pp. 257-260. 
 
46 rCJNCTIONAL NERVOUS DISEASES. 
 
 buzzing- noise above him, which came down, entered his head, and then 
 went to his stomach, after which he lost consciousness. 
 
 The nerves of general sensibility are affected as well as those of special 
 sense. In fact, the term aura, which refers to the sensation of a breath, 
 strictly applies only to sensory prodromata. The latter may consist of 
 painful sensations, starting- from some part of the trunk or limbs and ris-' 
 ing rapidly to the head, or of a sensation in the head as if something had 
 cracked there, etc. Instead of pain there may be a sensation of numb- 
 ness, or even true ansesthesia. Nothnagel relates that in some of his pa- 
 tients, in whom this phenomenon lasted ten minutes or longer, he was able 
 to detect a palpable diminution of sensitiveness to the prick of a pin or 
 to changes of temperature. A very frequent sensory aura consists of a 
 feeling of pain in the epigastrium or lower down in the abdomen, which 
 rapidly rises to the throat; in other cases, the patients describe the sen- 
 sation as of a jumping or jerking character, although no movements can 
 be observed. As soon as the sensation reaches the throat or head, uncon- 
 sciousness supervenes. I have already referred to the case in which the 
 patient felt as if a large ball started from the anus and ran up the rec- 
 tum; it then appeared to pass up to the back, after which the fit imme- 
 diately developed. 
 
 The motor aura consist either of muscular contractions or paralysis, 
 which usually affect one limb or even the whole side of the body. The 
 paralytic aura is extremely rare, and has never come under my notice; 
 some authorities even doubt its existence. The motor aura is readily under- 
 stood from a few illustrative cases. In one typical example the patient, 
 a young man, while strapping his valise very tightly, noticed that his right 
 hand became violently extended and was then rapidly flexed; he turned 
 to walk to his father, who was standing at some distance from him, and 
 while doing so, the clonic contractions spread to the forearm and then to 
 the arm; he then lost consciousness, and the convulsion developed. In 
 another case, a man, who had received an injury to the lower and 
 outer part of the left leg several months previously, observed some twitch- 
 ings in this part which then spread to the thigh, the left side, and finally 
 the left arm, after which he immediately became unconscious. At times, 
 also, the muscular twitchings may begin in the face. Sometimes the pa- 
 tient performs rotatory movements, or even walks or runs a few paces, 
 before the convulsion develops. 
 
 A vaso-motor aura is also not infrequent; it may consist of flashes of 
 heat or cold, or patches of pallor or redness appear in different parts of 
 the skin. The aura may be limited to one limb or to the side of the face; 
 the part affected becomes red, hot, and perspiring, or the reverse phe- 
 nomena are noticed. This condition begins at the extremity of the limb 
 and runs upward to the neck or head. 
 
 It is sometimes evident that epileptic children who are too young to 
 describe their sensations, have an aura preceding their attacks. In sev- 
 eral cases the mothers of such children have informed me that whenever 
 the patient was about to have a fit, he would run to them, with a pecu- 
 liar expression of dread, as if for protection. As far as I am able to 
 learn, however, the aura in such young children is probably of a psy- 
 chical nature, as I have been unable to obtain any history of objective 
 changes in the little patients prior to the attack. 
 
 It not infrequently happens — in fact, we may observe in almost all 
 chronic cases in which the fits occur with great frequency — that the aura 
 sometimes makes its appeara^nce, but is not followed by a convulsion. 
 
EPILEPSY. 47 
 
 At times this is merely an effect of the natural course of the disease; but, 
 since the use of nitrite of amyl has come into vogue in the treatment of 
 epilepsy, I have noticed more frequently than formerly that the inhala- 
 tion of a few drops during the development of the aura has been instru- 
 mental in staving off the fit. I have also often observed that one of the 
 first signs of improvement, under the use of the bromides, is the fact that 
 the aura merely appears instead of the fully developed convulsion. 
 
 As we shall see at a later period, the aura sometimes furnishes valu- 
 able indications with regard to the origin of the epilepsy, and may thus 
 prove very important with regard to treatment. 
 
 We shall now examine the phenomena directly connected with the 
 convulsion more in detail. 
 
 The so-called epileptic cry is not observed in more than half the 
 cases. In some instances it is so low that it cannot be heard at a dis- 
 tance of more than a few feet (this has been the rule in my experience), 
 but at other times it is extremely loud. While I was interne in the 
 Hospital for Epileptics and Paralytics, I was once awakened by a pierc- 
 ing shriek which appeared to emanate from the adjacent ward. Upon 
 hurriedly entering the ward I found one of the patients in a convulsion; 
 upon recovering, she told me that she had been unconscious of the utter- 
 ance of this cry, although it had been loud enough to rouse me from a 
 sound sleep at a distance of more than fifty feet from the patient's bed. 
 In all the cases in which I was able to obtain any information upon the 
 point, the patient was already unconscious at the time the cry was emit- 
 ted. Dr„ Reynolds,' however, observed one case which proves that it 
 may be uttered while consciousness is still present. "The individual re- 
 ferred to was aware that he was making the noise, but he could not ar- 
 rest it; he heard remarks made in another room, and made signals to his 
 child to leave the room; but then lost all perception and volition." 
 
 It is probable that the cry is merely due to the vigorous tonic con- 
 traction of the muscles of expiration. The theory that it is the result of 
 a sensation of terror or surprise has not been substantiated. 
 
 It appears from the united testimony of all observers that the face is 
 usually pale at the onset of the attack, but there are numerous excep- 
 tions to this rule. Not infrequently the color of the face is unchanged 
 until toward the close of the tonic stage, and, in a few exceptional cases, 
 I have been informed by the friends of the patient that the face became 
 of a bright red color at the beginning of the convulsion. If the clonic 
 convulsions are at all marked, the face becomes dusky and puffed, and 
 this condition is intensified the more vigorous the contractions of the 
 muscles of the neck (trachelismus of Marshall Hall) have been. The pu- 
 pils, as I have frequently had the opportunity to notice, dilate from the 
 beginning and remain in this condition until the subsidence of the clonic 
 stage. Some authors have observed that during this latter period they 
 may alternately contract and expand, but they attain their normal size 
 when the patient recovers consciousness. It has been said, as the result 
 of ophthalmoscopic examination during the first period of the fit, that the 
 fundus of the eye is in an anasmic condition. But, apart from the scarcity 
 of these observations, the time for examination is so short, and the diffi- 
 culties connected with its performance under such circumstances are so 
 great that we are not disposed to lay much stress upon these results. 
 
 ' Epilepsy ; Its Symptoms, Treatment, and Relation to Other Chronic Convulsive 
 Diseases. 
 
48 ruNCTioisrAL neevoijs diseases. 
 
 The examination of the pulse during an epileptic convulsion is at- 
 tended with great difficulties on account of the incessant movements of 
 the muscles of the limbs. In some cases, indeed, the examination is ren- 
 dered impossible. 
 
 At times we are unable to detect any appreciable change in the fre- 
 quency or fulness of the pulse during the entire paroxysm. It appears, 
 however, from the observation of numerous authors, that the pulse is 
 usually small during the tonic stage, and in some instances it has been 
 found absent at the wrist, although the carotids were beating visibly and 
 forcibly. When the pulse can be felt during the clonic stage, it is rapid 
 and full, and the heart at this time beats tumultuously. 
 
 Magnan ' found, as the result of his investigations with the sphygmo- 
 graph, that during the tonic period the arterial tension is increased, and 
 the semitetanized heart beats with greater frequency. In the clonic 
 period, on the contrary, the cardiac pulsations are accomplished with ex- 
 treme slowness, and, at a later period, assume their normal rhythm, or 
 may even become slightly accelerated. Voisin * states that the ascending 
 branch of the sphygmographic tracing is higher than normal, and that 
 marked dicrotism is manifested for some time after the cessation of the 
 fit. He regards these appearances as sufficient to diagnose a case of 
 simulation from a real attack of epilepsy. Magnan, however, believes 
 that the sphygmograph will render no assistance in this respect. 
 
 These conflicting statements with regard to the condition of the pulse 
 during and immediately after an epileptic paroxysm, show that no defi- 
 nite symptoms are manifested in this respect. 
 
 Let us now enter a little more closely into the character of the mus- 
 cular contractions themselves. The first, or tonic stage, varies very much, 
 both as regards extent and intensity. At times this period may be en- 
 tirely absent, and the scene may be opened with clonic convulsions, which 
 persist to the end of the seizure, or, on the contrary, this first stage may 
 entirely predominate the scene, the clonic convulsions being either en- 
 tirely wanting, or of a very mild character. The contractions may be 
 present in every muscle of the body. Nothnagel even mentions a case in 
 which the epileptic cry was followed b}'' an active, whistling inspiration, 
 such as is only seen in well-marked spasm of the glottis. It is some- 
 times noticed in the beo-inninor of this stag'e that the face and neck are 
 drawn to one side by tonic contractions of the muscles before the patient 
 falls, after which the general convulsions make their appearance. 
 
 The clonic convulsions also vary greatly in their intensity. Sometimes 
 they are so severe as to cause great bodily injury. Thus the tongue may 
 be severely bitten, or even entirely divided, teeth may be broken, the 
 lower maxillary bone or clavicle fractured, and various muscles may be 
 ruptured from the intensity of their contraction. During this stage, the 
 urine, semen, and ffeces are often passed involuntarily. As we shall see 
 in the chapter on diagnosis, the latter phenomena are sometimes very 
 important in putting us on the track of nocturnal epilepsy. 
 
 Both stages of the convulsion, when severe, lead to great stasis in the 
 vessels, and this may be followed by ruptures in the minute blood-vessels, 
 giving rise to the development of a petechial eruption in the integument. 
 This is usually visible around the outer angles of the eye, but, in severe 
 cases, the entire face is involved and presents a speckled appearance. 
 
 ' Gaz. mc-d. de Paris, 1877. 
 
 ' Anuales d'hygiene publique, April, 18G8. 
 
EPILEPSY. 49 
 
 This may likewise be an important diagnostic sign in doubtful cases. It 
 is a s^^nptom which cannot be simulated, but unfortunately its absence 
 does not exclude the diagnosis of epilepsy. 
 
 Unconsciousness is usually complete during both stages of the fit. 
 The cornea may be touched without any response; the patients may fall 
 into the fire and be horribly burned without their knowledge, and they have 
 been known to drown in half an inch of water in cases in which they have 
 fallen face foremost into a cistern or bath-tub. The history of a case 
 which was very interesting in this respect was told me by my friend. Dr. 
 Janeway. A man had been found dead and was brought to the dead-house 
 without a previous history. Upon making the autopsy, Dr. .Janeway 
 found, as the sole cause of death, the presence of some dung in the larynx, 
 which had given rise to asphyxia. This led him to suspect that the man 
 had been an epileptic, and had probably fallen face foremost upon a 
 dung-heap, during a convulsion. An investigation into the circumstances 
 of the man's death proved the correctness of this surmise. 
 
 But consciousness may be entirely unaffected even during undoubted 
 attacks of grand mal. In one case under my observation, the patient, a 
 very intelligent man, assured me that during the first five years of his 
 disease the seizures were accompanied with loss of consciousness, but 
 that for a year afterward, although the body was strongly convulsed, he 
 retained his consciousness throughout the attacks. I should, however, 
 mention with regard to this patient that the epilepsy was undoubtedly 
 due to a syphilitic cerebral gumma. 
 
 According to Romberg, reflex action may be retained throughout the 
 attack, although consciousness is lost ; this author states that pouring cold 
 water on the body gives rise to reflex muscular contractions. 
 
 I desire to call attention to a peculiar anomaly with regard to the oc- 
 currence of coma, which is exemplified in the following case, whose paral- 
 lel I have been unable to find in the literature of epilepsy. 
 
 Case I. — J. B., set. 32 years, family history excellent, patient is 
 married, and has seven healthy children; excessive sexual indulgence. 
 He was perfectly healthy until about four years ago, at which time he 
 was compelled, in the course of his work, to enter an ice-house for an 
 hour and a half every afternoon, the patient always being in a state of 
 perspiration at the time of entrance. About this time, while he was 
 going to work one morning, he suddenly felt dizzy and weak, and a 
 small amount of water-brash regurgitated from his stomach and ran out 
 of his mouth. Since then he has had spells of this nature every day, or 
 even two or three times a day. At times he had an aura immediately 
 preceding the attack, consisting of a feeling of powerlessness in the left 
 arm. At other times, he would experience a feeling of pruritus in the 
 left eye, would then put his hand up to rub it and in a few seconds con- 
 sciousness became partly clouded. In several of these attacks, the patient 
 states that he thinks he lost consciousness entirely for a few seconds. 
 
 This variety of attacks lasted without being accompanied by other 
 symptoms until January 1st, when, while sitting in a chair, the patient ex- 
 perienced a feeling of numbness in his left leg, and told one of his sons 
 to rub the limb. This friction caused intense pain, but the patient was 
 speechless and unable to tell his child to stop. Within a few seconds 
 afterward he became unconscious, and tonic convulsions developed 
 throughout the body. His wife states that these spasms were not fol- 
 lowed by clonic convulsions. About three or four weeks afterward, the 
 4 
 
50 FUNCTIONAL NEEVOUS DISEASES. 
 
 patient had another fit while in his shop. For the first couple of months 
 the attacks of grand mal came on about once a month, but they then ap- 
 peared every two weeks. Until six months ago, the attacks of grand 
 mal were preceded by an aura, consisting of a sensation of numbness in 
 the left leg which rapidly rose to the arm. Within the last six months, 
 the fit has been preceded by spasmodic separation of the maxillse, so that 
 the patient was unable to close his mouth, and by a queer sensation in 
 the head. He alwaj^s has sufficient time during the aura to lie down or 
 seek a place of safety. 
 
 With the exception of the first two attacks of grand mal (occurring in 
 January and February, 1879), the paroxysms have been of a remarkable 
 nature. The convulsive phenomena corresponded exactly to the descrip- 
 tion of the grand mal which we have given in the beginning of this chap- 
 ter, but the patient retained consciousness throughout the tonic and 
 clonic convulsive stages. According to both his own and his wife's state- 
 ments, he remembered everything which had transpired during the convul- 
 sions. As soon as the convulsions ceased, however, he became comatose 
 for a period varying from five to fifteen minutes, the eyes being wide 
 open during this period. While in this comatose condition, he can be 
 partially roused but does not comprehend what is said to him. About 
 three weeks ago (end of October), the patient had an attack in which he 
 did not lose consciousness either during or after the convulsions. He is 
 now complaining of intense headache from which he has suffered for the 
 last two weeks; he had a similar attack in July, which lasted nearly a month. 
 Under the use of bromide of potassium in thirty-grain doses, three times 
 a day, the convulsions have ceased, but the headache from which he was 
 suffering has increased in intensity, and at times the pain is atrocious. 
 The patient's intellect has also begun to suffer ; memory is impaired, and 
 at times he is almost childish in his behaviour. The appetite has become 
 ravenous; the patient takes six or seven meals daily, and would eat more 
 if permitted. The general phj^sical condition of the patient is excellent; 
 no deviations from the normal with regard to motion or sensation, are 
 noticeable. 
 
 As we have previously stated, the duration of the coma following the 
 convulsions varies from a very few minutes to upward of forty-eight hours. 
 There does not appear to be any definite relation between the intensity of 
 the convulsive phenomena and the duration of the subsequent coma. 
 When the attack occurs during sleep, it is sometimes difficult to determine 
 the difference between natural sleep and the epileptic coma. The patients 
 usually lie quietly, though sometimes the breathing is noisy; if spoken to 
 sharply, or irritated by a movement, they may be partially roused, speak or 
 mutter incoherently, and then relapse into their previous somnolent con- 
 dition. If left entirely to themselves, the coma continues longer than if 
 they were disturbed from time to time. 
 
 As a rule, the patients return to their normal condition after they have 
 recovered from the coma. Sometimes they feel much better mentally 
 than they did for some time prior to the fit, as if the convulsion "had 
 cleared the brain." In other cases they are dull, stupid, and irritable for a 
 day or two, and, although they apparently act in a rational manner, may 
 not retain perfect remembrance of the occurrences during this period, 
 thus showing that consciousness is still slightly impaired. In more 
 exceptional cases, the patients perform a series of automatic acts imme- 
 diately after the cessation of the coma. One of my patients, after she 
 
EPILEPSY. 51 
 
 recovers from the epileptic coma, begins to undo her clothes and goes 
 about picking up various things. I observed another patient, under simi- 
 lar circumstances, rise from the floor and go to the door, the handle of 
 which he grasped firmly in the hand and rattled violently to and fro. 
 When I approached him he looked at me as if entirely unconscious of mv 
 presence, and allowed himself to be led to a seat. In a few minutes he 
 had recovered consciousness and felt perfectly well, with the exception of 
 a slight dull headache; he knew nothing of the occurrence of the fit until 
 I informed him. 
 
 The stage of coma may also be immediately followed bv a condition 
 of mania, or this may not occur until the lapse of two or three days. We 
 shall reserve the discussion of this feature until a later period. 
 
 The urine is usually passed in increased quantity after the occurrence 
 of a convulsion, and at the same time presents a lighter color. It differs 
 from the well-known hysterical urine, however, in the fact that the specific 
 gravity is not diminished, whereas in the latter it becomes considerably 
 lower, in fact I have seen it sink to 1,001. 
 
 Huppert ' states as the result of niunerous investigations that grand 
 mal convulsions are invariably followed by albuminuria for a few hours. 
 
 Though albumen has been found in the urine under such circumstances 
 by numerous observers, it does not by any means constitute an invariable 
 rule. I have made several examinations with regard to this point and 
 have always obtained negative results. We cannot therefore coincide 
 in the view that a diagnosis of epilepsy may be excluded, if the urine 
 passed after the suspected epileptic seizure does not contain albumen. 
 
 In some cases the patient has no sooner come out of one convulsion 
 that another one begins, until finally they follow one another in such 
 rapid succession that consciousness is not restored between t\je attacks. 
 This constitutes the condition known as the status epileptlcus (etat de mal 
 epileptique), and is of extremely serious import. We shall transcribe the 
 history of this affection from Bourneville's article,^ which is probably 
 the best treatise on the subject extant. According to this author, the 
 status epilepticus is characterized: 1st. by the frequent repetitions of the 
 fits which may even become almost continuous with one another; 2d, 
 by a variable degree of collapse, which may deepen into the most pro- 
 found coma, unattended by any return of consciousness; 3d, by a more 
 or less complete hemiplegia, developing after a variable duration of the 
 symptoms; 4th, by increased frequency of the pulse and respiration; 5th, 
 by a considerable elevation of the temperature, which persists in the brief 
 intervals of the fits. 
 
 Bourneville divides the affection into two periods, viz. : a convulsive 
 and a secondary meningitic stage. 
 
 The prodromata do not differ in any respect from those which are usu- 
 ally experienced by the patient prior to his ordinary attacks of convul- 
 sions. But the fits, instead of ceasing, follow one another rapidly, and 
 before the epileptic coma has entirely disappeared another convulsion 
 makes its appearance. The intervals between the fits become shorter and 
 shorter until they run into one another, and finally the patient appears 
 to be in one long-continued convulsion. The pulse is regular but usually 
 small, the respirations become frequent and labored. The temperature 
 begins to rise from the very beginning, and may rapidly reach a height of 
 
 ' Virchow's Archiv. Bd. 59, Heffc. 3 and 4. 
 
 '^ Etudes cliniques et thermometriques sur les maladies du systeme nerveux, 1873. 
 
52 FUJ^CTIONAL NERVOFS DISEASES. 
 
 104, 105, or 107° F. and upward.' The skin feels hot and scorching, the 
 face is covered with an abundant viscid sweat. Marked nystagmus is 
 present, and the face and neck may be drawn to one side. The pupils 
 are dilated either equally or unequally on the two sides, and do not react 
 normally to light. 
 
 After the convulsions have lasted for some time, hemiplegia develops 
 in a large number of cases, the face and limbs being affected as in ordi- 
 nary cerebral hemiplegia. When the limbs on the paralyzed side are 
 lifted up and then allowed to fall they drop like inert masses. The sen- 
 sorial and intellectual functions are totally abolished, and the patients lie 
 in a profound stupor which often deepens into coma. 
 
 Contracture sometimes occurs and involves either the muscles of the 
 jaw, neck, or limbs. These contractures are especially j^roduced after the 
 cessation of the fits or when they are becoming more infrequent. 
 
 Death may occur in this stage in a condition of extreme cyanosis, due 
 to the violence and frequent repetition of the convulsions. The number 
 of the fits varies. In one of Bourneville's fatal cases the patient had 
 twenty fits on the first day, forty-five on the second day, twenty-two on 
 the third day, twenty-seven on the fourth day, and twelve on the fifth. 
 
 Recovery may also occur in the convulsive period, and in such cases, 
 of course, the second stage is absent. 
 
 Secondary or meningitic stage. — At the close of the first stage, the 
 convulsions become more infrequent, and then cease, but another series 
 of symptoms develops. The intelligence is more or less affected, and the 
 patient is in a state of hebetude or coma. At intervals this condition 
 may be replaced for a few moments by maniacal delirium, which is often 
 very violent, and is sometimes accompanied by hallucinations. The 
 tongue is dry and coated, sordes is found upon the teeth, and nutrition 
 is profoundly disturbed, the whole body becoming rapidly emaciated. 
 At this time bedsores may make their appearance, varying from a simple 
 erythematous patch to a more or less extensive necrosis of the skin. 
 
 The situation of these bedsores is not by any means so fixed -as in 
 cerebral hemorrhage or softening. They may involve : 1, the sacral 
 region ; 2, the buttocks; 3, the fold between the buttocks; 4, the skin 
 covering the great trochanters. In addition to these symptoms, the tem- 
 perature, which had began to fall after the subsidence of the convulsions, 
 again rises. The entire group of symptoms may now increase in severity, 
 the vital forces rapidly fail, and the disease progresses to a fatal termina- 
 tion. Or, on the other hand, the collapse diminishes, the functions of 
 the skin become more normal, the tongue clears, the temperature again 
 sinks, and in a few days the patient is restored to his ordinary condition 
 of health. 
 
 Petit Mal, 
 
 This variety of epilepsy is much simpler in its manifestations than 
 the grand or haut mal, and can be described in very few words. The 
 usual course of the affection is shown by the following case: 
 
 Case II. — C. R., eet. 19 years ; no hereditary influence discoverable. 
 The patient had convulsions while teething. At the age of nine years 
 
 ' In one of my own cases, the temperature did not rise above 101° F., though the 
 patient had had at least twenty-five fits in rapid succession. 
 
EPILEPSY. 53 
 
 the patient began masturbating and has continued the practice ever 
 since. According to her own admission she has masturbated once every 
 night during this entire period, and the hesitating manner in which this 
 statement was made, led me to believe that the habit was indulged in 
 even more frequently. The epileptic convulsions began when the patient 
 was fifteen years old; during the first year of the disease she had three 
 attacks of grand mal, but none since that time. She has, however, had 
 at least three or four attacks of petit mal daily since her sixteenth year. 
 These seizures consisted of a simple loss of consciousness, attended with 
 pallor of the face ; the patient would sit and stare for a moment, in an 
 unconscious condition, and then immediately recover herself. The 
 attacks were frequently observed while the patient was sitting at table. 
 While engaged in eating, her face would grow pale, the eyes assume a 
 vacant stare, and the patient would become unconscious. If she had a 
 knife or fork in her hand at the time, she would not drop it. After a 
 few seconds, she would go on with her meals, not knowing that she had 
 had a seizure. If an attack occurred while the patient was standing or 
 walking, she would not fall or even totter. 
 
 This is the history of the mildest form of the attack, but very fre- 
 quently the disease presents more marked symptoms. Thus, the dura- 
 tion of the attack may be longer ; instead of lasting a few seconds, 
 the fit may continue for a minute or two, and even from five to ten min- 
 utes, although the latter period is extremely rare. At times the attack 
 is preceded by an aura, though this does not assume the importance that 
 it does in the attacks of grand mal. The aura usually consists of vertigo 
 lasting a few seconds, or of an epigastric pain. Sometimes it is preceded 
 by an indescribable sensation in the head. One patient informs me that' 
 he experiences an indescribable, pleasant sensation immediately preceding 
 the attack. The seizure may also be attended with slight convulsive 
 movements in various parts of the body. In the mildest forms they are 
 limited to the face and consist of a few grimaces, or of strabismus. The 
 friends of several patients have informed me that the latter performed 
 peculiar sucking movements with the lips and tongue during the attack. 
 The following interesting case illustrates a form in which more compli- 
 cated phenomena are prodiiced: 
 
 Case III. — Charles A., fet. 21 years ; family history unimportant. 
 The patient had convulsions w^hen he was three or four years old, and 
 these continued off and on until the age of seven or eight years, after 
 which they ceased. Since then the patient has been very healthy. Dur- 
 ing the past year, the patient has been employed off and on in a lunch- 
 room at night and slept during the day; the room in which the patient 
 
 worked was exceedina:lv hot. About ten weeks asro he first noticed 
 
 ■ . ... 
 
 spells coming on, attended with involuntary micturition. The attacks 
 
 developed at night while the patient was at work, and occurred three or 
 four times nightly. He was then thrown out of employment for a 
 month, and during this time the spells came on during the day, the 
 patient sleeping at night. The attack occurs in the following manner : 
 while the patient is busily occupied, he suddenly, without any premoni- 
 tion, loses consciousness, his face reddens and subsequently grows pale, 
 and he puts his hands to his head in an agitated manner ; he then passes 
 his water involuntarily. During the last week the patient has not mic- 
 turated during an attack. Consciousness is restored in a few minutes. 
 
54 FUNCTIONAL NERVOUS DISEASES. 
 
 There is no doubt that, in this instance, the excessive heat of the room 
 was a prominent factor in the causation of the attacks. In accordance 
 with my advice, the patient changed his occupation, and this measure 
 alone produced a marked diminution in the number of the fits. 
 
 This case differs from the usual run in the fact that the face grew red 
 in the beginning of the attack and then turned pale ; in the majority of 
 cases, the face turns pale at the onset of the attack and then, if the 
 paroxysm lasts for any length of time, grows dark or dusky. 
 
 Even more complicated movements than those just referred to are 
 performed in these cases. One of my patients, if the attack occurs 
 while he is seated, will rise from his chair and walk around as if looking 
 for something. Cases have been reported in which the attacks occurred 
 while the patients were performing on the piano or violin, and in which 
 they continued to play in time, although entirely unconscious. 
 
 We may also include in this category the cases which are known as 
 epileptic vertigo. These attacks are well shown in the history of the 
 patient given on page 49. They consist merely of a feeling of vertigo, 
 usually combined with faintness. 
 
 One feature which is frequently observed in this variety and which is 
 extremely important with regard to diagnosis, is the fact that the attack 
 is generally preceded by an aura of very short duration. This consists 
 of a feeling of sinking in the epigastrium or of indescribable anguish. 
 Sometimes the attack is accompanied by vague mutterings. One of my 
 patients told me that he went off into a " dream-like " condition, which 
 he could only explain by saying that everything around him appeared as 
 if he were in a dream. 
 
 The paroxysms may alternate with well-marked attacks of petit mal 
 or grand mal, and in such cases their nature soon becomes evident. In 
 some, however, they form preliminary symptoms which precede the de- 
 velopment of grand mal perhaps by several years, and in such instances 
 it is extremely difficult to form a correct conception of the condition. 
 But we shall discuss this subject more hi extenso in the chapter on 
 diagnosis. 
 
 Irregular Epilepsy. 
 
 This form of the disease is sometimes known as larvated epilepsy, but 
 we think the term is misapplied; the paroxysms are as distinct as in 
 either of the other varieties, the only difference being that they appear 
 in a peculiar form. In the great majority of cases, the seizures are only 
 observed in such patients that also suffer from grand or petit mal, and 
 some individuals are exquisite examples of all the forms of the disease 
 which we have described. In very rare instances the patient only ex- 
 periences the irregular paroxysms, and one such case has come under my 
 notice which I shall describe shortly. 
 
 Hughlings Jackson believes that these attacks are invariably pre- 
 ceded by a slight convulsion, but I cannot agree with him in this respect, 
 basing my opinion on the following personal case : 
 
 Case IV, — A. B., aet. 28 years; married five years; family history 
 entirely negative; the patient's general health has always been fair; 
 menses regular but attended with a certain amount of dysmenorrhoea. 
 The patient was accompanied by her husband, who desired to consult me 
 
EPILEPSY. 55 
 
 •with regard to the advisibility of sending her to an insane asylum, as she 
 \ras regarded as insane both by herself and husband. After making a 
 thorough physical exploration and finding nothing abnormal in the thor- 
 acic or abdominal viscera (she complained of vague symptoms referable 
 to these organs), I began to make an ophthalmoscopic examination. Just 
 as I had brought the light of the mirror to fall upon the eye, and before 
 I could catch a glimpse of the fundus, I noticed that the pupil dilated 
 to the utmost, the face became pale, and the patient started back as if in 
 affright. She then jumped up from her chair, looked with a terrified air 
 at the window of my office and exclaimed, "'Look at that black man. He 
 has a dagger. He is going to kill me." She then walked a few paces, 
 muttering some inarticulate words and in a few moments came to herself. 
 The pulse was unaffected during the paroxysm. After the seizures the 
 patient stated to me that she was absolutely unconscious of what had 
 transpired. I then obtained a history of preceding attacks of a similar 
 nature. Thus, on one occasion, the patient found herself in the immedi- 
 ate neighborhood of the East River, at a distance of several blocks from 
 her house, whereas the last she remembered was that she had been at 
 home. At another time she beat her husband, to whom she was de- 
 votedly attached, although she was entirely unconscious of what she was 
 doing. Attacks of this kind had occurred for three years, and had come 
 on without any exciting cause. Although I cross-questioned the patient 
 and her husband very closely, I could not obtain the slightest evidence 
 that she had ever suffered from petit or grand mal. 
 
 In this instance I had the patient under observation during the en- 
 tire attack, and could not detect the slightest spasmodic symptoms. The 
 series of phenomena manifested in this variety of epilepsy has been in- 
 cluded by Hughlings Jackson under the apt title of mental automatism, 
 and much more complex acts are performed than those reported m the 
 history of the above-mentioned case. 
 
 Another very important peculiarity with regard to these seizures con- 
 sists in the fact that a thought which was uppermost in the mind prior 
 to the attack may exert some influence upon the actions performed dur- 
 ing the unconscious condition. In addition, the patients may react, in 
 a measure, to something which is said or done by those around them, and 
 this apparently imparts a certain degree of volitional character to their 
 acts, although they are, in reality, profoundly unconscious. This is ex- 
 emplified in the following case : 
 
 Ca.se V. — The patient in question was a young woman, who suffered 
 from frequently repeated attacks of grand mal, and occasionally from 
 irregular seizures. While sitting in my office, I saw her suddenly rise 
 from her chair, walk forward a few paces, then turn around and attempt 
 to walk into a closet. From the blank expression of her face I judged 
 that she had lost consciousness. I walked up to her in order to examine 
 her pulse and the condition of her pupils; she endeavored to push away 
 my hand as I tried to grasp her wrist. I then ordered her, in a loud, 
 peremptory tone of voice, to sit down, and my demand was immediately 
 complied with. She remained seated for about a minute, muttering some 
 indistinct words which I was unable to understand, after which she re- 
 covered. I inquired whether she was aware that she had had a fit, and 
 she replied in the negative, stating that she knew nothing of what had 
 transpired. 
 
56 FUNCTIOIiTAL NERVOUS DISEASES. 
 
 Hughlings Jackson ' reports the two following cases, which are ex- 
 tremely interesting, with regard to this point: 
 
 Case VI. — " I was sitting on his bed taking his history, he sitting 
 by my side holding the inkstand. After asking him a question and get- 
 ting no answer, I looked at him. He remained sitting, but his head was 
 a little drooped, and his face slightly pale. He still kept hold of the ink- 
 stand, and after a moment moved as if to jDut it down. I tried to get 
 hold of it, as it was tilting, but he pushed me away with the other hand. 
 He was well again in about half a minute." 
 
 In the other case reported by Jackson, the history was furnished by 
 the patient. 
 
 Case VII. — " My wife and her sister being present, had been talk- 
 ing about supper, when it was agreed that my wife and I should have 
 some cold fowl, and the sister some cocoa, if there were any fire. She 
 went into the kitchen to see, and reported that there was one. Soon 
 after I began to feel chilly after being so warm with gardening, and I 
 said I would go down to the fire. I did so, and after standing there a 
 few minutes, I felt symptoms of an attack and sat down, I believe, on a 
 chair against the wall. And here my recollection failed, the next thing 
 I was conscious of being the presence of my brother and mother (who had 
 heen sent for, as they lived opposite), and I have since been informed 
 by my sister-in-law that she came into the kitchen, and found me stand- 
 ing by the table mixing cocoa in a dirty gallipot, half filled with bread and 
 milk intended for the cat, and stirring the mixture with a mustard spoon, 
 which I must have gone to the cupboard to obtain.'''' 
 
 " This caused them to send for my friends, to whom I talked, showing 
 no surprise that they were there, and entirely unconscious of what I had 
 been doing until told this morning." 
 
 These cases are of great importance from a medico-legal point of view. 
 They prove that not alone may the series of acts which are committed 
 during an irregular epileptic paroxysm appear to be logically connected 
 together as they are in healthy individuals, but that they may also bear 
 a certain relationship to desires expressed previous to the occurrence of 
 the attack. In the last-mentioned case, the patient had agreed that his 
 sister-in-law should have some cocoa, and during the paroxysm he was 
 found stirring the cocoa, although he was entirely unconscious of so 
 doing. But, as Hughlings Jackson remarks, if he had had a quarrel with 
 his sister-in-law prior to the attack, we can very readily imagine that this 
 fact may have acted upon him in his unconscious condition so as to lead 
 him to commit murder. Kleptomania is not an infrequent symptom dur- 
 ing these attacks, and has often brought the poor patients in contact 
 with the arm of the law. It is very often extremely difficult to diagnose 
 this variety, but we shall reserve the discussion of this part of the sub- 
 ject to the chapter on diagnosis. 
 
 We will finally refer to a number of conditions which have lately been 
 placed in this category, and are known as epileptoid states. 
 
 Griesinger * has called attention to an entire group of cases in which 
 
 ' West Riding Lunatic Asylum Med. Rep., vol. v., p. 105. 
 * Archiv. f. Psychiatric u. i^ervenkv. Bd. I. 
 
EPILEPSY. 57 
 
 the interparoxysmal symptoms are those usually regarded as characteris- 
 tic of hypochondria or hysteria, but which differ from the latter in the 
 fact that they are combined with vertiginous attacks. Griesinger regards 
 these cases as examples of mild epileptic paroxysms, and strongly devel- 
 oped interparoxysmal symptoms. It is very difficult to know where to 
 draw the line. Usually, when a patient suffers from the manifold symp- 
 toms of hypochondria, and complains at times of attacks of vertigo, the 
 latter are attributed to cerebral congestion, to gastric disturbances, to 
 constipation, etc. In the chapter on diagnosis we shall endeavor to point 
 out the way in which a distinction may be made. 
 
 Another very curious phenomenon has recently been included in this 
 group, viz. : paroxysmal attacks of sweating. H. Emminghaus ^ reports 
 the following interesting case: 
 
 Case VIII. — The patient was a woman, forty-five years of age, whose 
 courses were regular. While still a child she had suffered from well- 
 marked epileptic convulsions, but these had disappeared spontaneously at 
 the age of puberty. For a few years past, the patient has been attacked 
 at times with paroxysms of sweating, which came on suddenly while she 
 was engaged in some occupation and without any apparent cause. These 
 attacks were associated with a feeling of weakness and slight giddiness, 
 but after a few seconds all the symptoms disappeared, and the patient 
 then felt entirely well. 
 
 In conclusion we will devote a few lines to what has been recently 
 termed epileptoid "sleep-states" (schlafzustgende). In 1876, Westphal 
 had called attention to a peculiar condition in which the patient some- 
 times suddenly lapses into a doze or even into a sound sleep, although 
 he had been entirely wakeful immediately preceding the attack. West- 
 phal left it undecided whether this should be regarded as an epilep- 
 toid state; but last year Franz Fischer, Jr.,^ reported a case which he 
 thought justified him in positively regarding this condition as truly epilep- 
 toid. In this case the patient would sometimes go off into a dose while 
 standing or walking, and in a few of the attacks lost consciousness en- 
 tirely. A case has also come under my own observation which appears 
 to favor Fischer's interpretation of this phenomenon. In this case, which 
 will be described more in detail in the chapter on etiology, the patient, 
 who also suffered from undoubted grand mal, on one occasion, while sit- 
 ting at table, sank into a dreamy sleep, which afterward lapsed into 
 coma. Upon the restoration of consciousness, the patient found himself 
 in bed, in which he had been placed by his family. 
 
 Interparoxysmal Condition. 
 
 In some cases the interparoxysmal condition in epilepsy is one of un- 
 disturbed bodily and mental health. I have seen some instances in which 
 men of fine physical development, whose general health was perfectly 
 normal, suffered from well-marked epilepsy, and I have sometimes 
 thought that in these very patients the paroxysms were more severe than 
 
 ' Ueber epileptoide Schweisse, Arch, f . Psych. 1873. 
 2 Arch. f. Psych. 1878. 
 
58 FUNCTIONAL NERVOUS DISEASES. 
 
 in others. Hercules is believed to have suffered from this disease, and 
 hence arises one of its numerous appellations. 
 
 The mental condition may also be entirely normal. This statement is 
 abundantly verified by the fact that such great men as Julius Caesar, Ma- 
 homet, Napoleon, Newton, Petrarch, Peter the Great, and many others, 
 were afflicted with the disease. But in the large majority of cases this 
 does not hold good. In very many individuals the general health has 
 already suffered before the disease makes its appearance, and in some 
 the deterioration of health is, indeed, the exciting cause of the onset of 
 the malady. Sooner or later, in the large proportion of cases, the health 
 suffers to a greater or less extent, and in a few instances I have noticed 
 that the deterioration in health promptly makes its appearance, even after 
 a single fit. The patients usually complain of headache of a dull charac- 
 ter and g'enerally situated in the frontal region. The pain is not contin- 
 uous, but does not remain absent for more than a few days at the utmost. 
 In a few cases I have noticed that it acquired considerable intensity, and 
 became almost continuous in character; it is then frequently situated in the 
 occipital region. We may sometimes attribute the headache to the blows 
 upon the skull which the patients receive during their frequent falls. The 
 patients usually fall in one direction (very frequently on the face), and 
 after a while, the periosteum becomes considerably thickened from the 
 oft-repeated traumatism. Nervous tremors are noticeable in the muscles, 
 especially in the arms and legs, and are sometimes very annoying. The 
 tongue is coated and the patient complains of a bad taste in the mouth, 
 and of oppression in the epigastrium after eating. As these unfortunates 
 are, however, continually taking medicine, I am inclined to believe that 
 the dyspeptic symptoms are due to the direct action of the drugs on the 
 gastric mucous membrane. Bromide of potassium, for instance, which is 
 now so generally employed, has a notoriously bad influence on the diges- 
 tive functions. The bowels are usually confined, and this is often one of 
 the chief complaints made by the patient. Some of them, in fact, stoutly 
 affirm that the constipation exercises a powerful deleterious influence on 
 the frequency of the fits. The appetite often varies a great deal, and is 
 sometimes very capricious. While the patients at times eat sparingly, at 
 others they have a voracious and ravenous appetite. 
 
 No careful investigations have been hitherto made with regard to the 
 condition of the pulse and temperature, and my attention has not been 
 specially drawn in this direction, but I have seen nothing which leads me 
 to believe that there are any noteworthy disturbances in these respects. 
 
 The general appearance of confirmed epileptics is often characteristic. 
 The former refinement of expression disappears, the cheeks become puffy, 
 the lips look swollen and prominent, the eyes have a peculiar dull, staring 
 look ; in fine, the lower nature of the individual becomes more apparent. 
 Although this change of expression is not readily expressed in words, it 
 is, nevertheless, very characteristic, and a large experience with this class 
 of patients will often enable the physician to recognize an epileptic at the 
 first glance. 
 
 The mental condition presents much more interesting phenomena. 
 One of the first changes which is noticed in this respect is loss of memory. 
 As so frequently happens in cerebral affections, the memory for recent 
 events fails more quickly than that for remote occurrences. It has been 
 the generally taught doctrine that the memory fails more rapidly in cases 
 of petit mal than in grand mal, and until recently, I had implicitly 
 adopted this doctrine on trust. But within the past year, my faith has 
 
EPILEPSY. 59 
 
 begun to waver in this regard as I have seen quite a number of striking 
 exceptions to this rule. In one case in particular, the patient, a young 
 woman of nineteen, has had from three to four attacks of petit mal daily for 
 the last three years, and I found her memory entirely up to the average, 
 while she herself informed me that it had never been better. I have seen 
 quite a number of instances of this kind, though not so striking, within 
 tlie last few months, but my attention has not been drawn to this point 
 sufficiently long to confer any great value on these data. 
 
 The temper also undergoes a marked change. In a few cases the pa- 
 tients become very quiet and gentle, but, as a rule, they are the very 
 reverse. This is especially noticeable in the wards of an epileptic hos- 
 pital. It is extremely difficult to prevent the patients, whether male or 
 female, from coming to open wai'fare. They are continually bickering 
 and quarrelling on the slightest pretext, are extremely selfish and pilfer 
 whatever they can lay their hands on. They are very anxious for sym- 
 pathy (especially the female patients), and feign all sorts of complaints in 
 order to draw the attention of the physician to themselves. Very frequent- 
 ly the preceding symptoms increase in intensity for a short time before the 
 fit occurs. After the fits have lasted for a long time, and especially if they 
 occur, as they often do, in series comprising from three or four to fifteen or 
 twenty or more in a few days, the mental powers gradually deteriorate, the 
 memory fails almost entirely, the judgment is lost, and the patient becomes 
 entirely demented. In the latter cases, the mental decay is not gradual, 
 but receives a considerable and sudden impetus after each series of fits. 
 After they have sunk into this demented condition, the patients are hope- 
 lessly lost, so far as regards their mental powers. 
 
 The discussion of epileptic mental disorders is really within the prov- 
 ince of the alienist, and I shall therefore content myself with giving a 
 very brief summary of the remarks on this subject made by Krafft- 
 Ebing, ' the most recent writer of a systematic treatise on insanity. 
 This author divides epileptic mental disorders into three classes : 
 
 1. Epileptic psychical degeneration. 
 
 2. Transitory psychical disturbances, usually attended with delirium. 
 
 3. Epileptic psychoses. 
 
 "We have already described epileptic psychical degeneration above, so 
 that it is unnecessary to refer to it again. 
 
 The transitory attacks of psychical disorder may last from a few 
 hours to several days ; they occur either before or after the convulsions, 
 especially after a series of attacks. They sometimes develop irrespective 
 of any epileptic attack ; consciousness is either disordered or entirely 
 lost. The nature of the acts performed varies greatly ; they are cliarac- 
 terized by stupor and a sort of " somnambulistic " condition (daemmer- 
 zustaende). 
 
 The stupor is rarely the sole symptom ; it is usually combined with 
 frightful delirium and hallucinations, sometimes with exalted religious 
 ideas. At times, there are sudden outbreaks of violence, probably as 
 the result of fear. 
 
 The "somnambulistic" conditions may occur before or after epileptic 
 convulsions, or independently of them. 
 
 They include several varieties: 
 
 1. Petit Mal. — This is characterized by marked psychical depression, 
 combined with terror and confusion of ideas. Under the influence of 
 
 ^ Lehrbuch der Psychiatrie. 1879. 
 
60 FUNCTION" AL NERVOUS DISEASES. 
 
 these feelings, the patient wanders aimlessly around, believes that he is 
 being pursued by his enemies and is destructive to himself or others. 
 His consciousness of the acts performed while in this state is either par- 
 tially or entirely lost ; it is generally not connected with any previous 
 convulsion and often develops out of the condition of psychical degener- 
 ation found in chronic epilepsy. 
 
 2. Grand Mai. — This is a furious mania, characterized by rapid devel- 
 opment without any warning symptoms, by the extreme violence of the 
 maniacal acts and by terrible delirium, in which fear plays the chief part. 
 There are various gradations between this form and that described above 
 as petit mal. The maniacal condition may alternate in these patients 
 with periods of profound stupor. Grand mal usually occurs after con- 
 vulsions, especially when they have appeared in a series. It may last 
 from a few hours to several days, and after its cessation the patients re- 
 tain no consciousness of the occurrences during the attack. 
 
 3. Gonditiofis attended with religious delirium. — In this variety, the 
 patient considers himself to be God, Jesus, an angel, etc., believes him- 
 self in heaven, receives communications from the Deity, delivers 
 prophecies, etc. These ideas may change, and the patient thinks himself 
 in danger of eternal damnation, sees the flames of hell, etc. In these 
 cases, consciousness is only partly clouded, and the patient retains some 
 knowledge of what has occurred during the attack. 
 
 4. Conditions attended with dream-like ideas. — In these cases, the 
 patients appear to those surrounding them to be conscious of their acts, 
 but, in reality, they are in a sort of somnambulistic condition. They act 
 under the influence of various fanciful notions concerning themselves 
 and those surrounding them. In a case mentioned by Legrand du 
 Saulle, and which belongs in this category, the patient found himself on 
 board of a vessel off Bombay, although he last remembered himself in 
 Paris. All his actions in the interim had been a blank to him. In a 
 case under my own observation, the patienc left the city without any 
 object in view, and when he recovered consciousness, found himself in 
 the streets of Pittsburgh. 
 
 Epileptic psychoses. — Patients suffering from epilepsy may develop 
 insanity, which differs in no respect from that observed in other classes 
 of patients. But Samt has shown that there is also a specific form of 
 epileptic insanity, and this author states, " that every patient who is in 
 a condition of stupor, kneels in terror before the physician, calls him 
 ' God,' and at times becomes destructive," may be regarded as suffering 
 from epileptic insanity. Samt divides the disease into several varieties, 
 but the nature of this article will prevent us from entering any further 
 into a consideration of the subject. 
 
CHAPTER 11. 
 
 ETIOLOGY. 
 
 Epilepsy is one of the most frequent of all nervous diseases. Rey- 
 nolds states that it constituted seven per cent, of all the cases of nervous 
 disease which he met with in hospital practice. This agrees very closely 
 with the results of my own observation. Among 2,299 patients who at- 
 tended the clinic for nervous diseases in the Bellevue Out-Door Depart- 
 ment during the last three years, 156, or a little over six and three-fourths 
 per cent, suffered from the various forms of this disease. 
 
 The causes of epilepsy may be divided into two classes, viz.: the pre- 
 •disposing and exciting. 
 
 Predisposing Causes. 
 
 Heredity undoubtedly constitutes the most important factor in this 
 class, though its frequency is variously estimated by different authoi'ities. 
 Delasiauve ^ found that in 300 cases, no evidence on this point could be 
 obtained in 167, and that among the remaining 133 patients there was a 
 neuropathic tendency in only thirteen, or a little less than ten per cent. 
 In thirty-eight cases under Reynolds's ^ care, twelve presented a history 
 of nervous disease in the family, or a proportion of thirty-one per cent. 
 In 306 of Echeverria's cases, eighty had a neuropathic family history. I 
 ihave notes on this point in one hundred and twenty-four of my own cases, 
 and find heredity as an etiological factor in thirty of these patients, or in 
 twenty-three per cent. 
 
 Gowers,' who has had an extremely large experience at the English 
 National Hospital for the Paralyzed and Epileptics, found that among 
 1,250 epileptics, in whom this point was carefully investigated, an heredi- 
 tary neurotic tendency was present in 452, or thirty-six per cent. ; among 
 these, the female sex numbered fifty-seven per cent., and the male, forty- 
 three per cent. This author has included in his statistics only such cases 
 in which there was no reason to suspect cerebral tumor, chronic meningi- 
 tis, and syphilitic or other organic disease. 
 
 Martin * states that almost all the children of epileptics die during the 
 first years of life. This is one reason why the disease is not transmitted 
 more frequently, as it is to be presumed that a considerable proportion 
 of these children would be similarly affected if they had lived until a 
 more advanced age. 
 
 The powerful influence of heredity is also shown by the fact that 
 
 ' Traite de I'epilepsie, 
 
 ® Epilepsy; its Symptoms, Treatment, etc., 1861. 
 2 British Med. Journal, March 6, 1880, et seq. 
 ^ Annales medico-psychologiques, T. xx., p. o64. 
 
62 FUNCTIONAL NERVOUS DISEASES. 
 
 guinea-pigs, which have been rendered epileptic by experimental means, 
 may transmit the disease to their offspring. 
 
 Finally, in estimating the importance of this factor, we must take into 
 consideration the fact that the relatives of the patient, and the patient 
 himself, often endeavor to conceal the history of any antecedent nervous 
 disorder in the family, and frequently attempt, by hook and by crook, to 
 adduce some palpable physical factor as the cause of the disease. In in- 
 terrogating hospital patients we must also bear in mind that stupidity 
 often reigns supreme, and that a strict cross-examination may reveal the 
 presence of disease which has been previously denied. 
 
 We do not imply by the term hereditary influence, that the ancestors 
 must have had epilepsy. In fact, any nervous disease in the parent may 
 produce epilepsy in the children. 
 
 Thus, the existence of hysteria, chorea, insanity, obstinate neuralgia, 
 or even simple nervousness in the parent may be transmuted into epilepsy 
 in one of the descendants. It is true, however, that the nervous disease 
 exhibited in the parent is often transmitted directly to the offspring. 
 Thus there are numerous cases on record in which a tendency to commit 
 suicide has been transmitted from parent to offspring (usually from father 
 to son) for several generations, and, strange to say, this tendency is fre-» 
 quently manifested at about the same period of life in all the individuals 
 of the family. But in many instances, the neuropathic tendency will 
 give rise to the production of epilepsy in one child, chorea in another, 
 and idiocy in a third. This transmutation of disease is also often shown 
 in the same individual, so that a patient who was choreic in childhood, 
 becomes epileptic in manhood, and insane in later life. 
 
 In addition to these diseases, alcoholism in the parents may exercise 
 a similar baneful influence on the offspring. Quite a number of cases are 
 recorded in which the birth of an epileptic child was due to the occurrence 
 of conception while the father was intoxicated. That this is not a mere 
 coincidence has been shown by the fact that the children who were born 
 later, and in whom conception did not occur under such circumstances, 
 remained perfectly healthy. In two of my cases, also, I discovered that 
 the father was the victim of a periodical and uncontrollable desire to 
 drink, and that after such a debauch had ceased, he would remain entirely 
 abstinent until again seized by the uncontrollable craving. There is no 
 doubt that inebriety may be transmitted, and I have myself seen a few 
 cases in which several examples were presented in the same family. I 
 also see no reason for doubting that it may act directly in the production 
 of epilepsy in the offspring. The hereditary influence sometimes skips 
 one, and perhaps even two generations, and then reappears in the second 
 or third. In one case under my observation, the son escaped, while of 
 the latter's seven children, all suffered from epilepsy. In another of my 
 cases, the only hereditary history obtainable was that of insanity in the 
 great-grandaunt; this reappeared in two of the great-grandnephews as 
 chorea and epilepsy respectively. 
 
 Some of the older authors believed that phthisis in the parents is capa- 
 ble of developing epilepsy in the progeny, and this view has been more 
 recently supported by Echeverria. The notion has probably arisen from 
 the great frequency of phthisis; at all events, we would be unwilling to 
 accept this statement unless substantiated by careful statistics. 
 
 It would appear that in those individuals in whom the epilepsy is due 
 to hereditary influence, the disease makes its appearance, in a large num- 
 ber of cases, before the fifteenth vear of life. 
 
EPILEPSY. 63 
 
 Reynolds found that among twelve patients in whom an hereditary 
 taint could be traced, in ten the disease appeared before the age of fifteen 
 years, and in two between the ages of fifteen and twenty. 
 
 My own experience somewhat corroborates that of Reynolds. In 
 twenty-six cases with a neuropathic family liistory, the disease developed 
 nineteen times before the fifteenth year, five times from the fifteenth to 
 the twenty-sixth year. In one case the disease began at the age of sixty- 
 seven years, in a vigorous man, enjoying excellent health. In this pa- 
 tient, the hereditary taint was shown by the development of insanity in 
 two cousins. 
 
 Gowers has drawn different deductions from his statistics, and has 
 come to the conclusion that heredity possesses very little less influence 
 in the production of epilepsy during adult life than it does in childhood. 
 This is so contrary, however, to the general opinion of the great mass of 
 observers, that we are unwilling to accept this opinion unless substan- 
 tiated by the experience of others. 
 
 From a careful analysis of his cases, Reynolds concludes "that here- 
 ditary taint is not Avithout influence upon the character of the attacks; 
 but that the influence it exerts is favorable to the development of epilep- 
 sia gravior, rather than epilepsia mitior." 
 
 I will conclude my remarks on heredity by giving the family history 
 of an interesting case under my observation. The father was a periodi- 
 cal drinker; by his first wife (who was healthy) he had four children, two 
 daughters, one of whom was insane, and another imbecile (neither of 
 these had children); and two healthy sons, one of whom had an epi- 
 leptic, and the other an insane child. By the second wife (also healthy) 
 he had three sons, one of whom died of epilepsy, and another was epilep- 
 tic, and had an insane child; the third son was healthy and had seven 
 children. All of these had fits in infancy ; one was a confirmed epileptic, 
 and another suffered from epileptic insanity. 
 
 Sex. — The prevailing opinion, especially among the older writers, has 
 been that the disease is more common among females than among 
 males. Several of the more recent authors, however, are opposed to this 
 view. Among eighty-eight cases, Reynolds found forty -nine males and 
 thirty-nine females. Eulenburg * found seventy-three in males, and fifty- 
 nine in females; Nothnagel states that it occurs in about equal frequency 
 in both sexes. I have observed seventy-five cases in males and fifty-nine 
 in females. Gowers, whose statistics include 1,450 cases, found that there 
 were 114 females to 100 males; after the age of thirty years, however, 
 the proportion of males is greater than that of females, and this disparity 
 increases after forty. It is evident, therefore, that sex possesses very 
 little, if any, influence on the development of the disease. 
 
 Age. — This factor is more important as an etiological element than 
 the preceding one. In Reynolds's experience, the disease appeared in 
 forty-eight patients during the first seventeen years of life, in fourteen 
 .between the ages of seventeen to twenty years, and in fourteen from the 
 ages of twenty-one to seventy years. Among Gowers's patients, 12^ per 
 cent, began during tlie first three years of life, 29 per cent, in the first 
 ten years, 46 per cent, between the ages of ten and twenty years, and 
 15.7 percent, between the ages of twenty and thirty years. In my own 
 cases, I found that among ninety-three patients, the disease appeared in 
 the first seventeen years of life in fifty-seven patients, from seventeen to 
 
 ' Lehrbuch der Nervenkraakheiten. 1878. 
 
64 FUNCTIONAL NERVOUS DISEASES. 
 
 thirty years in sixteen, and from thirty to sixty-seven years in twenty 
 individuals. It has been supposed that the later the disease makes its 
 appearance the more is it due to causes other than heredity, although, as 
 we have seen, Gowers holds to the opposite opinion. In the twenty 
 patients in whom it first appeared between the ages of thirty to sixty- 
 seven years, in nine no cause could be obtained, in two it was due to 
 traumatism, in two to syphilis, in two to alcoholism, in one to sexual ex- 
 cess, and in one each to exposure, fright, heredity, smoking. This ex- 
 hibit runs counter to the current opinion according to which the develop- 
 ment of epilepsy after the thirtieth year of life is usually an indication of 
 cerebral syphilis. 
 
 I must, however, mention in this connection that I have omitted from 
 the category of syphilitic epilepsy, all those cases in which the patients 
 presented other well-marked tumor symptoms, such as paralysis of the 
 ocular muscles, facial paralysis, atrophy of the optic nerves, etc. 
 
 It is well also to be on our guard when confronted with epilepsy which 
 has developed late in life, lest the epilepsy is only one symptom of 
 some organic cerebral affection, and the older the patient is at the onset 
 of the disease, the more careful must be our search for other symptoms. 
 In two of my cases, however, the disease first appeared at the ages of 
 fifty-seven and sixty-seven years respectively, and their course showed 
 that they were evidently idiopathic epilepsy. In the former case the 
 patient, who was in tolerable health and presented an excellent family his- 
 tory, worried a great deal aVjout the intended removal of her daughter 
 from the city, and on the very day of her departure, the patient had the 
 first attack of grand mal. The attacks then occurred at irregular inter- 
 vals during the next two years until she came under my care. Under the 
 use of bromide of potassium, the convulsions entirely ceased and have not 
 returned for the past year.^ 
 
 The second patient, a healthy farmer, in whom the only etiological 
 factor obtainable was insanity in two cousins (showing the presence of 
 an hereditary taint), had the first attack at the age of sixty-seven, aftgr 
 which they appeared at short intervals for three years. During this 
 period he had upward of 150 attacks, all of them being well-marked 
 paroxysms of grand mal. For nearly a year the patient suffered from 
 epileptic mania, and was very violent, excitable, and destructive. The 
 last attack occurred during the summer of 1877, and since that time the 
 patient has been in excellent health, with the exception of an attack of 
 bronchitis, and his previous mental condition has been entirely restored. 
 
 Reynolds mentions a case of pure epilepsy which developed at the age 
 of seventy-one, and Heberden another at seventy-five. Other cases have 
 been reported at such an advanced age, but they form decided exceptions. 
 
 We shall now direct our attention to the accidental or exciting causes, 
 which are much more numerous than the predisposing. 
 
 Alcoholism. — This is, on the whole, a very infrequent cause of the 
 disease, and was observed in few of my cases. Among 608 cases ana-, 
 lyzed by Gowers with reference to etiology, only thirteen were trace- 
 able to chronic alcoholism. Alcoholic epilepsy may develop either in in- 
 dividuals who are in a continual state of semi-intoxication or in those 
 who go on occasional sprees, which terminate in mild delirium tremens. 
 
 ' As this book is going through the press, the patient died with symptoms which 
 I referred to a fatty and dilated heart. Unfortunately I was unable to obtain an 
 autopsy. 
 
EPILEPSY. 65 
 
 We must, however, exercise caution in pronouncing drink an etiological 
 factor. In one instance a patient was referred to nie by a medical friend 
 as a case of alcoholic epilepsy, but, upon careful questioning, I found 
 that although, at the present time, the fits only appeared when the pa- 
 tient went on a spree, the attacks had occurred during childhood, and that 
 there was an hereditary taint in the family. Cases of this kind are not 
 unfrequently observed, and I have several times noticed tliat in patients 
 in whom the disease had been latent for several years, the fits again re- 
 curred with the former frequency, after the patient had been drinking 
 heavily for some time. In the majority of my cases, the attacks which 
 were brought on by drunkenness occurred during the night, and were 
 always of the nature of grand mal. Magnan has shown that absinthe 
 possesses a great influence on the production of epilepsy, but Legrand 
 du Saulle believes that the nature of the stimulant is immaterial, that 
 brandy, whiskey, and wine are alike potent in this regard; this author 
 regards the alcohol as the only efficient factor. I am unable to offer any 
 opinion upon this question, as the only cases which have come binder 
 my notice, in which the convulsions could be attributed to intoxication, 
 were due to drinking whiskey, brandy, or beer. Fortunately, the habit 
 of drinking absinthe has not found much favor in this country, and we 
 will therefore be unable to institute any comparisons between its effects 
 and those of the stimulants habitually drunk here. 
 
 Sextial excesses. — In one of my cases, sexual excess constituted the 
 only traceable cause. The patient, a middle-aged man, had had inter- 
 course six or seven times a week since early manhood, had a perfect fam- 
 ily history, and was entirely well in all other respects. The older authors 
 laid great stress upon this factor as well as upon sexual continence and 
 masturbation, as active causes of epilepsy. The activity of these causes 
 has been greatly exaggerated, especially with reference to masturbation. 
 A very intelligent and observant patient in the male pavilion of the Epi- 
 leptic and Paralytic Hospital, told me that all the patients in the ward 
 practised masturbation, himself included, but that he had only begun the 
 habit after he was attacked with epileps3\ The reason that the practice 
 is so widespread in an epileptic hospital is obvious. The disease itself 
 produces a depression of the moral stamina of the patients, and the char- 
 acter of the affection prevents, in great part, the exercise of the sexual 
 functions in the natural manner. My own observation in the female 
 pavilion of the hospital has also taught me that masturbation is very ex- 
 tensively practised by female epileptics. But these facts are far from in- 
 dicating that the masturbation was the cause of the epileptic attacks. Al- 
 though I have carefully investigated this phase of the question for several 
 years past at my clinic in the Bellevue Out-Door Department (in which the 
 facilities for such investigations are, of course, much greater than in pri- 
 vate practice), I have been unable to find a single case of epilepsy which 
 I could with justice attribute to this cause. When tempted to believe that 
 a case of epilepsy is due to this habit, we should bear in mind how com- 
 mon the practice is among the young of both sexes, and that, if the soli- 
 tary vice possessed any marked degree of influence on the development of 
 epilepsy, the latter disease should be much more frequent than it really is. 
 I remember one patient, a maiden lady, thirty-one years old, who confessed 
 to me that, since the age of nine years, she had masturbated at least once 
 every night. The only effect produced on this patient was the develop- 
 ment of symptoms of nervous exhaustion, or, as it is now fashionably 
 termed, cerebral neurasthenia. 
 
Q6 FUNCTIONAL ITERVOUS DISEASES. 
 
 In a few instances the first epileptic convulsion has occurred during 
 the performance of the sexual act and only appears when sexual inter- 
 course is attempted. This occurs both in males and females, and is some- 
 times observed when the genital organs appear to be entirely normal. 
 In rare cases this is due in the female to the irritation of hypersensitive 
 portions of the genital tract, but these cases really belong to the category 
 of reflex epilepsy, and will be discussed under that heading. As a rule, 
 the convulsions which at first only occur during the sexual act, afterward 
 appear apart from this exciting cause, and the disease then runs the 
 course of ordinary epilepsy. But, even in cases of this character, we 
 should always carefully examine the patients with regard to the presence 
 of some hereditary predisposition. 
 
 A few cases have been reported by trustworthy observers in which the 
 epileptic attacks appeared to be due to the irritability produced by abso- 
 lute continence, and in which marriage and regular sexual intercourse 
 caused the disappearance of the disease. But these examples are very 
 exceptional and they should not lead us to advise matrimony in young 
 unmarried epileptics of either sex. We must remember that even though 
 marriage prove remedial in the parent, the disease or some other neurosis 
 may be transmitted to the offspring of such a union. At all events the 
 patient should be informed of the possibility of such an occurrence, and 
 the responsibility of the decision thrown upon his own shoulders. It is 
 unnecessary to state, however, that patients will rarely be deterred from 
 marriage by the possibility of a contingency of this nature. 
 
 Hejiex epilepsy. — In ten of my cases the disease was due to reflex 
 causes, which consisted: in six cases of injuries to the head; in three, to 
 various other parts of the body (leg, abdomen, back); and in one, to preg- 
 nancy. In one instance the causal relation between the injury and 
 the development of the epilepsy was ver}^ evident. The patient in ques- 
 tion was a young man, nineteen years of age, who presented no ascer- 
 tainable hereditary taint, and had shown no evidences of nervous dis- 
 ease until the age of two years, when he fell from a carriage, striking 
 upon his head. He was rendered unconscious by the blow for upward 
 of an hour and a half, and the same night was attacked by an epileptic 
 convulsion. These attacks recurred at intervals until the age of seven 
 years, at which period they ceased entirely and remained absent until the 
 age of seventeen (two years ago) ; during this time the patient enjoyed 
 excellent health. He then had another fall upon the head, after which 
 the epileptic attacks reappeared and have continued up to the present 
 time. As a rule, epilepsy will not develop from a blow upon the head, 
 unless the injury has been sufficiently severe to produce unconsciousness 
 for a considerable period. 
 
 In one instance, in which I succeeded in obtaining an autopsy, the 
 affection was caused by the pressure of exostoses upon the brain. These 
 growths, which measured about an inch in length at their base and three- 
 fourths of an inch in thickness, projected from the frontal bone and were 
 symmetrically situated on each side of the falx cerebri ; they had pro- 
 duced corresponding depressions in the anterior portions of the superior 
 and middle frontal convolutions. The only nervous symptoms existing 
 during life consisted of the epileptic attacks; the patient died of peri- 
 carditis and fatty degeneration of the heart. 
 
 Similar results may follow from depression of the skull, and from irri- 
 tation of the dura mater or surface of the brain by a splinter of bone. 
 Epilepsy is also not uncommonly observed in pachymeningitis, cerebral 
 
EPILEPSY. 67 
 
 gummata, and other tumors of the brain, especially when they are situated 
 on the anterior portions of the convexity. But in these cases, the epi- 
 lepsy is usually combined with other cerebral symptoms, to which we shall 
 refer in the chapter on diagnosis. In one patient, the disease began a 
 year and a half after an attack of cerebral hemorrhage, but the previous 
 history was so indefinite that I am unable to state positively whether the 
 latter affection acted as a cause of the epilepsy. 
 
 Injuries of the peripheral nerves also act as etiological factors. This 
 is usually due to lesions of the sensory and mixed nerves, but cases have 
 also been reported in which the epilepsy was secondary to an affection of 
 purely motor nerves. In these cases neuritis almost always develops ia 
 the injured nerves, and neuromata are sometimes observed upon them. 
 
 Thus, in one case the disease followed the development of a neuroma 
 in an amputation stump. In a case which came under my observation, 
 the epilepsy developed after an injury to the outer aspect of the left 
 leg; no symptoms of neuritis were manifested at any time. The epi- 
 leptic attacks were always preceded by a motor aura which began in the 
 injured leg and rapidly spread up the left side of the body. Although 
 there was no pain or tenderness over the injured part, the convulsions 
 rapidly became more infrequent from the local application of the con- 
 stant galvanic current three times a week. I lost sight of the patient, 
 however, within a couple of months after beginning the treatment, and 
 lam therefore unable to report upon the final termination. 
 
 These cases form the analogues of the epilepsy produced in various 
 animals, especially guinea-pigs, by certain experimental procedures, such 
 as blows on the head, section, or other injuries of the peripheral nerves, 
 etc., and which we shall describe at a later period in the chapter on path- 
 ology. As in animals, the cases in man which are due to traumatism 
 present, in extremely rare cases, an epileptogenic zone, i.e., a region whose 
 irritation will give rise to the production of an epileptic convulsion. My 
 own cases did not present this symptom, and I shall therefore give the 
 following abstract of a very interesting observation of this nature reported 
 by Dr. Neftel.' 
 
 Case IX. — H. W. K., fct. 24 years, entirely free from any neuro- 
 pathic tendency; was previously in perfect health. In July, 1869, he was 
 struck on the head, during a riot, with a loaded cane. He fell senseless to 
 the ground and, while in this condition, received several more blows upon 
 the skull. The first blow struck the right side of the forehead over the 
 frontal eminence, but no external marks of contusion were present. The 
 patient remained unconscious for seventy-two hours. During the second 
 week after the injury he remained very feeble, and, after the slightest ex- 
 ertion, lost consciousness, which remained suspended for ten minutes and 
 was attended with epileptic convulsions. After the lapse of three months 
 the patient began to w^alk about, but had several attacks while in the 
 street. 
 
 He began to suffer from headache as soon as consciousness had been 
 restored after the accident, and this has continued uninterruptedly ever 
 since. The pain is situated on the right side of the forehead and in the 
 right eye, the most sensitive part being the right external frontal crest. 
 ^ considerable pressure is made over the sensitive zone, the pains become 
 intensified to an intolerable degree, and the patient falls to the ground in 
 
 ' Arch, fur Psychiatrie. VII, 1877, p. 124. 
 
68 FUNCTIONAL NEEVOUS DISEASES. 
 
 an unconscious condition^' co7ivulsions then make their appearance lohich 
 were regarded, by the physicians who sate them, as ejnleptic in character. 
 At rare intervals, attacks of unconsciousness develop, although no pres- 
 sure has been made upon the epileptogenic zone. During the spontaneous 
 pains, the skin of the painful region is analgesic. 
 
 This patient was treated by local applications of galvanism, which soon 
 produced a remarkable improvement, but Dr. Neftel lost sight of him 
 after the current had been applied thirty-one times. 
 
 Dr. Neftel believes himself " justified in concluding, or at least in sur- 
 mising, that those cases of epilepsy, in which an epileptogenic zone is 
 present, have been caused by traumatism." The case at least teaches us, 
 apart from its intrinsic interest, to exercise great care in an examination 
 of patients suffering from traumatic epilepsy in searching for the pres- 
 ence of an epileptogenic zone. This remark is especially applicable with 
 regard to the epilepsy of young children, who so frequently suffer from 
 blows on the head. 
 
 In a certain number of cases epilepsy is due to teething. Gowers 
 found that among 180 cases beginning during the first three years of life, 
 seventy-two developed during dentition. We not infrequently notice 
 that epileptics have suffered from eclamptic attacks during the period of 
 dentition, and some authors believe that frequently recurring eclamptic 
 convulsions may produce an " epileptic habit " in the brain and thus give 
 rise to the independent existence of epilepsy. But the eclampsia of child- 
 hood is so overwhelmingly more frequent than epilepsy that we are very 
 skeptical with regard to its efficiency as a cause of the latter affection. 
 
 Diseases of almost all the organs of the body may act as exciting causes 
 of epilepsy. Several cases are reported in which various affections of the 
 ear acted in this manner. Fabrice de Hilden reported a case in which 
 epilepsy was due to the presence of a glass bead in the ear and was cured 
 by its removal. Schwig ' reports the following interesting example: 
 
 Case X. — The patient was eleven years old; one year and a half pre- 
 viously he fell from a baby carriage, struck upon the right cheek and 
 ear, and was dragged along for a short distance on a gravel road. Dur- 
 ing the next few days the patient complained of slight stitches in the 
 right ear, and five or six weeks later, an epileptic ccnvulsion suddenly 
 developed without any warning. The child had been very quiet and sub- 
 dued since the accident, in contrast to his former lively spirit. The epilep- 
 tic attacks were repeated at varying intervals. Upon examining the ear, 
 the auditory canal was found entirely occluded by a hard substance. The 
 mass was removed by a pair of forceps, and during this operation the 
 patient was seized with a convulsion; in the centre of the mass was 
 found a small stone with sharp angles. A period of ten months has 
 elapsed since the removal of the foreign body, during which no convul- 
 sion occurred. The boy, who was previously pale and had a stupid ex- 
 pression of countenance, is now the picture of health. 
 
 Moos'* has entered fully into the literature of this subject, and from 
 his article it appears that, apart from foreign bodies in the ear, epilepsy 
 may also be produced by inflammatory affections of the middle ear, and 
 caries of the bones of the ear. 
 
 • Archiv f. Ohrenheilkunde. Bd. XIY. 1878. 
 "^ Arch, f . Augen u. Ohrenheilk. IV. 2. 
 
EPILEPSY. 69 
 
 Affections of the respiratory passages may also give rise to epilepsy. 
 Sommerbrodt ' reports a case in which epilepsy was caused by the pres- 
 ence of a fibroma on the left vocal cord, and in which the attacks ceased 
 after the extirpation of the tumor. Charpigiion' observed a case in which 
 a foreign body in the bronchi produced epilepsy. Charcot observed epi- 
 leptic attacks in an old man suffering from chronic bronchitis and emphy- 
 sema, in whom the attacks were always preceded by a dry cough and a 
 feeling of titillation in the neck below the larynx. 
 
 Epilepsy also appears to be connected, in some instances, with disorders 
 of the female genital apparatus. Numerous gynaecologists believe that 
 amenorrhoea is a not infrequent cause of epilepsy. Graily Hewitt ' men- 
 tions an interesting case of this kind, in which the fits ceased upon the 
 appearance of the first menstrual epoch. 1 have, however, seen so many 
 cases in which epilepsy developing during childhood was combined, at 
 the age of puberty, with amenorrhoea, and in which, at a still later period, 
 the menses appeared and continued regularly without any apparent effect 
 upon the frequency of occurrence of the epileptic convulsions, that I 
 have become somewhat skeptical as to the existence of any causal rela- 
 tion between the two affections. The period of menstruation frequently 
 has considerable influence on the occurrence of the convulsions. Some- 
 times they develop immediately prior to the establishment of the men- 
 strual discharge, at others they do not appear until the latter has lasted 
 for a few days. I have found, however, as a general rule, that even when 
 the epileptic attacks were at first connected with the menses, they oc- 
 curred independently of them after the disease had lasted for a certain 
 length of time. 
 
 In one case the convulsions appeared to be due to anteversion of the 
 uterus, as they disappeared after the organ was restored to its normal po- 
 sition. In the following case, the epilepsy seemed to be the result of the 
 reflex irritation caused by the presence of a foetus in utero. 
 
 Case XI. — Elizabeth W., fet. 18 years, single; no hereditary influence. 
 When six years old the patient had scarlatina, and since then has been per- 
 fectly well until the beginning of this year (this history was taken Septem- 
 ber 5, 1876). She began to menstruate at the age of fourteen years, and 
 the courses have always been regular. On February 1 , 1876, the patient was 
 attacked with diphtheria in a very severe form, which was attended with 
 regurgitation of fluids through the nostrils. She had recovered by the 1st 
 of April. After recovery, the patient took a walk one afternoon in the 
 month of May, and states that she then caught cold. The same after- 
 noon she had the first epileptic attack (grand mal), followed by another 
 one during the night. On the next day there was a recurrence of the 
 diphtheria, and during the entire period of this relapse she had quite a 
 number of convulsions. Since then she has had them almost every night, 
 and often also in the day-time, with the exception of three and a half 
 months, from the middle of May until September 1st, during which time 
 she was in the country and only had two fits. Since September 1st she 
 has had them every day and night — sometimes as many as two in the 
 afternoon (never in the morning) and three or four at night. 
 
 Upon physical examination the patient was found to be in the fourth 
 month of pregnancy, and upon comparing the dates of the cessation of 
 
 > Berl, Klin. Wochenschr. 1876. « Gaz. des hopitaux, 1876. 
 
 =* Diseases of Women, 1874, p. 437. 
 
70 FUNCTIOITAL NERVOUS DISEASES. 
 
 the menses and the appearance of the first fit, it was found that the lat- 
 ter had developed within a couple of weeks after impregnation had oc- 
 curred. At the time of the first convulsion the patient was unaware of 
 her condition, so that the attack could not have been due to worry on 
 this account. Since her knowledge of this fact, however, she has been 
 exceedingly worried, and this has undoubtedly had considerable influ- 
 ence on the frequency of the fits. I kept the patient under observation 
 until she had reached the middle of the seventh month of pregnancy; during 
 this entire time the urine had been carefully examined on several occa- 
 sions with entirely negative results. During the last month the patient's 
 memory became worse and her general mental condition failed some- 
 what. I then consulted two eminent gynsBcologists as to the propriety 
 of bringing on premature labor, which I believed justifiable. My consul- 
 tants, however, entertained a diiferent opinion, and my suggestion was 
 not carried out. Soon after I lost sight of the patient. 
 
 It may be claimed that, in this case, the disease was due to the diphtheria, 
 but I doubt this, for the following reasons: In the first place, the pa- 
 tient had entirely recovered from the diphtheria at the time of the first 
 convulsion; secondly, the convulsions began within a couple of weeks 
 after impregnation; and finally, they increased in frequency toward the 
 end of pregnancy. The latter fact was not due to the increased worry, 
 as latterly the patient was becoming reconciled to her lot, her condition 
 was unsuspected by her family, and she had made arrangements to be 
 confined in a neighboring city, in order to obviate risk of detection. 
 
 Rosenthal ^ mentions a striking case of reflex epilepsy, relieved by 
 local treatment. 
 
 Case XII. — " A young woman, twenty-four years of age, who had 
 been previously healthy, suffered, at the end of the fourth month of mar- 
 riage, after the performance of the sexual act, from acute pains in the ab- 
 domen, which were soon attended by convulsions, combined with loss of 
 consciousness. During the following weeks the patient abstained from 
 coitus and enjoyed perfect health. When she again indulged in sexual 
 intercourse the epileptic seizures returned and soon began to occur spon- 
 taneously^ at first only at the menstrual epochs, and, at a later period, ir- 
 respective of the menses. The patient did not place herself under medi- 
 cal care until after separation from her husband. Upon examination a 
 very sensitive point was found at the anterior and inferior portion of the 
 vestibule of the vagina, at the level of the remains of the hymen and of 
 the adjacent mucous membrane. An attack of epilepsy could be inva- 
 riably produced by pressing upon this point and even by touching it 
 lightly with nitrate of silver; if the examination were prolonged the 
 attack lasted much longer. The uterus was normal and insensible to 
 pressure; there were no symptoms of hysteria. Ferruginous mineral waters 
 and local treatment proved ineffectual, but the attacks of epilepsy dis- 
 appeared after the excision of the sensitive parts, and have remained 
 absent for the past two years." 
 
 Disturbances of the digestive organs may also act as causes of the 
 outbreak of the disease; thus, it has appeared after an attack of subacute 
 gastritis, overloaded stomach, and from the presence of worms. But the 
 
 ' Diseases of the Nervous System, 1879, p. 840. 
 
EPILEPSY. 71 
 
 influence of gastro-intestinal disorders upon epilepsy is less evident and 
 frequent than that of any other series of reflex causes. 
 
 Fright, mental excitement or anxiety, may also act as etiological fac- 
 tors. Among G08 cases Gowers found 157 which were ascribed to these 
 causes. These cases were more numerous among females than among 
 males, and this is but natural, as the former are much more emotional 
 than the latter. A small number of examples have been reported in 
 which the excitement attendant upon seeing an individual during a con- 
 vulsion has been sufficient to give rise to an attack. In some instances, 
 cases which had developed in this manner recurred spontaneously after- 
 ward. 
 
 The last series of causes of epilepsy is composed of those factors which 
 affect the general system. Foremost among these are the infectious dis- 
 eases, although but little mention is made of them in the various Vr-orks on 
 this affection, except by 'Gowers, vvho reports nineteen cases due to scarla- 
 tina. Among my own cases the infectious diseases immediately preceded 
 the attacks in four cases, one of which occurred immediately after scarla- 
 tina, another during the course of scarlatinous nephritis, a third during 
 convalescence from typhoid fever, and the fourth after diphtheria. In the 
 second case referred to, in which the first attacks occurred during scarla- 
 tinous nephritis, the paroxysms might perhaps have been regarded as 
 urfemic in their nature, were it not for the fact that they were attacks of 
 petit mal, and occurred with extreme frequency (every day, and some- 
 times four or five times a day). After the disease had continued for 
 three years attacks of grand mal occurred. 
 
 We sometimes, on the contrary, find that an intercurrent infectious 
 disease, occurring during the course of. epilepsy, favorably modifies the 
 progress of the latter. Thus, in a female patient in whom the convul- 
 sions had occurred with great frequency during childhood, the disease 
 disappeared for a period of ten years, after passing through an attack of 
 typhoid fever, and only reappeared after the birth of her second child, 
 while she was worrying greatly over the bad habits of her husband. 
 
 Syphilis sometimes acts as a cause of epilepsy, the convulsions usually 
 developing during the tertiary stage. In only two cases under my obser- 
 vation did the attacks occur without being complicated by other cerebral 
 symptoms, and in these I am therefore inclined to believe that the epi- 
 lepsy was due to the direct action of the syphilitic virus upon the brain. 
 In the vast majority of cases, however, the convulsions of the tertiary 
 stage only constitute one of the symptoms of cerebral syphilis, and we 
 shall again refer to them in the chapter on diagnosis. 
 
 Until very recently it was supposed that syphilitic epilepsy only oc- 
 curred during the tertiary period. Fournier * has, however, collected 
 twelve cases (chiefly in females) in which the convulsions began during 
 the first months of secondary syphilis, and were accompanied by second- 
 ary manifestations (roseola, mucous patches, etc.). The epilepsy was re- 
 lieved in all cases under mercurial treatment. The following case will 
 serve as an illustration: 
 
 " The patient, a young, well-nourished woman, contracted syphilis 
 three months previously. Upon admission to the hospital she was found 
 to be suffering from enlargement of the inguinal glands, and had the re- 
 mains of the primary induration on the labia majora; a papulo-erosive 
 syphilide of the vulva and general roseola were present. A few days 
 
 ' Annales de dermatologie et de syphiligraphie, 1880, pp. 16 — 24. 
 
72 FUNCTIONAL NERVOUS DISEASES. 
 
 after her entrance into the hospital she was suddenly seized with two 
 convulsions, occurring in rapid succession, after which she remained 
 in a semi-comatose condition until the next morning. These two at- 
 tacks were seen by the interne, who stated that they were typical epi- 
 leptic convulsions. Upon the following day the patient had another 
 attack, which was witnessed by Fournier. There was no hereditary 
 neuropathic tendency or any other discoverable cause of epilepsy. The 
 patient was put upon the protoiodide of mercury and rapidly improved; 
 she was seen a year later, but there had been no return of the convulsions." 
 
 It has also been found in a few cases that epilepsy may result, in chil- 
 dren, from congenital syphilis. 
 
 Overexertion, whether mental or physical, is also regarded as a cause. 
 I have seen two examples of each variety. In one of the latter cases the 
 first convulsion appeared after a day's tramp of forty miles on the West- 
 ern prairies; in the other, the first attack came on after the patient, a 
 girl of sixteen, had run a considerable distance, and was tired and over- 
 heated in consequence. 
 
 In one case the disease was distinctly traceable to excessive smoking. 
 The patient was a man, get. 45 years, in whom not the slightest evidences 
 of a neuropathic family history could be discovered. The patient himself 
 has, however, been of a very nervous disposition since arriving at man- 
 hood. He has always been a very steady smoker, and for six months 
 prior to his first convulsion, which occurred in September, 1876, indulged 
 excessively in his favorite habit, especially on Sundays, upon which day 
 he smoked continuously from morning until night. From the occurrence 
 of the first fit until the patient came under my notice (June, 1878), he 
 had had ten attacks, all of which occurred on Sunday evenings. I placed 
 the patient on fifteen-grain doses of bromide of potassium, and only per- 
 mitted him to smoke three pipes daily. Under this treatment the fits 
 disappeared until the autumn of 1879, when he had another convulsion. 
 Upon inquiry, however, I discovered that he had discontinued the medi- 
 cine for a month previously, and had, at the same time, increased his al- 
 lowance of tobacco. A renewal of the treatment, and a diminution in the 
 amount smoked, has again resulted in a cessation of the attacks until the 
 present time (July, 1880). 
 
CHAPTER III. 
 
 PATHOLOGICAL ANATOMY. 
 
 TnE pathological anatomy of epilepsy is extremely unsatisfactory, and 
 can be disposed of in a very short space of time. 
 
 The most varied lesions have been found affecting all parts of the 
 brain, not alone the membranes and substance of the brain, but also the 
 bones of the skull. The latter are usually thickened and the dipioe has 
 disappeared, but, in rarer cases, the bones are abnormally thinned. I 
 have found these appearances in the most varied forms of insanity, 
 whether they were complicated with epilepsy or not. Sometimes exos- 
 toses are observed in various parts of the skull, and I have reported a 
 well-marked case of this kind in the chapter on etiology. Considerable 
 stress has been laid on stenosis of the foramen magnum, as this anomaly 
 has been observed in quite a number of cases. 
 
 Lasegue ' has recently claimed that epilepsy is due to a malformation 
 or vice of consolidation of the bones which form the base of the skull. 
 According to him, this malformation is indicated by the following char- 
 acteristic appearances : the frontal protuberance is usually much more 
 marked on the right side than on the left ; there is a corresponding pro- 
 jection of the malar bone ; the face is rotated, the osseous line of the 
 palate deviates from the median line of the body ; deformity of the arch 
 of the palate ; lowering or raising of one of the orbits ; one side of the 
 face is sunken, corresponding to the projection of the other. In confir- 
 mation of his views, Lasegue states that epilepsy usually begins from the 
 twelfth to the eighteenth years, a period which corresponds to that of the 
 consolidation of the bones of the base of the skull. 
 
 Garel,* who also investigated this topic, found fifty-two cases of facial 
 asymmetry among ninety-four epileptics, or SSyVo P^r cent. Among 
 ninety-four cases of non-epileptics taken indiscriminately, he found 
 thirty-eight cases of facial asymmetry, or 40y\2„- per cent. The difference 
 between epileptics and non-epileptics in this respect is, therefore, too 
 small to entitle the as3'mmetry to be looked upon as a cause of the disease. 
 
 The cerebral meninges sometimes present the evidences of chronic 
 meningitis, and at times they are entirely normal. I have found inflamma- 
 tion of the dura mater (pachymeningitis) in several insane epileptics, and 
 in one of them, who died in the status epilepticus, the membrane on the 
 dura mater was sufficiently thick to produce compression of the frontal 
 and parietal lobes on the right side of the brain. I have, however, 
 found similar pachymeningitic exudations in other insane patients who 
 had never suffered from epilepsy, as well as in sane individuals who have 
 had the most various diseases. 
 
 The examinations of the structure of the brain itself has likewise led 
 
 1 Bulletin de I'Acad. de Mcdecine, 1877. 
 ' Lyon Medical, Jan. 6, 1878. 
 
74 rUNCTIONAL NERVOUS DISEASES. 
 
 to various results. In perhaps the majority of cases no abnormal appear- 
 ances have been observed. Schroeder van der Kolk,' to whose researches 
 great importance has been attached, sums up the results of his investiga- 
 tions as follows : 
 
 "In the commencement of epilepsy it would seem that no apparent 
 organic change exists. Rapidly, however, probably in consequence of 
 the repeated congestion, the presence of a more albuminous cellular fluid 
 between the nervous filaments is manifested, which may first cause more 
 or less hardening, and may subsequently give rise to fatty degeneration 
 and softening. In addition, dilatation of the arterial capillaries and 
 thickening of their walls ensue." 
 
 " These blood-vessels in the medulla oblongata run chiefly in the region 
 of the roots of the hypoglossus and vagus, as well as in the septum and 
 corpora olivaria. The posterior half of the medulla oblongata from the 
 fourth ventricle, in epileptic subjects, appears, on a transverse section, 
 redder and more hyperaemic than in the normal state, whether the suffer- 
 ers died during an attack or not." 
 
 " In epileptics who bite the tongue during the fit, the capillary ves- 
 sels are usually wider in the course of the hypoglossus and corpora oliva- 
 ria ; in those who do not bite the tongue they are wider in the course of 
 the vagus." 
 
 Echeverria substantiated the results of Van der Kolk's investigations, 
 and, in addition, found even more advanced lesions. In the medulla 
 oblongata, he observed granular cells, an increase in the number of amy- 
 loid bodies, and pigmentation of the ganglion cells, especially in the nu- 
 clei of the hypoglossal and pneumo.gastric nerves ; hyperplasia of the 
 connective tissue was also noticeable. He also observed similar lesions 
 in various portions of the convolutions of the brain, but while they were 
 sometimes absent in these localities, they were invariably present in the 
 medulla. 
 
 Echeverria also found the following changes in the cervical sympa- 
 thetic, which he considers characteristic of the disease : the ganglion 
 cells were broken up, shrunken, or infiltrated with brownish colored gran- 
 ules, which concealed the nuclei.' The cells were atrophied from the 
 pressure caused by the increase of slender, nucleated, transparent fibres, 
 fatty graniales, and amyloid corpuscles. Many of the nerve-fibres had 
 lost their contents, so that nothing was left but the sheaths ; in others 
 the fibres had become granular ; the tubes, which were destitute of axis 
 cylinders, contained numerous oval nuclei. 
 
 Ludwig Mayer, who made careful investigations "with regard to these 
 points, has found all these changes in other cerebral diseases, and regards 
 them as secondary to the frequent recurrence of circulatory disturbances. 
 I have made no investigations with regard to the occurrence of such 
 changes in the medulla, but I may state that I have frequently found 
 these lesions in different parts of the cerebral convolutions in various 
 forms of insanity, and have always regarded them in such cases as second- 
 ary to chronic cerebral congestion. 
 
 It is very evident, therefore, that these lesions are not the causes, 
 but rather the effects of epilepsy. 
 
 ' On the Minute Structure and Functions of the Spinal Cord and Medulla Oblongata, 
 and On the Proximate Cause and Rational Treatment of Epilepsy, 1859. 
 
 ' Labiraoff states that pigmentation of the ganglion cells is habitually found in older 
 people, and is not infrequent even in the young. 
 
EPILEPSY. 75 
 
 Epilepsy may also be secondary to any localized aiTections in the brain, 
 such as tumors of the meninges or brain tissue, hemorrhages, softening 
 from various causes, abscesses, cysts, etc. Tumors of the dura mater and 
 cortex play an important part in this connection. 
 
 There is no doubt, therefore, from this brief resume of the results of 
 the anatomical investigations with regard to this disease, that there is no 
 pathological anatomy of epilepsy. All the numerous changes which have 
 been observed are either secondary lesions or they shed no light upon the 
 real cause of the affection. We are also inclined to believe tiiat the path- 
 ological anatomy of the future will not add much to our knowledge, or 
 rather, will not dispel our ignorance concerning the disease. It appears 
 to us, in view of the perfection to which modern histological methods 
 have arrived, and of the numerous and careful investigations which have 
 been made by enthusiastic observers, that some positive results should 
 have been reached, if they are within the range of possibility. Perhaps 
 it will be left for the physiological chemist, to whose domain so many 
 other pathological questions will be relegated, to discover the true essence 
 of the disease. But our ignorance on this point should not daunt us in 
 the search of a curative remedy. Our art pre-eminently is or should be 
 a healing one, and it is far better to grope blindly and empirically for 
 better therapeutic agents, than it is to fold our arms in despair until the 
 anatomist has informed us what the lesion really is. 
 
 Pathology . — Numerous experimental investigations have been made 
 in order to shed some light upon the pathology of epilepsy, but opinions 
 are still at variance on this point. Some authorities locate the primary 
 lesion in the convolutions of the brain, others in the pons and medulla. 
 
 Kussmaul and Tenner first showed, by experiments on the lower ani- 
 mals, that anosmia of the brain will give rise to loss of consciousness and 
 general convulsions (at first tonic, then clonic). They concluded, from 
 their experiments, that the primary disturbance was situated in the 
 medulla oblongata (which is now known to be the site of the vaso-motor 
 centre), and that irritation of the medulla gave rise to spasm of the cere- 
 bral vessels, anaemia of the organ, and consequently produced loss of con- 
 sciousness and convulsions. From the result of his anatomical investiga- 
 tions, Schroeder van der Kolk was also led to look upon the medulla ob- 
 longata as the site of the disease. 
 
 Brown-Sequard has made numerous experiments on the artificial pro- 
 duction of epilepsy in animals, especially in guinea-pigs. He showed 
 that the disease develops in these animals after various injuries to the 
 nervous system, such as division of peripheral nerves, incision of the col- 
 umns of the spinal cord, etc. AVithin a month to a month and a half after 
 the experiment, the first attack of epilepsy usually develops. After this 
 they may occur spontaneously or upon irritation of the so-called epilepto- 
 genic zone, which includes the cheek and anterior portion of the neck. 
 Brown-Sequard also made the curious observation that the young of guinea- 
 pigs, who have been made epileptic in this manner, may develop the dis- 
 ease spontaneously. These experiments have been repeatedly verified by 
 Schiff, Westphal, and numerous other observers. Westphal also showed 
 that similar results may be obtained by striking the animals gently upon 
 the head; in these cases, he found small hemorrhagic extravasations in 
 the medulla oblongata and upper portion of the cervical cord. 
 
 Still later, Nothnagel ' showed that the " convulsive centre " for the 
 
 • Virchow's Archiv. Bd. XLIY. 
 
76 FUNCTIONAL NERVOUS DISEASES. 
 
 muscles of the entire body is situated in the pons varolii. The theory 
 mentioned above was then modified in view of the results of Nothnagel's 
 investigations. This author believes that " the irritation of the vaso- 
 motor centre and of the centre for the muscles (convulsive centre) is co- 
 ordinate," and that one of these parts may alone be irritated. In this 
 manner he explains the variations in the character of the epileptic seizures. 
 Thus, irritation of the convulsive centre alone would give rise to convul- 
 sions unattended by loss of consciousness (as in the case mentioned on 
 page 49), while irritation of the vaso-motor centre would produce loss of 
 consciousness or psychical disturbances, according as the secondary cere- 
 bral anaemia affects the entire convolutions or only certain portions. 
 
 This view presupposes an abnormal irritability (in many cases of a 
 congenital nature) of the pons and medulla. 
 
 The English school of investigators, following the lead of J. Hugh- 
 lings Jackson, have formulated a different hypothesis. Jackson, in an 
 article published in the " West Riding Reports for 1873," states that " de- 
 fined from the paroxysm, epilepsy is a sudden, excessive, and rapid dis- 
 charge of gray matter of some ^:»a?*^ 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 therefore occasionally ' explodes.' The two 
 definitions are different faces of the same thing." Since the publication 
 of this article, Jackson ' advanced the opinion that the cells of the brain 
 suffer secondarily in epilepsy as a consequence of arterial disease, and that 
 there is thrombosis or embolism of small arteries in most cases. 
 
 According to this theory, the nerve-cells are in a condition of unstable 
 equilibrium (attributed by some to excessive, by others to deficient nutri- 
 tion), and the phenomena of epilepsy are due to the sudden and violent 
 action of these cells, i. e., to the sudden liberation of nerve-force. 
 
 The various modifications in the phenomena observed during a 
 paroxysm are supposed to be due to the location of the nerve-cells which 
 are thus affected. 
 
 Probably the strongest argument in favor of the theory that the " dis- 
 charge " begins in the convolutions is found in the fact that so many 
 epileptics present a special sense or even intellectual aura, which could 
 not have been produced by any functional disturbance of the pons varolii 
 or medulla, but must be attributed to a " discharge " of the higher cen- 
 tres, viz., the convolutions. 
 
 Gowers claims that the hypothesis of vaso-motor spasm is unneces- 
 sary, as all the phenomena can be explained by the discharge of gray 
 matter. 
 
 There is no doubt that all the symptoms of epilepsy may be inter- 
 preted in the light of Jackson's theory, but his views are, after ail, mere 
 matters of speculation, and we shall, therefore, forbear from their further 
 consideration. 
 
 ' Lancet, Jan. 35, 1879. 
 
CHAPTER lY. 
 
 ' DIAGNOSIS AND PROGNOSIS. 
 
 In chronic cases of grand mal, in which there is a history of repeated 
 typical epileptic convulsions, occurring- spontaneously and not accom- 
 panied by any other cerebral symptoms, the diagnosis is evident at the 
 first glance. But mistakes are readily made, even in cases of grand mal, 
 when the convulsions occur only at night. Nocturnal incontinence of 
 urine in the adult should always arouse our suspicions in this direction. 
 If, in addition, the patient complains of being worn out in the morning 
 and feeling "as if he had been working all night," if the tongue feels 
 sore and the pillow is stained with a little blood, or if a petechial erup- 
 tion is found in various portions of the face, especially around the outer 
 angles of the eyes — when all these symptoms are combined, the testi- 
 mony in favor of nocturnal epilepsy is very strong indeed. In cases of 
 this nature, we should always direct the patient to sleep with a com- 
 panion, so that we may obtain positive evidence of the existence of the 
 disease. In exceptional cases of this kind we may thus be able to deter- 
 mine the presence of epilepsy in individuals in whom it had not been 
 suspected. 
 
 If a patient gives a history that he has suffered some contusion or 
 injury during his sleep and was entirely unaware of any accident, careful 
 examination should also be made. Trousseau mentions a case in which 
 dislocation at the shoulder-joint occurred twice at night, the patient 
 being ignorant of the accident until he awoke in the morning. Basing 
 his opinion on these facts, Trousseau made a diagnosis of nocturnal epil- 
 epsy, and other details which were then communicated by the patient 
 dissipated all further doubt. 
 
 Sometimes we are called upon to differentiate real from feigned epi- 
 lepsy. When the malingerer is intelligent and has closely observed the 
 disease, it may be very difficult to detect the simulation. Thus Trousseau 
 relates, in his lecture on epilepsy, that Calmeil simulated an epileptic 
 convulsion so perfectly in Esquirol's presence, that the latter thought the 
 attack was real. Dr. Gorton, of the State Asylum for Insane Criminals, 
 informed me that he had under his care a thief who feigned epilepsy so 
 well that a number of London hospital physicians were deceived. As a 
 rule, however, the deception is readily detected with a little care. An 
 individual feigning epilepsy usually finds a soft spot to fall upon, pallor 
 of the face does not develop, the pupils are not dilated, the reflexes are 
 preserved, the face does not become so dusky during the clonic stage, 
 and the attack is not followed by coma ; general sensation is well pre- 
 served, and the patient reacts upon a sufficiently powerful stimulus. 
 Yoisin regarded the changes in the sphygmographic tracings of the 
 pulse during an attack as pathognomonic, but further investigations have 
 disproved this statement. In determining whether a convulsion is 
 
At 
 
 78 FUNCTIONAL NERVOUS DISEASES. 
 
 feio-ned or real, we should be guided by tlie tout ensemble of the symp- 
 toms, and not by the presence or absence of a single one. A great deal 
 •will depend upon the quickness of observation and the judgment of the 
 physician. 
 
 The diagnosis of petit mal is much more difficult than that of the 
 grand or haut mal. When the two forms are combined, petit mal is 
 readily recognized on account of its combination with well-marked con- 
 vulsive seizures. But when the former variety alone occurs, its true sig- 
 nificance is frequently overlooked, and it is often mistaken for simple 
 svncope or vertigo. Petit mal is often preceded by an aura, and this 
 should always be inquired into very carefully, as it is a very important 
 sio-n. Furthermore, the attack may occur in a patient who is otherwise 
 in perfect health, and in whom no cause for syncope can be discovered ; 
 the former is also often accompanied by inarticulate muttering, and, if 
 the individual is closely watched, slight convulsive twitchings may be no- 
 ticed in the face or hands. 
 
 The sufferer from petit mal is usually unconscious of the occurrence of 
 the " weak spell" and, if not told by those around him, might have a con- 
 siderable number of attacks without becoming aware of it. Upon close 
 inquir}', we may discover that the patient's memory is failing, that his in- 
 tellectual powers are not up to their normal condition, and perhaps that 
 another member of the family has suffered from epilepsy or some other 
 severe neurosis. 
 
 Quite a large number of cases have come under my observation in 
 which this affection had been entirely overlooked, and we are convinced 
 that the profession is not by any means fully alive to the frequency or 
 gravity of this form of epilepsy. The following case will show how 
 readily the nature of the disease may be misconstrued, as it was only 
 by a mere accident that I was led to recognize its true character. 
 
 A young woman, fet. 22 years, consulted me with reference to an 
 angina pectoris which had lasted for four years. She complained of 
 attacks, occurring at irregular intervals, during which she had severe 
 shooting pains in the prjecordial region, radiating thence into the left 
 arm; this was accompanied by dyspnoea, great dread, and a feeling as 
 if the heart had stopped beating. At the termination of these symptoms, 
 which only lasted a couple of seconds, the patient would faint away. 
 Upon obtaining this history, I made a careful physical examination of the 
 heart, but the results were entirely negative. I then questioned the patient 
 with regard to the condition of the uterus, thinking that the angina was 
 perhaps the reflex result of irritation of that organ. She gave a history 
 of profuse leucorrhoea, menorrhagia, and severe pain in the back, I then 
 proceeded to make a vaginal examination, but my finger had no sooner come 
 in contact with the os uteri, than the patient became perfectly rigid, and 
 did not answer me when addressed. Upon touching the cornea no re- 
 sponse was elicited, the respirations ceased, the pulse remained normal; 
 the color of the face did not change. After a period which appeared to 
 me about a minute, the patient recovered consciousness but was bewil- 
 dered for a short time. The character of the disease Avas now evident. 
 The fainting spells Avere true attacks of petit mal, and the symptoms of 
 angina pectoris merely constituted an aura. Upon questioning the patient 
 more carefully, I then discovered that she frequently had fainting spells 
 without any previous anginal seizures, and that she would fall wherever 
 she happened to be; I also learned that her memory had failed con- 
 siderably. The only cause to which I could attribute the disease was 
 
EPILEPSY. 79 
 
 mental distress arising' from the ill-treatment of herself and mother by her 
 step-father. 
 
 The recognition of the variety of peculiar attacks which we have de- 
 scribed under the heading of irregular epilepsy is often extremely difficult. 
 Their distinguishing feature consists in the fact that they usually occur 
 in patients who are also affected either with grand or petit mal, and the 
 occurrence of any group of symptoms appearing in paroxysms should 
 always arouse our suspicions under such circumstances. But, as we have 
 previously stated, the usual forms of the disease may never have occurred. 
 Important characteristics of these seizures consist in the fact that they 
 occur suddenly and spontaneously in paroxysms of variable duration; 
 that an aura may be present, that consciousness is either entirely lost or 
 at least disordered, and that no symptoms are noticeable during the in- 
 tervals between the attacks. 
 
 We should always examine carefully into the presence of any neuropathic 
 family history or of an}' of the predisposing or exciting causes of epilepsy. 
 Whether or no the symptoms described by Griesinger as epileptoid condi- 
 tions, should be included under this head will depend in great measure upon 
 the individual bias of the observer. Their epileptic character is rendered 
 more probable if the patient has previously suffered from well-marked con- 
 vulsive seizures. This must be especially taken into consideration before 
 making a diagnosis of epileptic sweating, such as we have referred to on 
 page 57, since very similar attacks frequently occur during what we have 
 termed the menopause neurosis, and evidently stand in no relation to 
 epilepsy 
 
 We are frequently called upon to distinguish epilepsy from eclampsia 
 infantum. There is nothing in the symptomatology of the convulsions 
 which will serve to differentiate the two diseases. The convulsions of 
 epilepsy, however, recur at longer or shorter intervals, usually without 
 any exciting cause, after the disease has become developed, and, as a rule, 
 only one convulsion occurs at a time. It is also important to enter care- 
 fully into the family history in order to determine whether any hereditary 
 neuropathic tendency is manifested. Eclampsia infantum follows some 
 definite exciting cause, such as dentition, intestinal worms, gastric irritation, 
 or the onset of an acute disease. Very frequently, also, the little patient 
 suffers from a series of convulsions, which follow one another in rapid 
 succession, and which may last for hours with hardly any intermission. 
 In not a few cases, however, it will be impossible to make a differential 
 diagnosis for a very long time, and in some instances this difficulty is 
 obviated by saying that eclampsia infantum, if frequently repeated, may 
 become converted into true epilepsy. 
 
 Difficulty is sometimes experienced in distinguishing the uraemic con- 
 vulsions of cirrhosis of the kidneys from true epilepsy. The urtemic 
 convulsions may occur suddenly in a patient who has apparently enjoyed 
 perfect health, and indeed several series of attacks may be repeated at 
 variable periods, although the patient appears to be well during the in- 
 tervals. There are several symptoms, however, presented by patients 
 suffering from granular kidneys, which are very characteristic and enable 
 us, with a little care, to make a correct diagnosis. In the first place, 
 various grades of hypertrophy of the left ventricle are present in all 
 cases; this usually produces no symptoms and is unnoticed by the patient. 
 The tension of the arteries throughout the body is greater than normal, and 
 is shown by increased resistance of the radial pulse. The urine is increased 
 in quantity and diminished in specific gravity. There may be a slight 
 
80 FUNCTIONAL NERVOUS DISEASES. 
 
 amount of albumen present, or the urine may be entirely free from it ; a 
 few hyaline casts are observed from time to time. The character of the 
 convulsion also differs somewhat from that of epilepsy. It is usually very 
 violent, is never preceded by an aura, and the subsequent coma may be 
 very profound and even give rise to serious alarm. Furthermore, we not 
 unfrequently find that the convulsions occur in series, during which cere- 
 bral hemorrhage may be produced. 
 
 Hysterical convulsions are usually distinguished with readiness from 
 those occurring in epilepsy. The former generally occur in young fe- 
 males, who also present other well-marked symptoms of hysteria; con- 
 sciousness is not lost during the attack, but is, at most, slightly disordered; 
 the convulsive movements do not present the same regularity observed in 
 an epileptic seizure; the patient throws herself into peculiar positions, rolls 
 around from one place to another; respiration is not so completely inter- 
 rupted, and the entire attack may last from several minutes to an hour 
 or more. 
 
 Hysterical convulsions may be very frequently repeated, but coma 
 does not often develop after these attacks. Bourneville has shown that 
 a rapid succession of hysterical seizures may be readily diagnosticated 
 from the status epilepticus (vide page 51), by the fact that the latter is 
 attended by a rapid rise of temperature, while the former is never accom- 
 panied by this symptom.* Finally, hysterical convulsions may often be 
 arrested by measures which are directed toward the imagination of the 
 patients. We must not forget, however, that epilepsy and hysteria are 
 frequently combined in the same patient, especially among the inmates of 
 an hospital for epileptics. 
 
 The epileptic seizures which occur as a symptom of cerebral syphilis 
 (gummata, vessel changes, etc.), should also be distinguished from idio- 
 pathic epilepsy. In the former disease, the patient generally gives a 
 history of previous infection with the syphilitic virus, and other manifes- 
 tations of the cerebral disorder are presented prior to the development 
 of the epilepsy. Prominent among these symptoms is intense headache, 
 which always grows much worse at night; ptosis, pupillary disturbances, 
 or paresis of various portions of the body make their appearance ; optic 
 neuritis is often present. When convulsions occur, any paresis which may 
 have been present is usually deepened into paralysis, and this may par- 
 tially disappear after a variable period. Not infrequently the convulsions 
 are at first unilateral, and we have sometimes seen them confined to one 
 limb. Unless active treatment is instituted, however, the convulsions 
 soon become general, and then differ in no respect from those of ordinary 
 epilepsy. One of the most characteristic features of this disease is its 
 curability under anti-syphilitic remedies, though, unless treatment is be- 
 gun soon after the first cerebral symptoms have presented themselves, 
 there is great danger of a relapse. It is also important to remember 
 that these manifestations of syphilis generally make their appearance 
 after the age of thirty, so that this fact should always put us on our 
 guard. 
 
 Epilepsy offers, on the whole, a very gloomy prognosis, and some phy- 
 sicians have even gone so far as to deny its curability in any case. This- 
 is, however, not true, as a very small percentage of cases appear to re- 
 cover spontaneously. 
 
 ' As previously mentioned, I have observed a case of status epilepticus in which 
 no rise of temperature occurred. 
 
EPILEPSY. 81 
 
 It must be remembered that the convulsions may run a very irregular 
 course, and a case should, therefore, not be regarded as permanently cured 
 unless at least three years have elapsed since an epileptic seizure has oc- 
 curred. 
 
 In a considerable number, perhaps a majority, of the cases, the fre- 
 quency and severity of the fits may be very materially diminislied, and in a 
 few they will entirely disappear. The chances of recovery increase ac- 
 cording as the disease is due to some definite, removable cause, as in cer- 
 tain cases of reflex epilepsy. The duration of the disease prior to begin- 
 ning treatment is also of importance, the chances of recovery being 
 greater the earlier the affection is recognized and treated; it is generally 
 supposed that, if the patient has already had 100 convulsions before the 
 treatment is begun, the prognosis is very poor; if as many as 500 have 
 occurred, there is not the slightest chance of recovery. 
 
 The prognosis is somewhat better when the disease begins early in 
 life, than if it develops during manhood. An hereditary influence decid- 
 edly lessens the patient's chances, and cases of this kind are also more 
 liable to become complicated with mental disorders. It is still undecided 
 whether the grand or petit mal is the more curable. Judging from my 
 own experience, I am inclined to believe that the latter form is more sus- 
 ceptible of improvement than the former. I have also begun to entertain 
 considerable doubt in the general belief that petit mal is more apt to be 
 attended with psychical disorders than the grand mal. 
 
 Those patients in -whom epileptic mania has developed usually go from 
 bad to worse, and generally terminate eventually in dementia. Never- 
 theless, I have seen several cases in the young in whom a return to a nor- 
 mal condition of intellect was effected, although the patients had suffered 
 from considerable mental disturbance. 
 
 The prognosis as regards life is excellent, and death only occurs in ex- 
 ceptional cases from an accident during the convulsion, such as suffoca- 
 tion, drowning, fracture of the skull, cerebral hemorrhage, etc. When 
 the status epilepticus develops, however, a fatal termination is not infre- 
 quent either in the convulsive or meningitic stage. But these cases are 
 comparatively rare. 
 
 In some cases, an example of which is shown in the following history, 
 a fatal result follows, although the cause of death remains unknown or is 
 very obscure: 
 
 Case XIII. — Anne C, vet. 26 years, single, no hereditary taint discover- 
 able. The patient was always of a nervous temperament, but in tolerably 
 fair health, until five years ago. At that time she obtained extremely 
 little sleep for a period of five months (was acting as a nurse). The first 
 epileptic paroxvsm developed shortly afterward, and was of the nature of 
 grand mal. The attacks then made their appearance with continually in- 
 creasing frequency, the memory began to be impaired, and, finally, the 
 patient became very forgetful. When she first came under my observa- 
 tion, a marked hysterical condition was manifest. The treatment con- 
 sisted of the administration of bromide of potassium, gr. xv. t.i.d. As 
 the patient was unable to find employment on account of her condition, I 
 admitted her to my wards in Randall's Island Hospital, February 14, 1880, 
 and the dose of bromide was then increased to gr. xxx. t.i.d. Soon after 
 admission, the hysterical symptoms became aggravated, and the patient 
 (who was a Protestant) began to suffer from the delusion that the nurse 
 and the Catholic patients in the ward were abusing and persecuting her. 
 6 
 
82 FUNCTIONAL NERVOUS DISEASES. 
 
 At intervals she refused food, stating that an attempt was being made 
 to poison her. On several occasions she attempted to run out of the hos- 
 pital in her night-gown, and sometimes used violence toward the other pa- 
 tients. She gradually became more morose and listless and finally took to 
 bed (March 20th). After this she lay in a stupid condition, interrupted on 
 one occasion by an attack of excitement, during which she attempted to 
 get out of bed, and struck an attendant. She then refused food during 
 an entire week (for fear of being poisoned), and was fed by means of 
 rectal enemata. The patient gradually sank and died April 8, 1880. 
 
 Autopsy — held by the curator, Dr. Habirshaw. Brain. — On the in- 
 ferior portion of the right occipital lobe was a small patch of enlarged 
 vessels, presenting the appearance of minute hemorrhages. The pia 
 mater was slightly roughened over the vertex and adherent in some 
 places; the interior of the brain, including the ganglia, was congested. 
 Lungs. — The lower lobes of both lungs contained a few lobules of catar- 
 rhal pneumonia of various sizes, attended with hypostatic congestion; 
 some of the bronchi contained thick pus. 
 
 Neither the morbid appearances in the brain or lungs were sufficient 
 to account for the symptoms. Another case of a very similar nature, and 
 also attended with a fatal result, has come under my observation. In this 
 instance I was unable to obtain an autopsy. 
 
CHAPTER V. 
 
 TREATMENT. 
 
 Many authorities regard the disease as entirely incurable, and do not 
 even attempt to treat it, while others have recorded a large proportion 
 of successes. In our opinion, the truth lies midway between these two 
 extremes. 
 
 One of the most important points to be remembered is that every 
 case must be treated by itself; that we must treat the patient, not the 
 disease. In pursuance of this object, we should, if possible, ascertain 
 the etiology of the affection. In a large proportion of cases this is im- 
 possible, and in others the cause cannot be removed, even when known. 
 But in a certain number, especially in reflex epilepsy, the cause cannot only 
 be determined but can also be readily made to disappear. It is unneces- 
 sary for me to refer again to these etiological factors, as they have been 
 discussed in extenso in the section on etiology, and their treatment be- 
 longs partly to surgery, partly to other branches of medicine. The 
 treatment of diseases of the ear, throat, chest, genital organs, etc., which 
 act as causes of the epileptic seizure, is similar to that usually resorted 
 to in such affections. The prominence which has been attached to 
 trephining for injuries of the skull which have acted as causes of epi- 
 lepsy, requires that we should enter into this subject somewhat more 
 fully. There is no doubt that the advocates of trephining for epilepsy 
 have entertained exaggerated views with regard to the influence of in- 
 juries of the skull, in the production of the disease. Among 3,000 cases 
 of epilepsy, Althaus did not find a single one which presented fracture 
 of the cranial bones, with depression of the skull. Several cases have 
 come under my notice in which the disease was supposed to be due to 
 injury of the skull, although careful inquiry showed no grounds for this 
 assertion. As we have before remarked, the statements of patients or 
 their relatives with reference to etiology should always be subjected to 
 careful scrutiny before being accepted. In examining the favorable 
 statistics with regard to the effects of trephining which have been 
 advanced by several writers, we must take into consideration the fact 
 that, as a rule, the unfavorable cases are not reported, and furthermore, 
 that a considerable proportion of the favorable ones have been published 
 within a few months after the operation, at a period, therefore, in which 
 it is unwarrantable to draw any conclusions with regard to the final 
 result. 
 
 On the whole, therefore, we should not advise the performance of 
 trephining, unless the epilepsy evidently followed an injury to the skull, 
 which was accompanied by distinct fracture of the bones, with depres- 
 sion. If irritation of the injured part is capable of producing a con- 
 vulsion, the indications for the operation are rendered much stronger. 
 
 In cases of syphilitic epilepsy, the indications for treatment are very 
 clear. When the convulsions occur during the early secondary stage, 
 
84 FUNCTIONAL NEKVOUS DISEASES. 
 
 as in the form recently described by Fournier, mercurial treatment i» 
 alone required. When the attacks occur during the tertiary stage, and 
 are either svie materia, or form part symptom of other manifestation* 
 of cerebral syphilis, iodide of potassium should also be administered in 
 combination with mercury. If the disease has not lasted too long, the 
 prognosis is very good, but we cannot afford to use the drug in homoeo- 
 pathic doses. I usually administer the mercurial separately from the 
 iodide, as the latter must be increased very much more rapidly than the 
 former. The iodide of potassium is first given in fifteen-grain doses- 
 three times a day, from one-twenty-fourth to one-sixteenth of a grain of 
 the bichloride of mercury being exhibited at the same time. In a week^ 
 the quantity of iodide may be increased by half, and if a fit has occur- 
 red in the interim, the dose may be doubled. The quantity is gradually 
 increased in this manner until the iodide eruption makes its appearance or 
 the stomach begins to revolt. If this quantity succeeds in preventing the 
 occurrence of the fits, the amount is slightly reduced, and the patient held 
 at this dose. If the attacks continue, the quantity of iodide administered 
 should be increased until, if necessary, half an ounce, or even an ounce, is- 
 taken per diem. When such large amounts are administered, I usually 
 order thirty grains of subnitrate of bismuth, with five or ten grains of the 
 bicarbonate of soda, to be taken before each dose of the iodide, in order 
 to counteract the irritating effects of the latter upon the gastric mucous 
 membrane. These patients often suffer from violent headache. In such 
 cases, frequently repeated blisters, applied to the nape of the neck, prove 
 very serviceable; in others resort may be had to the use of the actual 
 cautery, but I have not derived so much benefit from this measure as 
 from the application of blisters. 
 
 One great drawback against which we have to contend in these 
 patients is owing to the fact that they are apt to discontinue the remedy 
 as soon as the fits have ceased for a couple of months. This is a great 
 mistake, and I always make it a rule to forcibly impress upon my patient 
 the necessity of continuing treatment for a year and a half or even 
 two years after the last fit occurred. A patient who has, at any time, 
 had manifestations of cerebral syphilis, is always liable to a relapse, and 
 this can only be prevented by the long-continued and faithful use of the 
 iodide. We must also bear in mind that the quantity to be administered 
 is not regulated by the dose laid down in the materia medica, but by the 
 effect produced upon the patient. 
 
 When the attacks are due to excessive sexual intercourse, or to 
 masturbation, such practices must, of course, be interdicted. But while 
 the former cause can be easily removed in the majority .of cases, the 
 latter desideratum is not so readily obtained. If the masturbator, usual- 
 ly a child, has a narrow prepuce which is causing irritation of the glans, 
 it should be circumcised, and I have recently had a case in which the 
 fits have remained absent for the last four months since the operation, 
 no other treatment having been adopted. In girls, in whom no local 
 treatment can be employed, we can only resort to careful watching of 
 the patient by the relatives. I also usually recommend that the patient 
 be compelled to sleep with an adult, as I have found that many of the 
 little patients Avill masturbate as soon as they get warm in bed. In those 
 rare cases in which the attacks develop during coitus, tlie performance of 
 the sexual act must, of course, be strictly prohibited. 
 
 But, as we have shown in the chapter on etiology, in the majority of 
 cases the cause is either unknown or is of such a nature that it cannot 
 
EPILEPSY. 85 
 
 be relieved either by surgical or medical measures. We must also re- 
 member that a considerable proportion of the cases of reflex epilepsy only 
 come to us for treatment several years after the cause first began to ope- 
 rate, and that, in many of these patients, the epilepsy has acquired an 
 independent existence, and will not disappear, even though the original 
 cause be successfully removed. In the large majority of cases, therefore, 
 we can only treat the disease symptomatically. 
 
 The treatment of epilepsy may be divided into two parts, viz. : the 
 use of general and medicinal remedies. We shall first study the former. 
 
 There is a widespread notion in the profession, as well as among the 
 laity, that epileptics must be kept idle; that they should not be allowed 
 to do either any mental or physical labor. This view is undoubtedly er- 
 roneous. With regard to mental exercise, there is no doubt that the ten- 
 dency of the disease itself is to produce deterioration of intellect, and 
 this mental infirmity will be increased by allowing the patients to grow 
 up uneducated. It is true, however, that excessive mental work will ag- 
 gravate tlie frequency of the occurrence of the fits. In fact there are 
 some patients wiio only have a convulsion after they have undergone 
 some severe or prolonged mental strain. Continued reading is especially 
 injurious to epileptics. But we must not fall into the other extreme, and 
 debar them from all reading. It is, indeed, not alone not injurious to 
 allow them to read, attend lectures, amusements, etc., but it is even bene- 
 ficial when confined within proper limits. Such a course of conduct 
 tends to preserve the mental tone of the patient and to divert his atten- 
 tion from his malady, which is, otherwise, always uppermost in his mind. 
 
 This practice also tends to prevent the patient from continuing the 
 habit of masturbation, which, when it once gains the upperhand in an 
 epileptic, has a bad influence upon the frequency of the attacks. 
 
 These remarks will also apply to manual labor; the patients usually do 
 well with a proper amount of johysical exercise. Of course this must not 
 be excessive. In some of my dispensary patients I have frequently seen 
 the fits increased in frequency to a terrible extent, and, upon inquiry, 
 have found that this could be attributed to overwork, and that their 
 number immediately diminished when the character of the work was 
 •changed. 
 
 When patients, whether male or female, have become epileptic at the 
 age of puberty, marriage is frequently advised by the physician in attend- 
 ance. The theory on which this advice is based, appears to be that the 
 epilepsy is due to some unknown derangement of the sexual system, and 
 that this will disapppear in consequence of the regular performance of 
 the sexual act. A few cases are on record which appear to substantiate 
 this view, but they are very exceptional. It must also be remembered 
 that, even in some of these cases, although the epilepsy disappeared in 
 the parent, it reappeared in the offspring. 
 
 But the majority of writers are opposed to the marriage of epileptics. 
 In Denmark this matter has become the subject of legislative interfer- 
 ence, and the fact that one party to a marriage was an epileptic prior to 
 the marriage, without the knowledge of the other, constitutes a valid 
 ground for divorce. We believe that this is, theoretically, the proper 
 plan to pursue. Even if we hold that marriage will prove curative of the 
 affection, the risk which the parent runs of transmitting this terrible dis- 
 ease to the offspring is so great that he should be warned against mar- 
 riage. Although there is no legislation on the subject in this country, 
 the medical profession can do a great deal toward preventing such alii- 
 
86 FUNCTIONAL NERVOUS DISEASES. 
 
 ances. In the event that our advice in this respect is disregarded, as it 
 so frequently is, it becomes a grave question whether it is not our moral 
 duty to override the letter of the code, and inform the other partner in 
 the projected marriage of the actual state of affairs. 
 
 If the general condition of the patient is below par, the ordinary tonic 
 remedies, such as iron, quinine, cod-liver oil, etc., should be administered. 
 Some authors have discountenanced the use of iron in this disease, be- 
 cause it tends to produce plethora. In order to test the truth of this 
 statement, I have often given iron, not alone to anaemic epileptics, but 
 also to those Avho were in excellent general health. I have yet to find 
 any bad effects from its administration. 
 
 Opinions vary with regard to the diet of epileptics. The notion has 
 become prevalent among the laity, and is even widespread among phy- 
 sicians, that nitrogenized food should be sparingly partaken. 
 
 Thus, Hughlings Jackson advises that epileptics should not eat much 
 nitrogenized food, nor, indeed, much of any kind of food, basing his opin- 
 ion on the view that the nervous tissues in this disease are over-nourished 
 with regard to quantity. 
 
 Dr. Merson,' who made some extended observations on this question, 
 arrived at the following conclusions: "In a considerable number of 
 those who took nitrogeneous food during the first month, it was observed 
 that soon after commencing that diet they became much more dull and 
 stupid than they had previously been, would sit in a dreamy, listless 
 manner for a great part of the day, were very slow and languid in their 
 movements, and took little notice of what was going on around them. 
 No relation was traced between it and the recurrence of 
 the fits. As soon as the diet was changed to the farinaceous, it was 
 remarked that the condition of hebetude began to pass off, and in some 
 of the cases the change was very remarkable. The improvement in the 
 mental condition was not always accompanied by any marked diminution 
 in the number of fits." Merson continued his experiments for two 
 months, and found a slight decrease in the number of fits in a large pro- 
 portion of the patients who were kept on a farinaceous diet, but the dif- 
 ference was not very marked. 
 
 The results obtained by this experimenter are not decided enough to 
 be very convincing. My own experience leads me to believe that it is 
 unnecessary to limit the quantity or quality of the food, with the excep- 
 tion that all heavy, indigestible substances are to be avoided, as well as 
 strong tea or coffee. The use of spirituous liquors should also be care- 
 fully interdicted. 
 
 We now turn to the medicinal agents which are employed to combat 
 the disease itself. The number of drugs which have been used in the 
 treatment of epilepsy is legion, and a couple of pages could be filled 
 with their mere enumeration, I shall, however, only mention those 
 which have proven useful in my own practice. In considering the 
 remedial effects of any agent in this disease, we must bear in mind that 
 any change is apt to prove beneficial for a time. Thus, if the adminis- 
 tration of one drug is stopped and another is substituted for it, the 
 number of fits will be frequently diminished for several weeks or even 
 months, after which they resume their former frequency. 
 
 Bromide of potassium is by far the most potent of all remedies. 
 Various other bromides (sodium, ammonium, etc.) have been employed 
 
 ' West Riding Lunatic Asylum, Med. Rep. V., 1875. 
 
EPILEPSY. 87 
 
 in preference, but I have never seen them succeed where the potash salt 
 failed. It produces a considerable amount of improvement in the major- 
 ity of cases, in others it is entirely useless, and in a few its administra- 
 tion must be discontinued, as the patients grow steadily worse. I have 
 found that the latter event is more apt to occur in cases of nocturnal 
 epilepsy or in petit mal. The character of the fits often changes under 
 the influence of this drug. As an indication of improvement, we some- 
 times find that the aura alone develops at times, the convulsions remain- 
 ing absent. Exceptionally, I have also noticed that in cases in which the 
 convulsions had previously occurred without an aura, the latter symptom 
 developed under the influence of the bromides. The mental symptoms 
 also undergo improvement ; the irritable temperament may disappear, 
 the dull, stupid expression vanishes, and the patients may acquire a 
 greater interest in the affairs going on around them. 
 
 The manner in which the drug is administered must be carefully reg- 
 ulated. When benefit is derived from this remedy it should be continued 
 uninterruptedly for years, and I always make it a rule to administer it 
 for at least two years after the last convulsion has occurred. The initial 
 dose is fifteen grains, t.i.d., taken preferably on an empty stomach 
 (about three hours after meals), and in plenty of water. When the 
 stomach is dainty, it may be combined with a little bicarbonate of soda 
 and a simple bitter. Dr. E. C. Seguin advises its administration in 
 Vichy water, and I can also recommend this plan as very satisfactory. 
 In cases of nocturnal epilepsy a double dose should be taken at night. 
 The quantity administered should be gradually increased until slight 
 bromism is produced (irritability of the stomach, acne eruption, anaes- 
 thesia of the pharynx and velum palati, fetid breath, feeble pulse, drow- 
 siness). Different patients vary greatly in this respect, and I have some- 
 times given three drachms daily for several weeks at a time before any 
 symptoms of bromism became apparent.' When these symptoms develop, 
 the quantity administered must be diminished, or the drug entirely with- 
 held for a few days. My own experience is corroborative of that of Dr. 
 Seguin who found that the acne-eruption of bromism may be held some- 
 what in check by the administration of small doses of Fowler's solution. 
 After the bromism has subsided the remedy is continued in somewhat 
 smaller doses for a few months, at least, before it is renounced as useless. 
 The patients should be strongly impressed with the idea that, under no 
 consideration, should the bromide be discontinued, unless under the 
 advice of the physician. If patients, who formerly had a number of fits 
 per week, go several months without a convulsion, they often consider 
 themselves cured, and omit the medicine. We often find, in such cases, 
 that the fits return after a very short intermission. When very large 
 doses are required it is sometimes advantageous to combine the bromides 
 with hydrate of chloral, ten to fifteen grains of the latter being given at 
 a time. In this manner we can diminish the amount of bromide to the 
 point of tolerance by the patient, and, in some cases, the chloral appears 
 to have a special remedial action. This plan should not be continued, 
 however, for a very long time, as hydrate of chloral soon exerts a delete- 
 rious influence on the general health. 
 
 Belladonna was highly praised by Trousseau in the treatment of this 
 
 ' Three cases have come to my notice in this city, in which death was due to over- 
 doses of bromide of potassium ; the condition of the patients should therefore be 
 very carefully watched when large doses are given. 
 
88 FUNCTIONAL NERVOUS DISEASES. 
 
 disease, and other observers have also reported favorable results from the 
 use of this remedy. At the present time atropia is used in preference, as 
 the alkaloid is much more constant in its effects, and the dose can there- 
 fore be graduated more carefully. My experience with it in diurnal at- 
 tacks of grand mal has not been very satisfactory; at the most I have 
 merely noticed a slight diminution in the frequency of the convulsions. 
 In nocturnal epilepsy, however, and especially in the various forms of 
 petit mal, I have derived marked benefit from this drug. It should be 
 begun in doses of ^^ grain, repeated three times a day, and gradually in- 
 creased until dilatation of the pupils occurs; it should not be pushed be- 
 yond this slight physiological effect. As an example of the rapid im- 
 provement which sometimes occurs, I may refer to the patient mentioned 
 on page 52, in whom the disease had lasted for four years before coming 
 under treatment, and who had three or four attacks of petit mal daily. 
 As soon as the patient was brought under the influence of atropine the 
 attacks disappeared, and during the entire period in which she was un- 
 der observation (upward of a year), no attacks occurred unless the drug 
 had been discontinued for a few days. The memory also improved very 
 rapidly. 
 
 Strychnia has been very little used in epilepsy, but I have sometimes 
 obtained excellent results in cases similar to those in which I employ 
 atropine, viz., in nocturnal attacks and in petit mal, especially in the 
 former. In such cases it is sometimes combined to advantage with bro- 
 mide of potassium. The dose varies from one-forty-eighth to one-thirty- 
 second of a grain three times a day, and continued uninterruptedly so 
 long as it produces good results. It possesses the advantage of acting as 
 a nerve tonic, and may be continued for a long time without producing 
 any deleterious effects on the economy. Conium is sometimes used in 
 this disease, but I have usually given it in combination with bromide of 
 potassium, when the latter does not give sufficiently good effects. The 
 dose is five drops of the fluid extract, gradually increased. The remedy 
 must be exhibited very cautiously, as some patients are very susceptible 
 to its influence, and it readily produces symptoms of poisoning. 
 
 Quite a number of metallic remedies have been employed from time 
 to time, but we shall content ourselves with mentioning two, viz.: nitrate 
 of silver and oxide of zinc. Nitrate of silver for a long time occupied a 
 prominent part in the treatment of epilepsy, and some undoubted cases 
 of recovery have occurred under its use. At the present time, however, 
 it is very rarely administered, and this is undoubtedly due, in part, to the 
 fact that patients are occasionally met whose entire integument has be- 
 come' blue from the long-continued use of the drug, while the epileptic 
 convulsions have persisted with all their original severity and frequency. 
 
 Oxide of zinc appears to be gaining more favor recently than it 
 formerly enjoyed. It is employed either alone or in combination with 
 bromide of potassium, in doses of five to ten grains, which may be grad- 
 ually increased to twenty grains. I have seen good effects from it when 
 given in both ways, but do not think that it can compare with the bro- 
 mides in efficacy. 
 
 In those cases, however, in which the bromides are useless, or the other 
 remedies mentioned above are not indicated, faithful trial should be made 
 of the zinc salt. Valerianate of zinc has also been recommended, but it 
 possesses no advantage over the oxide; in addition, it is extremely dis- 
 agreeable to the task. 
 
 Nitrite of amyl has recently come into vogue in the treatment of 
 
EPILEPSY. 89 
 
 epilepsy, especially when the convulsions are preceded by an aura. It 
 should always be used whenever the warning is sufficiently long to enable 
 the patient to inhale it before the fit begins. The dose varies from two 
 to five drops (by inhalation), and even more may be required, as some 
 patients become very quickly habituated to its effects. A convenient 
 plan consists in keeping a single dose of the amyl in thin capsules of 
 glass, which can be carried in the pocket, and crushed in the fingers as 
 required.* If the patient is too poor to afford this expense, he may keep 
 a dose of the remedy in a small glass vial, and, when he feels the fit com- 
 ing on, can pour the amyl into the palm of his hand and then inhale it. 
 By some physicians it is administered regularly in three to five drop doses, 
 t.i.d. ; I have tried this plan in a few cases, but have not derived any 
 benefit from it. When given during the aura, however, it very frequent- 
 ly aborts the attack, and in this manner may very decidedly reduce the 
 number of convulsions. Some of the patients complain that when a fit 
 does occur under such circumstances it is more than usually severe. 
 
 Nitrite of amyl has also proved of decided advantage in the treatment 
 of the status epilepticus, and, in fact, appears to be the only agent which 
 promises any chances of success in this complication. In these cases, 
 however, much larger doses are required, and as many as ten to fifteen 
 drops are often necessary. 
 
 Galvanism has recently been employed in this disease, but the major- 
 ity of observers have come to the conclusion that it is entirely useless. 
 
 ' This plan was devised, I believe, by Dr. McBride of this city. 
 
N'ETJEALGIA. 
 
 CHAPTER I. 
 
 CLINICAL HISTORY. 
 
 Neuralgia is a paroxysmal disease, and is chiefly characterized 
 (sometimes solely) by the presence of pain. This appears under peculiar 
 conditions which distinguish it from other painful affections. The parox- 
 ysm usually begins quite suddenly, although it is sometimes preceded for 
 a little while by sensations of cold, numbness, or " drawing " in the affected 
 region. Then suddenly a twinge is felt along the course of one of the 
 nerves, and instantly subsides, to be followed in a few moments by an- 
 other, and then by another, the intervals between the pains growing 
 gradually or rapidly shorter, until finally they may become almost con- 
 tinuous. Their character is variously described by different patients, 
 sometimes as shooting, darting, lancinating, boring, twisting, wrenching, 
 "as if a coal of fire were being drawn along the nerve," etc. The pains 
 are sometimes truly atrocious, and have frequently led patients to commit 
 suicide. 
 
 The paroxysm develops spontaneously, or in consequence of some very 
 trifling cause, such as a movement of the lips or cheeks while speaking or 
 eating, in trigeminal neuralgia, or a slight movement of the foot, in sci- 
 atica, etc. The pain always runs along the anatomical course of certain 
 nerves, and usually in the direction from the centre to the periphery, al- 
 though the reverse of this statement sometimes holds good. I have espe- 
 cially observed the latter state of affairs in brachial neuralgias, but I am 
 unable to explain the reason of this peculiarity. Another striking char- 
 acteristic of a large number of neuralgic affections is their periodicity. 
 In those which are due to malarial influences this is the rule, and the par- 
 oxysm of pain occurs with the same regularity as the chill of intermittent 
 fever ; it usually assumes the quotidian, sometimes the tertian type, but 
 it has never, in my experience, occured at longer intervals than on alternate 
 days. But periodicity is frequently manifested even in cases which are 
 not connected with malaria. I have noticed, however, that the paroxysms 
 are more apt to occur in such cases toward the middle or latter part of 
 the afternoon, difPering in this respect from the former variety. Periodici- 
 ty may even be noticeable when the neuralgia is due to an organic affec- 
 tion of the nerves, and I saw it so well marked in the first stages of a case of 
 cancer of the vertebrae that a distinguished physician of this city, who saw 
 the patient in consultation, at first made a diagnosis of malarial neuralgia. 
 The subsequent history of the patient, however, showed the incorrectness 
 
92 FUNCTIONAL NERVOUS DISEASES. 
 
 of the diagnosis, and the case finally went on to a fatal termination. This 
 peculiar character of periodicity is not restricted to neuralgia, but is also 
 common to other nervous affections, and no very satisfactory explanation 
 has ever been offered for its occurrence. The duration of the paroxysms 
 is extremely various ; sometimes the}^ only last a minute or tv^o, some- 
 times they may continue for several da3's or even longer, v?ith very short 
 intermissions. As a rule, the duration of the paroxysms increases with 
 the progress of the disease, and those which occur in old age are usually 
 the most violent and prolonged. 
 
 The other sensory disturbances include the puncta dolorosa or painful 
 points described by Valleix, and which were considered by him as charac- 
 teristic of neuralgia. This term refers to circumscribed spots, situated 
 along the course of the nerves, where they emerge from bony canals 
 or foramina, where they pass through firm aponeuroses, or where they 
 become superficial under the skin, and sometimes under the mucous mem- 
 branes. Pressure upon these localities during an attack of neuralgia pro- 
 duces severe pain at the site of pressure, and may also reproduce the pain 
 in the corresponding nerve. The painful points are sometimes observed 
 during the intervals between the pai'oxysms, though not by any means 
 so often as during the attacks. If the skin is pinched up in a fold over 
 the site of the painful point, and pressure is made upon the integument, 
 we can readily determine that the pain is not due to hyper^esthesia of the 
 skin. In fact, the reverse is sometimes noticed, and the integument is 
 found to be decidedly aneesthetic, while the underlying nerve is exquisitely 
 tender to the touch. Valleix stated that the puncta dolorosa were pres- 
 ent in almost all cases of neuralgia, but, in common with a great number 
 of other observers, I have found them absent in a large percentage of 
 cases. It would, therefore, be unwise to exclude the diagnosis of neu- 
 ralgia from the absence of the painful points. 
 
 Trousseau, in combating Valleix's view of the pathognomonic char- 
 acter of this symptom, called attention to the presence of the point apo- 
 physaire, or spinal point, as characteristic of neuralgia. He states that 
 " the spinous point, as its name indicates, is situated over the spinous 
 processes of the vertebrae, and, since my attention has been drawn to it, 
 I have never known it to be absent." The spinous point usually corre- 
 sponds to that vertebra from which the affected nerve emerges, but it is a 
 remarkable circumstance that a tender spot is sometimes feic upon press- 
 ure over the first or second cervical vertebra in cases of trigeminal neu- 
 ralgia. I have observed this in quite a number of instances, and, in some 
 have succeeded in sending a thrill of pain through the affected fifth nerve 
 by pressing upon the spinous processes of the tender vertebrge. At times 
 pain is not produced by pressing upon this part itself, but will develop 
 when pressure is made immediately to one side. In such cases, T have 
 always found that the painful spot was situated upon the same side as 
 the neuralgia. But these " spinous points " are not by any meaijs so 
 frequent as Trousseau believed, and, in fact, great caution must be exer- 
 cised in determining their presence, especially in females. We should 
 never rest satisfied with one examination, but should press upon the ver- 
 tebrae several times in succession, and at the same time endeavor to 
 divert the attention of the patient from the object of the examination. 
 If one of the processes is really tender, pressure upon it will produce a 
 change in the expression of the face, which is more reliable than the mere 
 statement of the patient. If we pay attention to all these details, we 
 will soon come to the conclusion that a large proportion of the spinous 
 
NEURALGIA. 93 
 
 points are purely imaginary. Although we do not attach the same diag- 
 nostic importance to the points ajyophysaires as was attributed to them 
 by Trousseau, they possess consideral)le importance with regard to thera- 
 peutics, as we will endeavor to show in the chapter on treatment. 
 
 Hypeniesthesia and anresthesia in the distribution of the affected 
 nerves are frequently observed. They were first described by Tuerck, in 
 1850, and later by Trousseau, who thought that the presence of ansesthesia 
 "Was indicative of deep-seated nerve lesions. Nothnagel' has studied this 
 subject very thoroughly, and finds that hyperassthesia is primary, and 
 lasts from two to eight weeks, and is then followed by anresthesia. Erb's 
 observations corroborate those of Nothnagel to a gr':*at extent, but the 
 former author has also determined the existence of anaesthesia in the 
 first week of the disease; in some cases no sensory disturbances have been 
 noted. In a few instances the hyperaesthesia or anaesthesia were diffused 
 over the entire corresponding half of the body. 
 
 Attention must also be drawn, at this point, to the frequent presence 
 of irradiated pains in other parts of the body. Thus it is not at all in- 
 frequent that, at the height of a paroxysm of trigeminal neuralgia, pain 
 is felt in the occipitalis major nerve on the same side; the development 
 of trigeminal neuralgia during the course of cervico-occipital neuralgia is 
 observed with less frequency. At times, however, the irradiation may 
 occur to remote parts of the body, as is observed in the development 
 of trigeminal pain during the course of sciatica. The irradiated pains are 
 usually not so severe as those of the primary paroxysm, and they only 
 develop when the latter attains considerable intensity. 
 
 In a large percentage of cases the symptoms which we have described 
 above are the only ones observed, and they may be unaccompanied by 
 any others during the whole course of the affection. But severer cases, 
 and sometimes even milder ones, may be accompanied by various motor, 
 vaso-motor, secretory, and trophic disturbances, which may prove much 
 more serious than the primary affection. 
 
 We will find, during our consideration of special neuralgias, that 
 while the motor, vaso-motor, and secretory complication are much more 
 frequent than the trophic disorders, the latter are more important, and 
 will also merit careful attention. 
 
 Motor cotnjylications. — When the neuralgia affects purely sensory 
 branches of a nerve, the motor complications are necessarily reflex; when 
 the nerve is mixed, they are usually manifested in the course of the same 
 nerve, though even in the latter instance they may be radiated to other 
 branches. 
 
 The reflex complications are best seen in tic douloureux, in which the 
 muscular twitchings, induced by the neuralgia of the fifth pair, appear 
 in the facial muscles which are supplied by the seventh. They vary from 
 slight fibrillary twitchings to well-marked and rapid convulsive movements. 
 The convulsive phenomena occurring in the course of the affected nerve 
 are best observed in sciatica, and I have sometimes seen the limb raised 
 violently from the ground in the course of this affection. Paralyses have 
 also been noticed during neuralgias, but although they have been de- 
 scribed during the first stages, I have never observed them until the 
 neuralgia has lasted for a long time. The paralysis is, of course, most 
 marked in the limbs, and I have seen considerable loss of power in invet- 
 erate sciatica. This can be readily distinguished from the immobility 
 
 ' Virch. Arch. BJ. 54, 1873. 
 
94 FUNCTIONAL NERVOUS DISEASES. 
 
 of the parts caused by a dread of the renewal of the pain on motion, and 
 in my experience has always been attended with considerable atrophy of 
 the muscles — an atrophy which T could not entirely explain on the theory 
 of the disuse of the muscles, and which I was therefore compelled to 
 regard as a trophic change. 
 
 Vaso-motor complications. — These are not very numerous or impor- 
 tant. During the paroxysms the arteries leading to the affected region 
 are frequently dilated and pulsate strongly and visibly; the surface of the 
 body is red and hot, and its temperature is somewhat raised when com- 
 pared with the corresponding part of the body on the opposite side. In 
 other cases, on the contrary, the reverse is observed, the skin is pale and 
 cool, and slight rigors are experienced in the affected region. A certain 
 amount of oedema of the subcutaneous cellular tissue may develop during 
 a paroxysm, but it is never very marked, and usually disappears shortly 
 after the termination of the attack. 
 
 Secretory complications. — These are observed almost exclusively in tri- 
 geminal neuralgia, because this is almost the only form in which a nerve 
 is affected which possesses an influence over any of the secretions. 
 
 For this reason we prefer to postpone their discussion until the con- 
 sideration of the special varieties of neuralgia. 
 
 Tropjhic complications. — We now enter upon an extremely interesting 
 field of observation, which is at the same time of great importance, since 
 the effects produced are frequently of a lasting character. This subject 
 also opens up the question of the existence of special trophic centres, but 
 the character of this article precludes our entering into the discussion. 
 We will therefore assume, without further argument, that the entire series 
 of changes which we shall describe in this section are due to an affection 
 of special trophic nerves. And we shall first take into consideration the 
 trophic affections of the skin. 
 
 We must premise our remarks by the statement that the severest 
 forms of cutaneous trophic disturbances (glossy skin, deep ulcerative 
 eruptions, etc.) only occur when the nerves are seriously injured or in- 
 flamed, and therefore rarely form part of the clinical history of simple 
 neuralgia. 
 
 The lesions of the latter include simple atrophy of the entire skin, 
 which appears smoother than that of the corresponding part of the body, 
 is thinner than on the opposite side, and appears to be more shining than 
 normal. In one case I also observed lesions of an opposite nature, viz., 
 hypertrophy of the skin, a phenomenon which I have found referred to 
 by a few authors, but described by none. The patient in question was 
 suffering from neuralgia of all three branches of the trigeminus (the mo- 
 tor branch was also involved, and the case will be again referred to in the 
 chapter on peripheral paralysis). Upon first examining him, I thought 
 that he was suffering from facial paralysis on the affected side, as the 
 face remained almost motionless on that side, and the natural folds of the 
 skin were partially effaced. Upon careful investigation, however, I found 
 that this condition of affairs was due to hypertrophy of the skin (per- 
 haps, also, in part, of the subcutaneous cellular tissue), which was dark, 
 rough, and could with difficulty be pinched up into a fold. The apparent 
 facial paralysis was due to the inability of the muscles to move the thick 
 and stiff integument, although there was no reason to believe that the 
 muscles had lost their power. 
 
 The skin in severe neuralgia is also apt to take on an erysipelatous 
 action, which presents the appearances of ordinary erysipelas, but does 
 
NEURALGIA. 95 
 
 not run a severe course, and never endangers the life of the patient. Pig- 
 mentation and roughening of the skin have been noticed by several ob- 
 servers, notably by Anstie; it sometimes disappears after the paroxysm 
 has subsided. In one case I saw a scaly eruption develop in the course of 
 the affected nerve, and disappear as the neuralgia was relieved. Herpes 
 zoster constitutes one of the most interesting of these trophic affections 
 of the skin. This is observed almost exclusively in trigeminal and intercos- 
 tal neuralgias, especially in the latter, appearing sometimes in severe and 
 sometimes in the course of mild affections. 
 
 The eruption appears usually on the right side of the body, and is 
 strictly limited to the course of the nerves; in very rare instances it ap- 
 pears on both sides at the same time, and, if it is situated along correspond- 
 ing intercostal nerves, may form a complete zone around the trunk. The 
 eruption consists of large vesicles, situated on an inflamed base; they 
 contain, at first, a clear, limpid fluid which, at a later period, becomes 
 cloudy and opaque; the vesicle usually ruptures and a scab forms, which 
 gradually dries and disappears. Sometimes the eruption appears before 
 the neuralgia, but usually the reverse is noticed. This eruption may pre- 
 sent great importance on account of the peculiarity of its site; we shall 
 return to this phase of the subject in discussing trigeminal neuralgia. 
 
 The appendages of the skin may also become involved in these trophic 
 changes. The hair frequently changes its color during the paroxysms, 
 and is restored during the intervals. One of my patients, a woman suffer- 
 ing from supra-orbital and occipital neuralgia, noticed, during each par- 
 oxysm, that a lock of hair in the course of the supra-orbital, and another 
 in the course of the occipitalis major nerve, turned gray, but that the 
 original black color was restored after the paroxysm had subsided. If 
 this process is frequently repeated, the hair may finally remain perma- 
 nently gray. In other instances, the hair acquires a coarser and more 
 brittle texture (Anstie). In some cases the hairs have a tendency to fall 
 out (especially in neuralgias of the nerves of the limbs), in others a denser 
 growth develops in the course of the affected nerves. The nails may be- 
 come pale and discolored, and marked by irregular, transverse furrows; 
 they are also apt to be clubbed and to have a diminished rate of growth. 
 Under such circumstances they present a similar appearance to that ob- 
 served in certain cases of cerebral hemiplegia which are attended with 
 trophic changes in the joints, fingers, and toes. Traumatic neuralgias 
 are complicated by certain other more profound trophic changes of the 
 skin, to which we shall refer at a later period. 
 
 The muscles may undergo atrophy quite rapidly, and this is undoubt- 
 edly a trophic change, though some authorities consider it merely as the 
 effects of disuse. But this is negatived by the fact that even in com- 
 plete paralysis of the limbs in consequence of cerebral lesions, very little 
 atrophy occurs, and then only after a long period of time. Friedreich, 
 however, would attribute the atrophy in such cases, as he does in progres- 
 sive muscular atrophy, to neuritic changes in the terminal filaments of the 
 nerves, 
 
 Anstie states " that the periosteum of bone and the fibrous fascije in 
 the neighborhood of the painful points of neuralgic nerves not unfre- 
 quently take on a condition of subacute inflammation, with marked 
 thickening and tenderness on pressure." It is difficult to determine, 
 however, whether these lesions are primary or secondary. In some cases 
 there is no doubt, from the clinical history of the affection, that the peri- 
 osteal thickening is the result of simple or rheumatic chronic inflamma- 
 
96 FUNCTIONAL NERVOUS DISEASES. 
 
 tion, and has acted as the direct cause of the neuralgia, on account of its 
 pressure upon the nerves. 
 
 The trophic disorders of the organs of special sense will be discussed 
 under the heading of trigeminal neuralgia, as they are not observed in any- 
 other forms of the disease. 
 
 Neuralgia produces various degrees of reaction upon the general sys- 
 tem, and it is an interesting fact that these effects are much more marked 
 in affections of the trigeminus than in other varieties, even though the 
 latter equal the former in intensity. A patient may suffer for years from 
 terrible neuralgia of the limbs, -while his general condition remains excel- 
 lent, despite the helplessness to -which he may be doomed. In addition, 
 these neuralgias do not often produce a very depressing effect upon the 
 mind, although I once observed a patient -who suffered such terrible agony 
 during a first attack of sciatica (and after the paroxysm had only lasted 
 an hour) that it was with great difficulty he was prevented from com- 
 mitting suicide. The ulterior effects of trigeminal neuralgia are much 
 more marked, however, although, even in this form, many patients suffer- 
 ing from severe and intractable pain, present a perfectly healthy appear- 
 ance. But very frequently these patients are forced to keep themselves 
 on restricted diet, as the least movement of the jaws in deglutition may 
 suffice to develop a severe paroxysm of pain, and they prefer to starve 
 themselves rather than to undergo their terrible tortures. Some of these 
 sufferers are even afraid to speak, dreading a renewal of the attack from 
 this cause. It seems to me that intense and long-continued pain must 
 markedly diminish the nutritive changes occurring in the economy, as I 
 am unable to explain, in any other way, the fact that the loss of weight 
 in these patients is not commensurate with the lessened ingestion of food. 
 Neuralgia also produces, at times, serious effects upon the mind. Apart 
 from the suicidal tendency, which so frequently arises in tic douloureux, 
 melancholia is apt to develop, and the prognosis as regards recovery from 
 the mental disturbance is not very good. It is frequently, however, 
 difficult to determine whether the melancholia is due to the neuralgia, or 
 whether they are both the expressions of a deep-seated disorder in the 
 central nervous system. The family history is sometimes of importance 
 in determining this point. 
 
 There is very little to be said with regard to the inter-paroxysmal 
 period of neuralgia, as almost the entire interest centres in the par- 
 oxysms. During the intervals pain is entirely absent in mlid cases, but 
 in severe ones there may be considerable dull pain and tenderness along 
 the course of the affected nerves, which is heightened in damp weather, 
 although it may stop short of a paroxysm. The cutaneous anaesthesia, 
 to which we referred in describing the paroxysms, persists in severe and 
 chronic cases, during the intervals of the attacks. Many of the trophic 
 changes to which we called attention above, also continue, and may even 
 persist after the primary disease has entirely subsided. 
 
CHAPTER 11. 
 
 ETIOLOGY. 
 
 General Causes. 
 
 Seredity. — As in a large number of other functional neuroses, hered- 
 ity plays a very important part in the etiology of this affection. This 
 fact possesses considerable importance, from a prophylactic, as well 
 as a therapeutic point of view. Neuralgia is classed, in this respect, 
 with epilepsy, hysteria, chorea, insanity, inebriety, etc. This has been 
 most strongly and clearly shown by Anstie, who has collected a consider- 
 able number of cases, in which the hereditary interchangeability of the 
 various neuroses to which we have referred is very distinctly manifested. 
 Anstie appears to think, moreover, that phthisis in the parents is capa- 
 ble of giving rise to the development of neuralgia in the offspring, but, 
 from the great prevalence of the former disease, we should be inclined 
 to think that this is merely a coincidence. At all events, a positive 
 statement concerning such a relation of phthisis and neuralgia could only 
 be substantiated by a very large and accurate array of statistics. We find 
 sometimes that neuralgia appears in several children belonging to the 
 same family, although there is nothing in the family history of the an- 
 cestors to account for its production. In one case of this kind which 
 came under my notice, the children of one of the parents inherited the 
 neuralgic tendency. A most striking proof of the allied nature of neu- 
 ralgia and various functional neuroses is its interchangeability with them 
 in the same patient. The following case is a good illustration of the 
 combination of neuralgia with more serious neuroses: Mrs. I. B., ast. 30 
 years, married; one brother suffered from chorea; all her brothers and 
 sisters are of a nervous temperament. I could get no history of nervous 
 disease in her parents or other relatives. The patient herself suffered 
 from chorea when she was thirteen years old. She began to menstruate 
 at the age of fourteen years, and the menses have been regular ever 
 since. At the age of sixteen, she had an attack of inflammatory rheu- 
 matism, and soon afterward was affected with trigeminal neuralgia. The 
 patient married when eighteen years old, and as soon as she became 
 pregnant, noticed pains " like jumping toothache," in the back of the 
 neck, the right shoulder, and the right arm; the right arm was cold, and 
 she could not move it on account of the severe pain produced thereby. 
 During the next six years the patient had trigeminal neuralgia on the 
 right side. Five years ago, she again became pregnant, and suffered 
 from very intense sciatica, which continued until the birth of the child. 
 Three years ago, she became pregnant a third time, and then had an at- 
 tack of intense lumbago; she began to act strangely during this preg- 
 nancy, and became insane when the child was seven weeks old. She was 
 then removed to an asylum, in which she remained for thirteen months 
 (one and a half years ago), at the end of which time she was discharged 
 7 
 
98 ruNCTioisrAL nervous diseases. 
 
 .cured. She remained well until six weeks ago. The patient is now in 
 the seventh month of pregnancy, and presents a very angemic appear- 
 ance. There is no oedema to be detected in any part of the body, and 
 an examination of the urine revealed nothing abnormal. The patient 
 Avas in good health, since her discharge from the asylum, until one and a 
 half months ago, when she began to complain of weakness, palpitation 
 of the heart, and shortness of breath on exercise. At this time she also 
 began to suffer from melancholy, lost her spirits, disliked company, and 
 thought that " something terrible was going to happen "; she also suffered 
 from sleeplessness during this time. For the last few weeks, she has be- 
 gun to complain of dull pains, interspersed occasionally with shooting 
 pains in the right shoulder; during the past week she has suffered from 
 right sciatica, which is well marked at the present time, and presents all 
 the characteristic symptoms. She states that she feels just as she did be- 
 fore her previous attack of insanity. The patient is perfectly regular in 
 her habits; does not indulge in stimulants nor excessive sexual inter- 
 course. 
 
 I ordered a glass of porter daily, and placed the patient on the tinc- 
 ture of the chloride of iron internally, and administered nitrite of amyl 
 by inhalation (three drops three times a day). The patient began to im- 
 prove immediately, and within less than three weeks had entirely recov- 
 ered, the neuralgia as well as the tendency to melancholia having disap- 
 peared. Six months later there was a slight return of the former symp- 
 toms, but a few days of similar treatment restored the patient to excel- 
 lent health and spirits. 
 
 It is not extremely unfrequent to find that neuralgia, epilepsy, and 
 insanity, appear in the same individual at different periods of life. In 
 fact. Trousseau has described a form of trigeminal neuralgia which he 
 calls tic epileptiform, and which he regards as very similar to true epi- 
 lepsy. We shall refer to this subject again in describing trigeminal neu- 
 ralgia. It is characteristic of those neuralgias which are due to heredity 
 that they are of a very severe type and intractable to treatment. Anstie 
 has found that heredity influences the development of neuralgia in the 
 most various parts of the body, but for my own part, I have only found 
 its effects distinctly marked in affections of the trigeminus and sciatic. 
 
 The predisposition to neuralgia may be acquired not only from hered- 
 ity but also during the developmental period of youth, from overtaxing of 
 the mental powers. Anstie laid great stress on the importance of this fac- 
 tor, especially when combined with a false, sentimental religious training. 
 But we doubt whether this element is as prevalent now, even in England, 
 as it was ten years ago (when Anstie wrote), thanks to the impetus which 
 has been given of late years, by physicians and educators, to more phy- 
 siological methods of teaching. In our own country, at least, we know 
 from actual observation that the false, forcing plan of education has been 
 done away with in considerable part. But, although great reforms are 
 being consummated in this direction, nevertheless much still remains to 
 be done, which requires the careful and thoughtful consideration of our 
 profession. 
 
 Sex. — It would appear from the experience of most authors that the 
 female sex presents a greater tendency to the development of neuralgic 
 affections than the male sex. Among 178 cases which came under my 
 own observation, 108 were females and 70 males. I have not included 
 in this classification those cases in which the neuralgia formed part of 
 
NEURALGIA. 99 
 
 the symptomatology of hysteria, which is notoriously much more com- 
 mon among females, and an enumeration of which would, therefore, in- 
 crease the above-mentioned disproportion to a still greater extent. When 
 we come to examine the individual varieties of neuralgia, we find that 
 the female sex predominates in one form, and the male in another. 
 
 Thus among ninety-five cases of trigeminal neuralgia, seventy-one 
 were females, and only twenty-four males, while among twenty-five cases 
 of sciatica there were eight females and seventeen males. In intercos- 
 tal neuralgia the latter relation is again reversed, and the large majority 
 of cases are found in females. In the articles on the special forms of 
 neuralgia we shall enter more in detail into these various considerations. 
 
 A(/e. — An analysis of my cases shows that from the tenth to the twen- 
 tieth years of life, there were fourteen cases; from the twentieth to the 
 thirtieth years, forty-eight cases; from the thirtieth to the fortieth years, 
 forty-seven cases; from the fortieth to the fiftieth years, thirty-four cases; 
 from the fiftieth to the sixtieth years, nineteen cases; from the sixtieth 
 to the seventieth years, tweh'e cases; and from the seventieth to the 
 eightieth years, four cases. We therefore find that the first ten years of 
 childhood present no tendency toward the development of neuralgia. 
 This fact is also demonstrated by an analysis of 543 cases reported by 
 Valleix, Eulenburg, and Erb, among which number there were only three 
 cases below the age of ten years. 
 
 The largest number occur between the ages of twenty and forty years, 
 and the sexes are equally represented in proportion to the number of 
 neuralgics. Our statistics, therefore, run counter to the general opinion 
 that the largest number of cases of the disease appear in women before the 
 thirtieth year. They also serve to contradict the view that the tendency 
 to neuralgia disappears almost entirely after the age of sixty. From the 
 ages of sixty to eighty years, I observed sixteen cases, which, when com- 
 pared with the number in other bicennial periods, does not by any means 
 show a diminution in the neuralgic tendency, if we take into consider- 
 ation the smaller number of individuals at such an advanced age. We 
 should also remember that neuralgias of old age are usually the most in- 
 tractable to treatment, and they are, in all probability, due to organic 
 changes in the central nervous structures, brought about by the general 
 decay and by the atheromatous changes so frequently observed in the 
 arteries at this period of life. 
 
 Weather. — Not only do patients, as a rule, suffer most in damp and 
 windy weather, but primary attacks are also apt to develop under such 
 conditions. This is not true, however, of all varieties of neuralgia. Thus 
 it is not often observed in trigeminal neuralgia, compared with the large 
 number of cases of this variety. In occipital and sciatic neuralgias, how- 
 ever, this is a very frequent mode of causation. I have often observed 
 that sciatica is not uncommon in coach drivers, in whom the constant 
 sitting position and the exposure to inclement weather act together in 
 producing very severe forms of the disease. The manner in which these 
 causes act in producing the disease (as well as all other " colds "), is en- 
 tirely unknown, and it would be idle and unprofitable to enter into a 
 discussion of the various theories which have been advanced to explain 
 their modus oi^erandi, since all are insufficient, and are based on more or 
 less hypothetical grounds. 
 
 Sexual system. — Great stress has been laid by some authors upon the 
 influence of the period of puberty, especially in girls, when connected with 
 deficient or painful menstruation, and of the menopause, in producing 
 
100 FUNCTIONAL NERVOUS DISEASES. 
 
 various kinds of neuralgias. But we cannot agree with this view. Ner- 
 vous disorders not infrequently appear at these periods, but they do not, 
 except in comparatively rare cases, assume the neuralgic type. 
 
 During the period of puberty hysteria is apt to be developed, and 
 neuralgia not infrequently appears as one of the symptoms of this latter 
 disease. But the affection then presents certain characteristics of its 
 hysterical origin, and should not be classed among true neuralgias. The 
 menopause is also liable to be attended with a peculiar nervous disorder, 
 the chief characteristics of which are sudden flashes of heat, or heat fol- 
 lowed by cold, which usually start from the stomach and pass up the chest 
 or to the back ; sudden attacks of perspiration, which arise without any 
 provocation and only last a short time; dizziness; not infrequently, 
 marked increase of sexual desire. This condition is sometimes compli- 
 cated by a serious depression of spirits, which may pass into melancholia, 
 often tinged with a religious element.' But we have very rarely had rea- 
 son to attribute an attack of neuralgia to this cause; all those which did 
 appear to have any connection with the menopause were cases of trigem- 
 inal neuralgia. 
 
 We entertain similar views with regard to the effects of excessive 
 sexual intercourse or masturbation. While these factors are liable to 
 cause a condition of nervous exhaustion attended with vague pains in 
 the head and in various other parts of the body, these do not often assume 
 the characteristics which we have described in the chapter on the clinical 
 history of neuralgia. 
 
 JDejoressed general health. — Under this heading we include anaemia, 
 arising from direct loss of blood, excessive lactation, long-continued and 
 exhausting diarrhoea, etc., and the cachexije, caused by the development 
 of carcinoma, pulmonary phthisis, etc. When the general health and 
 vitality are lowered by any of these causes, neuralgia finds a fertile field 
 for its production. These causes appear to affect chiefly the trigeminal 
 and intercostal nerves, and the etiological relation between the anaemia 
 and neuralgia is conclusively shown by the disappearance of the latter as 
 soon as the former is removed. In the cachexise developing during the 
 course of incurable diseases, the neuralgia produced is apt to continue 
 with increasing severity until death. 
 
 Constitutional diseases. — Syphilis may act as a cause of neuralgia in 
 two different ways. In the first place, it may produce pressure upon the 
 nerves in any part of their course, either from thickening of the bones or 
 periosteum, or the development of gummy tumors in adjacent tissues, or 
 from changes in the nerves themselves, such as thickening of the nerve 
 sheaths, hyperplasia of the connective tissue between the nerve-fibres, or 
 gummv infiltration into the nerves. The effect of such lesions is patent, 
 and neuralgias due to them may affect any of the nerves of the body on 
 account of the irregularly disseminated character of these lesions in the 
 tertiary stage of syphilis. 
 
 It appears, however, that not only may the disease' be produced by 
 direct syphilitic lesions of nerves, but that it may be also due to the direct 
 action of the syphilitic virus. I have neither been able to find any men- 
 
 ' We may here remark that the bromide of potassium, in thirty-grain doses t.i.d., 
 acts like a charm in the majority of these patients. Whenever the melancholic ten- 
 dency is present, we have derived considerable benefit from the inhalation of nitrite 
 of amyl, gtt. iij. t.i.d. After a while this dose may be increased, as the patients aro 
 apt to become habituated to it. 
 
NEURALGIA. 101 
 
 tion made of this circumstance in the works on neurolofry which I have 
 consulted, nor have I met with any cases in practice; but Fournier, the 
 distinguished French syphilog^rapher, states that he has observed cases 
 of supra-orbital and sciatic neuralgia during secondary syphilis, and in 
 which there was no appreciable lesion of the nerves. Tills view is also 
 advanced by Dr. Keyes in his recent work published in this series. He 
 states that " the essential influence of the syphilitic poison, without phys- 
 ical lesion, doubtless occasions some nervous symptoms, especially early 
 in the disease, such as neuralgias, inordinate appetite, sciatica, local areas 
 of analgesia and anaesthesia at the backs of the hands, and elsewhere." 
 A knowledge of this fact is of course important with regard to treat- 
 ment. 
 
 Blood-poisoning. — Blood-poisoning, due to infection with pus, etc., 
 is not infrequently attended, if the patient recovers from the immediate 
 effects of the disease, by terrible and widely diffused neuralgias which 
 often last for years. The disease is so diffused that we must attribute it 
 to the poisonous action of the material which has been introduced into 
 the blood upon the sensory portions of the nerves or nerve-roots. The 
 distinguished German surgeon, Pitha, was himself a sufferer from excru- 
 ciating neuralgias due to this cause, and has given an admirable and 
 graphic account of his disease, ' which is of such an interesting character 
 that we shall give a brief abstract of it. 
 
 Case T. — " In the early acute stage, the two shoulder-joints were suc- 
 cessively attacked by the most violent boring pains, which, after lasting 
 for hours, suddenly and completely disappeared. Hence the pain darted 
 off to the pelvic region, affecting the bladder, especially its neck, and 
 then the entire urethra. At a later period the pain was confined to the 
 neck of the bladder, simulating perfectly all the symptoms of stone. I 
 felt with the utmost distinctness the spicula at the surface of the calculus 
 being forced, during the paroxysm, into the orifice of the bladder. Grad- 
 ually I lost this sensation completely, and it only accidentally appeared 
 again in a milder degree at the end of two years. While jumping over a 
 ditch I suddenly experienced the sensation of a stone in the bladder strik- 
 ing against the symphisis. So plainly did the existence of the stone 
 seem on various occasions, that all the preparations were made for litho- 
 tripsy, but, to my great astonishment, the most careful exploration of the 
 bladder, repeated five times, failed to discover the calculus, and I became 
 convinced at last that it did not exist. The most severe neuralgia which 
 I at present suffer from affects the heel; and the pain at its greatest se- 
 verity takes on exactly the form as if the periosteum were being separated 
 
 from the os calcis Omalgia, cystodynia, proctalgia, and 
 
 neuralgia intercostalis, ulnaris, ischiadica, peronea, cruralis, and digito- 
 rum manus et pedis, tortured me one after another, and often several 
 simultaneously, sometimes only for a short time, and at others for days 
 together, producing an amount of suffering that was difficult to endure." 
 
 Malaria. — In malarial districts this constitutes one of the most im- 
 portant factors in the etiology of neuralgia. Even in our own city it 
 forms a considerable contingent in the latter affection. In the majority 
 of cases it affects the supra-orbital branch of the trigeminus (popularly 
 known as brow-ague), and the paroxysm of pain appears instead of the 
 
 1 Med. Times and Gazette, 1875, ii., p. 356. 
 
102 FUNCTIONAL NERVOUS DISEASES. 
 
 fall-blown malarial attack. Other nerves are much more rarely affected, 
 tliough there is hardly a sensory nerve in the body which may not be- 
 come involved. Next to the trigeminus, the sciatic nerve is most fre- 
 quently the seat of pain, and then follow the other nerves without any 
 distinct preference. As we have stated in the chapter on clinical histor}', 
 even neuralgias which are undoubtedly due to organic affections of the 
 nerves, may run a distinctly periodical course, so that this feature is not 
 pathognomonic of the malarial character of the affection. We are not 
 justified in attributing an attack of neuralgia to malaria, unless we find 
 upon inquiry that the patient has been subject to malarial influences, or 
 can detect an enlargement of the spleen upon physical examination.^ 
 
 Mhewnatism, etc. — The loose manner in which this term has been em- 
 ployed in medical literature, has been the cause of a great deal of confu- 
 sion. The laity frequently use the terms neuralgia and rheumatism inter- 
 changeably, and so-called rheumatic influences are regarded as frequent 
 causes of the former affection. But rheumatism, in the strict seTise of 
 that term, is very rarely the cause of neuralgia, and, in these rare cases, 
 it appears that the sciatic nerve is always the one involved. In former 
 times gout was also regarded as a frequent cause of neuralgia, but the 
 simple gouty diathesis does not often act in this manner. Whenever 
 neuralgia develops in gouty patients in consequence of the latter process, ifc 
 is almost always due, as Anstie has pointed out, either to the malnutrition, 
 of the nervous system induced by the changes in the blood-vessels, or to 
 the pressure of gouty deposits in the joints, tendons, etc., upon adjacent 
 nerves. 
 
 Neuralgias may also develop during convalescence from small-pox, 
 scarlatina, rubeola and typhoid fever, but it is very probable that in these 
 cases the disease is similar to the other nervous disturbances, such as peri- 
 pheral paralysis, circumscribed atrophy of muscles, etc., which are ob- 
 served from time to time after these infectious diseases. Nothnagel has 
 also called attention to the development of well-marked neuralgia in the 
 first stages of typhoid fever. This must not be confounded with the 
 cutaneous hyperresthesia {which is sometimes extremely acute) not un- 
 commonly observed in the first week or two of the disease, and which is 
 entirely distinct from neuralgia. 
 
 Lead, mercurial, and arsenic poisoning are also regarded as causes of 
 this disease, but the pains to which these affections give rise, though they 
 are sudden and shooting in character, are situated chiefly in the muscles, and 
 are not confined to the district of a single nerve. We are hardly justified, 
 therefore, in considering them as evidences of true neuralgia. 
 
 We have a case under observation at present in which wandering 
 neuralgic pains developed in the lower limbs as a sequel of acute arsenical 
 poisoning. These were soon followed, however, by atrophy and paralysis 
 of the limbs, some loss of sensation, and paralysis of the bladder. The 
 symptoms are probably due to subacute transverse myelitis, and the neu- 
 ralgic pains were merely a part symptom of this affection. 
 
 Alcohol and tobacco. — The excessive use of these substances is also 
 productive of bad results in this direction, not so much as an effect of 
 
 ' We wish to call attention to the fact that the opinion laid down in some of the 
 text-books, with regard to the position of the spleen, is erroneous, and that the org'an 
 does not normally extend forward beyond the middle of the axillary space. This 
 was first pointed out to me several years ago by my friend Dr. Janeway, and I have 
 since then frequently verified his opinion by observations upon the cadaver. 
 
NEURALGIA. 103 
 
 acute intoxication, but rather of their long-continued introduction into 
 the system. The immoderate use of tobacco sometimes gives rise to attacks 
 of angina pectoris, which is undoubtedly a true neuralgia, but a consid- 
 eration of which is beyond our province at the present time, since we are 
 onlv discussing neuralgias of the superficial nerves. Aside from this form 
 tobacco is very rarely a cause of the affection. 
 
 Alcohol in very rare cases may produce neuralgia as a result of acute 
 intoxication. Thus, I have seen three cases of sciatica due to acute 
 alcoholism. As a rule, however, alcoholism produces these effects as the 
 result of long-continued drinking, in consequence of changes in the 
 blood-vessels, etc. The headaches to which drinkers are so frequently 
 subject cannot be classed, however, under the category of true neuralgias. 
 They are due to cerebral pachymeningitis (which is very often observed 
 in drunkards) to congestion of the brain, to Bright's disease (cirrhotic or 
 *' whiskey " kidney), gastric catarrh, etc. 
 
 Local Causes. 
 
 The term local causes refers to those which act directly upon the 
 nerves, either at their origin in the cerebral or spinal centres, during their 
 course to the periphery, or perhaps even at the peripheral terminations. 
 "Within the cranial cavity this category includes tumors at the base of 
 the brain which press directly upon the Gasserian ganglion, periostitis of 
 the petrous portion of the temporal bones, aneurism of the internal caro- 
 tid. In the spinal canal, it comprises tumors of the cords, localized men- 
 ingitis, pachymeningitis, and peripachymeningitis, spondylitis deformans, 
 caries and cancer of the vertebrce, the pressure from aneurisms of the 
 aorta. 
 
 During the course of the nerves, neuralgia may be produced by pres- 
 sure from without, such as from aneurismal dilatation of adjacent vessels, 
 enlarged cheesy or calcareous glands, various neoplasms, the pressure of 
 the intestine (herniie into the sciatic and obdurator foramina), or its con- 
 tents, pressure of dilated venous plexuses, periosteal thickenings (either 
 of bones across which the nerves pass, or of bony canals which they 
 traverse). Neuralgia may also be due to lesions of the nerves themselves, 
 such as those produced by injury, idiopathic neuritis, or the development 
 of tumors in the nerves (neuromata, pseudo-neuromata, gliomata, etc.). 
 We shall refer to these special causes more in detail when we describe 
 the individual varieties of the disease. 
 
 Reflex Causes. 
 
 By reflex neuralgias we mean those in which the cause is situated with- 
 in the distribution of a nerve other than that which is the site of the neu- 
 ralgic pain. One of the most important factors in this category is func- 
 tional disturbance of the organs of sight. Dr. George T. Stevens (JTedi- 
 cal Record, October 13, 1877), has advanced the following propositions in 
 this connection : 
 
 1. Among centripetal influences which generate neuralgia, the irrita- 
 bility arising from a perplexity or exhaustion of nerves engaged in the 
 function of accommodation of the eye, must be regarded as by far the 
 most frequent and important. 
 
104 FUNCTIONAL NERVOUS DISEASES. 
 
 2. Many inveterate cases of chronic neuralgia not amenable to other 
 forms of treatment, readily yield to the simple process of relieving the 
 eye from irritation resulting from direct accommodation. 
 
 These views are confirmatory of the statements of Anstie, who also 
 lays great stress upon the efficacy of eye troubles in the production 
 of neuralgia. But these opinions appear to us to be exaggerated. In 
 our own experience, at least, this cause has only been operative in a small 
 number of cases, producing in the large majority of individuals other symp- 
 toms, such as dull headache, inability on the part of the patient to apply 
 himself steadily to any mental work, a general tired feeling, and some- 
 times considerable dizziness, etc. 
 
 Caries of the teeth is a frequent source of neuralgia, especially in the 
 branches of the trigeminus. But Anstie mentions a peculiar and inter- 
 esting case in which uterine neuralgia was immediately relieved by the 
 removal of a carious tooth. Salter has also called attention to the com- 
 parative frequency of cervico-brachial neuralgias which are due to this 
 cause. 
 
 Foreign bodies in the various cavities of the head may also give rise 
 to eccentric neuralgias, and, in one instance, a neuralgia of twelve years 
 standing was relieved permanently after the removal of a foreign body 
 from the cheek. 
 
 Reflex neuralgias may develop from various functional or organic dis- 
 orders of the intestinal tract. 
 
 The genito-urinary system, both in the male and female, also figure 
 not infrequently among the causes of the disease. This is especially 
 true of uterine disorders, to which are attributed numerous neuralgias, 
 especially those of the lower limbs. The following interesting case, 
 reported by Hunt,' is one in which there can be no doubt of the reflex 
 origm of the neuralgic affection. " The patient began to suffer from 
 severe neuralgic pains along the course of the trigeminus during the 
 seventh month of pregnancy. Premature delivery began during the 
 second night after the beginning of the neuralgia ; the pain attained its 
 maximum during parturition, but ceased after its completion. When the 
 hand was introduced into the uterus in order to remove the placenta, the 
 pain returned with great severity, and lasted while it was being removed. 
 It vanished immediately after this was done." 
 
 Mauriac ^ has called attention to the comparative frequency of reflex 
 neuralgias in various parts of the body, during the course of gonorrhoeal 
 orchi-epididymitis. 
 
 In addition to cases in which the irritation is situated in the viscera, 
 others are reported in which injury in the course of one nerve has pro- 
 duced neuralgia in the distribution of another. Such cases are extremely 
 rare, and we have only found records of them as occurring in the trigem- 
 inus, occipital, and brachial nerves. Thus, an injury to the ulnar nerve 
 has been known to produce trigeminal neuralgia. 
 
 ' On the Nature and Treatnaent of Tic Douloureux, Sciatica, and other Neuralgic 
 Disorders, London, 1844, p. 99. 
 ' Gaz. med. de Paris, Dec, 1878. 
 
CHAPTER III. 
 
 PATHOLOGY. 
 
 As in all the other functional neuroses, this field of investigation is 
 extremely unsatisfactory. The pathological anatomy of neuralgia has 
 been the subject of laborious investigation, but the results are very mea- 
 gre. In a considerable proportion of the cases in which it was possible 
 to examine the condition of the affected nerves, either post-mortem or 
 after the operation of neurectomy, no anatomical lesions were discover- 
 ed. Billroth states that he has so frequently obtained negative results, 
 that " he has become tired of making the examination." At other times 
 various macroscopic and microscopic lesions are found, not alone in the 
 nerve-tissues themselves, but also in the surrounding structures. The 
 following are the lesions which have been observed: congestion and thick- 
 ening of the sheath of the nerve; sclerotic changes and atrophy of the 
 nerve itself; neuromata, true and false; tumors growing from the sur- 
 rounding tissues and pressing upon the nerves; simple atrophy of the 
 nerves; capillary hemorrhages into their substance; granular degenera- 
 tion of the axis cylinders; hypertrophy of some of the fibres, and atrophy 
 of others; inflammation of the ganglia on the roots of the nerves; calca- 
 reous degeneration of these ganglia; atrophy from pressure of exostoses, 
 tumors, retracting inflammatory processes, etc., etc. 
 
 It is very evident, however, from the negative character of the exam- 
 ination in so many cases, and from the multiplicity of the lesions which 
 have been observed in others, that there are no anatomical characters pe- 
 culiar to neuralgia. It is even doubtful whether many of these lesions 
 are not of a secondary nature, caused by the often repeated vascular dis- 
 turbance in the nerves (occurring in the paroxysm of pain), and by the 
 trophic changes so frequent in this disease. 
 
 The site of the affection has been variously located by different writers, 
 but the most plausible theory is that advocated with great enthusiasm by 
 xA.nstie, who believes that the morbid process is situated in the posterior 
 roots of the nerves, or in the gray matter immediately connected with 
 them. 
 
 This observer believes that "the morbid change in the nerve-centre is 
 probably, in the vast majority of cases, an interstitial atrophy, tending 
 either to recovery, or to the gradual establishment of gray degeneration, 
 or yellow atrophy, of considerable portions or the whole of the posterior 
 root, and the commencement of the sensory trunk as far as the ganglion." 
 The great objection to his views is that these lesions have never been 
 found in neuralgia, although frequent examinations have been made in 
 the hope of discovering them. But although this is true, Anstie never- 
 theless adduces weighty reasons for locating the disease in this situa- 
 tion, and it may very well be that his views are correct, in this respect, 
 although the lesion is perhaps of a molecular or chemical nature. Among 
 
106 FUNCTIONAL NEEVOUS DISEASES. 
 
 the arsruments which he has brousrht forward to show the central nature 
 of neuralgia are: 
 
 1. The disease is undoubtedly an hereditary neurosis in numerous 
 instances, and, as such, must be due to some changes in the central 
 nervous system. 
 
 2. There are certain organic diseases of the spinal cord, notably loco- 
 motor ataxia, in which neuralgic pains play an important part in the 
 symptomatology. In addition, it must be remembered that locomotor 
 ataxia is a disease of the posterior columns of the spinal cord, and that, 
 in some cases, some of the fibres of the posterior roots of the nerves have 
 been found implicated in the sclerotic changes. Even in cases in which 
 the posterior nerve-roots present no anatomical lesions, it is probable that 
 they are in a condition of irritation. 
 
 3. The peripheral irritation of a particular sensory nerve ma}'^ produce 
 neuralgia in nerves which are connected with the irritated one only 
 through the spinal centre. This is incontrovertible proof that some dis- 
 turbance must have been transmitted through the sensory portions of the 
 cord, as such a reflex transmission is explicable in no other manner. The 
 secondary implication of the spinal cord after lesions of the peripheral 
 nerves, is admitted also in the theory of neuritis migrans, and Anstie 
 states that, although the lesion of the posterior nerve-roots in neuralgia 
 is usually non-inflammatory in its origin, nevertheless, in rare instances, it 
 may consist of a localized centripetal myelitis, secondary to inflammation, 
 of the primarily affected nerve. 
 
 4. Unless the neuralgia is very slight and of short duration, it is gen- 
 erally accompanied by vaso-motor spasm, secretory, sensory, motor, and 
 trophic disorders. This combination of symptoms is also most readily 
 explained by a lesion situated in the position claimed by Anstie. 
 
 There are some cases, however, to which this theory will not by any 
 means apply. How, for instance, can we accept the doctrine of a central 
 lesion in a case in which a trigeminal neuralgia, which had lasted for 
 twelve years, was immediately and permanently removed by the removal 
 of a foreign body from the cheek? 
 
 Then again there are numerous other instances in which neuritis or 
 injuries to nerves near their periphery, etc, give rise to neuralgia, and in 
 these cases likewise it is more plausible to assume a peripheral origin of 
 the neuralgic affection. 
 
 But, in spite of all the objections which may be advanced against 
 Anstie's theory, it is the one which is capable of explaining the majority 
 of phenomena observed in the course of neuralgia, especially in those in 
 which heredity is a prominent etiological factor, or in which the affection 
 is due to a constitutional cause. 
 
 Uspensky * has propounded a theory of neuralgia, based on physiolo- 
 gical considerations, which is analogous to that arrived at by Anstie as 
 the result of his profound investigations into the clinical history of the 
 disease. Schiff, Heidenhain, and Ranke had shown that irritation of the 
 nerves produces a rise of temperature and changes the normal alkaline 
 reaction of the nervous tissues to a neutral reaction in the nerves and an 
 acid reaction in the nerve-centres (on account of the formation of lactic 
 acid and the acid phosphate of soda). These products of disassimilation 
 irritate the nervous system, and Uspensky considers himself justified in 
 the opinion " that every pain is either produced, or at least accompanied, 
 
 ' Deutsch. Arch. f. Klin. Med. 1876. 
 
NEURALGIA. 107 
 
 by the formation of a certain quantity of these products of disassimila- 
 tion in the nerve-tissues, and by their effect upon the nervous system." 
 
 He sums up his theory in tlie following words: " Under the influence 
 of a constant but weak irritation of the peripheral nerves, the sensory 
 nerve-cells of the posterior horns of the spinal cord are continually called 
 into action, and produce, as a reflex effect, a peristaltic contraction of the 
 vessels, which leads to the absorption of the products of nervous energy. 
 In the course of time the absorption diminishes on account of previous 
 increased activity, and the products which irritate the nervous tissues 
 then begin to accumulate. When they have reached a certain amount 
 they first produce, on account of the irritation of the sensory nerve-cells, 
 tetanic contraction of the vessels, and then paralytic dilatation. Repeated 
 recurrence of the circulatory disturbance may lead to atrophy of the sen- 
 sory nerve-cells, and cause a change in the calibre of the vessels, with loss 
 of their tonus." 
 
 While this theory is very ingenious and the conclusions at which 
 Uspensky arrives with regard to the localization of the lesion agree, in 
 the main, with those reached by Anstie, nevertheless his argument is 
 based on purely hypothetical grounds, and some of his premises are more 
 than problematical. 
 
 Beiiedikt, finally, also holds somewhat similar views, maintaining that 
 a considerable number of ne^iralgias are due to neuritis of the primarily 
 affected nerve, which, spreading upward along the nerves, may finally 
 lead to atrophy of the posterior horns. He also believes that the changes 
 at the bottom of neuralgia may be primarily situated in the spinal cord, 
 and be due to circulatory disturbances in the posterior horns, or to slight 
 meningeal inflammations at the posterior part of the cord. The great 
 objection to this view, as to the others mentioned above, is that, on the 
 one hand, these lesions are not always present in neuralgia, and that, on 
 the other, they may be present, although neuralgia is absent. 
 
 We are of the opinion that while Anstie's theory probably holds good 
 with regard to a considerable number of neuralgias, notably those which 
 are due to hereditary influences or to constitutional diseases, nevertheless 
 it is far from being conclusively proven. We can therefore only accept 
 it as a good " working theory." 
 
 The causation of the puncta dolorosa is another stumbling-block. The 
 usually accepted theory has been that the painful point is the site of a 
 localized neuritis, or at least of congestion, and that these lesions account 
 for the production of pain. We must remember, however, that even if 
 such a local lesion of the nerves were demonstrated (which it is not), the 
 pain on pressure should be felt at the peripheral distribution of the 
 nerves, in the same manner that a blow upon the "funny bone " produces 
 a sensation of tingling in the little and ring fingers. 
 
 According to Sandras, the puncta dolorosa do not depend on the condi- 
 tion of the nerves, but rather on that of the adjacent tissues, Avhich ren- 
 der the spots more capable of being pressed upon. The same objections 
 may be urged against this as against the former view. 
 
 According to a very plausible theory, the painful spots are explained 
 by the presence in the affected nerve of the recurrent sensory fibres de- 
 monstrated by Arloing and Tripier. It is supposed that these fibres ter- 
 minate in that portion of the nerve corresponding to the painful spot, and 
 that pressure upon the latter will therefore give rise to pain in the part 
 pressed upon. The only objection to this theory is that proof is still 
 wanting that the recurrent fibres do terminate in the spots referred to. 
 
CHAPTER ly. 
 
 DIAGNOSIS AND PROGNOSIS. 
 
 Although the term neuralgia has been very loosely applied to the 
 most various kinds of painful affections, nevertheless the disease, although 
 symptomatic of numerous underlying processes, is very clearly defined, 
 and, as a rule, readily recognizable. 
 
 As we have seen in the chapter on clinical history, neuralgia pre- 
 sents the following characteristics: 
 
 1. The pain is always paroxysmal, at least in the beginning, and 
 exacerbations are manifested even after the disease has lasted for 
 years. 
 
 2. The paroxysm usually begins suddenly, the pain is shooting, dart- 
 ing, lancinating, boring, etc., and is referred along the course of the 
 nerves. 
 
 3. The paroxysm develops spontaneously, or in consequence of some 
 trifling cause not at all commensurate with the severity of the pain pro- 
 duced. 
 
 4. In perhaps the majority of cases, puncta dolorosa are observed iu 
 some portion of the course of the nerves. 
 
 5. Vaso-motor, secretory, or trophic disorders are noticed in a consid- 
 erable proportion of cases. 
 
 There are, of course, other symptoms which are corroborative, but the 
 first three are essential to the diagnosis of neuralgia. 
 
 A considerable number of other painful diseases may be mistaken for 
 neuralgia, and perhaps the most frequent one is myalgia, or so-called 
 muscular rheumatism. This affection is sometimes supposed to be 
 closely related to true rheumatism, but such a view is entirely errone- 
 ous. The disease is located, not in the joints or fibrous tissues, as 
 in articular rheumatism, but in the muscular or terminal filaments of the 
 nerves. 
 
 As in severe neuralgias, the part affected is kept immovable in 
 order to prevent a fresh attack of pain, but, unlike neuralgia, the parts 
 may be subjected to passive motion without increased suffering. In 
 myalgia, in other words, the pain develops on active contraction of 
 the muscles, and not from passive contraction or mere motion of the 
 parts. 
 
 The pain of myalgia, also, is diffused over the entire surface of the 
 affected muscles, and is not confined to the course of any special nerves; 
 it is dull and steady, not sharp and paroxysmal as in neuralgia. Further- 
 more, myalgia is never accompanied by puncta dolorosa; the whole mus- 
 cle is tender to pressure, and this is especially marked at its origin and 
 insertion, Avhere its structure becomes tendinous. Finally, a very char- 
 acteristic difference between the two diseases is found in the different 
 effects of the faradic current. True neuralgia is usually rendered worse 
 
NEURALGIA. 109 
 
 by a strong current of faradism, while myalgia is always relieved by it, 
 and sometimes cured as if by magic' 
 
 Osteocopic pains of syphilis are also often mistaken for neuralgia. 
 They usually occur in the secondary stage, and instead of being of a 
 lancinating character, and running along the course of the nerves, as in 
 true neuralgia, they are of a. boring character, and confined to a cir- 
 cumscribed spot upon the surface of the bones. As a rule, to which 
 there are very few exceptions, they present very marked exacerbations 
 at ni"-ht. Another differential diagnostic point is furnished by the re- 
 sults of treatment, since mercury usually produces excellent results in 
 osteocopic pains, and would probably only exaggerate the symptoms in 
 cases of neuralgia. 
 
 In the condition commonly known as cerebral ancemia (but which 
 is only a form of ordinary, general anaemia), pains in the head are 
 almost always observed, and are very frequently mistaken for neuralgia. 
 They present, however, very marked differences. The pains of anremia 
 are usually diffused over the entire vertex, are attended with a sensa- 
 tion of heat, and, instead of being paroxysmal, are continuous, dull, and 
 of a peculiar lifting character (they are sometimes likened to a pot of 
 boiling water). The entire scalp may be excessively tender on pressure, 
 but there are no true puncta dolorosa. In addition, the patients usually 
 suffer from insomnia (although they complain of drowsiness during the 
 day), from palpitation of the heart, shortness of breath on exercise, 
 and all the other well-known signs of anremia. The conjunctivas will 
 usually be found paler than normal, although the patients not infrequent- 
 ly present a good complexion. 
 
 In certain cases neuralgia may be mistaken for neuritis, and, in the 
 minds of a great many, these are convertible terms. As we have repeat- 
 edly shown, the- most intense neuralgia may develop, although the affected 
 nerve is entirely normal (this is rendered most evident when we remem- 
 ber that neuralgia may develop as the result of an affection of an entirely 
 different part of the body from that which is the seat of the pain), and, on 
 the contrary, neuritis may be well marked without the development of 
 neuralgia. Nevertheless, it is sometimes very difficult, or even impossi- 
 ble, to differentiate these affections, and the two conditions may even be 
 combined. In neuritis, the pain is usually continuous, though it some- 
 times presents remissions, the entire course of the affected nerve is tender 
 (when superficial, it is sometimes distinctly swollen), and there are no 
 puncta dolorosa; motor paralysis and localized atrophy of muscles soon 
 become evident in severe cases. We must confess, however, that some 
 of these differential symptoms may be absent, and we may therefore be 
 unable to determine the exact nature of the malady with which we have 
 to deal. 
 
 As a rule, spinal irritation is readily distinguished from true neural- 
 gia. The most marked differential point is the wandering character of 
 the pains in the former aft'ection. Spinal tenderness is a prominent 
 symptom, and the tender spinous processes correspond somewhat to 
 Trousseau's pohits a2:>oph]/salres. They differ, however, in the fact that 
 they are apt to vary their location from time to time. Cutaneous hy- 
 
 ' One patient who had very severe myalgia of the back of the neck and shoulders, 
 and who had been thereby incapacitated from work for two months, was entirely cured 
 after one application (ten minutes' duration) of as strong a primary faradic current aa 
 he could bear ; many similar cases have come under my observation. 
 
110 FUNCTIONAL NERVOUS DISEASES. 
 
 peraesthesia and various other hysterical symptoms are combined with 
 the spinal tenderness. In some cases, however, a true neuralgia may 
 lead to the development of spinal irritation, and the two affections are 
 not infrequently combined in young females. 
 
 Finally, we will consider the differences between neuralgia and the 
 pains of locomotor ataxia. We must remember that pains may for years 
 constitute almost the sole symptom of tabes dorsalis, and they are, 
 therefore, frequently mistaken in the first stage for ordinary neuralgia, 
 thus leading to grave errors both as regards prognosis and treatment. 
 In ataxia, however, the pains are situated in both lower limbs: they are 
 described as being situated sometimes in the muscles, sometimes along 
 the course of the nerves, they are more irregular in their appearance than 
 true neuralgic pains, they rapidly move from one portion of the limbs to 
 another, and are not accompanied by vaso-motor or trophic disorders. 
 Even in this early stage, the patellar tendon reflex is generally absent. 
 But, in the majority of cases, other characteristic symptoms are also 
 present, such as contraction of the pupils, diplopia, atrophy of the optic 
 disc, the cincture feeling, disturbances of the bladder and of the sexual 
 function, anaesthesia of the lower limbs, notably of the soles of the feet, 
 and inco-ordination of movement. 
 
 But not alone is it important to differentiate neuralgia from other 
 painful affections, we must also endeavor to determine whether the peri- 
 pheral nerves or the central nervous system is involved. A careful inves- 
 tigation of the etiology of the case is often of great importance in 
 arriving at a conclusion in this respect. Thus, for instance, if one of the 
 peripheral nerves has been subjected to a trauma, and a neuralgia devel- 
 ops which is strictly confined to the distribution of such nerve, we are 
 perfectly justified in believing that the lesion which has given rise to the 
 neuralgia is situated at the injured part of the nerve. But it is only in 
 a few cases that we can form an opinion so readily and satisfactorily. 
 In many instances we can only arrive at a probable conclusion after 
 carefully studying the attendant complications. 
 
 The distribution of the pain is of importance. If all the branches of 
 a nerve are affected, we are warranted in the belief that the lesion is 
 situated either in the trunk of the nerve or at its central origin. If only 
 one branch of the nerve is involved, and this condition persists during 
 the entire course of the disease, the lesion is probably situated in the 
 affected branch, since it is not probable that a lesion which is situated in 
 the trunk of a nerve, will merely select the fibres going to one branch. 
 But the restriction of the symptoms to a small branch does not posi- 
 tively exclude the central nature of the affection, since the fibres of the 
 nerve diverge at the centres, and we can readily understand that a 
 central lesion may involve one set of fibres or cells, to the exclusion of 
 others. 
 
 When motor and trophic disturbances are observed within the dis- 
 tribution of the nerve which is the seat of pain, the lesion is almost 
 undoubtedly situated in the trunk of the nerve. This is not true in all 
 cases, as these complications may be reflex in their character, but in such 
 an event they will not often be strictly confined to the course of the 
 painful nerve. 
 
 Neuralgias which form complications of cerebral or spinal diseases 
 are accompanied by the symptoms of tlie primary affections. Cerebral 
 diseases are accompanied by disorders of the special senses, or of the 
 other cranial nerves, paralysis of one or more limbs (usually on one side 
 
NEUKALGIA. Ill 
 
 of the body), epileptiform convulsions, disturbances of the intellect, etc. 
 Spinal cord diseases are attended by oculo-pupillary disorders (when the 
 lesion is in the upper part of the cord), motor paralysis (frequently of a 
 paraplegic type), atrophy of muscles, increased or diminished reflex 
 excitability, sensory disturbances (usually anjcsthesia), interference with 
 the functions of the bladder and rectum, etc. 
 
 Tlie prognosis of neuralgia depends entirely upon that of its under- 
 lying cause. If due to an organic lesion, the prognosis will depend upon 
 that of the latter affection, whether it is of such a nature as to permit 
 removal by internal medication or by the knife, or whether it is of a cen- 
 tral nature and not amenable to treatment. 
 
 When due to a constitutional cause, the prognosis again depends 
 upon the character of the primary disease. Thus, a syphilitic neuralgia 
 presents an excellent prognosis, while one occurring as the result of a 
 tuberculous cachexia almost always continues until the death of the 
 patient. 
 
 Neuralgias of old age present a gloomy prognosis, although this is 
 not so absolutely unfavorable as Trousseau would have us believe. We 
 may, however, regard it as a general rule that a neuralgia which develops 
 after the age of sixty will continue (usually with increasing severity) 
 until the death of the sufferer. 
 
 Those cases which are due to heredity do not present any especially 
 bad prognosis with regard to the individual attacks, but they manifest a 
 greater liability to relapse and to the transformation of the disease into 
 some other neurosis. 
 
 The large class of neuralgias which is caused by anasmia, etc., usually 
 furnishes a favorable prognosis, and this improves so much the more, the 
 earlier the patient comes under treatment. After neuralgias have lasted 
 for a long time, secondary changes are apt to develop in the nerves and 
 surrounding tissues, and these react unfavorably upon the course of the 
 disease. As we shall see at a later period, the locality of the pain also 
 possesses considerable influence upon its prospects as regards a speedy 
 or tardy recovery. 
 
CHAPTER Y. 
 
 TREATMENT. 
 
 In treating neuralgias, we should, above all, endeavor to determine 
 the cause of the disease, and, if possible, attempt its removal. Thus, in 
 malarial neuralgias, the exhibition of large doses of quinine will usually 
 cause the disappearance of the neuralgic symptoms. In many chronic 
 cases, however, quinine fails us, and we are then compelled to resort to 
 some form of arsenic. I usually prescribe Fowler's solution in five-drop 
 doses t.i.d., and rapidly increase by addition of a drop to each dose 
 until gastric irritability or oedema of the lower lids begins to develop. 
 The drug is then discontinued for a few days, until the gastric irritation 
 has subsided, after which it is administered in doses slightly smaller than 
 those which sufficed to produce the gastric symptoms. It may now be 
 continued in this manner for a long time without giving rise to any dis- 
 agreeable effects (it should be given in a little water immediately after 
 each meal, before the patient rises from the table). In addition to the 
 use of Fowler's solution, benefit is also derived in these chronic cases 
 from cool sponge-baths of the entire body, followed by vigorous shampoo- 
 ing, and from the administration of brandy or whiskey. 
 
 In syphilitic neuralgias, the treatment varies according to the charac- 
 ter of the disease. When the pain is produced without any local lesion 
 in the affected nerve, the greatest benefit is derived from the use of some 
 form of mercury ; when the neuralgia is due to pressure upon the nerves 
 from syphilitic periostitis, etc., or to syphilitic changes in the nerves 
 themselves, we must employ iodide of potassium. As we have previously 
 remarked concerning the nervous manifestations of tertiary syphilis, we 
 should only stop at that dose of the iodide which cures the affection. 
 We may begin with ten to fifteen grains t.i.d., and increase this dose 
 as the necessities of the case demand. Relief is usually experienced 
 within a few days. Syphilitic neuralgias are not infrequently the fore- 
 runners of more serious affections of the nervous system, and the admin- 
 istration of the iodide should therefore be continued for one or two 
 years after the disappearance of the symptoms. 
 
 In the comparatively rare cases of true rheumatic neuralgias excel- 
 lent results are obtained from the administration of salicylic acid. I 
 generally make use of the following formula : 
 
 ^ . Acid salicylic 3 ij- 
 
 Sodas bicarb 3 ij. 
 
 Glycerinse, 
 
 Aquae , aa ? ij. 
 
 M. 
 
 Of this mixture, one tablespoonful is to be taken three times a day, 
 shortly after eating, until slight evidences of intoxication become mani- 
 fest. 
 
NEURALGIA. 113 
 
 In those cases in ^;vhlch heredity or an acquired neuropathic disposi- 
 tion plays an important part, the tone of the nervous system is lowered, 
 and We must endeavor to improve it by moans of rest and generous 
 food. • 
 
 Whenever jpossible, prophylactic measures should be adopted, and 
 these refer especially to the education of the patients. Childhood and 
 youth are rarely subject to neuralgia, and a great deal may be done at 
 this time to elevate the tone of the nervous system, and tiius prevent the 
 development of neuralgia at a later period. The children should not be 
 allowed to go to school until the ages of seven and eight, and should not 
 be subjected to the "cramming" method of education. From a physi- 
 cal point of view, the plan adopted should be that known as the "hard- 
 ening" method. The patients should be subjected to daily cold wash- 
 ings or baths, regulated and moderate gymnastics, an abundant and 
 varied diet, and, especially, sufficient sleep. Our invariable advice in 
 these cases is, " Let the patients eat as much as their stomachs will 
 digest, and sleep as long as they can." When the patients arrive at 
 more mature years, they should abstain from mental overwork, and shun 
 alcoholic and sexual excesses. The care of the eyes is also an important 
 element, and their condition should always be investigated when the 
 patient is greatly occupied in reading or writing, fine needlework, or any 
 pursuit in which the eyes are subject to continuous strain. 
 
 These measures are important, not alone to prevent the production of 
 neuralgia, but also because such patients are apt, under adverse circum- 
 stances, to develop other neuroses. 
 
 A large number of cases are due to anremia, and we must then, of 
 course, resort to ferruginous tonics. The nature of the iron preparation 
 is not very important, but the carbonate of iron and, at the present time, 
 dialyzed iron, are most in vogue.' In addition, we must eudeajt'or to 
 ascertain and remove the cause of the anfemia. 
 
 When the neuralgia is produced by local causes, or when it is of a peri- 
 pheral nature, special treatment is required. Thus, when the affection is 
 due to the presence of a foreign body, the pressure of a tumor or cicatrix 
 upon the nerve, etc., surgical interference must be resorted to in order to 
 remove the offending substance. 
 
 When no cause can be determined, or when it is of an organic nature 
 and cannot be removed, symptomatic treatment is indicated. Among 
 such measures, the use of morpliine as a palliative is probably resorted 
 to most frequently. In some cases it acts not alone as a palliative, but 
 also as a direct curative agent. Not very infrequently, a severe neuralgia 
 will be permanently relieved by the administration of a sufficiently large 
 dose of morphine. It vrould seem, in such cases, as if the entire relief 
 from pain procured by its administration breaks the "painful habit" of 
 the nerve, and thus allows it to recover its tone. We must be very cau- 
 tious, however, about beginning the use of morphine in neuralgia, and 
 should not resort to it unless compelled by the severity of the pain. 
 Whenever it does become necessary, the morphine should be administered 
 hypodermically, not only because it acts more quickly when given in this 
 manner, but also because a smaller dose is required to produce a given 
 
 ' We should bear in mind that iron preparations should always be given in very 
 small doses, not alone because only a small quantity is absorbed, but also because tha 
 unabsorbed portion quickly interferes with the intestinal functions. 
 8 
 
114 FUNCTIONAL NEKVOUS DISEASES. 
 
 effect. The only objection to this method of administration is that the 
 opium habit develops more readily than when the morphine is given by 
 the mouth. After a vphile, of course, the dose must be increased; and in 
 chronic, incurable cases, almost incredible quantities of the different forms 
 of opium are taken. It is immaterial whether the injection is made over 
 the course of the painful nerve, or at a distance from it. No definite 
 statements can be made concerning the dose, as this must vary with the 
 severity of the pain and the known peculiarities of the patient. 
 
 Atropine is also useful as a palliative, though not so generally ap- 
 plicable as morphine. It may be administered either hypodermically or 
 by the mouth, and I have noticed as a curious fact, with regard to this 
 drug, that it sometimes acts more quickly and powerfully when given by 
 the mouth than when it is introduced hypodermically. The initial dose 
 is from gr. -gJg- — -^-^, to be repeated as the pain returns, until evidences of 
 its physiological effects (dilated pupils, dry throat, red face and chest, rapid 
 pulse) become apparent, after which the remedy is to be discontinued 
 until these symptoms have subsided. Very many persons are peculiarly 
 susceptible to atropine, and I have seen the above mentioned physiolo- 
 gical effects, with the addition of restlessness and a tendency to delirium, 
 following the administration of one one-hundredth of a grain. These 
 phenomena sometimes persist for two or three days (in one case we found 
 them last a week) after the discontinuance of the drug. But its palli- 
 ative effects cannot be compared with those of morphine, and it should 
 only be used when the patient presents an idiosyncrasy with regard to 
 the latter, or when it fails to produce the desired effect. 
 
 We also wish to refer to the sedative action of hypodermic injections 
 of simple water. This plan is not much employed, but we have found it 
 useful in quite a number of cases. In order to relieve pain by this 
 method, we merely inject a hypodermic syringeful of water into the sub- 
 cutaneous cellular tissue. When this method was first proposed (we for- 
 get the name of its inventor) hot Avater was used, but we have since 
 found that similar effects are produced, whatever the temperature of the 
 water may be. Sometimes the injection of one syringeful of water will 
 relieve the most intense pain within a few moments, at other times the 
 sedative action develops slowly, and several minutes elapse before its 
 effects are produced. In the majority of cases, however^ it produces 
 little or no effect, and we are unable to determine beforehand what the re- 
 sult of this manipulation will be. It would be well if systematic inves- 
 tigations were instituted, in order to determine to what cases this method 
 is applicable. Its modus operandi in relieving pain is unknown, but that 
 the opinion which attributes its sedative action to the results of the im- 
 agination is erroneous, is proven by the following personal case, which is 
 interesting in very many other particulars : 
 
 Case II. — Mrs. A. B., fet. 54 years, married; no hereditary tendency 
 known, but her children present a marked neuropathic disposition (epi- 
 lepsy, hysteria, nervosisme). Two years ago (1873), Mrs. B. injured her 
 left breast as she was leaving a street car, and soon afterward a small, 
 hard, painless lump appeared at the site of injury; subsequent develop- 
 ments proved this to be a scirrhous growth. 
 
 I was first called to see the patient toward the end of April, 1ST5, 
 and found lier suffering from a violent attack of neuralgia, the pain 
 migrating iiito various parts of the trunk and upper extremities; the 
 attack had developed quite suddenly. After a few days the zieuralgic 
 
NEURALGIA. 115 
 
 affection became strictly periodical in its appearance, being attended with 
 severe chills and regularly intermittent variations in temperature of the 
 quotidian type. At the end of a week the attack succumbed to forty-five 
 grain doses of quinine i^er diem. The patient remained well for only 
 three weeks, when the neuralgia recurred, the pains becoming gradually 
 more and more atrocious in character. This attack lasted until the mid- 
 dle of August. None of the many drugs emplo^^ed produced the slight- 
 est beneficial effect except atropia, which, when given to the extent of 
 producing marked dilatation of the pupils, dryness of the pharynx, rapid 
 pulse, and slight tendency to delirium, produced considerable relief. 
 After using it for a few weeks, however, it became entirely iuefficient. 
 A peculiar fact noticeable in the employment of the atropine was that, 
 when administered by subcutaneous injection, it produced less effect than 
 when tlie same amount was given by the mouth. The only relief that 
 could eventually be obtained was from the hypodermic administration of 
 Magendie's solution of morphine, the dose of which was finally pushed to 
 250 drops ^je?' diem (often as many as 400) in order to render the patient 
 tolerably comfortable. In conjunction with morphine, I employed subcu- 
 taneous injections of water. And here it may be well to mention a very 
 curious fact with regard to the comparative effect on this patient of hypo- 
 dermic injections of morphine and water. The former always produced 
 a more profound and permanent effect in relieving pain than the latter; 
 but while, in the beginning of the malady, the relief experienced from the 
 morphine was almost instantaneous, and that produced by the water only 
 became palpable after the lapse of four or five minutes, toward the latter 
 stages of the disease this relation was reversed, the relief experienced 
 from the water being instantaneous, while that from the morphine was 
 felt only after the lapse of several minutes. 
 
 The neuralgic pains were chiefly confined to the nerves of the upper 
 or lower extremities, but certain of the intercostal nerves were sometimes 
 implicated; at no period during the entire course of the disease did any 
 tenderness on pressure exist over any part of tlie spinal column. The 
 neuralgia continued, with short intermissions and continually increasing 
 severity, and was only terniinated by death (January 31, 1877), the im- 
 mediate cause of which was acute pleurisy of the left side, complicated 
 with oedema of the lungs. 
 
 Autopsy. — The results of the autopsy, which want of time prevented 
 me from making as carefully as was desirable, were substantially as fol- 
 lows: 
 
 JBrain. — Dura mater : slight pachymeningitis over the convexity of 
 both cerebral hemispheres; a few small cancerous nodules were scattered 
 over the inner surface of dura mater; calvarium normal. 
 
 Spi7icd cord. — Only the dorsal portion of the cord could be examined; 
 the cord itself was entirely free from disease; dura mater: slight pachy- 
 meningitis, apparently of about the same date as the cerebral; this mem- 
 brane was very firmly adherent to the vertebrcC, and minute carcinoma- 
 tous deposits projected from its inner surface. 
 
 J^ertebrce. — The bodies and laminae of the dorsal vertebrae (which were 
 the only ones examined) were infiltrated with the cancerous neoplasm to 
 such an extent that they could be cut with the knife; there was no mal- 
 formation of the vertebrEe. The long bones of the body could not be ex- 
 amined. 
 
 3Iamma. — The tumor of the left breast was nearly as large as a hen's 
 ^gg} and presented the ordinary appearances of scirrhous cancer. 
 
116 FUNCTIONAL NERVOUS DISEASES. 
 
 Ijungs. — Right lung slightly cedematous; pleura normal; under the 
 right pleura, and growing from the ribs, were a few small cancerous nod- 
 ules. Left lung slightly a?dematous; left pleura coated with fibrinous 
 exudation; small amount of fluid in pleural cavity. 
 
 Liver. — Surface perfectly smooth; size of the organ perhaps a trifle 
 greater than normal; liver-tissue largely infiltrated with carcinoma, the 
 deposits varying in size from that of a pea to a walnut. The consistence 
 of the new growth was a little firmer than that of the normal liver-tissue; 
 the carcinomatous portions occupied at least one-half of the entire bulk 
 of the liver. 
 
 Ovaries. — Right ovary was transformed into a scirrhous mass of ap- 
 parently homogeneous structure, which had attained almost the size of a 
 goose-egg. 
 
 The other organs were normal. 
 
 Histological appearances. — The new growths in all the organs pre- 
 sented the appearances of carcinoma simplex of a rather small-celled va- 
 riety; in some places the amount of stroma present was very much 
 diminished, constituting the softer variety of cancer; in other places tlie 
 relative proportion of stroma to cells became reversed, and the growth 
 presented the appearances of scirrhus. 
 
 We will next consider the class of remedies known as counter-irritants, 
 which include the ordinary fly-blister, cantharidal collodion, bisulphide of 
 carbon, electricity, and the actual cautery. I formerly made much more 
 extensive use of counter-irritants in the treatment of neuralgia than I do 
 at the present time, and how restrict their employment almost exclusively 
 to those cases in which there is marked tenderness over the spinous pro- 
 cess corresponding to the affected nerve (^vo^\^%&^^x'?, point apophysaire). 
 In such cases counter-irritants usually act admirably; in occipital neural- 
 gia we have found that the application of one or two blisters is generally 
 sufficient to relieve the pain entirely. The use of the ordinary fly-blister 
 and of cantharidal collodion is so common, that it is unnecessary to dwell 
 upon their mode of application. 
 
 The bisulphide of carbon is employed by pouring a few drops upon 
 some cotton and then applying this to the skin, the cotton being pressed 
 firmly against the integument in order to prevent evaporation. Within 
 one or two minutes severe pain begins to be felt, and the skin is then 
 found intensely reddened. The cotton should not be applied more than 
 two minutes, as the pain continues to increase for a little while after its 
 removal, and would soon become unendurable. Although the bisulphide 
 produces counter-irritation very rapidly, and is quite ready of application, 
 it possesses the inconveniences of being very painful, and also of being 
 excessively foetid. 
 
 Electricity may also be employed as a counter-irritant. For this pur- 
 pose we use the strongest secondary faradic current which the patient 
 can bear, the electrode consisting of a wire brush. This is applied over 
 the part to be irritated, the brush being either pressed firmly against the 
 skin or gently stroked to and fro across the surface. The counter-irrita- 
 tion is developed within a few moments, and disappears very soon after 
 the electrode is removed; while the brush is in contact with the skin, 
 however, the pain is very intense, and considerable fortitude is necessary 
 in order to tolerate it for even a few seconds. 
 
 The actual cautery with the hot iron is generally included under the head 
 of counter-irritants, but we think that it is erroneously classed among 
 
NEURALGIA. 117 
 
 tliese asrents. Paquelin's cautery may be employed, or an ordinary blast- 
 lamp, using- either a glass or an iron rod. When neither of these instru- 
 ments can be obtained, a poker heated in a good coal fire will suffice for 
 ail practical purposes. Most authorities state that the iron should be 
 wiiite-hot, but this is not necessary, and I have always found that a 
 cherrv-red heat will answer very well. There is a widespread feeling 
 ainony- the laitv (which has been fostered by blood-curdling newspaper 
 articles), that the application of the actual cautery is an heroic measure, 
 entailing excruciating agony. But, on the contrary, its application is 
 almost entirely painless when properly performed. The iron should be 
 applied verv gentlv and rapidly to the skin, so as to leave no scar orsup- 
 puratinof sore, and the entire operation only lasts a fraction of a second. 
 In fact, the pain is sometimes so insignificant, that I have used the iron 
 without the knowledge of the patient, and whenever I could rely upon 
 the statements of my patients in this regard, they have always informed 
 me that the pain of the application was not worth mentioning. It may 
 either be emploved on the spine or along the course of the affected 
 nerves. It is a singular fact that the pain may sometimes be relieved by 
 the application of the cautery to a distant part of the body. Thus, there 
 are quite a number of authentic cases on record in which the application 
 of the cautery to the lobe of the ear has relieved an attack of sciatica 
 (this plan was borrowed from veterinary practice). The manner in which 
 the actual cautery produces its beneficial effects is unknown, but there is 
 no doubt that it sometimes relieves neuralgia as if by magic. Even pains 
 which are due to an incurable organic affection, like locomotor ataxia, may 
 be relieved by its agency. It presents this advantage over the ordinary 
 methods of counter-irritation, that it produces no subsequent pain or an- 
 noyance, even if it proves unsuccessful as a palliative. 
 
 Electricity has also been extensively used as a palliative measure, and 
 both currents have been employed. The faradic current is employed in 
 two wavs, viz.: with the wire brush, and with the aid of sponge electrodes 
 placed along the course of the nerves. The former method is really a 
 form of counter-irritation, and we have previously discussed it under that 
 heading. The second method, viz. : that in which sponge electrodes are 
 placed along the course of the affected nerve, is not very much employed 
 at present. My own experience with it has been so unsatisfactory, that 
 I have entirely discarded it for several years past. 
 
 The use of galvanism, however, in the treatment of neuralgia is 
 attended with much greater benefit than that derived from the faradic 
 current. It is a much more valuable measure in peripheral neuralgias, 
 and those in which there is no gross anatomical lesion, than in central 
 ones, due to an organic lesion. The majority of authors advocate the 
 use of the descending current. When I first began the systematic use of 
 galvanism in the treatment of neuralgias, I also complied strictly with 
 this rule until I discovered accidentally, while galvanizing the sciatic 
 nerve of a patient suffering from sciatica, that equal relief was experi- 
 enced when the current was passing in the opposite direction. I have 
 had such frequent opportunity of verifying this experience, that I have 
 become convinced that the direction of the current is entirely immaterial. 
 
 The usual method of applying the galvanic current is to place one 
 electrode over the tender point which is present along the spinal column, 
 or, when this is absent, along the course of the nerve, and the other elec- 
 trode farther down in the course of the nerve near its peripheral distri- 
 bution. The strength of the current employed should vary according to 
 
118 FUNCTIONAL NERVOUS DISEASES. 
 
 the susceptibility of the patient. Beg-inning with a mild current, its in- 
 tensity is gradually increased, until a disagreeable burning sensation is 
 produced, and the current is then allowed to flow uninterruptedly for a 
 period varying from five to ten minutes. This' shoud l)e repeated daily 
 or every other day. We are usually able to determine after the first sit- 
 ting whether the current will have a beneficial effect or not. In favorable 
 cases a distinct amelioration of the pain is produced lasting from half an 
 hour to one or even two days, and when this palliative effect is naarked, 
 the patient is usually cured in from one to three weeks. As a rule, to 
 which there are occasional exceptions, the cases will not be relieved if the 
 cure is not complete within three or four weeks after beginning galvanic 
 treatment. We will find, in the course of our remarks on the special 
 forms of neuralgia, that some varieties are more susceptible to the influ- 
 ence of galvanism than others. 
 
 We will next consider the action of those remedies which appear to 
 have a special effect on neuralgic affections. 
 
 The number of these so-called specifics is legion, but there are not 
 many which possess any great value. We will only refer to those from 
 which we have derived benefit in practice. These include strychnia, ar- 
 senic, phosphorus, gelsemium, aconitia, bromide of potassium, oil of tur- 
 pentine, nitrite of amyl. 
 
 We have only obtained good results from strychnia in trigeminal and sci- 
 atic neuralgias, and in the last couple of years have limited its use almost 
 entirely to the treatment of the latter affection. While we do not claim for 
 it a specific action in this disease, we are nevertheless convinced that it 
 relieves more cases than any other single remedy. We should begin its 
 use in doses of one-forty-eighth of a grain given three times a day, and 
 can then increase the quantity administered by one teaspoonful daily un- 
 til the phosiological effects are produced (stiffness in the lower limbs, 
 and sometimes slight spasms, increased reflex excitability, pain in the 
 throat, nervousness). In bad cases, the patient should be kept slightly un- 
 der the influence of the drug for two or three weeks, and if recovery does 
 not occur in that period, it will be useless to continue its administration. 
 
 The patient should, however, be carefully watched during the entire 
 period of its exhibition, and the drug discontinued as soon as marked 
 effects become evident. Some patients are extremely susceptible to its 
 influence, and I have seen a vigorous adult suffer severely from the ad- 
 ministration of three doses of one-forty-eighth of a grain which were taken 
 in the course of twenty-four hours. 
 
 Arsenic frequently does good service. It is preferably administered 
 in the form of Fowler's solution (beginning with five drops three times a 
 day and gradually increasing up to ten or twelve drops at a dose). 
 
 This drug is one of the best nerve-tonics with which we are acquainted, 
 and may be administered with benefit for a very long time. It is useful, 
 at times, in all forms of neuralgia, but is especially serviceable in those 
 varieties which are apparently combined with degeneration of blood- 
 vessels occurring in old age or in hard drinkers. 
 
 Phosphorus, from its presence in the tissues of the brain, was regarded, 
 in former times, as a sine qua non in the treatment of functional nervous 
 diseases. It was, however, gradually losing its prestige in the treatment 
 of neuralgia, when it was again brought strongly to the notice of the pro- 
 fession by Thompson. My own experience has not been very satisfactory 
 with this agent, and I now limit its use to those cases which are accom- 
 panied by evidences of nervous depression, especially when caused by 
 
NEURALGIA. 119 
 
 mental overwork. Squibb's solution of phosphorus in cod-liver oil fur- 
 nishes a very nice method of administration, but I have usually employed 
 it in combination with strychnia and quinine, adoptin<j the formula known 
 as the Hammond mixture. 
 
 1^ . Strychnije sulph gr. i. 
 
 Ferri pyrophosphatis, 
 
 Quinife sulph iia 3 i. 
 
 Acid phosphor, dil., 
 
 Syr, zingiberis aa 3 ij. 
 
 M. Sig. — 3 i- t.i.d. 
 
 Gelsemium sempervirens had been long employed in this country in 
 the treatment of neuralg'ia, but it did not meet with general favor until 
 the seal of European approbation had been placed upon it. This druo- 
 has been chiefly used in trigeminal neuralgia, especially in the dental 
 forms, and my own experience conforms with that of most observers who 
 have used the remedy, viz. : that it relieves some cases with great rapiditv, 
 while others of an apparently similar nature are not benefited in the 
 least. The fluid extract is the most reliable preparation, and may be 
 given in doses of gtt. v. to x., t.i.d. The patient should be carefully 
 watched while the drug is being administered, as it has a very powerful 
 paralyzing action upon the heart, and may very rapidly produce great 
 muscular prostration. 
 
 Aconitia had been recommended in neuralgia by Benj. Brodie and bv 
 Romberg, but afterward fell into disuse until extolled in the highest terms 
 by Gubler several years ago. In this country. Dr. Seguin was prominent 
 in bringing it into public notice, and for a year or more, I have used it 
 extensively. I must confess, however, that my expectations with res"ard 
 to the effects of this drug have not been entirely realized. While it pro- 
 duced decided relief in the larger number of cases in which it was used, 
 it produced a complete cure in only a few. When the preparation is 
 good (Duquesnel's aconitia' is the only reliable article), it is an extremely 
 powerful poison (only equalled in virulence, perhaps, by nicotine) and 
 should be given in exceedingly small doses. 
 
 The dose is from yfo — jij °^ ^ grain, given three times a day, and 
 this may be increased by one dose daily until the physiological effects 
 (dryness of the throat, slowness of the pulse, and tingling of the tongue, 
 roof of the mouth, and tips of the fingers) are produced. If immedi- 
 ate relief is not obtained, it should be continued for several weeks before 
 being discarded. Although this remedy does not fulfil the enthusiastic 
 encomiums of Prof. Gubler, it will, I think, be found to be one of the most 
 generally useful of all anti-neuralgics, and in some even desperate cases 
 the pain is found to disappear as soon as the patient is fully under its in- 
 fluence. I also wish to emphasize the fact that, whenever necessary in 
 the treatment of neuralgias, the remedies employed should be pushed 
 to the production of their full physiological effects, before they are re- 
 nounced as useless. The physician, although avoiding recklessness, 
 should be bold in the use of his medicinal armamentarium. 
 
 ' Sir. Rice, chemist to Bellevtie Hospital, informs me by verbal communication, 
 that Duqiicsnel's aconitia is composed of aconitia proper and of pseudo-aconitia. the ef- 
 fects of the latter being directly antagonisric to those of the former. An English pre- 
 paration of aconitia, which, according to Mr. Rice, is chemically pure, will soon appear 
 in the market. 
 
120 rUNCTIOJSTAL NERVOUS DISEASES. 
 
 Bromide of potassium was, at one time, regarded as a panacea for a 
 considerable number of nervous disorders, and neuralgia was also included 
 in this category. But it has no direct palliative effect whatever in the 
 latter disease. It is useful in those cases which are complicated with hys- 
 teria, or with an irritable condition of the nervous system arising from 
 any source, but in such instances it merely soothes the nervous system, 
 and does not relieve neuralgic pain. It must, therefore, alwaj's be com- 
 bined with some other remedy, and large doses are usually required. It 
 is given to advantage with hydrate of chloral in those cases in which the 
 patients suffer from insomnia, when this condition is due to causes other 
 than pain. 
 
 Oil of turpentine, though very little employed at the present time, 
 sometimes proves very useful in chronic cases of sciatica. It should be 
 given in doses of half an ounce to an ounce, immediately after meals. 
 
 Nitrite of amyl has been recommended of late in the affection under 
 discussion, and quite a number of cases have been reported, in which it 
 has produced happy results. My own experience with it in this disease 
 has been small, and while my results have not been very striking, they are, 
 however, sufficiently satisfactory to stimulate to further trial. The nitrite 
 of amyl should be administered by inhalations, beginning with three-drop 
 doses three times a day, and gradually increasing, as the necessities of the 
 case demand. 
 
 Finally, we must devote a little attention to the surgical treatment of 
 neuralgia, although this should be included, strictly speaking, in the 
 province of the practical surgeon. These measures include neurotomy 
 (nerve section), neurectomy (excision of a piece of a nerve), nerve 
 stretching, and ligature of arteries. 
 
 Although it has been very conclusively shown that cut nerves do not 
 unite by first intention, nevertheless the union occurs very rapidly, and 
 there is some reason to believe that the regeneration of a piece two inches 
 in length will not occupy a longer time than that of a portion only a frac- 
 tion of an inch. For this reason, therefore, simple neurotomies should 
 not be resorted to whenever neurectomy can be performed, and, in addi- 
 tion, as large a piece of the nerve as possible should be removed. In the 
 operation of stretching the nerve an incision is made along the length of 
 the nerve, and the latter is laid bare and detached from surrounding tis- 
 sues; the finger is then introduced beneath the nerve, and vigorous trac- 
 tion made. When this operation is performed upon small nerves, the 
 traction must be exercised with great caution in order to obviate their 
 rupture. This accident happened to Czerny while stretching one of the 
 branches of the trigeminus, and he was compelled, in consequence, to ex- 
 sect a portion of the torn nerve. The inodus operandi of the relief 
 obtained by the operation is entirely unknown. 
 
 Ligature of the carotid has been employed several times in hopeless 
 cases of tic douloureux, but this operation should only be resorted to as a 
 dernier ressort. 
 
 Surgical interference is especially indicated when the disease is of a 
 peripheral nature. This does not, however, constitute an absolute rule, 
 as neurectomy has been known to produce a cure when the neuralgia was 
 the result of a central affection. Such an effect is regarded as the result 
 of an " alterative " action upon the nutrition of the central nervous sys- 
 tem — another method of expressing our ignorance. Neurectomy is very 
 rarely dangerous, but it should, nevertheless, be only used as a last resort. 
 The prognosis of the operation, as regai'ds complete and permanent re- 
 
NEURALGIA. 121 
 
 covery, is not ver}'' good. A relapse may occur long after the operation, 
 and Gussenbauer reports one case in which the disease returned five years 
 after exsection. 
 
 Five years ago Arloing and Tripier demonstrated that recurrent 
 nerves pass from the peripheral ramifications of one nerve to those of ad- 
 jacent ones, and therefore pain which is located in the distribution of one 
 nerve may be attributed to an affection of another, and perhaps entirely 
 healthy one. These facts are of great importance, not alone from a phy- 
 siological, but also from a practical standpoint. They teach us that great 
 caution must be exercised in the determination of the nerve to be oper- 
 ated upon, as it has been found, on more than one occasion, that a por- 
 tion of the wrong nerve has been exsected, and a second operation there- 
 fore rendered necessary. We will discuss this subject more in detail in 
 our remarks on the special forms of neuralgia. 
 
CHAPTER VI. 
 
 TRIGEMINAL NEUEALaiA,' 
 (Prosopalgia.) 
 Clinical Histoky. 
 
 Teigeminal neuralgia is unilateral in almost all cases, and does not often 
 affect all the branches of the nerve. Whenever this is the case, the pain 
 often radiates into the occipital nerve or cervico-brachial plexus. The 
 supraorbital branch is by far the most frequently involved; and, when 
 this occurs in a malarial patient, the affection is popularly known as 
 brow-ague. Any nerve twig may, however, be separateh^ implicated to 
 the exclusion of all the others, and there are even a few cases on record 
 in which the branch going to the tongue was alone affected. 
 
 The paroxysm of pain may develop with extreme rapidity, but there 
 are usually some prodomata for a few hours before the onset. These 
 consist of a feeling of "drawing "in the distribution of the nerve, of 
 numbness, slight wandering pains, or a sensation of coldness. Then 
 slight " stitches " begin to run along the nerve ; they soon increase in sever- 
 ity, and appear to dart with fearful rapidity (sometimes running toward 
 the centre as well as toward the periphery). A lull then occurs, during 
 which merely a numb pain is appreciable; but this calm is only tempo- 
 rar}', and is interrupted in a moment or two by another attack of pain. 
 The entire paroxysm lasts for a period varying from a few minutes to 
 Sfcveral hours. Trousseau has described one variety uuder the title 
 epileptiform neuralgia, which he thinks is analogous to, and, in some in- 
 stances, is an expression of true epilepsy. This form develops at an 
 ad\anced age, the pain is extremely intense and always darting in char- 
 acter, and is accompanied by convulsive movements of the side of the 
 face involved (tic douloureux). The patients endeavor to mitigate the 
 pain to a certain extent by firmly compressing the cheek with the hand, 
 and this may be done so forcibly and continuously that the skin is par- 
 
 ' The trigeminus is divided into three branches, viz., the ophthalmic, superior 
 maxillarj', and inferior maxillary. The ojiJitJialmic branch supplies the lachrymal 
 gland, the conjunctiva and integument of the upper lid, the skin of the frontal region 
 as far as the vertex, the mucous membrane of the frontal sinus, the ciliary muscle and 
 iris, the integument of the nose, inner surface of the lower lid, the lachrymal sac, 
 and caruncula. The snpeiiw mnxilUiry branch supplies the integument of the temple 
 and side of the forehead, the upper teeth, antrum, lower eyelid, side of the nose, the 
 integument and mucous membrane of the u;.per lip. The inferior maxillary branch 
 supplies the integument of the temporal region, the auditory meatus and integument 
 of the ear. the temporo -maxillary articulation, the parotid gland, the mucous mem- 
 brane of the tongue, mouth, and gums, the lower teeth, integument of the chin and 
 lower part of the face, and the lower lip. 
 
NEURALGIA. 123 
 
 tially rubbed off and the face denuded of the beard; they are unable 
 to take solid food for fear of producin<^ a paroxysm, and for the same 
 reason articulation is interfered with, since even the movements of 
 the cheek may give rise to the pain. When the paroxysm reaches its 
 height, the patients may become delirious for a few moments on account 
 of the atrocious character of the pains. We cannot agree with Trous- 
 seau's view of the close relationship of this form of the disease with epi- 
 lepsy. To our mind it is merely a severe form of neuralgia, occurring at 
 that period of life when arterial degeneration is going on, and the nutri- 
 tion of the nerves suffers severely in consequence. Nor do we agree with 
 Trousseau in giving such an extremely unfavorable prognosis in this va- 
 riety. These cases are, at times, combined with melancholia, and this is 
 not surprising if we reflect upon the intensity of the sufferings of the pa- 
 tients and upon the unfavorable prospects as regards recovery which is 
 usually offered to them by physicians. 
 
 Puncta dolorosa are very commonly observed, and are readily recogniz- 
 able. The following ones are observed in neuralgia of the ophthalmic 
 branch: a supra-orbital point, at the supra-orbital notch or foramen, a 
 parietal point, at the summit of the parietal protuberance, a nasal point, 
 at the upper part of the lateral aspect of the nose; in neuralgia of the 
 superior maxillary branch, we find an infra-orhital point, at the infra-orbi- 
 tal foramen, a nasal point, at the lower part of the lateral aspect of the 
 nose, a malar point, over the middle of the malar bone, a superior gen- 
 <7^yrt/ point, in the upper gums; in neuralgia of the inferior maxillary 
 nerve, a temporal point, immediately in front of the lobe of the ear, a 
 mental point, at the mental foramen, and an inferior gengival point, in 
 the lower gums. Other puncta dolorosa have been mentioned by various 
 writers, but these are the only ones which we have been able to detect. 
 We must also refer to the fact that Trousseau's point apophysaire is fre- 
 quently observed over the first or second cervical vertebrae, though it is 
 not by any means so constant as the distinguished French observer be- 
 lieved. Pressure upon the tender spinous process sometimes sends a 
 thrill of pain through the supraorbital nerve. 
 
 When the ophthalmic branch is the seat of the disease, numerous 
 concomitant symptoms may be manifested. The most frequent are in- 
 tense redness of the conjunctiva and profuse secretion of tears; there is 
 not infrequently an erysipelatoid condition of the integument of the 
 forehead. The hair of the eyebrow and of the scalp, in the distribution 
 of the affected nerve may turn gray or become brittle or coarse. Her- 
 pes as a complication of trifacial neuralgia is almost exclusively limited 
 to the distribution of the ophthalmic nerve (herpes ophthalmicus). It is 
 usually confined to the upper lid or forehead, but it sometimes involves 
 the cornea, leading to opacity of that organ, which disappears after a 
 time in most cases. It is also liable to produce iritis in such instances 
 from an extension of the corneal inflammation to the subjacent tissues or 
 from the presence of the eruption upon the iris. Quite a number of 
 cases have been reported which appeared to indicate the direct depen- 
 dence of glaucoma upon neuralgia of the trigeminus. Irritation of the fifth 
 nerve has been known to produce increased tension of the eyeball. 
 But this question appears to be still unsettled, and it remains for further 
 investigations by ophthalmalogists to decide this mooted point. In one in- 
 teresting and rare variety of ophthalmic neuralgia, the pain is strictly 
 confined to the interior of the eyeball, and is of a tensive boring charac- 
 ter. This is usually looked upon as a neuralgia of the ciliary nerves; 
 
124 FUNCTIONAL NEEVOrrS DISEASES. 
 
 sooner or later it is generally combined with neuralgia of some other 
 branch of the trigeminus. 
 
 In neuralgia of the superior and inferior maxillarj'- branches, the vaso- 
 motor complications are most marked. The face is red and hot, and per- 
 spires profusely, and the carotid throbs violently. The secretion from 
 the nose on the affected side is usually increased, and in one case, I saw 
 it assume a sero-purulent character during the continuance of the pain, i 
 The tongue may be furred on the painful side, and the buccal secretions 
 increased in amount. The skin of the cfieek is sometimes thinned and 
 shining in chronic cases; it is in this region, also, that I observed the hy- 
 pertrophy of the integument and subcutaneous cellular tissue in the case 
 mentioned in the general remarks on neuralgia. 
 
 Gross has described a peculiar form of neuralgia affecting these two 
 branches in old, toothless people. He attributes it to the compression 
 of the terminal filaments of the dental nerves by the deposit of newly 
 formed osseous tissue in the cavities of the alveolar processes. 
 
 Reflex amaurosis has also been attributed to neuralgia of the dental 
 nerves, but this statement needs verification before being fully accepted. 
 
 The duration of trigeminal neuralgia frequently depends upon our 
 ability to remove its cause. When the neuralgia develops after the age 
 of fifty, or in consequence of irremediable organic changes, the patients 
 are very liable to suffer from ever-increasing pain until death puts an 
 end to their tortures. The patients (even those suffering from the se- 
 verer forms) may retain an appearance of health for a long time, but 
 sooner or later, the continuous depressing influence of the pain and the 
 insufficient nutrition of the body caused by their fear of taking food, 
 lead to progressive emaciation, and sometimes to a markedly hN'sterical 
 frame of mind. Such patients lose their power of will, their judgment 
 becomes impaired, and tlie emotional nature is unduly excited. A ref- 
 erence to their ailment is sometimes sufficient to cause them to weep 
 profusely. They become unable to attend to business, not so much on 
 account of the pain (some patients are able to go through their usual occu- 
 pations while suffering terrible tortures, and without manifesting their 
 affliction to those around them), but rather from peevishness and inabil- 
 ity to direct their minds to any subject requiring careful thought and at- 
 tention. Blandford has observed one form of neuralgia which alternates 
 with attacks of insanity. 
 
 Etiology. 
 
 S^ex. — In my own experience, the female sex has suffered twice as 
 often as the male; among 107 patients, 71 were females and 36 males. 
 We should also take into consideration that I have not included, in this 
 number, any cases of hysterical clavus or of migraine, which are re- 
 garded by some writers as neuralgic in character, and which are almost 
 exclusively met with in females. This preponderance on the part of the 
 female sex is probably due in great measure to the influence of the child- 
 bearing period, and of the menopause. 
 
 Afje. — More than half of my cases developed between the ages of 
 twenty to forty years, or that period at which the struggle for life is 
 most severe, and in which the nervous system is accordingly subjected to 
 the greatest amount of wear and tear, in which the males are engrossed 
 in the cares of business, and are pressed by their competitors in the race 
 for a subsistence, and the females are compelled to devote themselves to 
 
NEURALGIA. 125 
 
 the claims of society, or, in the poorer classes, to the earning of their 
 daily bread, in addition to the manifold duties of maternity. 
 
 Heredity. — Though I have, unfortunately, no statistics in this respect, 
 my ex})erience has been that an hereditary influence is exercised more 
 frequently in the development of trigeminal than of any other form of 
 neuralg-ia. This is, no doubt, due to the fact that the brain (which con- 
 tains tlie nucleus of origin of the fifth nerve) is more frequently the site 
 of disturbance on account of bad hereditary influences than the spinal 
 cord, from which the sensory nerves of the body originate. An acquired 
 neuropathic disposition may, of course, also lead to the development of 
 trigeminal neuralgia, but we have discussed this subject with sufficient 
 fulness in our general remarks on etiology. 
 
 Ancemia^ etc. — Trigeminal neuralgia develops, in numerous individuals, 
 as soon as the general condition is somewhat below par, whatever the cause 
 of this deterioration of health may be. Thus, it may be caused by anosmia 
 from direct loss of blood, profuse discharges, etc., by cachexise of various 
 kinds (tuberculosis, carcinoma, etc.), or by overwork. Mental overwork 
 is especially effective in this respect, and is much more likely to produce 
 neuralgia when the patient is continually worrying or fretting. One 
 of my friends, who suffers occasionally from slight neuralgic attacks due 
 to this cause, finds that the pain disappears if he takes a hearty meal. 
 Sexual excesses are also injurious, and very frequently act as an exciting 
 cause. 
 
 Reflex causes. — A source of irritation situated in the most remote 
 parts of the body may act as the exciting cause of this form of neuralgia. 
 One of the most important causes in this category is straining the 
 eyes, though, as we have previously stated, we are of the opinion that 
 the frequency of this factor is overestimated, because a clear distinction 
 is not usually made between trigeminal neuralgia and other forms of 
 headache. Functional abuse of the eyes usually leads to supraorbital or 
 to ciliary neuralgias. 
 
 Disorders of the genital organs and of the intestinal tract may also be 
 included among these causes. In one case I found that a severe attack 
 of trigeminal and occipital neuralgia was caused by the presence of a tape- 
 worm in the intestines, and that the pain disappeared after the expulsion 
 of the latter. But cases of this nature are so infrequent that we are 
 compelled to admit the pre-existence of a neuropathic disposition in such 
 individuals. 
 
 Organic lesions. — In the cranial cavity there are several conditions 
 which may act as causes of trigeminal neuralgia. Romberg reported the 
 "Well-known case in which the autopsy showed that an aneurism of the in- 
 ternal carotid had pressed upon the Gasserian ganglion and the origin 
 of the trigeminus, and had thus given rise to intense neuralgia of many 
 years' duration. Other tumors at the base of the brain (carcinoma, syphi- 
 loma, cholesteotoma, etc.), may act in a similar manner. Exostoses grow- 
 ing from the petrous portion of the temporal bone and periostitis of this 
 part should be included in the same category. In the peripheral course 
 of th'fe nerves, they may be irritated by tumors growing from adjacent 
 parts of the face, by wounds of various kinds, the presence of foreign 
 bodies, the spread of inflammation from middle ear troubles, dental caries 
 or exostoses of the alveolar processes. 
 
 Constitutional causes. — Malaria and syphilis are the only general dis- 
 eases which have an undoubted influence upon the production of this form 
 of neuralgia. Malaria is a very important factor, and usually gives rise 
 
126 FUNCTIONAL NERYOUS DISEASES. 
 
 to supra-orbital neuralgia, though in rare oases it may produce pain in 
 the distribution of all the branches of the trigeminus. This variety is 
 easily detected by its periodicity and ready amenability to treatment by 
 quinine, or, in chronic cases, by arsenic. 
 
 Syphilis may give rise to neuralgia either during the secondary or ter- 
 tiary stage. The former variety is extremely rare, and no cases have 
 come under my own notice. The latter form is more common, and is due 
 to gummatous infiltration of the nerves or their neurilemma, or to com- 
 pression of the nerves by gummy growths. But even this la.tter form is 
 not so frequent as is generally supposed, and the mistake undoubtedly 
 arises from the fact that osteocopic pains are often regarded as neural- 
 gic in character. 
 
 Cold. — Sudden checking of perspiration from exposure to a draught, 
 etc., has been regarded as a frequent cause of trigeminal neuralgia, though 
 the modus operandi of its action is very obscure. There is no doubt, how- 
 ever, that it sometimes acts as an excit'ng cause ; we also find in cases of 
 this kind that considerable relief is often obtained by the application of 
 warmth and diaphoresis. 
 
 A considerable contingent of cases remains, however, in which no 
 cause is ascertainable, in which we must remain satisfied with the 
 bare diagnosis of neuralgia, and in which merely symptomatic treatment 
 is therefore admissible. 
 
 Diagnosis akd Peogkosis. 
 
 The headache of ancBinia is often mistaken for neuralgia, but it can 
 be readily differentiated. The pain of anaemia is not confined to the 
 course of the nerves, but is diffused over the forehead or the entire vertex. 
 It is of a dull or lifting tensive character, and is continuous, never par- 
 oxysmal. The temperature of the scalp is sometimes raised very appre- 
 ciably, and the integument may be acutely hyperEesthetic. 
 
 Migraine (hemicrania) has been regarded by many authorities as a 
 form of neuralgia, but it is now almost universally considered to be a 
 neurosis of the sympathetic nerve. The d fferential diag-nosis between 
 migraine and trigeminal neuralgia is usually effected with great readiness. 
 While neuralgia is rarely observed before the age of twenty, migraine 
 generally begins about the period of puberty, and sometimes even much 
 earlier. Furthermore, heredity plaj^s a much more important part in the 
 etiology of migraine than it does in that of neuralgia. The pain also 
 presents entirely different characteristics. In migraine it is of a throb- 
 bing, dull character, and, unlike that of neuralgia, is felt deep within the 
 skull, and not in the distribution of special nerves. Migraine is also 
 sometimes accompanied by hyperjethesia of the auditory and optic nerves, 
 and also by hallucinations of these two senses. The course pursued by 
 the tv.'o affections is entirely different. An attack of migraine rarely 
 lasts more than twenty-four hours, and the patient is then free from 
 suffering until another attack occurs. We must not forget, however, that 
 the two affections may be combined in the same patient. 
 
 Claviis hystericvs. — This is a fixed pain, situated in the parietal region 
 near the sagittal suture ; the suffering has been likened to that produced 
 by driving a nail into the scalp. It is always combined with other well- 
 known symptoms of hysteria. These characteristics are sufficient to 
 differentiate it from triireminal neurala'ia. 
 
NEURALGIA. 127 
 
 Osteocopic pains. — These are also frequently mistaken for true neu- 
 ralgia, when they occur in the forehead. They usually make their ap- 
 pearance durini^ the secondary stage of syphilis, and almost always occur 
 at night; they are confined to one spot, and are sometimes excruciating, 
 " as if the bones were being split." They readily recover under the use 
 of mercurials. 
 
 Headache of JtrlgJii's disease. — Although the diagnosis between 
 this condition and trigeminal neuralgia is ajjparently very easy, never- 
 theless mistakes sometimes occur. Within the last six months, two 
 grave errors of this kind have come under my notice. In one case the 
 patient had been treated for upward of two years for neuralgia. The 
 character of the pain alone should have led to a suspicion of serious 
 organic trouble; it was bilateral, of a dull, continuous character (lasting 
 day and night), and attended with frequent attacks of vomiting. An 
 examination of the patient's heart revealed the existence of hypertrophy 
 of the left ventricle without valvular lesion. Suspicion was therefore 
 directed to the kidneys, and an examination of the urine showed a low 
 specific gravity, and the presence of a very large amount of albumen. 
 The diagnosis of Bright's disease was therefore evident. 
 
 The various conditions which we have enumerated above are frequent- 
 ly mistaken for neuralgia. Such an error is chiefly attributable to the 
 loose manner in which the term neuralgia is employed by the profession. 
 If we bear in mind the distinguishing characteristics of neuralgic pain to 
 which we have referred in the general remarks on diagnosis, the differen- 
 tiation from other painful affections will be readily made iu almost all 
 cases. 
 
 Prognosis. — This depends in great part upon the etiology. If the 
 neuralgia is due to malaria, syphilis, exposure, ana?mia, or overwork, the 
 attack will soon subside, as a rule, when we are in a position to successfully 
 combat the primary cause. The prognosis is also very favorable when 
 the neuralgia is reflex in its nature. A great many of the so-called 
 idiopathic cases, however, especially those which Vjegin late in life, and 
 those which are due to anatomical lesions of the nerves, are very obstinate 
 in their nature, resisting all medical treatment, and sometimes even surgi- 
 cal interference (neurotomy, etc.). A large proportion, also, of those 
 cases which are due to hereditary influence, present a gloomy prognosis 
 as regards complete recovery. Although such an attack of neuralgia 
 may, perhaps, yield readily to treatment, nevertheless there is great 
 liability to relapse, whenever the tone of the nervous system is lowered 
 from any cause, such as mental overwork, sexual or alcoholic excesses, 
 etc. But, on the whole, trigeminal neuralgia is not such a bugbear as it 
 is generally regarded, and there are numerous measures at our command, 
 which, if they will not cure, will at least produce decided relief in most 
 cases, and there are very few in which life cannot be made tolerable to 
 the sufferers. 
 
 Treatmext. 
 
 The remarks which have been made on page 112 et seq. will also apply to 
 the treatment of trigeminal neuralgia, but there are some special points to 
 which we desire to call attention. In the first place, severe cases de- 
 mand entire mental rest, especially when the patient has a bad family 
 history. If there are any evidences of serious hereditary neuroses, 
 especially if there has been any insanity in the family, we must regard 
 
128 FUNCTIONAL NEEVOUS DISEASES. 
 
 the patient with suspicion. If he is engrossed in the cares and anxie- 
 ties of business, he should, for a time, give up his occupation when tliia 
 plan is practicable. Physical rest should also be obtained. The exercise 
 allowed the patient must at first be of a mild character (walking, car- 
 riage-riding, fishing, etc.). He must be especially warned against the 
 dangers of sexual excesses, and it is perhaps advisable to counsel abso- 
 lute continence until the patient has entirely recovered from the neu- 
 ralgia. 
 
 The diet should be varied and plentiful, and the appetite stimulated in 
 every possible way. Unfortunately the movements of mastication will 
 frequently give rise to the development of a paroxysm of pain, and the 
 nutrition of the patient is thus seriously interfered with. We must 
 then place our chief reliance on a milk diet. In those unfortunate cases 
 in which the pain produced during eating is so excruciating that the 
 patients will only take very minute quantities of food at a time, we 
 should, without much delay, begin to nourish the patient by means of 
 rectal alimentation. This is especially important because the severe 
 cases to which we now refer usually occur in old age, and the vital 
 powers are therefore in danger of sinking from the combined depressing 
 influences of the terrible pains and the insufficient amount of nourish- 
 ment. 
 
 In protracted cases the condition of the eyes should always be care- 
 fully examined, and if it is found necessary, reading (especially news- 
 papers) should be entirely interdicted. 
 
 Other reflex sources of irritation must be carefully inquired into. 
 The condition of the genital organs and of the intestinal tract should 
 also be investigated. We must, however, advise caution in respect to 
 the habit of indiscriminately pulling out carious teeth (sometimes even 
 sound ones) when a patient suffers from a severe attack of neuralgia. In 
 bad cases this is sometimes carried so far that all the teeth are removed 
 from one side of the jaw, the patient, in the meanwhile, growing steadily 
 worse. It is to be remembered that the teeth are essential factors in the 
 process of digestion, and that they should, therefore, not be sacrificed 
 unwarrantably. They should not be extracted until we have made a care- 
 ful search for other causes, and unless manipulation of the supposed 
 offending tooth produces a decided increase of pain. 
 
 In that form of neuralgia known as neuralgia of the jaw-bones, which 
 was first described • by Gross (and which he attributed "to the com- 
 pression of the minute nerves distributed through the wasted alveolar 
 processes, dependent on the encroachment of osseous matter upon the 
 walls of the canals in which they are enclosed "), this distinguished sur- 
 geon obtained admirable results by resecting the affected part of tlia 
 alveolar process. A succinct account of the operation is given in the 
 American Journ. of Med. Sciences, for 1870. 
 
 Trigeminal neuralgia, due to malaria, must be treated, of course, like 
 all other manifestations of this disease, with large doses of quinine. The 
 best plan is to slightly cinchonize the patient for two or three days, and 
 then continue the remedy for a couple o.f weeks in tonic doses. This 
 variety presents a very great tendency to relapse whenever the system is 
 subjected to malarial influences. 
 
 The syphilitic forms of this neuralgia are treated with mercurials and 
 iodide of potassium respectively, according as they appear in the secon- 
 dary or tertiary stages. We must repeat, even at the risk of appearing 
 tiresome, that these remedies must not be discontinued as soon as the 
 
NEURALGIA. 129 
 
 neuralgia has disappeared, but should bo administered for a long time 
 afterward. 
 
 Syphilitic neuralgias are very frequently the forerunners of more 
 serious nervous affections, which can, in such cases, only be forestalled by 
 persevering, long-continued anti-syphilitic medication. We should also 
 Avarn these patients against the dangers of alcoholic excesses. One of the 
 severest forms of cerebral syphilis is that due to changes in the coats of 
 the blood-vessels, and these would only be aggravated by excessive in- 
 dulgence in stimulants. 
 
 In other forms of trigeminal neuralgia resort is had to the use of nar- 
 cotics or so-called specifics. 
 
 In my own practice I have learned to dispense with narcotics to re- 
 lieve trigeminal neuralgia, until other remedies have failed me. It is to 
 be remembered that this form of neuralgia is especially apt to be long- 
 continued, that in such cases the opium habit is very liable to be estab- 
 lished (especially because we must employ the hypodermic method of 
 administration), and that when this has once developed, an attempt to 
 diminish the quantity of morphine injected will almost inevitably lead to 
 a decided increase in the intensity of the pain. This is not an imaginary 
 evil, as the majority, perhaps, of the cases of chronic opium-eating which 
 have fallen under my notice, have been due to the administration of opium 
 begun in this very disease. 
 
 But when we have determined to use opium (the best method of ad- 
 ministration is the hypodermic injection of Magendie's solution) we should 
 always bear in mind that our object is to relieve the pain as rapidly as 
 possible. It is much better to give a single large dose than a couple of 
 smaller, insufficient ones; by the latter method an equally large amount of 
 opium may enter the system without producing the desired effect. It is 
 impossible to state in so many words what dose is requisite, since this de- 
 pends entirely upon the severity of the pain, and the individual suscepti- 
 bility of the patient. In exceptional cases, opium appears to have not 
 only a palliative, but also a markedly curative effect. It is sometimes found 
 that the patient remains permanently free from the pain, as soon as the 
 latter has been entirely relieved through the use of a full dose of the drug. 
 In those cases (and unfortunately they are very frequent) in which narco- 
 tics must be employed for a long time, the use of morphine may be alter- 
 nated from time to time with hypodermics of atropine or of pure water, 
 whenever either of these agents is found serviceable. In this manner we 
 can avoid accustoming the system to the administration of morphine, and 
 can thus restrict the quantity exhibited to the lowest possible amount. 
 Morphine or atropine should never be injected into the face, because thev 
 produce no better effect when administered in this manner than when in- 
 jected at a distance, and furthermore, abscesses develop at the site of in- 
 jection in exceptional cases, and might thus lead to deformity. Bartholow 
 also recommends aquapuncture for its palliative effects, thirty to sixty 
 drops being injected, and the operation repeated in two minutes if not suc- 
 cessful. 
 
 In aconitia we possess a remedy which appears to single out trigem- 
 inal neuralgia for the display of its curative properties. The initial dose 
 of this remedy is gr. y-|-(J-, t.i.d., and increased by a single dose daih- 
 until its physiological effects are produced. The drug is now prepared 
 in the form of granules, but we do not favor its exhibition in this shape, 
 because we cannot graduate the dose as carefully as is desirable in dealing 
 with such a virulent poison. This remedy has produced recovery in a case 
 9 
 
130 FUNCTIONAL NERVOUS DISEASES. 
 
 in which all three branches of the trigeminus had been unsuccessfully ex- 
 cised, and I have also seen a patient in whom it produced relief after an 
 unsuccessful excision of the inferior dental nerve had been made. In a 
 certain proportion of cases, however, it fails us entirely, whereas it may 
 produce a perfect success in other and apparently similar ones. But 
 aconitia has already proved a very valuable addition to our anti-neuralgic 
 remedies, and after the enthusiam of some observers has been moderated, 
 and the indications with regard to its use have been more clearly defined, 
 it will assume its position as, perhaps, one of our best remedies for the 
 disease under consideration. 
 
 Arsenic, in the form of Fowlers solution, is also a valuable agent. 
 We have previously referred (page 118) to the manner in which it should 
 be administered. This drug appears to be especially indicated in the 
 severe and obstinate cases developing in old age, and we have sometimes 
 been surprised to see what marked and rapid improvement will occur in 
 some which were apparently hopeless. xVrsenic does not appear to me to 
 act directh' upon tlie neuralgic affection, but rather by giving tone to the 
 general nervous system. I have arrived at such a conclusion from the 
 fact that it is an invaluable agent in all neuroses due to nervous exhaus- 
 tion or in which the nutrition of the nervous S3'stem is impaired in old 
 age. 
 
 Gelsemium sempervirens is especially reliable in dental neuralgias, but 
 is also useful in a considerable number of other varieties of facial neural- 
 gia. Tliis should also be given until slight toxic effects become noticea- 
 ble, the initial dose varying from live to ten drops of the fluid extract. 
 It is often difficult to obtain a reliable preparation. 
 
 Strychnia has also been employed in this affection, but I cannot recom- 
 mend it very highly, and, at present, I only use it after having made an 
 unsuccessful trial of the drugs previousl}^ mentioned. My experience 
 with it has been so unsatisfactory that I am gradually abandoning its use 
 in this disease. 
 
 Whenever the affection is attended with tenderness of the first or 
 second cervical vertebras iypoint apophysaire) it is advisable to employ 
 counter-irritation over the tender spot (either with a fly-blister or with 
 the electrical wire brush) in combination with some of the remedies which 
 we have just mentioned. Counter-irritation, under these conditions, 
 almost always produces a certain amount of relief. 
 
 The employment of the faradic current is not only devoid of advan- 
 tage in this affection, but, on the contrary, I have seen a single applica- 
 tion of this form of electricity convert a mild case into an extremely 
 severe one. The galvanic current is not open to this criticism, but its use 
 is attended with fewer successes in this tlian in any other form of neural- 
 gia. In applying it, one electrode should be placed upon the nape of 
 the neck, and the other over the exit of the branches of the nerve from 
 their bony canals under the integument of the face. The current should 
 only be employed continuously, and, in cases in which we suspect a cen- 
 tral origin, we may place both electrodes over the mastoid processes, and 
 allow a current to pass through the brain. As soon as the patient becomes 
 dizzy the application is discontinued, and a weaker current employed. 
 We must be careful to use only mild currents upon the face, and their in- 
 tensity should be increased very graduall}' and cautiously. The applica- 
 tions may last from five to ten minutes, and are repeated daily or every 
 other day. ^ * 
 
 When internal medication or the use of galvanism, etc., prove useless, 
 
NEURALGIA. 131 
 
 we are compelled to fall back upon surgical interference as a dernier res- 
 sort. In no other form of neuralgia has this mode of treatment been more 
 frequently or more successfully employed. Recourse may be had to neu- 
 rotomy, neurectomy, nerve-stretching or ligature of the carotid. The 
 operation of neurotomy is very simple (it can be done subcutaneously 
 without even disfiguring the patient), but it is usually barren of results on 
 account of the ready reunion of the divided ends of the nerves. Neurec- 
 tomy is the operation generally resorted to, and portions of the nerves have 
 been excised in every part of their course, the daring knife of the sur- 
 eeon enterino- even as far back as the foramen rotundum at the base of 
 the skull. 
 
 Dr. Dennis, who has lately reviewed the subject of neurotomy ' as 
 applied to the superior maxillary nerve, thinks that the operation offers 
 the best chances of success when the excision is made between the 
 spheno-palatine ganglion and the foramen rotundum. There can be no 
 djjubt, even from the n erel}^ cursory review which we have made of the 
 surgical literature of the subject, that this operation (which is the most 
 difficult and dangerous of all the operations for neurectomy of the 
 trigeminus), is steadily gaining favor among practical surgeons. We 
 must refer the reader to surgical treatises for a description of the modus 
 operandi of these operations. Some of them, such as excision of a 
 portion of the inferior dental nerve (while in the canal) are of a very 
 simple nature, and may be performed without the possession of special 
 surgical training. 
 
 Nerve-stretching has also been resorted to within the last few years, 
 in cases of trigeminal neuralgia, and this method can already point to 
 some successes. The operation has been performed upon all three 
 branches of the nerve, and is stated to' be of service even when the 
 neuralgia has a central origin. It should be done cautiously, and the 
 nerve not pulled upon too strongly. It is reserved for future investiga- 
 tions to determine the special indications for nerve-stretching and neu- 
 rectomy in this form of neuralgia, and their relative merits. 
 
 Finally, we must mention the opera.tion of ligature of the carotid for 
 obstinate cases of this disease. This was proposed b}^ Nussbaum, and 
 has been performed quite frequently by this and other German surgeons, 
 in most cases with admirable results. But the operation can only be 
 looked upon as a last resort, and should only be performed after medi- 
 cinal agents, netirectomy, and nerve-stretching have been faithfully 
 employed. 
 
 Despite the large number of cases of trigeminal neuralgia which 
 have been operated upon, its surgical treatment is still in a somewhat 
 chaotic condition, and not until the surgeon enters more carefully into 
 the minute details of the affection, will the indications for the various 
 operations be more precisely defined. 
 
 J New York Med. Journal, 1879. 
 
CHAPTER yn. 
 
 OCCIPITAL NEUKALGIA. 
 Clinical Histoet. 
 
 This term refers to an affection of either the occipitalis major ' or 
 minor nerves. When the auricularis magnus, subcutaneous colli, or 
 supra-clavicular nerves are involved, the affection is known as cervico- 
 occipital neuralgia. Occipital neuralgia is not, by any means, a very 
 uncommon affection, while cervico-occipital neuralgia is extremely rare, 
 and I have only seen it in combination with other varieties. 
 
 The character of the pain is entirely similar to that described in 
 prosopalgia, but it usually presents a much less degree of severity. It 
 shoots along the back of the head as far as the vertex, and when the 
 occipitalis minor is involved, likewise affects the lobe of the ear. When 
 the other above-mentioned nerves are implicated, the pain darts into the 
 lower part of the face and chin, the front of the neck, and the upper 
 part of the chest and shoulder on the same side. Occipital neuralgia is 
 much more commonly bilateral than an}^ other form of the disease. The 
 only painful points which we have been able to detect are an occipital 
 point, a little to the outside of the occipital protuberance, and another, 
 at the point at which the nerve becomes superficial {between the occipital 
 bone and the first cervical vertebra). A point apophysaire can be read- 
 ily detected, in most cases, over the second or third cervical vertebra. 
 During the paroxysms of pain the patients hold the head and neck as 
 immovable as possible, because a fresh attack is ver}^ readily induced 
 upon the slightest movement. It is important to remember, however, 
 that the head does not assume any characteristic position in this affec- 
 tion. "Occipital neuralgia is attended with very few complications, and 
 the only one which I have ever noticed has been a change in the color of 
 a lock of hair situated in the course of the nerve. 
 
 Dr. Julius Schreiber ** reported a unique case of double occipital 
 
 ' The occipitalis major nerve makes its exit from the spinal canal between the first 
 and second cervical vertebiee, passes upward and becomes superficial ut the lower pos- 
 terior border of the scalp, very close to the median line. It then passes uiiward to 
 supply the integument as far as the vertex. The occipitalis minor nerve is a branch 
 of the third cervical, escapes behind the sterno-mastoid muscle, upon which it ascends 
 to the occiput half-way between the lobe of the ear and the median line. It supplies 
 the integument of the lateral portion of the occiput, and sometimes the median sur- 
 face of the ear. The auricularis magnus is a branch of the third cervical, and sup- 
 plies the integument of the mastoid process of the concha ot the ear and the external 
 auditory canal. The subcutaneous colli is also a branch of the third cervical, and 
 supplies the integument of the upper part of the neck and under surface of the 
 chin. The supra-clavicular nerves arise chiefly from the fourth cervical, and pass 
 downward to supply the lower part of the neck and the upper parb of the thorax. 
 
 ^Berl. kl. Wschr., 1877, p. 726. 
 
NEURALGIA. 133 
 
 neuralgia, due to malaria, in which vaso-motor and secretory disturbances 
 appeared in the course of the trigeminus. These complications consisted 
 of redness of the face, injection of the conjunctiva, a profuse discharge 
 of tears, increase in the nasal secretion, and sneezing. The patient was 
 relieved by large doses of quinine. 
 
 Occipital neuralgia is not infrequently combined with trigeminal, 
 sometimes one form being more severe, sometimes the other. This com- 
 bination occurred in eleven cases under my observation. The pain of 
 one variety rnay be so predominant that the patients fail to mention the 
 milder pain. In a smaller number of cases, it is combined not alone with 
 trigeminal, but also with brachial neuralgia, and in these cases we have 
 always found marked tenderness along several of the upper cervical 
 vertebrae. 
 
 Etiology. 
 
 In my own cases I have found no especial difference with regard to 
 sex, the cases being distributed almost equally among both, although the 
 females are slightly in the preponderance. Some authors have had a dif- 
 ferent experience, however, and Eulenburg states that the proportion of 
 females to males is as five to one. 
 
 The disease chiefly affects adult life, the youngest of my patients be- 
 ing twenty-five years old, and the oldest seventy-six years. The majority 
 vary from twenty-five to fifty-five years, only two of my patients being 
 above the latter age. 
 
 The chief exciting cause appears to be exposure, and this is readily 
 understood, as the back of the neck is peculiarly liable to these influences. 
 The patients are also very liable to relapses from renewed exposure to 
 such causes. 
 
 Spondylitis deformans is also a not infrequent cause of the affection. 
 Special attention was called to this process by Dr. Julius Braun in a 
 pamphlet which he published upon the subject several years ago.' It 
 consists of a chronic inflammation of the ligaments and osseous tissues of 
 the vertebrae (chiefly the lateral processes), attended with enlargement 
 and deformity of the bones, and with marked tenderness of the affected 
 tissues. Although Braun entertains exaggerated views concerning the 
 frequency and importance of spondylitis deformans, we think it acts more 
 frequently as a cause of occipital and brachial neuralgias than has been 
 hitherto supposed. I can frankly state that I have probably overlooked 
 this process in more than one instance prior to the appearance of 
 Braun's article, and the affection is scarcely mentioned either by ortho- 
 pedic surgeons or by neurologists. 
 
 In rare instances occipital neuralgia may be due to various other 
 causes. Thus, it may arise from syphilis, malaria, caries of the first or 
 second cervical vertebra;, tumors of the spinal cord pressing upon the 
 nerves at their exit from the canal, direct injury from blows, or the pres- 
 ence of a carious tooth. Heredity exercises little influence upon its pro- 
 duction, the only case of this nature with which I am acquainted being 
 mentioned by Anstie; but even in this patient, brain-work and exposure 
 are mentioned as the exciting causes. 
 
 In those cases which are combined with brachial neuralgia I have 
 long thought that the disease was probably symptomatic of a subacute 
 
 ' Klin. u. Anat. Beitraege z, Kentniss d. Spondylitis Deformans. 
 
134 FUNCTIONAL NEKVOUS DISEASES. 
 
 mening'itis of the posterior portion of the cervical cord. My opinion is 
 based on tlie fact that the pain, in such cases, is not infrequently bilat- 
 eral (radiating into both arms and into both sides of the occiput), that 
 they are all attended with diffuse tenderness of the entire cervical spine,, 
 and that the pain gradually disappeared after the continued application of 
 counter-irritation to this reo-ion. 
 
 Diagnosis and Prognosis. 
 
 Occipital neuralgia is most frequently mistaken for myalgia affecting 
 the muscles at the back of the neck, this region, as vrell as the shoulders, 
 being a favorite site of muscular rheumatism. A careful observation will 
 suffice to discriminate these two affections, and we have entered so fully 
 (page 108) into the characteristics of myalgic pain, that it is unnecessary 
 to refer to this subject again. 
 
 Caries of the first and second cervical vertebrre may also be mistaken 
 for the disease under consideration. At the onset, cervical caries may 
 present no symptoms beyond those of occipital neuralgia, and it may, 
 therefore, be impossible, for a while, to diagnose the former affection. 
 But even at this early period our suspicions should be aroused if the neu- 
 ralgia is bilateral, and resists treatment very obstinately. After a short 
 lapse of time, however, other symptoms are manifested which reveal the 
 true nature of ^he disease. Whenever the patient wishes to move his 
 head, he assists himself by pulling the head upward with his hands; 
 there is considerable interference with the rotatory or flexion movements 
 of the head. Finally, the head may become fixed in one position, the 
 face usually being directed downward and to one side. In some cases 
 an attempt at rotation or flexion of the head will give rise to a grating 
 sound, which is heard by the patient; the grating may also be palpable 
 to the hand when placed upon the affected region. Finally, some pa- 
 tients present evidences of pressure upon the spinal cord, in the shape of 
 cervical paraplegia or of hemiplegia. 
 
 Cancer of the vertebrfe may be also mistaken for simple neuralgias 
 (occipital, brachial, etc.), but we Avill refer to this subject at a later period. 
 
 The lyrognosis of occipital neuralgia is usually good. The large ma- 
 jority of cases recover within a short period, though in a few exceptional 
 cases they may resist the most active measures of treatment and even 
 surgical interference. 
 
 Teeatment. 
 
 The recognition of the malarial or syphilitic nature of the disease is. 
 sufficient to indicate to us the plan of treatment to be pursued in such 
 cases. When the neuralgia is due to spondylitis deformans, the best 
 treatment consists in the continued application of the compound tincture 
 of iodine to the affected parts, the daily use of warm baths, and the inter- 
 nal administration of small doses of the iodide of potassium (gr. x., t.i.d.). 
 The patients usually experience great relief from such measures, even 
 thougli the deformity of the vertebrre does not disappear. The actual 
 cautery may also be resorted to in severe cases of this kind. 
 
 The treatment of ordinary attacks of occij^ital neuralgia is of a very 
 simple nature. Counter-irritation furnishes the best method of treat- 
 
NEURALGIA. 135 
 
 nient. We may employ either the ordinary fly -blister (which produces 
 the most permanent e.'^ects) or the electrical wire brush; these should 
 be applied directly over the point apop/iysaire. Marked relief very 
 seldom fails to be produced by these measures, even in long-standing 
 cases. In addition, we may employ with advantage the constant gal- 
 vanic current, applied directly along the course of the affected nerve. 
 When the pain is very severe, hypodermic injections of morphine or atro- 
 pine; are useful, and I have sometimes thought that special benefit is de- 
 rived froni making the injections m loco dolenti. If the case resists these 
 methods of treatment, excision of a portion of the nerve may be per- 
 formed. This is very readily done in the case of the occipitalis major 
 nerve, on account of its superficial position during the greater part of its 
 course. Very few cases, however, will be found in which it becomes ne- 
 cessary to resort to such extreme measures. In fact, in my experience, 
 this is the most readily curable of all forms of neuralgia. 
 
CHAPTER YIIl. 
 
 BRACHIAL NEURALGIA. 
 Clinical History. 
 
 Although one of the more infrequent forms of neuralgia, especially 
 in civil life, this variety often rivals trigeminal neuralgia in intensity, and 
 is also interesting on account of the numerous and important trophic 
 changes with which it may be complicated. The neuralgia may be 
 strictly limited to the course of one nerve, but, in the majority of patients, 
 several branches of the brachial plexus are involved at the same time. 
 This is due to the fact that the nerves are situated in such close apposi- 
 tion in the neck and arm, and that there are frequent anastomoses be- 
 tween them. Henle (" Anatomie des Menschen ") has furnished a plate 
 representing the cutaneous distribution of the individual nerves of the 
 plexus, but, for the reasons just mentioned, this is of very little service 
 in practice. 
 
 The pains of this variety of neuralgia do not so often present the peri- 
 odicity which is frequently observed in other forms of neuralgia, ^. e., the 
 paroxysms appear more irregularly and, at the same time, more often than 
 in other varieties. A striking characteristic of brachial neuralgia is the 
 fact that the pains dart both up and down the nerves in the majority of 
 cases, instead of merely toward the periphery, as they usually do in other 
 forms. 
 
 Weir Mitchell,' to whose valuable observations we are largely in- 
 debted, has applied the term " caifsalgia " to one form of pain (observed 
 in traumatic neuralgias), which he describes in the following terms: " Its 
 favorite site is the foot or hand. The great mass of sufferers described 
 this pain as superficial, but others said it was also in the joints, and deep 
 in the palm. If it lasted long it was finally referred to the skin alone. 
 
 " Its intensity varies from the most trivial burning to a state of tor- 
 ture, which can hardly be credited, but which reacts on the whole economy, 
 until the general health is seriously affected. The part itself is not alone 
 subject to an intense burning sensation, but becomes exquisitely hyperaes- 
 thetic, so that a touch or a rap of the finger increases the pain. Expos- 
 ure to the air is avoided by the patient with a care which seems absurd, 
 and most of the bad cases keep the hand constantly wet, finding relief in 
 the moisture rather than in the coolness of the apj^lication. Two of these 
 sufferers carried a bottle of water and a sponge, and never permitted the 
 part to become dry for a moment. As the pain increases the general 
 sympathy becomes more marked. The temper changes and grows irrita- 
 ble, the face becomes anxious, and has a look of weariness and suffering. 
 The sleep is restless, and the constitutional condition, reacting on the 
 
 * Injuries of Nerves, 1873. 
 
NEURALGIA. > 137 
 
 wounded limb, exasperates the hyperaesthetic state, so that the rattling of 
 a newspaper, a breath of air, the step of another across the ward, the vi- 
 brations caused by a military band, or the shock of the feet in walking, 
 gives rise to increase of pain. At last the patient grows hysterical, if we 
 may use tlie only term which describes the facts. He walks carefully, 
 carries the limb with the sound hand, is tremulous, nervous, and has all 
 
 kinds of expedients for lessening his pain Motion of the part 
 
 WHS unendurable in some of the very worst cases; but, for tlie most part, 
 it did no harm, unless so excessive as to flush the injured region." 
 
 The internal cutaneous, ulnar, and radial nerves are the ones which 
 are most frequently involved, but it is comparatively rare to find even 
 these nerves affected to the entire exclusion of other branches. This cir- 
 cumstance is very readily understood, if w^e remember that Arloing and 
 Tripier have shown that numerous recurrent sensory fibres, pass from 
 the trunk of one nerve to that of another at various heights (most nu- 
 merous as the nerves approach the periphery). 
 
 Brachial neuralgia is frequently associated with other varieties, espe- 
 cially with occipital and trigeminal neuralgias, as we have already stated 
 in discussing these affections. 
 
 Numerous /)«;ic<a dolorosa are mentioned by various authors, but we 
 have found very few which are constant. A spinal point over the lower 
 cervical vertebrfe is present in almost all cases which attain any considera- 
 ble degree of severity. An axillary point is also frequently observed over 
 the course of the plexus in the axillary space. At the elbow we may find 
 an ulnar point, between the olecranon process and the internal condyle; 
 an external cutaneous point, above the external condyle, where the mus- 
 culo-cutaneous nerve becomes superficial. The other painful points are 
 inconstant. 
 
 The motor complications are not very important; they consist of stiff- 
 ness of the limb from rigidity of the muscles, and this may even be so se- 
 vere as to lead to considerable contracture. Muscular atrophy may de- 
 velop, both from disuse of the limb and from an affection of the trophic 
 fibres in the course of the nerves. Fibrillary twitching-s of the muscles 
 are sometimes observed, and even tonic and clonic convulsions of the en- 
 tire limb have been noticed. These phenomena are not, however, by any 
 means so frequent as in neuralgic affections of the lower limb, except in 
 cases in which the disease is due to a direct wound of the nerve. 
 
 Hyperresthesia, or more properly speaking-, hyperalgesia of the skin, is 
 a frequent complication. The integument may be exquisitely painful to 
 the slightest touch, while tactile sensibility is unaltered or diminished. 
 The patients also often complain of a sensation of formication and numb- 
 ness. 
 
 The trophic complications are at once the most interesting and 
 important, but they do not attain any considerable intensity unless the 
 neuralgia is due to an injury of the nerve. The skin and its appendages 
 are the parts most frequently involved, giving rise to what is known as 
 glossy skin. This condition, as far as w^e know, is limited to the fingers 
 and to the palm or dorsal surface of the hand. The integument of the 
 affected portion appears to be thinner than normal, the creases are par- 
 tially or entirely effaced, as if the skin were drawn tightly over the bones, 
 and it has a peculiar shining look. Glossy skin is usually combined with 
 hypertesthesia of the integument, though we have not seen it attended 
 with the burning pain which Weir Mitchell mentions (none of my cases, 
 however, were of a severe character). Various eruptions have been ob- 
 
138 FUNCTIONAL NERVOUS DISEASES. 
 
 served upon the skin, such as herpes (which runs along the course of one 
 of the superficial nerves), ordinary eczema, pemphigus, etc. Foul-look- 
 ing and very obstinate ulcers may be left in the wake of these eruptions. 
 Diminution of perspiration is the only secretory disorder of the skin which 
 1 have noticed, but Weir Mitchell has observed, in addition, excessive se- 
 cretion of sweat, which was sometimes of " a disagreeable odor, like vine- 
 gar." The hair presents the same modifications which we have refei-red 
 to in connection with trigeminal neui-algias, viz., atrophy, hypertrophy, 
 change of color, and brittleness. The nails may also suffer, the rate of 
 growth is diminished, they become more strongly curved in both direc- 
 tions, fissures appear in them, and they present a dirty, yellowish color. 
 
 Finally, we must refer to a peculiar affection of the joints, which may 
 involve any of the articulations of the limb, but is usually confined to the 
 fingers. In one case under my observation all the joints of the fingers of 
 the left hand, together with the elbow-joint, were involved. The ends of 
 the bones appear to be swollen, slight redness and perhaps a little swell- 
 ing is sometimes observed around the joints, and they are extremely ten- 
 der upon the slightest pressure in any direction. Contracture and anky- 
 losis of the affected joints are very apt to develop under these circum- 
 stances. The following case, reported by Weir Mitchell, is a good illus- 
 tration of the manner in which these changes may be combined. 
 
 Case III. — B. D. L., aged forty-three, a farmer from Maine. Enlisted, 
 July, 1862. He was healthy to the date of his wound, received July 2, 
 18G3x at Gettysburg. While kneeling and aiming, he was shot in the right 
 side of the neck. He felt pain in the wound, but none down the arm. He 
 spun around, feeling stunned, and fell on his back, not unconscious. In 
 five minutes he arose and walked to the rear, where the wound was dressed 
 with cold water, no splint being employed either then or later. . At first 
 all motion was lost. In an hour he could move his fingers and abduct 
 the arm, but not flex it. He thinks sensation Avas perfect, except as to 
 the ulnar distribution. Within an hour he had severe earache, and pain 
 in the shoulder, arm, and forearm. During the second week he began to 
 have burning pain in the hand. At this time, which probably marked 
 the onset of neuritis, the shoulder-joint grew stiff, then the elbow, and 
 lastly all of the fingers. This condition was excessively painful, and re- 
 mained unchanged. The tremor, which is constant in the upper arm mus- 
 cles, began the day of the wound, and had not ceased on his admission to 
 our wards. 
 
 Site of vjound.— On admission, October, 18G3, it was noted that the 
 ball had entered the right side of the neck, in front, three inches above 
 the clavicle, in the outer edge of the trapezius. The missile passed down- 
 ward and outward, and struck the anterior edge of the supra-spinal fossa 
 of the scapula, five inches external to the spine of the first dorsal vertebra. 
 Both wounds sloughed, leaving scars one and a half inches in diameter. 
 The patient is well and florid. The shoulder is motionless from stiffness. 
 The lower joints are alike stiff, swollen, red, and painful ; the arm, semi- 
 prone and flexed, is carried across the chest, supported by the sound hand. 
 He has slight motion throughout, but the effort causes fibrillar tremor 
 and exquisite pain. 
 
 Sensation. — The sense of touch is everywhere good, save that there is 
 slight numbness of the back of the hand and forearm. Some causalgia is 
 felt in the palm, but no other pain, except on movement. 
 
 Nutrition. — The palm is thin and red and purplish, and on it the pa- 
 
NEITRALGIA. 139 
 
 tient uses water, now and then, as a dressing; there is no atrophy; the 
 wound is healed, but tender, as are also the upper nerve-tracks. Muscu- 
 lar hypera?sthesia of the deltoid and tricej^s is present. The nails are 
 remarkably curved, the hair is scanty, the sweat ill-smelling and acid. 
 The shoulder muscles alone have lost electro-muscular contractility (in- 
 duction current). Under ether, the joints when moved are found to be 
 free from well-marked organic adhesions. 
 
 Passive motion and electricity caused speedy pain in movement, and 
 in February, 1864, he was able to move all the joints with diminished 
 pain. The muscles were, at this time, sensitive to induced currents, and 
 the numbness and causalgia had nearly disappeared. He was allowed a 
 furlough, at the expiration of which he deserted. 
 
 Etiology. 
 
 Brachial neuralo^ia resembles sciatica with regard to etiology, in the 
 fact that both are frequently caused by agencies which act upon the nerves 
 after their escape from the spinal canal. Heredity plays a very unim- 
 portant part in its causation, and Anstie only mentions one case in which 
 the patient's family presented a neuropathic history. It is so rarely due 
 to this cause that the majority of authors do not refer to it. Salter re- 
 ports several cases of this form of the disease which were due to the reflex 
 irritation of a carious tooth, and other observers have reported similar 
 cases. Salter believes that such patients suffer from a predisposition 
 (either acquired or congenital) to neuralgia. Not an inconsiderable num- 
 ber of cases occur as complications of occipital and sometimes of trigem- 
 inal neuralgia. The brachial neuralgia then presents a lesser severity, 
 but I have sometimes noticed that this form persists after the occipital 
 or trigeminal affections have disappeared. Constitutional diseases, such 
 as malaria and syphilis, are very rai'ely, if ever, the causes of this form of 
 the disease. The large majority of the cases are due to local causes, which 
 may be situated at the spinal column, in the course of the nerves, or at 
 their peripheral distril^ution. The lesions of the vertebrse which may 
 give rise to it include spondylitis deformans, caries, and carcinoma. Braun 
 reports seven cases in which this was one of the symptoms of spondylitis 
 deformans affecting the cervical vertebrce. This is readily determined by 
 the local tenderness on pressure and by the presence of deformity, espe- 
 cially of the lateral masses. We refer to pages 144, 145 for our remarks 
 on the diagnosis of caries and carcinoma of the vertebrae. 
 
 Brachial neuralgia may, for a considerable period, be the sole symp- 
 tom of chronic cervical pachymeningitis; as a rule, the affection is then 
 bilateral and is combined with double occipital neuralgia. It may be im- 
 possible to determine the origin of the neuralgia for a month or two, but 
 other characteristic symptoms of pachymeningitis then make their appear- 
 ance, consisting of gradually increasing motor paralysis of the arms, with 
 contracture and progressive muscular atrophy, especially involving the 
 hands. 
 
 As I have remarked in the chapter on the etiology of occipital neu- 
 ralgia (page 133), I have long thought that this form, as well as brachial 
 neuralgia, may be sometimes due to subacute meningitis of the cervical 
 portion of the cord. ' 
 
 In the course of the nerves numerous exciting causes have been noted, 
 such as aneurism of the subclavian artery, pressure from adjacent tumors. 
 
140 FUNCTIONAL NERVOUS DISEASES. 
 
 wounds of various kinds (gunshot, lancet, knife), pressure of the frac- 
 tured end of a bone or of superabundant callus, implication of the nerves 
 in a retracting cicatrix, a direct blow, etc. 
 
 The exciting causes at the peripheral distribution of the nerves in- 
 clude the pressure of true or false neuromata, and the irritation arising 
 from punctured wounds. Three of my cases were due respectively to the 
 thrust of a rusty needle, a nail, and the point of a pair of scissors into the 
 fingers. In all of these cases the neuralgia affected various nerve-branches 
 in the forearm and shoulder. 
 
 Diagnosis and Prognosis. 
 
 Brachial neuralgia is sometimes mistaken for myalgia of the shoulders 
 and arms, but the previous remarks which we have made on this subject 
 will also apply here. Rheumatic inflammation of the shoulder- or elbow- 
 joints is recognized by the existence of fever, swelling of the affected 
 joints, local heat and tenderness, and the evident implication of the gen- 
 eral sj^stem. There is very little danger, however, of making such mis- 
 takes unless the case is examined superficially, and too much reliance 
 placed upon the patient's statement that he is suffering from " neuralgia," 
 a term which, in the mouths of the laity, is expressive of very many con- 
 ditions. 
 
 The main diflficulty consists in a determination of the exciting cause 
 of the disease. Whenever the affection is bilateral, and especially when 
 it is combined with occipital neuralgia, we must pay special attention to 
 the condition of the spinal column, and consider the possibility of the dis- 
 ease being secondary to spond3'litis deformans, caries, or carcinoma of the 
 vertebrge. We shall enter into this subject m.ore in detail under the head- 
 ing o£ intercostal neuralgia, and refer the reader to page 144 for our re- 
 marks on the subject. Chronic cervical pachymeningitis is recognized by 
 its steady progress, the implication of the occipital nerves as well as the 
 brachial plexuses, the coietinually progressing paralysis and atrophy of the 
 muscles of the upjier limbs, especially the hands, the development of con- 
 tracture of the upper limbs, and the final spread of the motor and sensoiy 
 disturbances to the lower limbs. 
 
 Those agencies which we have enumerated in the section on etiology 
 as acting upon the nerves after their exit from the vertebral canal, must 
 be determined by an accurate history of the case, and a careful examin- 
 ation of the arm by sight and touch. In obscure cases we must carefully 
 examine the chest in order to determine whether the neuralgia may not 
 be due to the pressure of a subclavian aneurism, or other intra-thoracic 
 growth. 
 
 Treatment. 
 
 One of the essential features in the treatment of brachial neuralgia, 
 whatever maybe its origin, is the maintenance of entire rest of the parts. 
 We not infrequently find that, after the disease has been apparently cured, 
 a relapse readily occurs in consequence of some unusual exercise. 
 
 During a paroxysm of pain the instincts of the patient will teach him 
 to hold the arm quiet, but he must also be enjoined to shun manual exer- 
 cise for several weeks after the pain has disappeared. 
 
 Medicinal measures are of little avail in this affection. When the par- 
 
NEURALGIA. 141 
 
 oxysms are unendurable we must, of course, resort to the use of hypodor- 
 mic injections of morphine or some of its substitutes. 
 
 Galvanism has proven by far the best remedial agent, in my hands, 
 in the treatment of this aifection. One electrode (it is immaterial which) 
 should be applied over the lower cervical vertebra?, and the other over the 
 course of the brachial plexus in the arm (the current should be moderately 
 strong and not applied longer than five to ten minutes). If the neuralgia 
 affects only the nerves in the arm, this application will be sufficient; but if 
 the forearm is also involved, a second application should be made, one 
 electrode being now applied to the plexus and the other to the affected 
 nerve. The sittings may be held daily, or every other day. 
 
 Counter-irritation is usually a valuable adjuvant, especially when the 
 disease is due to spondylitis deformans. In the latter event, the counter- 
 irritation is best secured by the application of tincture of iodine, repeated 
 with sufficient frequency to cause blistering; warm baths are also very 
 serviceable in these cases. In those cases which are not due to spondy- 
 litis, we may employ emplastrum cantharidis over the vertebra?, and, in 
 obstinate cases, over the tender spots in the. course of the nerves. The 
 actual cautery may also be resorted to, especially along the nerve-trunks. 
 This measure sometimes produces admirable results within a very short 
 period. 
 
 Surgical interference is frequently required in this form of neuralgia, 
 either to relieve the nerves from the pressure of a strangulating cicatrix 
 or of superabundant callus, to remove a neuroma, etc. I noticed as a 
 curious fact in the three cases previously mentioned as due to the prick of 
 a pin, blade of scissors, and nail, and in which the neuralgia appeared in 
 almost all the nerves of the arm, that the pain was very markedly im- 
 proved after several applications of the faradic current to the finger which 
 had been the site of the injury. In some inveterate cases it will become 
 necessary to resort to section or resection of the nerves; in such cases 
 great caution must be exercised, and the patient very carefully examined 
 in order to determine which nerve or nerves should be operated upon. 
 This problem is often solved with great difficulty on account of the abun- 
 dance of recurrent sensory fibres. Some successful cases of nerve-stretch- 
 ing for brachial neuralgia have been reported, and in these, as in all other 
 mixed nerves, it is not at all improbable that this operation will finally 
 supersede that of neurectomy entirely. 
 
 In the terrible form of neuralgia known as causalgia, Weir Mitchell 
 recommends the continual application of water dressings to the affected 
 part, and repeated blisters; hypodermic injections of morphine, preferably 
 into the seat of pain, are indicated when the pain is intolerable. 
 
CHAPTER IX. 
 
 INTERCOSTAL NEURALGIA. 
 CLi>ficAL History. 
 
 This constitutes one of the most frequent as well as the mildest forms 
 of neuralgia. The pain is strictly confined to the course of the nerves 
 (in the vast majority of cases to the anterior branches), and the parox- 
 ysms differ in no respect fvom those of other varieties of this affection. 
 If the pain is severe the patient leans toward the affected side (usually 
 the left), and is afraid to take a long breath. A paroxj^sm may be ex- 
 cited by coughing, sneezing, or any other sudden movement in which the 
 thorax and abdomen take part. The pain is usually felt on the left side, 
 from the sixth to ninth intercostal spaces. In one variety of intercostal 
 neuralgia, which sometimes attains an intolerable intensity, the breast is 
 the seat of pain, usually in the female, though a few cases have been re- 
 ported in the male (Cooper's irritable breast). This pain is purely neural- 
 gic in character, and does not appear to follow the definite course of any 
 single nerve, but darts through the breast in all directions. In neuralgia 
 of the breast, as well as in ordinary intercostal neuralgia, the integument 
 is often extremely hyperjesthetic (in the former case over the entire 
 breast, and in the latter along the course of the painful nerve), so that 
 the slightest touch is unendurable; the patients frequently complain of 
 the pain caused by the pressure of the clothes. In many cases, however, 
 firm pressure over the painful region will produce decided relief. After 
 a certain length of time the h^^perfesthesia gives way to anaesthesia, 
 though I have often observed the former condition even aftor the disease 
 has lasted for a long period. 
 
 Puncta dolorosa are very generally observed in this disease, though 
 it would be a mistake to believe that they constitute 'an absolutely essen- 
 tial feature. They are usually three in number, but one or even two of 
 these may be absent. They are termed respectively the spinal point, 
 which is situated to one side of the spinous process at the exit of the 
 nerve from the intervertebral foramen, the axillary, situated near a line 
 dropped from the middle of the axillary space, and the sternal point, 
 about an inch from the sternum, or, in the nerves distributed to the abdo- 
 men, near the median line over the rectus muscle. 
 
 Herpes zoster is the onlj'' complication of intercostal neuralgia which 
 possesses any importance. From the frequency with which herpes is re- 
 ferred to as a complication of neuralgia in foreign journals, it appears to 
 be much more common in Europe than it is in our own country. Accord- 
 ing to Baerensprung it is more frequent on the right side than on the left; 
 in very rare instances it is bilateral, and encircles the trunk like a girdle. 
 Its appearances are similar to those observed in ophthalmic zoster, and 
 we refer the reader to tJie description of the former affection on page 95. 
 
ISTEURALGIA. 143 
 
 Sometimes the eruption appears prior to the development of the neural- 
 gia, at other times the latter ceases as soon as tlie herpes has devel- 
 oped. It is frequently a very obstinate and distressing coniplicatioii, and 
 the slightest contact with the ulcerated surface may cause excruciating 
 agony. 
 
 Intercostal neuralgia differs somewhat from other varieties in the fact 
 that the patients often suffer from a dull, steady pain along the nerve 
 during the intervals between the paroxysms, and this interparoxysmal 
 pain is often a source of considerable distress; it is sometimes so severe 
 that the patients are compelled to restrain the movements of respiration 
 on one side, as in cases of pleurisy with effusion. 
 
 This disease is frequently combined with trigeminal and other neural- 
 gias, but it always follows in the wake of the latter, and does not attain 
 an equal severity. Anstie mentions a case of death from intercostal neu- 
 ralgia in a woman set. 70 years, in whom the disease was complicated with 
 intractable herpes ; death was directly due to exhaustion, consequent on 
 the severe and protracted pain. This case, however, is an extremely ex- 
 ceptional one, and I can find no reports of similar ones. 
 
 Etiology. 
 
 m 
 
 The large majority of cases of intercostal neuralgia develop in women 
 between the ages of twenty and forty years. It is, however, not infre- 
 quently met with in girls at the agie of puberty, and sometimes also plays 
 a part in the affection which we have termed the menopause neurosis 
 (page 100). 
 
 The period in which intercostal neui-algia usually appears corresponds 
 to the child-bearing age, and this is explained by the fact that itpommon- 
 ly results from excessive lactation, profuse leucorrhoea, and, as we have 
 observed in many cases, after the patient has lost considerable blood dur- 
 ing deliver3\ These patients always present evidences of anaemia, such 
 as palpitation of the heart, shortness of breath on slight exercise, drow- 
 siness in the day-time, and often insomnia at night, weakness, anremic 
 heart-murmurs, etc. We desire to call attention to the fact that this 
 class of patients, although markedly ani^mic, often present a very ruddy 
 complexion, which is sometimes so marked that we have seen physicians 
 make a diagnosis of congestion of the brain from the mere appearance of 
 the face. Upon close inquiry it will be found, however, that the redness 
 often allernates with sudden pallor, and this symptom is probably due to 
 vaso-motor paralysis as the result of the profound ani'emia. 
 
 Malaria is very rarely a cause of intercostal neuralgia, and periodicity 
 is not well marked in this variety. 
 
 Exposure to cold, etc., also plays a very unimportant part in the eti- 
 ology of the affection, and changes in temperature possess very little in- 
 fluence on the intensity of the jiain. 
 
 The other causes of intercostal neuralgia are also infrequent, and 
 chiefly include various affections of the vertebrae or membranes of the 
 spinal cord. It is not uncommonly one of the first symptoms of Pott's 
 disease, and is very generally present in the later stages when an aliscess 
 has formed which presses upon the cord or upon the roots of the nerves. 
 It is also a frequent symptom of locomotor ataxia. But we must not 
 confound the cincture feeling- of ataxia with true neuralgia, as the former 
 lacks the essential features of neuralgic pain. Intercostal neuralgia is 
 
144 FUNCTIONAL NERVOUS DISEASES. 
 
 also a symptom of spondylitis deformans and of carcinoma of the vertebrae. 
 In tlie latter affection it is always bilateral, and, as in the case which we 
 mentioned on page 114, the pains may present such perfect periodicity as- 
 to lead to a diagnosis of malarial infection. The neuralgia of carcino- 
 m:i3 vertebrariuu is usually caused by pressure upon the nerves at their 
 exit from the intervertebral foramina. Finally, aortic aneurism (of the 
 descending arch or abdominal portion) sometimes gives rise to intense in- 
 tercostal neuralgia, usually on one side. In one obstinate case under my 
 cliarge, a neuralgia of the ninth intercostal nerve was apparently due 
 to the pressure of a lipomatous tumor upon the nerve in the first half of 
 its course. In rare instances caries or necrosis of the ribs may also give 
 rise to this disease. 
 
 As this is usually a mild form of neuralgia, we should always examine- 
 the patient carefully for the organic diseases we have mentioned above* 
 whenever the pain does not yield readily to treatment. 
 
 Diagnosis. 
 
 Intercostal neuralgia is frequently mistaken for pleurodynia or muscu- 
 lar rheumatism involving the muscles which cover the ihorax. It resem- 
 bles this affection in the fact that the latter is also increasec^ by move- 
 ments of respiration, and that the breathing is therefore shallow on the' 
 affected side. But the pain does not follow the course of any definite 
 nerve, and is never shooting in character; furthermore, the puncta dolo- 
 rosa and hyperjesthesia of the integument are wanting. These patients 
 are also very liable to suffer from muscular rheumatism in other localities, 
 especially the shoulders or back of the neck. 
 
 Pleurisy, in which the pain is often of a neuralgic character, is dis- 
 tinguished by the clinical history as well as by the results of physical ex- 
 amination (friction murmur, dulness or flatness on percussion, which varies 
 with the change in the position of the patient, diminished vocal resonance, 
 etc.). Before the exudation has been formed, however, it is often very 
 difficult to differentiate the two affections, and sometimes the dOubt is only 
 cleared up by the subsequent history of the case. It is not sufficient to 
 have made a diagnosis of intercostal neuralgia; we should also endeavor 
 to determine its origin, and especially whether it is symptomatic of any 
 more serious affection. It is sometimes one of the first symptoms of 
 Pott's disease, and it may be very difficult, in the beginning, to determine 
 the nature of the primary affection. As we have stated in the remarks 
 on its etiology, intercostal neuralgia is most frequent between the ages 
 of twenty and forty years, and its development in a young child should 
 therefore put us on our guard. In addition to the youthful age of the 
 patient, inquiry should be made with regard to previous strumous history, 
 and to injury to the spine from a fall or blow. An additional differential 
 point of importance is the usually bilateral character of the neuralgia in 
 Pott's disease, whereas the idiopathic variety is almost invariably unilat- 
 eral. In Pott's disease the affected vertebra are tender on pressure with 
 tlie finger, and pain is also produced when the patient comes down firmly 
 upon his heels. In addition, the patients grow tired after slight exertion, 
 and the movements of the affected portion of the spinal column are stiff 
 and slower than usual. The manner in which the patients sit down or 
 rise from a chair is very characteristic. They move slowly, assist them- 
 selves in rising by grasping the arms of the chair, and keep the spinal col- 
 
NEURALGIA. 145 
 
 umn stiff. At a later stag-e of tlie disease, deformity of the vertebral col- 
 umn becomes manifest. Although this is a very valuable sign of Pott's 
 disease, it must be remembered that it is not absolutely pathognomonic in 
 all cases, and that other symptoms must be present in order to justify such 
 a diagnosis. 
 
 When the intercostal neuralgia is secondary to spondylitis deformans, 
 this affection is readily determined by visual and tactile exploration, 
 which reveals the presence of an irregular deformity, usually situated 
 over one lateral mass; it sometimes converts the entire vertebra into an 
 irregular, misshapen mass, and may cause ankylosis between it and the 
 adjacent vertebrae. It is a disease of adult, and usually, in fact, of ad- 
 vanced life, and this circumstance furnishes one of the most important 
 differential points between it and Pott's disease. 
 
 Intercostal neuralgia, like other forms of this affection, may also be 
 secondary to carcinoma of the vertebrre. It is sometimes extremely diffi- 
 cult to diagnose the primary affection. The latter disease usually de- 
 velops in females after the age of forty, and is generally secondary to 
 carcinoma in other parts of the body. The local symptoms are very obscure, 
 and do not aid much in the diagnosis. In three very well marked cases 
 which have come under my observation, not the slightest deformity of the 
 spine was discoverable. A characteristic feature of this affection is the 
 terrible intensity of the neuralgic pains, and the fact that treatment has 
 no effect upon them. We are compelled to resort to continually increas- 
 ing doses of morphine, until finally enormous doses must be taken in 
 order to produce even moderate palliative effects. 
 
 All of my cases were secondary to carcinoma of the breast, and the 
 discovery of cancer in any of the organs of the body is one of the most 
 important aids in diagnosis. 
 
 Tkeatmekt. 
 
 A considerable proportion of the cases develop in young married 
 women, suffering from profuse leucorrhoea, who are in the habit of nurs- 
 ing their children for an excessively long period (sometimes even two 
 years in the hope of preventing impregnation). The indications there- 
 fore are to relieve the anaemia produced by these drains on the vital 
 powers. The child should be taken from the breast as soon as prac- 
 ticable, and fed from the bottle. This is usually in the interest, not 
 only of the mother but also of the child, since the breast-milk is apt 
 to be poor in quality under such conditions. The leucorrhoea is merely 
 the result of the low condition of the system, and may usually be relieved 
 within a very short time by prolonged vaginal injections of hot water 
 (morning and evening for ten to fifteen minutes at a time). A mild 
 stimulant (beer or porter) may be taken with the meals, and a ferrugi- 
 nous tonic administered (dialyzed iron or the formula of the tincture of 
 the chloride which we have so often recommended). These cases improve 
 in a few days under such treatment, and are generally entirely relieved 
 within a couple of weeks. 
 
 Cases due to other causes are usually of a more severe character, and 
 may require more active measures of treatment. Here also we must 
 look for sources of debility and anremia, and endeavor to remove them 
 if possible. In the w^ay of medication, we may supplement the use of 
 iron by the addition of round doses of quinine. Even those cases which 
 are not of a malarial nature (comparatively few are) derive great benefit 
 10 
 
146 FUNCTIONAL NERVOUS DISEASES. 
 
 from doses which will produce a slight grade of cinchonism for two or 
 three days. 
 
 Counter-irritation also proves very useful; we have derived most 
 benefit from the application of blisters over the spinal painful point, ac- 
 cording to Anstie's recommendation. If this plan does not succeed, we 
 may apply them in succession over the various puncta dolorosa. The 
 blisters need not exceed an inch to an inch and a half in size, and as soon 
 as one spot heals another one may be applied. The electrical wire brush 
 over the spinal painful point has also been used as a means of counter- 
 irritation with some success. In severe cases the use of hypodermic in- 
 jections of morphine or atropine, and the constant galvanic current 
 become necessary. The latter agent does not by any means possess the 
 same efficacy in this form of neuralgia as it does in some others, notably 
 sciatica. In one obstinate case surgical interference was resorted to by 
 Nussbaum, who excised a portion of one of the intercostal nerves in order 
 to obtain relief from the excruciating pain. The operation was entirely 
 successful, although the disease had existed for twenty years prior to the 
 operation. 
 
 "When intercostal neuralgia is complicated with herpes zoster, very 
 little can be done for the eruption itself. It should be merely coated 
 with a mild dusting powder, such as subnitrate of bismuth or powdered 
 starch, to prevent the contact of the air, and care should be taken to keep 
 the clothes from rubbing against the ulcers. The galvanic current (one 
 electrode upon the spinal column at the exit of the affected nerve, the 
 other along its course) often gives excellent results in such cases, though 
 in others it does not produce the slightest beneficial effect. 
 
CHAPTER X. 
 
 LUMBAR NEURALGIA.' 
 Clinical History. 
 
 WiiEX compared with sciatica or trigeminal neuralgia, this form is 
 relatively infrequent, especially in the male sex, though it is not so rare 
 as generally believed. Its apparent rarity is due to a widespread ten- 
 dency to classify all neuralgic affections of the lower limbs under the gen- 
 eric head of sciatica. All branches of the lumbar plexus are never in- 
 volved at one time, the affection being generally limited to one or two 
 trunks. In the majority of cases the pain does not attain any great se- 
 verity, but at times the paroxysms rival those of tic douloureux in 
 intensity. 
 
 The most generally affected nerve in lumbar neuralgia is one of the 
 cutaneous branches of the crural, then follows in order of frequency the 
 ilio-inguinal and ilio-hypogastric,' which are usually implicated at the 
 same time; obturator neuralgia is an exceedingly rare affection. 
 
 The character of the pain presents no peculiarities apart from those 
 described in other forms. When the pain is very severe in one branch of 
 the plexus, it is the rule to observe irradiation into some of the other 
 branches at the height of the paroxysm. Exquisite hyperassthesia of the 
 integument, so that the patient winces at the slightest touch, often devel- 
 ops in the distribution of the affected nerve. 
 
 In neuralgia of the ilio-inguinal, the pain darts into the scrotum in the 
 male and the labium major in the female; this variety is often attended 
 with frequent and painful micturition. I have noticed this symptom in 
 males as well as in females. Various puncta dolorosa have been described, 
 but I have been unable to discover any in several cases of this kind, with 
 the exception of the spinal point near the first lumbar vertebra. 
 
 In crural neuralgia the pain is felt in the distribution of the internal and 
 middle cutaneous nerves to the anterior and inner aspects of the thigh, 
 and sometimes the inner part of the leg and foot as far forward as the 
 great toe. The painful points are found at the middle of the groin where 
 the nerve passes out of the pelvis from underneath Poupart's ligament, 
 
 ' The lumbar plexus is formed by the anterior branches of the four upper lumbar 
 nerves. It divides into the ilio-hypogastric, ilio-inguinal, genito-crural, external cuta- 
 neous, obturator, and anterior crural, the cutaneous branches of which are distributed 
 as foUows : the ilio-hypogastric to the gluteal region, midway between the anterior 
 and posterior spinous processes of the ilium, and to the hypogastric region ; the ilio- 
 inguinal to the scrotum and upper, inner part of the thigh in the male, and the labia 
 in the female ; the genito-crural to the upper and anterior portion of the thigh ; the 
 external cutaneous to the outer side, and outer portion of the anterior aspect of the 
 thigh, nearly to the knee ; the obturator to the inner side of the thigh above the knee. 
 The anterior crural has two cutaneous branches, the middle and internal cutaneous, 
 the former being distributed to the anterior aspect of the thigh as far as the knee, the 
 latter to the inner aspect of the thigh, leg, and foot as far forward as the great toe. 
 
148 FUNCTIONAL NERVOUS DISEASES. 
 
 and at the inner side of the knee-joint. In rare instances herpes zoster 
 occurs in crural neuralgia. In severe cases the limb is held motionless 
 as in sciatica, to prevent an increase in the severity of the painful par- 
 ^oxysms. It is unnecessary to give the symptoms of each form in detail; 
 they merely differ with regard to the distribution of the pain. 
 
 A good example of this variety of neuralgia, and which at the same 
 time illustrates the frequent dependence of the disease upon other affec- 
 tions, is shown in the following case, which I saw in consultation with Dr. 
 John Munn, of this city, to whose kindness I am indebted for the follow- 
 ing notes: 
 
 Case V. — S. L., aet. 23 years; a kept mistress; no neuropathic 
 tendency in the family. The patient took cold during her first menstrua- 
 tion (at the age of fourteen) and this was immediately followed by severe 
 pain in the distribution of the middle and external cutaneous nerves of 
 the right lower limb. The pain was sharp and excruciating, much worse 
 at night, and lasted for three months. After this, " catching cold " would 
 cause the pain to reappear; she was never worse during menstruation. 
 In 1877, her physician thought she had some uterine trouble, and sent 
 her to Hot Springs, where she had a very severe attack of neuralgia. 
 In 1878 she was treated by Drs. Briddon and Seguin during a very bad at- 
 tack lasting nearly three months, but with very little benefit from the treat- 
 ment (morphine and galvanism). The patient came under Dr. Munn's 
 care on April 1, 1879. Upon examination, signs of endocervicitis were 
 found present, and the uterus was slightly retroverted and a little lower 
 down in the pelvis than normal. There was some tenderness on pres- 
 sure to the right of the uterus anteriorly. Applications were made to 
 the OS uteri for a month, with marked improvement in the condition of 
 the organ; the neuralgic symptoms improved at the same time, although 
 they were not treated directly. 
 
 June 1st. — The pain again returned in a very severe form, after in- 
 dulgence in sexual intercourse, which had been interdicted. I saw the 
 patient in consultation on June 15th; the pain was of an excruciating 
 character, and confined to the anterior and lateral aspects of the right 
 thigh, extending nearly to the knee; it was of a shooting character, but 
 unattended with hyperassthesia or trophic disturbances; no painful points 
 along the spine. Cervical catarrh again present, and tenderness felt 
 upon pressing deeply into the abdomen on the right side over the brim 
 of the pelvis about midway between the symphysis and sacrum. Pres- 
 sure at this point sometimes gave rise to shooting pains down the thigh. 
 
 I advised the continuance of the local treatment of the uterus, to- 
 gether with the internal administration of Fowler's solution and aconitia, 
 gr. yJ-g- night and morning, in increasing doses until the physiological ef- 
 fects are produced. 
 
 July 1st. — The pain has ceased and her condition is excellent; treat- 
 ment with arsenic continued. The patient then went to Saratoga for the 
 summer, and remained well, with the exception of a few occasional 
 twinges, until October 1st. The pain now returned in a very violent 
 form, and persisted with a few intermissions until November 11th. She 
 was then seen by Dr. Thomas in consultation, who found slight retrover- 
 sion of the uterus. Dr. Thomas believed that the neuralgia was due to 
 some obscure neurosis, and that the uterine disorder Avas only a partial 
 cause; he advised replacement, but expected no good from it. 
 
 Toward the end of November I again saw the patient in consultation. 
 
NEURALGIA. 149 
 
 The pain was now of a frightful character, and could only be controlled 
 by immense doses of morphine, as mucli as 100 minims of Magendie's so- 
 lution having been administered on one occasion within three hours. 
 The patient was in an extremely hysterical condition, which was partly 
 due to continual worry from the belief that she was about to be discarded 
 by her lover. 
 
 A large number of remedies had been resorted to in succession (bro- 
 mide of potassium, atropine, aconitia, strychnine, blisters, etc.) in he- 
 roic doses, but ijot the slightest benefit was obtained. A tolerable amount 
 of relief was only afforded by hypodermics of morphine. On December 
 9th the patient started for Baltimore, the pain having subsided some- 
 what during the last week; this is probably due to the fact that the 
 cause of her mental worry has been removed. Since that time the pa- 
 tient has felt perfectly well. 
 
 This case is interestisg from several points of view. In my opinion 
 the chief cause of the protracted character of the disease was the hys- 
 terical condition, induced by leading a life of luxury, with no object in 
 view save pleasure. I am also convinced that the uterine disorder was a 
 potent etiological factor; it is quite probable that the patient suffered 
 from mild pelvic peritonitis during her first menstrual epoch, and that 
 some slight inflammatory products remained in the pelvis and acted 
 partly as the exciting cause of the neuralgia. 
 
 Etiology. 
 
 This form of neuralgia is so infrequent, that very little is definitely 
 known with regard to its etiology. It may be due to carcinoma, spon- 
 dylitis deformans, or caries of the lumbar vertebrae, or to growths of va- 
 rious kinds in the pelvis. In one of my patients crural neuralgia fol- 
 lowed a forceps delivery. In a considerable proportion of the cases it 
 appears to be of a reflex nature, due, as Mauriac has shown, to orchitis 
 or epididymitis; it may also be connected with uterine disease, as in the 
 case reported above. 1 have also seen a few examples of ilio-inguinal neu- 
 ralgia in male patients who were victims of " nervous debility " and 
 the general lowering of morale which occurs when the individual is suf- 
 fering from seminal emissions and its accompanying train of symptoms. 
 This is not infrequently combined with neuralgia of the testis, an ex- 
 tremely distressing malady. Neuralgia of the obturator nerve has been 
 observed in obturator hernia, and the occurrence of the former should 
 always lead to a careful examination with regard to the presence of the 
 latter. Perhaps the majority of cases of lumbar neuralgia are found to 
 develop during severe paroxysms of sciatica, and in this event the mid- 
 dle and internal cutaneous nerves (branches of the crural) are usually the 
 ones involved. In some instances, indeed, the lumbar neuralgia which 
 has begun under such circumstances acquires an independent existence, 
 and becomes even more formidable than the primary sciatica. Finally, 
 a small number of cases have been reported, in which the disease was ap- 
 parently due to exposure or to overexertion of some of the lumbar muscles. 
 
 Diagnosis. 
 
 Lumbar neuralgia must be differentiated from myalgia of the lum- 
 bar muscles or lumbago; the character of the pain, its distribution, the 
 inability to move the affected muscles without producing severe suffer- 
 
150 FUNCTIONAL NEEVOTJS DISEASES. 
 
 ing, and the consequent fixed position of the trunk, and the absence of 
 puncta dolorosa, are sufficient to exclude neuralgia. In rare cases, how- 
 ever, lumbago is combined with lumbar neuralgia, as in a patient recently 
 under my observation, in whom lumbago of long standing became com- 
 plicated with neuralgia of the ilio-inguinal nerve. Myalgia of the ante- 
 rior thigh muscles may also be mistaken for crural neuralgia, but atten- 
 tion to the symptoms mentioned above will prevent error. 
 
 The latter form may also be mistaken for morbus coxae or neuralgia of 
 the hip-joint (Brodie's joint), but we shall enter into this subject at some 
 length under the head of sciatica (page 158), which is also liable to be 
 confounded with these two affections. 
 
 One of the main indications in making the diagnosis is to determine 
 the nature of the primary lesion. In all cases in which a definite cause 
 is unknown, the lumbar spine and pelvis should be subjected to careful 
 physical exploration. The etiological factors vary but little from those 
 which we have described with reference to neuralgias of the upper limb 
 (with the exception of its occurrence in uterine affections), so that we 
 may refer to the remarks on diagnosis under that head. Before affirming 
 the existence of any connection between a uterine affection and some form 
 of lumbar neuralgia, we should satisfy ourselves that the latter improves, 
 pari 2ycissu, with the former, and has followed it in point of time. We 
 must not forget, also, that both affections may be the expression of de- 
 pressed vitality of the general sj'stem. 
 
 Treatment. 
 
 Fortunately this disease does not often assume extreme severity. 
 The indications for rational treatment can very rarely be met. In cases of 
 spondylitis or caries of the spine, and in uterine disease, the appropriate 
 treatment for these affections may prove useful, but in the majority of 
 cases we must rely chiefly on symptomatic measures. 
 
 Counter-irritation, in the form of fly-blisters applied over the painful 
 spots at the exit of the affected nerve from the lumbar spine, is of decided 
 advantage. It should be applied more vigorously than in intercostal 
 neuralgia, as the nerves are farther removed from the integument. The 
 actual cautery may also be used, preferably along the course of the cu- 
 taneous distribution of the nerve. The chief reliance must be placed 
 upon the use of morphine, when the pain is intolerable, and upon the 
 steady application of the continuous current. In employing the latter 
 one electrode is placed at the exit of the nerves from the lumbar spine, 
 the other upon some portion of their external course. The current should 
 possess considerable intensity, as the nerves are situated deeply, and are 
 therefore not readily affected by electricity. I should also mention that 
 in the case of lumbago and ilio-inguinal neuralgia to which I have referred, 
 and which had caused constant and severe suffering for a year, relief was 
 very quickly obtained by the use of the faradic current, applied over the 
 painful parts. Internal remedies have not appeared to be of much ser- 
 vice. In my own hands the greatest amount of relief has been obtained 
 from the use of strychnia, beginning in doses of gr. -^, t.i.d., and gradu- 
 ally increasing until physiological effects are obtained. Sometimes, as 
 occurred in the case reported on page 148, abundant opportunity will be 
 afforded us to experiment in succession with a considerable proportion of 
 the neurotics contained in the materia medica. 
 
CHAPTER XI. 
 
 SCIATICA. 
 Clinical History. 
 
 This form of neuralgia ranks next to that of the trigeminus in impor- 
 tance and interest, on account of its severity and frequency. The disease 
 usually begins with prodromata, consisting of a feeling of heaviness in the 
 limb, numbness and tingling, or a sensation of coldness. Exceptionally 
 a paroxysm begins suddenly, and in one instance I saw a patient (who 
 had never suffered from any form of neuralgia previously), in whom one 
 of the most violent paroxysms which I have ever seen, developed im- 
 mediately after rising from a kneeling posture. The pain is of a markedly 
 lancinating, darting character, and may involve the entire course of the 
 nerve; it usually darts toward the periphery, but sometimes shoots up and 
 down the nerve with intolerable violence. It is sometimes so intense as 
 to cause even the bravest patient to cry out in agony and to roll on the 
 floor in despair. In one of my cases the pain was so severe, notwithstand- 
 ing the hypodermic injection of a very large dose of morphine, that I 
 could only restrain the patient by main force from committing suicide. 
 But these cases are very rare, nor do we find, save in exceptional in- 
 stances, that the hysterical, broken-down condition of mind is produced 
 which is met with in bad cases of trigeminal neuralgia. In the begin- 
 ning of the affection the pain is very commonly limited to the upper part 
 of the course of the nerve, and after a while it spreads to the lower 
 branches. But the reverse also holds good, and individual branches (per- 
 haps such a small twig as the plantar nerve) may be alone affected 
 throughout the entire course of the disease. If the patient is intelligent 
 and a good observer, he will be able to trace the course of the nerve with 
 his finger, and this is sometimes done as accurately as by a well-informed 
 anatomist. 
 
 Puncta dolorosa are observed in nearly all cases. The most usual 
 sites in the order of frequency are: a gluteal point, beneath the gluteal 
 fold, half-way between the trochanter major and the tuber ischii; a point 
 at the emergence of the nerve from the sciatic foramen ; a point at the pos- 
 terior superior spinous process of the ilium; one or two popliteal points, at 
 either side of the popliteal space, immediately within the hamstrings; a 
 fibular ^o\nt^ behind the head of the fibula; two ?na/^eoter points, at the pos- 
 terior part of each malleolus. ^\\q point apophysaire is not by any means 
 so common as the puncta dolorosa, and its distribution varies somewhat, 
 tenderness being sometimes appreciable over one or more of the sacral 
 vertebra, and at times over the first and second lumbar vertebrae. We 
 not infrequently find, especially in those cases in which there is consid- 
 erable dull pain in the intervals of the paroxysms, that the entire- length 
 of the nerve is sensitive to pressure. 
 
152 FUNCTIONAL NERVOUS DISEASES. 
 
 The pain is usually confined to one nerve, but in some cases both 
 are involved, even when the disease is not connected with any affection of 
 the spinal cord. But we should always be careful to exclude diseases of 
 the spinal cord or its membranes whenever we are brought in contact with 
 a case of bilateral sciatica. 
 
 Patients suffering from severe forms of this disease are generally con- 
 fined to their back. The slightest movement of the limb, the act of defe- 
 cation, coughing, sneezing, sitting down, and sometimes the mere con- 
 tact of the bedclothes with the affected leg will prove sufficient to pro- 
 duce a paroxysm of pain. In severe cases, the pain is often irradiated to 
 the distribution of other nerves, usually the crural, though even more dis- 
 tant nerves, such as the trigeminus, may be thus affected. The irradiated 
 pain, however, never attains the severity of the primary affection. 
 
 When the pain is severe, disturbances of sensation are usually well 
 marked. In the beginning of the attack we generally meet with hyper- 
 lesthesia of the skin, which may be either localized in small spots or dif- 
 fused over the entire distribution of the nerve. In some cases the hyper- 
 jesthesia is so well marked that the slightest contact with the skin is 
 agonizing to the patient, so that he cannot even bear the weight of the 
 bedclothes. x\fter the disease has lasted for a long time anaesthesia de- 
 velops and is sometimes very pronounced. Very frequently, also, we may 
 notice spots of hypersesthesia and of anaesthesia on the limb at the same 
 time. 
 
 Sciatica presents important and interesting motor complications, which 
 are usually manifested only in cases that attain considerable severity. 
 Fibrillary twitchings are not uncommonly observed, especially in the calf 
 muscles and those of the back of the thigh. At times these muscular 
 twitchings become more widespread, and the whole limb is thrown into 
 clonic convulsions; these are only observed at the height of the paroxysm, 
 and soon subside. In one extremely severe case the whole body was thrown 
 into violent convulsions (not preceded by tonic spasm and unattended 
 with loss of consciousness), but, as the patient had been drinking whiskey 
 very freely (this appeared to be the exciting cause of the sciatica), I am 
 unable to state positively whether the convulsions were the result of the 
 neuralgic affection or not. 
 
 Contracture sometimes occurs at the knee-joint. We do not now re- 
 fer to the voluntary stiffness of the limb assumed by the patient in order 
 to prevent pain, but to a rigidity of the hamstring muscles, which cannot be 
 overcome by any reasonable exercise of muscular power, either on the part of 
 the patient or the physician. The knee may be bent at quite a sharp an- 
 gle, and the contracture may persist for several weeks or even longer; it 
 does not disappear during sleep. 
 
 The gait in severe cases is peculiar. The patient in walking keeps 
 the limb slightly flexed at the knee, and walks on the toes of the affected 
 foot. The gait is stiff and awkward, and the patient favors tiie sound 
 limb. The entire muscular tissues of the limb sometimes atrophy. The 
 amount of wasting is usually slight, and is due to the comparative disuse 
 of the limb occasioned by the severe pain. But, in exceptional cases, the 
 muscular atrophy is excessive, and cannot be accounted for in this man- 
 ner. We must therefore fall back upon the supposition that it is a 
 trophic change, due to the implication of the trophic fibres contained in the 
 nerve-trunk by the morbid process which has given rise to the neuralgia. 
 
 Hypertrophy of the muscles of the thigh and calf has also been ob- 
 served in one case. 
 
NEURALGIA. 153 
 
 The following history, the notes of which were obtained through the 
 kindness of my house pliysician, Dr. Wyrnan, exemplifies most of the 
 motor disorders observed in severe forms of sciatica. 
 
 Case VI. — Wm. Schmidt, a3t. 30 years; single; admitted to Randall's 
 Island Hospital, September 25, 1879; family history good, never had 
 rheumatism, denies venereal. The patient always enjoyed good health 
 prior to this disease. In November, 1877, he was shipwrecked, and com- 
 pelled to remain in the water for twenty-four hours. About six weeks 
 after this exposure he began to have pain in the left gluteal region, which 
 extended down the back of the thigh, following the course of the sciatic 
 nerve. The pain was increased very much during bad weather, so that 
 he often had to take to his bed. Not obtaining relief, he was admitted to 
 the Homoeopathic Hospital, Ward's Island, and after remaining there three 
 months unimproved, the surgeon cut down upon the sciatic nerve and 
 stretched it. After this operation the patient says his pains were very 
 much increased, and he was never free from them except while under the 
 influence of an opiate. He was discharged unimproved at the end of six 
 months. 
 
 March 29, 1879, he was admitted to Charity Hospital, Jersey City, 
 where the wound made by the operation for nerve-stretching healed, but 
 the sciatica did not improve. He was treated with the actual cautery along 
 the course of the nerve; the patient remained there two months, and was 
 then admitted to Randall's Island Hospital. 
 
 On admission his general condition was poor; he complained of 
 intense paroxysms of shooting pain (which forced him to whimper) 
 along the entire course of the left sciatic nerve, and which were greatly 
 heightened by the slightest movement of the limb. The pain was so se- 
 vere that he was compelled to keep to bed constantly. There were fre- 
 quent fibrillary twitchings in the muscles of the back of the thigh, and 
 marked atrophy of the muscles of the affected limb (unfortunately no 
 record was kept of the difference in the measurements of the two limbs, 
 but I have a distinct recollection that the affected thigh was at least 
 one and a half to two inches less in circumference than the healthy one). 
 Aconitia, gr, Jg^ t.i.d., was ordered, to be gradually increased until the 
 physiological effects were obtained. This treatment was continued until 
 October 2Gth, and produced slight improvement. 
 
 October 27th. — Ordered strychnite sulph., gr. -j'^, t.i.d., to be increased 
 one dose daily until the full effects of the drug were obtained. 
 
 November 5th. — Since the administration of the strychnia, his general 
 condition has improved very much; he has a fine appetite, and has gained 
 in flesh. He is often comparatively free from pain, and rests well at 
 night. At varying intervals, which have been longer in duration since 
 the use of strychnia was begun, severe paroxysms were felt. At such 
 times the hypodermic administration of morphia has been resorted to 
 with good effect. He is at present taking gr. ^ of strychnia daily, this 
 treatment was continued until November 29th, with several intermissions 
 of a few days each, whenever the physiological effects of the drug were 
 too pronounced. The duration of the intervals between the paroxysms 
 was considerably increased, but the pain felt during the latter was still 
 extremely severe. 
 
 December 2d. — Ordered atropine sulph., gr. ^^, t.i.d., to be increased 
 one dose daily. 
 
 December Gth. — The patient received six doses of atropia (gr. -^j) 
 
154 FUNCTIONAL ISTEEVOUS DISEASES. 
 
 yesterday; this morning he has dryness of the throat, and disturbance of 
 vision; pupils dilated. He has not had a paroxysm of severe pain since 
 the administration of the drug was commenced. The paroxysms then 
 appeared again, and the atropia was continued until .January 10th, with 
 several intermissions of a few days each. The patient now feels much 
 better, except when he moves the affected limb. For the past few weeks 
 the limb has been contractured at the knee-joint; the contracture could 
 not be overcome by the patient or by myself, on account of the severe 
 pain to which such attempts gave rise. To relieve this symptom, hot 
 sitz-baths were ordered. 
 
 January 6th. — The patient experiences a good deal of relief from the 
 baths. The hamstring muscles, which were formerly contracted, are now 
 becoming relaxed, so that the leg can be extended without producing pain. 
 
 January 20th. — The patient is improving rapidly; he is up and about 
 the ward, but has to walk with crutches. 
 
 January 28th. — Crutches taken away; patient walks with a stick, and 
 has slight pains in locomotion. 
 
 February 2d. — Patient walks now without difficulty; the pains have 
 entirely disappeared. The muscles of the affected limb have regained 
 the greater part of their natural strength (no measurements were taken). 
 The patient's general condition is excellent. Discharged cured, and has 
 since gone to work. 
 
 The other complications of sciatica are infrequent and unimportant. 
 In some cases the limb is hot and perspiring, in others the skin is dry and 
 brittle; the integument may be of a uniform red color or mottled in ap- 
 pearance; sometimes it is paler and cooler than the other limb. Glyco- 
 suria constitutes the most interesting of the vaso-motor complications of 
 sciatica, although very few observations have been made on this subject. 
 
 Schiff had shown that section of the sciatic or other large nerve-trunks 
 in certain of the lower animals was capable of producing mellituria, and 
 this physiologist, as well as others who have corroborated his experi- 
 ments, have regarded the symptom as due to reflex paralysis of the vaso- 
 motor nerves supplying the liver. Braun ' found several cases of sci- 
 atica in which sugar was demonstrable in the urine, and the correctness 
 of his observation has been since verified by Rosenbach, Though the 
 histories of these cases are unsatisfactory, it appears that they never 
 lead to true diabetes, but only to a temporary mellituria. The presence 
 of sugar in the urine in such cases has been explained in the same 
 manner as Schiff's cases of experimental diabetes, but this view is purely 
 hypothetical, and further investigation may cause a change of opinion in 
 this respect. The subject is very interesting, and one which is worthy of 
 thorough and continued research. 
 
 Etiologt. 
 
 The etiology of sciatica is well defined by Eulenburg when he calls it 
 " the type of peripheral, accidental neuralgias." 
 
 Anstie observed four cases in which heredity played an important 
 part, but this is probably an exceptional experience. Many authors 
 scarcely mention heredity as one of the etiological factors in this affec- 
 
 ' Syatematiches Lehrbucb der Balneotherapie, 1868, 
 
NEURALGIA. 155 
 
 tion, and all are agreed that it has very little influence in this direc- 
 tion. 
 
 The disease is very infrequent in childhood, and Soltmann,^ the latest 
 writer on the subject, has not met with a single example at this period of 
 life. The majority of the cases occur between the ages of twenty to 
 fifty years, but the affection develops not infrequently long after the lat- 
 ter age, three of my cases beginning at the ages of sixty-eight, seventy, 
 and seventy-four years respectively. 
 
 According to the united testimony of the majority of authors, the 
 male sex is much more subject to sciatica than the female, and in my own 
 cases the proportion has been as one to two and a half. Arnoldi, who 
 has furnished the largest statistics on the subject, finds that females were 
 affected almost as frequently as males (173 males, 1G6 females), but this 
 statement is entirely opposed to the common experience of physicians. 
 
 The majority of the causes which give rise to sciatica are those which 
 act upon the nerve after its exit from the spinal canal. The lesion may, 
 however, be situated in the bones of the spinal column or within the 
 canal. This category includes spondylitis deformans, cancer of the ver- 
 tebrfe, or the presence of gummata which have grown from the dura 
 mater or from the vertebras themselves. These various lesions act by 
 simply producing pressure upon the roots of the nerve, and the neuralgia 
 caused thereby is of a peculiarly lancinating character. In very rare in- 
 stances false and even true neuromata have been found within the spinal 
 canal and growing upon the Cauda equina. J^ may also be produced by 
 numerous processes situated within the pelvic cavity, both in the male 
 and female. Any affection which interferes with the return of venous 
 blood from the pelvis will predispose to its development. The sciatic 
 nerve is surrounded by a large number of veins, the greater part of which 
 constitute the hemorrhoidal plexus. These veins are large, wide-meshed, 
 and possess no valves, so that an obstacle to the flow of blood in them 
 will very readily give rise to a varicose condition, and consequently to 
 pressure upon the nerve. Such an obstacle may be due to cirrhosis of 
 the liver, or to any other disease of that organ or of adjacent parts which 
 will interfere with the portal circulation. Within the pelvis itself this 
 condition may be due to pregnancy, to the use of forceps during delivery, 
 to the growth of intra-pelvic tumors, to exudations into the broad liga- 
 ments or into Douglas' cul-de-sac, or to an accumulation of hardened 
 fseces in the rectum. It has been doubted by some writers whether the 
 latter cause is ever capable of producing pressure upon the sciatic nerve, 
 but a case which was recently under my observation is, to my mind, con- 
 clusive in this regard. The patient in question had had no evacuation 
 for twelve days, and complained of formication and anaesthesia, which 
 was confined to the exact distribution of the left sciatic nerve. The 
 exhibition of a purge, which produced a free passage, caused these 
 symptoms to disappear entirely. It is difficult to determine, however, 
 whether the causes we have just mentioned act by pressing directly upon 
 the nerve or by producing dilatation of the hemorrhoidal plexus and 
 secondary pressure in this manner. 
 
 In the course of the nerve outside of the pelvic cavity, there are also 
 numerous lesions capable of producing sciatida. This category includes 
 injuries to the nerve, such as those produced by gunshot wounds (which 
 are very rarely met with except in military surgery), wounds made by the 
 
 ' Gerhardt's Handbuch der Kinderkrankh. 
 
156 FUNCTIONAL NEEVOUS DISEASES. 
 
 lancet in venesection (not very infrequent formerly, but never observed at 
 present), blows from blunt instruments, falls on the buttocks, popliteal 
 aneurism, neuromata, syphilitic and other tumors of the nerve itself or 
 of surrounding tissues. Those cases which are attributed to severe mus- 
 cular strain should be included under the head of injury to the nerve.^ 
 Some writers are skeptical with regard to the efficacy of this cause, but 
 one of the most severe cases of sciatica which has come under my obser- 
 vation occurred in a robust farm-hand, immediately after lifting a heavy 
 beam. At the time of the accident he " felt something crack " in the 
 lower part of the back, and immediately began to suffer from intense 
 pains along the sciatic nerve which resisted all treatment for upward of 
 a year. 
 
 Cotugno had called attention to the fact that sciatica prevails endemi- 
 cally in the neighborhood of Naples, and that this circumstance is ex- 
 plained by atmospheric influences. There is no doubt that the affection 
 is more apt to develop in moist, windy weather, and the severity of an 
 attack always increases under such conditions. Exposure to atmospheric 
 changes also explains the comparative frequency of sciatica in those whose 
 occupation requires them to be exposed to all kinds of weather. I have 
 noticed this especially in coachmen, but in this class two causes may co- 
 operate in the production of the disease, viz., the exposure to changes of 
 weather, and the constant sitting position which the patients are com- 
 pelled to assume, and in which the sciatic nerve may be pressed upon by 
 the projecting seat. • 
 
 Sciatica is not often due to constitutional causes, and differs in this 
 respect from other forms of neuralgia. As a rule the patients are not 
 anaemic at the beginning of the disease, although this condition is readily 
 produced after the sciatica has lasted for some time, on account of the 
 depressing influence of the pain, the lack of exercise, etc. But we find 
 that sciatica not infrequently develops in old age, after degeneration of 
 the vessels has begun, although this is not of such frequent occurrence, 
 by any means, as in the case of trigeminal neuralgia. In such an event 
 the disease may continue uninterruptedly until death. 
 
 Malaria is not so often a cause of sciatica as it is of other neuralgias, 
 and is not even mentioned by many neurologists as an etiological factor. 
 According to Schramm, malarial sciatica usually affects the entire trunk 
 of the nerve (usually the right), and in rare cases is bilateral. In one 
 case under my observation the pain took the place of the chill, and was 
 confined to the plantar branch of one nerve. It generally assumes the 
 quotidian, but sometimes the tertian type. We must remember, how- 
 ever, that malarial neuralgia may sometimes be continuous, and on the 
 other hand, that the pain may assume a pure intermittent type, although 
 the neuralgia is due to some other cause, or may even be symptomatic 
 of an organic lesion of the nerve. We should, therefore, not make a 
 diagnosis of malarial sciatica unless other evidences of malarial infection 
 are present, or unless quinine exercises a specific influence upon its course. 
 
 Syphilis is also an infrequent cause of this disease, though it would 
 appear from recent investigations that it is produced more often in this 
 manner than was formerly believed. Fournier called attention to the 
 fact that sciatica may be caused by the mere presence of the syphilitic 
 virus in the blood during the early secondary stage. Its development in 
 this stage must, however, be very rare, since it is hardly ever observed 
 even by specialists in venereal diseases. Dr. R. W. Taylor, of this city, 
 who has written an interesting article on syphilitic sciatica in the I^ew 
 
NEURALGIA. 157 
 
 York Medical Journal, March, 1880, has only met with two cases in tlie 
 secondary stage, and Dr. Keyes informs me that he has not observed a 
 single example. In the large majority of cases, however, it is due to 
 syphilitic changes in the nerve itself, or to irritation or compression of the 
 nerve by gummy growths in the adjacent tissues. 
 
 Considerable doubt has been cast upon the reported cases of alterna- 
 tion of acute articular rheumatism and sciatica. No instances have 
 come under my own notice, and the cases reported in the journals are 
 described so unsatisfactorily that it is difficult to arrive at a definite con- 
 clusion in the matter. There can be no doubt, however, that a causal 
 connection between these two affections does exist in rare instances. 
 
 Fournier has reported seven cases of sciatica occurring during the 
 course of gonorrhoeal rheumatism (which is not a true rheumatism), and 
 others have been since observed. The pain in this variety usually dis- 
 appears with the rheumatic affection. 
 
 Sciatica has also been attributed to gout, but it is doubtful whether 
 this does not act merely as a predisposing cause on account of the 
 abdominal plethora which is so common in the latter affection. 
 
 I also \\^ish to call attention to the relation of delirium tremens to 
 sciatica. Three of the severest cases of sciatica which have come under 
 my observation occurred during the first period of a mild attack of 
 delirium tremens, in patients who had never been previously subject to 
 neuralgia. In all three patients the disease was of very short duration 
 (in one it only lasted twenty-four hours), but during this time their tor- 
 tures were terrible. Relief could only be obtained by the hypodermic 
 injection of large doses of morphine. 
 
 Reflex irritation possesses very little efficacy in the production of 
 sciatica. It sometimes develops in the course of other neuralgias, such 
 as trigeminal or brachial, but it is difficult to determine whether this is 
 the result of a reflex irradiation of the pain, or the expression of a gen- 
 eral cause. In the larger number of cases the source of reflex irritation 
 appears to reside in the genital organs. Mauriac has shown that it may 
 occur during the course of gonorrhoeal epididymitis. It has also been 
 observed as the result of stricture of the urethra or of a stone in the 
 bladder. It may be due to a uterine disorder which has not produced 
 any pressure upon the nerve. A few apparently authentic cases have 
 been reported in which sciatica was caused by the presence of worms in 
 the intestines. 
 
 Diagnosis and Peognosis. 
 
 Sciatica is perhaps more frequently mistaken for myalgia of the muscles 
 of the loins and thigh than for any other form of disease. But the latter 
 affection usually involves not alone the muscles of the posterior, but also of 
 the anterior part of the thigh; in other words, the pain is not strictly lim- 
 ited to the distribution of the sciatic nerve. Pancta dolorosa, which fre- 
 quently form such a prominent part in the history of sciatica, are never 
 present in myalgia, and the pain and tenderness are diffused in the latter 
 affection, while in sciatica, as Valleix expresses it, the patient marks out 
 the course of the pain with the tip of the finger. The pain of myalgia is 
 always absent when the limb is kept perfectly quiet, while that of sci- 
 atica, although aggravated by movement, also develops when the leg is 
 motionless. We have previously referred, in the general chapter on diag- 
 
158 JFUNCTIOJfAL NERVOUS DISEASES. 
 
 nosis, to the characteristics of myalgic pain, and these alone will usually 
 be suiBcient to enable us to make a differential diagnosis. 
 
 Locomotor ataxia is often distinguished with difficulty from sciatica. 
 Cases have been reported in which ataxia was diagnosed, although no other 
 symptom beyond that of the ataxic pains had been observed for a period 
 of even twenty years, and we can therefore readily conceive that a differ- 
 ential diagnosis is often very difficult and sometimes even impossible. 
 The pains of ataxia are invariably bilateral, and always of the most marked 
 lancinating character. They are not confined to one part of the course of 
 the nerve, but affect indifferently sometimes one, sometimes the other por- 
 tion, and are frequently situated deeper than ordinary sciatica, involving 
 not only the muscles, but apparently also the bones, and even the various 
 joints. They are often accompanied by a sensation of pressure (cincture 
 feeling) around the ankles, calves, thighs, or lower part of the chest or 
 abdomen. The patient may experience difficulty in voiding the urine, or 
 suffers from incontinence. Another symptom of considerable value 
 (though it is very frequently absent) is irregularity of the pupils. The 
 most important diagnostic sign of ataxia is the absence of the patellar 
 tendon reflex, which is almost invariable (T found it present, however, in 
 an undoubted case of ataxia in the paralytic stage). The patellar reflex 
 is obtained by directing the patient to cross one knee over the other, and 
 allow the pendent leg to hang loosely. If the ligamentum patellce, which 
 is thus placed upon the stretch, be then tapped smartly with the finger 
 or with a pleximeter, a sudden forward movement of the entire leg will 
 be produced in healthy individuals.' In ataxia this phenomenon becomes 
 lost, even before any ataxic movements are visible in the gait. 
 
 Sciatica is sometimes, though rarely, mistaken for hip-joint disease 
 and vice versa, but this error can only be made during the first stage of 
 morbus cox». The latter disease is accompanied by drooping and partial 
 effacement of the gluteal fold on the affected side, the limb appears to 
 be somewhat shortened, and tenderness is manifested when the joint sur- 
 faces are brought in contact with one another. There is interference with 
 the perfect mobility of the limb at the hip-joint, and this important point 
 is determined by placing the patient on a horizontal even surface, the 
 healthy limb being also on the level surface, and the diseased limb re- 
 maining flexed; it will then be found that the pelvis is at right angles to 
 the horizontal limb, and that the lumbar spine is in contact with the sur- 
 face upon which the patient rests. As soon, however, as an attempt is 
 made to carry the flexed limb into the same position as the other, the 
 pelvis Avill be found to tilt upward, carrying the lumbar spine along with 
 it, so that the hand can be introduced underneath the vertebrae. These 
 symptoms are always present in hip-joint disease, and a careful examina- 
 tion will, therefore, enable us to make a differential diagnosis. 
 
 Hysterical joints (Brodie's joint) are sometimes differentiated with 
 difficulty from sciatica when the hip is involved. This affection is char- 
 acterized by extreme tenderness of the joint to slight pressure, while 
 firm compression is often very well borne. Painful points can be usu- 
 ally detected around the joint. Contracture of the hip (which disappears 
 during chloroform narcosis) is a common feature, and may lead to a sus- 
 picion of inflammation of the joint. One of the most important differen- 
 tial diagnostic points is the fact that hysterical joints, unlike sciatica, 
 
 ' I have recently noted its absence in two of my students, who were perfectly 
 healthy. 
 
NEURALGIA. 159 
 
 almost invariably appear in young females in whom other well-marked 
 symptoms of hysteria are also present. 
 
 An important feature in tlie diagnosis of sciatica is the localization of 
 the primary lesion. It is impossible for us to enter into this subject in ex- 
 tenso, and we can only refer to our remarks on the etiology of the dis- 
 ease. But we desire especially to impress the necessity of a careful ex- 
 ploration of the pelvis (by palpation, vaginal and rectal exploration), 
 whenever we have to deal with an obstinate case which resists ordinary 
 methods of treatment. Entirely unlooked for and veiy valuable data will 
 sometimes be revealed from a compliance with this rule. In every case 
 of double sciatica we should not alone make a pelvic exploration, but also 
 carefully examine the condition of the vertebral column. 
 
 Treatment. 
 
 The exciting cause of sciatica can sometimes be removed by a resort 
 to surgical measures, such as the extraction of foreign bodies, the extri- 
 cation of the nerve from constricting cicatrices, or from exuberant callus 
 formed after fracture of the pelvis or long bones of the limb, ligature for 
 aneurism of the popliteal artery, etc. When the affection is due to the 
 pressure of intra-pelvic exudations, etc., great relief is sometimes afforded 
 by the successive application of fly-blisters to the iliac fossa in combina- 
 tion with palliative doses of morphine and careful attention to the regu- 
 lation of the bowels. In a large number of cases we are powerless to re- 
 move the exciting cause, even though it be well known, and we are then 
 compelled to rely exclusively on the use of palliative measures. 
 
 In ordinary cases of sciatica it is well to begin treatment with the ad- 
 ministration of a saline cathartic, even when the patient states that the 
 bowels are regular. We often find that the quantity of fgeces voided is 
 insufHcient, although the patient goes to stool every day, and an aloes 
 pill, taken at bedtime, is very serviceable under such circumstances. The 
 diet should be carefully regulated, and fatty or very feculent substances 
 allowed only in moderation. The patient should be examined with regard 
 to the presence of hemorrhoids, and appropriate treatment adopted. 
 These measures are especially indicated in cases in which the patient has 
 recovered from one attack and is in danger of a relapse. 
 
 When the pain of a paroxysm is unendurable the hypodermic admin- 
 istration of morphine is indicated in doses adapted to each individual 
 case. Many authors recommend that the injections be made over the 
 track of the nerve, or even into its tissue; but apart from the fact that 
 an injection into the nerve itself is an operation which can only be per- 
 formed with great difficulty with an ordinary hypodermic needle, I have 
 been unable to observe any special beneficial effects from local injections. 
 
 Dr. Comegys ' has obtained benefit from hypodermic injections of 
 ether during the attack, and regards this as a curative measure. 
 
 The cui-ative treatment of sciatica consists in the use of counter-irri- 
 tants, the administration of certain nervines, the application of galvanism, 
 and surgical interference. 
 
 Fly-blisters constitute the most serviceable form of counter-irritation. 
 They are best applied over the painful spots, beginning above and passing 
 to the one below when the sore caused by the blister previously applied 
 
 ' Cincin, Lancet and Clinic, 1879, it 10. 
 
160 FUNCTIONAL NERVOUS DISEASES. 
 
 is beginning to heal. When necessary, a considerable portion of the 
 upper part of the nerve can be traversed in this manner. The actual cau- 
 tery (if we include this among counter-irritants) is the least painful and 
 most convenient form at our command. It may be applied either across 
 the nerve or along its course, and should be employed every four or five 
 days. Although not productive of such good results as the application 
 of the fly-blister, the actual cautery often proves very useful. An Italian 
 author has reported thirty-three cases of cure from cautery of the lobe of 
 the ear. The electrical wire brush or counter-irritation by means of bi- 
 sulphide of carbon may also be resorted to, but these measures are of 
 secondary importance. In some obstinate cases a hypodermic injection 
 of nitrate of silver over the course of the nerve has been productive of ex- 
 cellent results. 
 
 Sulphate of strychnia has produced better effects in my hands, in cases 
 of sciatica, than any other single drug. 
 
 In the beginning, gr. J^ — J^ may be administered three times a day, 
 and this quantity should be increased by one dose daily until the physio- 
 logical effects of the drug become manifest. It should then be continued 
 in somewhat smaller doses for a period of two or three weeks before be- 
 ing abandoned; if the patient improves under its use it may be adminis- 
 tered for a much longer period. This remedy proves most useful in idio- 
 pathic cases or those due to exposure, etc. It is impossible, however, to 
 predict whether the drug will be of service or not in any individual case. 
 Some patients are relieved within a week or ten days, in others a cure is 
 not effected within several weeks or a month, while a considerable pro- 
 portion are unaffected by its administration or grow steadily worse. 
 
 Atropine is also a useful remedy, and, like strychnia, must be admin- 
 istered in continually increasing doses until slight toxic effects develop. 
 As in the case of strychnia, we cannot determine in advance whether any 
 advantage will be obtained from its employment, and we will often find, 
 in severe and prolonged cases of this disease, that we must pass blindly 
 from one remedy to another, in the hope that our endeavors will finally 
 prove successful. 
 
 Turpentine has been employed as a remedy for sciatica for more than 
 a century, and at one time was held in very high favor. It may be given 
 in half-ounce doses (preferably in capsules), and should be taken imme- 
 diately after meals. I have failed to obtain any good results from this 
 drug. 
 
 Of late I have made some use of aconitia in bad cases of sciatica, but 
 the employment of this remedy has not been attended with very brilliant 
 results in my hands. It has sometimes served to produce decided palli- 
 ative effects, but has not caused complete relief. 
 
 Galvanism is perhaps the most generally useful remedy at our com- 
 mand in the treatment of sciatica. I have employed this agent exten- 
 sively during the past five years, and have become more and more con- 
 vinced that it is more effective than any other single remedy. If galvan- 
 ism is employed in the expectation that every case will succumb to its in- 
 fluence, we will be sorely disappointed, but I have found that a consider- 
 able proportion, perhaps a half of all the cases, undergo marked improve- 
 ment or complete recovery. In exceptional instances, however, the pa- 
 tients grow steadily worse under this plan of treatment. Dr. V. P. 
 Gibney, Surgeon to the Hospital for Ruptured and Crippled, who has had 
 remarkable success in the treatment of sciatica by galvanism, has kindly 
 furnished me with the manuscript of an article which he read at the re- 
 
NEURALGIA. 161 
 
 cent meeting of the American Medical Association, and I cannot do bet- 
 ter than by giving- the following abstract of his paper: 
 
 " Of thirty-two cases of sciatica treated by the strong galvanic cur- 
 rent, twenty-four were relieved of pain immediately after the first applica- 
 tion, three got moderate relief, and five obtained little or no relief. The 
 immediate relief was only temporary, the paroxysms returning, as a rule, 
 within twelve hours, but with less severity and persistency, the applica- 
 tions being repeated daily in many instances. 
 
 " Sixteen cases had no relapse, and can with safety be pronounced per- 
 manently cured, four obtained no permanent relief, and seven had slight 
 relapses of a mild character, but insufficient to keep them from work. 
 
 " About ten sittings was found to be the average number necessary to 
 effect a cure, the current varying from twenty to forty Stoehrer's cells or 
 their equivalent. In applying the electricity the positive pole is placed 
 directly over the exit of the sciatic nerve from the sciatic foramen. The 
 latter spot can be found by placing the thumb of the hand correspond- 
 ing to the affected limb over the tip of the trochanter major, and the mid- 
 dle finger over the tuber ischii; then the tip of the index finger will fall 
 directly over the great sciatic foramen. If firm pressure be made here, 
 referred sensations will be felt in the distribution of the nerve. The 
 negative pole is placed in the popliteal space, or wherever there is most 
 pain or numbness in the course of the nerve. The sittings should occupy 
 ten to fifteen minutes every day or twice a day during the first week. 
 The current must be strong enough to cause severe pain and even vesica- 
 tion." 
 
 I have very little to add to these remarks, which, in the main, accord 
 entirely with my own experience. In my practice, however, I have found 
 that the position of the poles is immaterial, the ascending current being 
 as efficacious as the descending. Nor have I ever found it necessary to 
 use a current of sufficient intensity to produce vesication. 
 
 When the sciatica is present in a very severe form it is advisable to 
 employ the electricity in the manner recommended for neuritis of the 
 sciatic, the nerve being galvanized in sections. 
 
 As a rule, to which there are very few exceptions, galvanism proves 
 curative, if at all, within a few weeks. If the disease has not undergone 
 marked improvement within a fortnight, it will be useless to continue 
 the treatment further. 
 
 Surgical measures are not resorted to very frequently in the treatment 
 of sciatica. Excision of the nerve is never admissible, as it is always fol- 
 lowed by complete paralysis of the limb, usually attended with atrophy. 
 This operation can always be superseded by that of nerve-stretching, 
 which is readily performed on account of the superficial position of the 
 nerve and its large size. Nerve-stretching appears to be serviceable even 
 in cases in which the neuralgia is due to an inflammatory process in the 
 nerve. 
 
 In a few cases the surgeon is called upon to remove tumors which 
 press upon the nerve, to excise cicatrices, etc. These operations do not 
 always prove successful, on account of the violence to which the nerve is 
 subjected, and the subsequent inflammatory reaction which is thus de- 
 veloped. 
 
 11 
 
Peripheral Paralysis. 
 
 CHAPTER I. 
 
 CLINICAL HISTORY. 
 
 Paralysis is a loss of muscular power due to an interference with the 
 transmission of nerve force from its site of development in the central 
 nervous system to the termination of the nerve-fibres in the muscles. The 
 term paresis simply implies a partial paralysis. 
 
 Peripheral paralysis is that variety in which the interference with the 
 transmission of nerve force is due to some lesion which is operative be- 
 tween the exit of the nerves from the nerve-centres, and their termination 
 in the muscular fibres. The affection may develop slowly or suddenly, ac- 
 cording to the nature of the underlying cause. Thus, a sabre-cut which 
 entirely divides the filaments of a motor nerve must produce immediate 
 paralysis in its distribution. The gradual compression of a nerve, how- 
 ever, by a slowly developing neoplasm in its neighborhood will produce 
 paralysis very slowly, and the gradually developing loss of power may be 
 preceded by various symptoms of irritation on the part of the nerve, as 
 we shall show hereafter. 
 
 All parts of the muscular system may be subjected to paralysis; 
 changes in the appearance of these parts are due to the fact that the an- 
 tagonist muscles have no opposing force to overcome, and therefore exer- 
 cise traction upon the paralyzed ones. Thus, in paralysis of the seventh 
 nerve, the face is drawn to the sound side because the healthy muscles no 
 longer meet with any opposition to their tonic contraction. 
 
 The distribution of peripheral paralysis is entirely different, in the 
 vast majority of cases, from that due to diseases of the brain or spinal 
 cord. In the former the paralysis is situated, as the very term implies, 
 in the distribution of individual nerves or of a number of nerves. Thus, 
 only a single muscle may be paralyzed, as for instance in a lesion of the 
 posterior thoracic nerve which supplies the serratus magnus muscle. When 
 the paralysis is due to some affection of the brain or spinal cord, however, 
 the muscles affected are those which belong together functionally, and, as a 
 rule, a limb is paralyzed as a whole. Thus, in cerebral affections, the par- 
 alysis usually assumes the hemiplegic, and in disorders of the spinal 
 cord, the paraplegic type. There are, however, numerous exceptions to 
 this rule; not infrequently only one limb is paralyzed as the result of cen- 
 tral diseases, and in very rare instances only a few muscles are involved. 
 But in such cases there are usually other concomitant symptoms which 
 indicate the site of the lesion. It must also be remembered that affections 
 
164 FUNCTIONAL NERVOUS DISEASES. 
 
 of the peripheral nerves sometimes, though rarely, give rise to widespread 
 paralyses. Thus, compression of the cauda equina may cause paralysis 
 of the lower limbs. In one case, which I shall report in full at a later 
 period, the hemiplegia which was present was due, in my opinion, to an 
 afPection of the peripheral nerves. Finally, a large number of the nerves 
 of the body may be subjected at the same time to some lesion capable of 
 producing paralysis. 
 
 Another important difference between peripheral and central paralysis 
 is the fact that the affected muscles rarely atrophy to any appreciable ex- 
 tent in the latter. Thus, patients suffering from cerebral hemiplegia may 
 have lost entire control of the paralyzed muscles for years, yet the differ- 
 ence in the circumference of the healthy and paralyzed limbs will be so 
 slight that it can scarcely be detected. The small difference which does 
 exist is undoubtedly due in part to the wasting of subcutaneous adipose 
 tissue in the paralyzed side. In peripheral paralysis, on the other hand, 
 muscular wasting always occurs, and usually with considerable rapidity. 
 The same phenomenon is observed in a few diseases of the medulla oblon- 
 gata and spinal cord, which are, however, recognizable by other attendant 
 symptoms, to which we shall revert at length in the section on diagnosis. 
 
 Central paralyses are less frequently attended with sensory disturb- 
 ances than the peripheral forms. This is especially true of cerebral 
 forms, because the fibres which conduct motion and sensation are situated 
 at a greater distance from one another in the brain than they are in other 
 parts of the nervous system. In the peripheral nerves the motor and 
 sensory fibres are mingled indiscriminately with one another, so that any 
 noxious influence acting upon one set of fibres must necessarily affect at 
 the same time the other. It is nevertheless true that, as an almost inva- 
 riable rule, the sensory fibres are less involved than the motor, and, when 
 the paralysis is not well marked, it is not infrequent to find that no sens- 
 ory disturbance whatever can be detected in the distribution of the af- 
 fected nerve. It is very difficult to explain this peculiar phenomenon, 
 but it is none the less true that not only are the sensory disturbances less 
 marked than the motor, but that the former also disappear more rapidly 
 than the latter. Perhaps the sensory fibres, as has been conjectured, 
 represent a lower grade of development than the motor, and are there- 
 fore less susceptible to external influences. 
 
 Unlike central paralysis, the peripheral form is usually attended with 
 vaso-motor and trophic disturbances. This is readily understood when 
 we remember that the peripheral nerves contain vaso-motor and trophic 
 as well as motor and sensory fibres, and that the former must therefore 
 be implicated to a certain extent in any affection of the nerves. These 
 disorders are rarely present in cerebral diseases, but in one class of spinal 
 affections they take a prominent part, which will form the subject of fur- 
 ther comment at a later period. 
 
 Finally, the reactions of the affected nerves and muscles to faradism 
 and galvanism differ markedly in peripheral paralysis from those observed 
 in the vast majority of central nervous affections, as we show shall at 
 length in the course of this section. 
 
 Peripheral paralysis may be due to various causes, such as traumatism, 
 inflammation, rheumatic influences, etc., and as the clinical history varies 
 considerably according to the cause, we shall enter into the symptoma- 
 tology of each of these varieties in detail. 
 
PERIPHERAL PARALYSIS. 165 
 
 Injuries of Neeves. 
 
 We shall first consider that form of paralysis which is due to complete 
 section of the nerves, the history of which has been very thoroug-hly in- 
 vestigated by means of physiological experiments, as well as by observa- 
 tions upon the human subject. This variety is produced by direct 
 wounds of the nerve, such as arises from incised wounds with a knife, sa- 
 bre, piece of glass, bullets, etc. 
 
 When a nerve has been cut across, a change in the white substance of 
 Schwann first becomes evident. Within a very few days this portion co- 
 agulates and then breaks up into large, irregular masses presenting a 
 double contour. These masses gradually disintegrate into smaller and 
 smaller fragments, until finally nothing remains visible but an accumula- 
 tion of fine fat globules which only present a single outline (the fat gran- 
 ules take up a greater space than the original medullary substance, and 
 the nerve-sheath or neurilemma therefore appears swollen). After a 
 few weeks these products of degeneration begin to be absorbed, and fi- 
 nally disappear in great part. The axis cylinder does not change so rap- 
 idly as the medullary substance, and some observers even maintain that 
 it remains entirely unaffected. The weight of evidence, however, is to 
 the effect that the axis cylinder also slowly undergoes a similar fatty de- 
 generation, and is finally absorbed, so that at length the neurilemma is 
 almost empty or encloses a small amount of the products of degeneration. 
 The neurilemma also undergoes changes ; it becomes thickened, its nuclei 
 increase in size and number, and numerous white globules pass between 
 It and the adjacent ones. The latter become converted into spindle- 
 shaped cells, and finally into connective tissue, which is most abundant 
 in the neighborhood of the sheath of the nerve ; the nerve, therefore, 
 undergoes a sclerotic change. 
 
 But even if a considerable portion of the nerve is excised, the cut 
 ends may be again brought into union with one another by means of new- 
 formed fibres. The manner in which this process is effected is still in- 
 volved in obscurity. We know, hoAvever, from clinical experience, that 
 such union will occur despite seemingly impassable obstacles, so that it is 
 doubtful whether regeneration will not occur even when the cut ends of 
 the nerves have been carried past one another, and thus project in opposite 
 directions. This fact often proves a great obstacle to our therapeutic 
 measures, as in cases of neuralgia in which, after excision of a portion of 
 the nerve, we are anxious to avoid reunion of the cut ends. 
 
 The muscles supplied by the divided nerve also undergo important 
 changes. The muscular fibrilte diminish considerably in size, and the 
 transverse striai are not so well marked as in the normal condition; the 
 fibres present a cloudy and even granular appearance. Increase of the in- 
 terstitial tissue occurs as it does in the nerves; a large number of white 
 blood globules appear between the muscular fi.bres, become converted into 
 spindle cells, and finally into fibrous tissue. When these changes have 
 not attained any considerable intensity they may entirely disappear, and 
 all the parts involved (the nerves and muscles) resume their former nor- 
 mal appearance. 
 
 The central portion of the nerve may also undergo anatomical changes, 
 though these are not constant. They consist of the development of 
 neuromata or of an interstitial neuritis, which is usually limited to a small 
 portion of the nerve immediately adjacent to the seat of injury. In some 
 
166 FUNCTIONAL NERVOUS DISEASES. 
 
 cases, as we shall see at a later period, the neuritis may gradually spread 
 along the nerve jt?er coyxtinuitatem, and finally involve the membranes of 
 the spinal cord, or the spinal cord itself, in the inflammatory process. 
 This, however, rarely occurs when the nerve has been entirely divided. 
 
 In those cases in which the nerve has not been entirely divided, but 
 has undergone slighter grades of injury, such as partial division, compres- 
 sion or contusion, the appearances presented by the organs involved are 
 similar to those described above, but of less intensity. 
 
 The symptoms produced by complete section of a nerve depend upon 
 the character of the latter, whether motor, sensory, or mixed. In all cases 
 the trophic and vaso-motor fibres are paralyzed at the same time as the other 
 fibres. The muscles supplied by the nerve are immediately and completely 
 paralyzed, and remain so until regeneration has occurred. Sensation is not 
 always entirely lost in the parts supplied b}^ the nerve. Richet mentions 
 a case of division of the median nerve which was not followed by the 
 slightest loss of sensation. A considerable number of other cases have 
 been reported, in which the lost sensation reappeared at a time at which 
 regeneration of the cut nerve-fibres (they never unite by first intention) 
 could not possibly have occurred. Arloing and Tripier have explained 
 these cases by the existence of recurrent sensory fibres, which sometimes 
 pass (especially at the periphery) from the trunk of one nerve to that of 
 another. 
 
 The paralysis of the vaso-motor fibres is manifested by dilatation of 
 the vessels and rise of temperature in the parts to which the fibres are 
 distributed. After a variable period the temperature of the parts dimin- 
 ishes, on account of the ensuing atrophy and loss of mobility. In 
 complete section of the nerves, the paralysis of the trophic fibres produces, 
 as a rule, simple atrophy of the muscular tissue. In a few exceptional 
 cases, however, other trophic changes have also developed. 
 
 When the division of the nerve has been incomplete, or when the in- 
 jur}' is due to compression, contusion, or other source of irritation, the 
 symptoms vary somewhat from those described above. The j^aralysis, in 
 such instances, is not so complete, its distribution and severity depending 
 upon the extent of the nerve injury; twitchings and contractures of the af- 
 fected muscles may also be present. The sensory symptoms are also more 
 complex, and consist of anaesthesia (which may not be diffused over the 
 entire distribution of the affected nerve, but is sometimes interspersed 
 with spots of hyperaesthesia); shooting pains in the peripheral distribution 
 of the nerve, which sometimes assume a neuralgic character; a sensation 
 of numbness and tingling in the parts. The trophic sjnnptoms may be 
 very prominent, and are similar in character to those described on page 94. 
 In these cases, also, the symptoms of ascending neuritis are sometimes 
 mingled with those due to the injuiy itself, but we shall defer their dis- 
 cussion until a later period. In order to give a clear idea of the multi- 
 plicity of the symptoms which may follow nerve injuries, we republish 
 the following case from Weir Mitchell's treatise: 
 
 Case T. — " 'Wound of median and ulnar nerves^' atrophy and con- 
 traction of flexor muscles; atrophy of all the hand muscles ; neuro-trau- 
 matic arthritis; loss of sensatioji; moderate ijnproveme?it: discharge. 
 G. L., aged thirty-one; lumberman; enlisted. May, 1861, Company C, 1st 
 Minnesota Infantry. He was healtliy to the date of the wound, which 
 was received July 3, 1803. While advancing at a walk, and capping liis 
 gun, a ball entered the right biceps, three and a quarter inches above the 
 
PERIPHERAL PARALYSIS. 167 
 
 level of the internal condyle, and made its exit three and a quarter inches 
 directly below the same condyle, wounding the main artery and the ulnar 
 and median nerves. The hand and forearm flexed spasmodically, and the 
 man, tying a handkerchief around the arm to check the flow of blood, 
 walked to the rear, suffering with some pain down the front of the arm, 
 but not in the hand. Motion and feeling were both absent. Three hours 
 later the artery was tied. A cerate dressing was applied, and no splint 
 was at any time used. The wound healed in two months, and at this 
 time sensation and motion began to improve. He was admitted to Tur- 
 ner's Lane Hospital, December 24, 1863, when his case was thus described: 
 The right hand is congested and a little swollen. In the flexor carpi radi- 
 alis the loss from atrophy is one-half. In the other flexors, supinators 
 and pronators the loss is one-third. In the thumb muscles proper and 
 abductor minimi digiti it is one-fourth. 
 
 " The deep and superficial flexoi-s and the thumb muscles are slightly 
 contracted. Up to the third month the fingers were straight, but about 
 that time they began to bend, and on admission were semi-flexed. 
 
 " The biceps acts very little; the supinator longus, although enfeebled, 
 being competent to flex the forearm. Extension is incomplete from par- 
 tial contraction of the biceps, owing to the prolonged flexion of the arm; 
 pronation is incomplete, but the supinating power is entire. The hand 
 can be raised only to the arm level, when the contractions of muscles and 
 the state of the wrist-joint check it. The thumb has one-third flexion and 
 extension, owing to want of power. 
 
 "The first joints of the fingers are in good order; the second a little 
 swollen and stiff; the third joints are rigid, enlarged and painful, espe- 
 cially in the index finger. The first joints have pretty fair mobility; the 
 second but little; the third none at all. As the fingers are semi-flexed, 
 the will can still act on the first phalanges, and slightly on the second, 
 but the third rest bent and motionless. The same statement may be 
 made as to the power to voluntarily extend them. The contracted state 
 of the common flexors has now lessened, but the joint inflammations, 
 which arose early in the case, have fixed the fingers in the vicious posi- 
 tions into which they were drawn by the muscular shortening. 
 
 "Touch is good in the arm; absent in the jDalm and palmar face of the 
 fingers, except as to the thenar eminence. It is good on the dorsum of 
 the hand, but defective on the back of the last phalanx of the first finger, 
 the second and third phalanges of the second and third fingers, and on the 
 metacarpal bone of the fourth finger. 
 
 "Electro-muscular contractility is lessened in the supinator longus; 
 absent in the common flexors, though these have some voluntary power; 
 nearly absent in the thumb muscles, the muscles of the fourth finger, and 
 interosseal groups. 
 
 " The marked feature of this case was the obstinate and painful inflam- 
 mation, and stiffness of the third joints of the fingers, and of the articu- 
 lation of the wrist; yet these conditions were nearly entirely relieved by 
 three months of passive motion, electrization by induced currents, and the 
 dry wire brush, douches, and attention to the general health." 
 
 The changes in the electrical reactions of the affected nerves and 
 muscles are extremely interesting and important, both from a diagnostic 
 and prognostic point of view. 
 
 As a matter of course, no stimulation of the nerve above the site of 
 division will be able to produce a response in the muscles to which the 
 
16S FUNCTIONAL NERVOUS DISEASES. 
 
 nerve is distributed. The reappearance of muscular contractions after 
 such stimulation is the best evidence w^hich we possess that the divided 
 ends of the nerve have become united. 
 
 Within a few days after the receipt of the injury, the peripheral por- 
 tion of the nerve begins to lose its excitability to both the faradic and 
 galvanic currents, and this keeps on steadily increasing until finally it is 
 altogether lost, i. e., the muscles will no longer respond to electrical stim- 
 ulation of the nerve supplying them. Entire abolition usually occurs 
 within a period of about two weeks (exceptionally, the excitability of the 
 nerve to both currents is slightly increased for a few days after the 
 injury, but after this time it always pursues the course described). As 
 recovery occurs the irritability of the nerve to both currents slowly 
 reappears and increases until it has resumed the normal proportions. It 
 is a curious fact — and one which I have noticed on frequent occasions — 
 that even after the paralysis is on the high road to recovery the nerve 
 will not respond to electrical stimulus, although it readily allows the 
 transmission of the impulse of the will, i. e., the patient can move the 
 muscles voluntarily, although they will not contract upon passing an 
 electrical current through the nerve. 
 
 The muscles present different reactions according to the current 
 employed. Their faradic excitability begins to diminish in two or three 
 days, and then steadily decreases until it is entirely abolished within two 
 to three weeks. In those cases which never recover it remains perma- 
 nently absent ; in those which are susceptible of improvement the mus- 
 culo-faradic excitability reappears when recovery begins, and grows 
 stronger in proportion as improvement progresses. The galvanic excita- 
 bility of the muscles pursues an entirely different course. For the first 
 week or ten days it is either entirely unaffected, or is perhaps slightly 
 diminished. But at this time the galvanic excitability begins to grow 
 stronger and increases in proportion as the degeneration of the muscles 
 occurs, until finally the paralyzed muscles react to a much milder current 
 than the corresponding ones on the unaffected side of the body.' The 
 increase in the galvano-muscular excitability is sometimes so great that I 
 have frequently observed contraction of the paralyzed muscles from a 
 current of two cells, whereas the healthy muscles would only respond to 
 ten cells. As a rule the character of the muscular contractions is some- 
 what different from that of healthy muscles — they appear at a longer 
 period after the passage of the current, and continue for a longer time. 
 This change in the muscular excitability is known as the degeneration- 
 reaction {entartungs-reacti07i of Erb). If no improvement occurs in 
 the condition of the muscles the galvanic excitability begins to diminish 
 after a variable period, and finally becomes entirely extinct. As a rule 
 recovery is impossible after this has occurred, but some exceptions have 
 been reported, and two such have come under my notice. When im- 
 provement does take place the increased galvanic excitability gradually 
 diminishes until finally it becomes normal, 
 
 ' There are also other more complex changes in the reactions of the muscles to 
 galvanism. In healthy muscles the reaction at the closure of the negative pole is 
 much feebler than that at the positive ; in the paralyzed muscles the former reaction 
 increases much more rapidly than the latter, so that it finally becomes more powerful. 
 Furthermore, the reaction at the opening of the negative pole is greater than that 
 at the opening of the positive pole. In the paralyzed muscles the latter increases 
 much more rapidly than the former, and finally become superior to it. This has been 
 termed by Brenner " reversal of the formula." 
 
PERIPHERAL PARALYSIS. 169 
 
 The remarks just made only hold good for complete division of the^ 
 nerve ; when the injury has been less severe, the changes in the electrical 
 reactions are not so well marked. 
 
 In the mildest forms the nerves as well as the muscles present 
 entirely normal reactions to both currents, and these cases always recover 
 very rapidly. There are, however, numerous intermediate groups 
 between this class and the variety described above, and we find that the 
 electrical reactions vary according to the severity of the nerve-wound. 
 In some cases there is simple diminution of nerve and muscular excita- 
 bility to both currents, a certain grade of irritability being preserved 
 throughout the entire course of the affection. In others the musculo- 
 faradic excitability is lost, while the musculo-galvanic excitability, 
 though increased, does not present the " reversal of the formula " to 
 which we have referred. Numerous other variations have been reported, 
 but it is unnecessary to enter into their discussion ; they are merely 
 the result of variable degrees of change in the anatomical condition of 
 the affected parts. 
 
 Acute Neuritis. 
 
 The consideration of peripheral paralysis from inflammation of the 
 nerve, or neuritis, next claims our attention. Neuritis includes two 
 varieties, viz., the acute and chronic. 
 
 Acute neuritis is usually the result of injury of the nerve, either in 
 gunshot or other wounds ; idiopathic cases appear to be exceedingly 
 rare. As a rule the inflammation only affects the injured nerve or 
 nerves, or, in idiopathic cases, is limited to one nerve, or perhaps to a 
 plexus. In extremely rare instances, however, as in the cases recently 
 reported by Eichhorst ' and Leyden, " a very large number of nerves situ- 
 ated in different parts of the body are simultaneously involved. 
 
 In acute neuritis the nerve appears swollen, and is usually of a 
 speckled reddish color; small punctate hemorrhages are visible, scattered 
 here and there throughout the sheath and tissue of the nerve. The 
 capillaries are enlarged and are surrounded by numerous leucocytes 
 which have also escaped between the nerve-fibres ; the white substance 
 of Schwann has usually undergone fatty degeneration and has been 
 removed in places, so that the sheath of Schwann collapses. The axis- 
 cylinders present variable appearances ; sometimes they are in a con- 
 dition of simple atrophy, sometimes cloudy or granular ; a certain num- 
 ber disappear entirely. 
 
 The disease usually begins with a chill and considerable fever ; 
 intense pain at once develops along the course of the affected nerve, 
 which becomes swollen and exquisitely tender to the touch, so that the 
 slightest contact produces excruciating agony ; in some cases a red livid 
 streak is visible over the nerve, at other times the intqgument is oedem- 
 atous. These symptoms may be combined, in the beginning, with 
 delirium. The patient suffers continuously from pain -m loco vxorhi, and 
 this is accompanied at times by sharp, shooting pains in the distribution 
 of the nerve ; paralysis of the muscles which it supplies rapidly super- 
 venes. The skin is very hypergesthetic, but this condition may change 
 
 1 Virch. Arch. Bd. LXIX. = Charite-Annalen, Berlin, 1880. 
 
170 FUNCTIOlSrAL ITERVOUS DISEASES. 
 
 to anaesthesia after a few days ; the reflex excitability of the parts is 
 lost. The affected limb is kept motionless on account of the pain, and 
 contracture of the muscles rapidly occurs in some cases. After a variable 
 period the inflammation may undergo resolution, and the symptoms then 
 subside, or it may pass into a chronic condition. The following case, 
 reported by Weir Mitchell, is an excellent example of the latter variety: 
 
 "J. C, sergeant, consulted me on account of loss of power in the 
 arm, with severe neuralgia. At Gettysburg he received a ball-wound in 
 the left neck, splintering the clavicle and emerging through the trape- 
 zius. Some fragments of bone were lifted out of the wound, which did 
 well until a week later, when, on the way to Washington, he was sud- 
 denly taken with a chill of some severity, followed by high fever. At 
 the same time the whole arm began to ache, darting pains shot up and 
 down it, and the skin on the inside of the arm, below the axilla, was seen 
 to be red. The nerve tracks were extremely tender. On the third day 
 the whole arm was somewhat swollen, and the darting and aching pain 
 was only subdued by frequent hypodermic injections. His first notable re- 
 lief was obtained by an application of cut-cups to the neck and shoulder, 
 and gradually the pain lessened to its present grade of severity. The 
 ulnar and median were hard, enormously enlarged, and very tender. J. 
 C. described himself as having been made delirious by the earlier pain 
 of his disease; and even when seen by me after it had been abated, he 
 showed very plainly that the mind as well as the body had suffered — his 
 memory being impaired, and his temper excessively irritable." 
 
 As we have stated above, two very interesting cases have been re- 
 ported in which the neuritis involved a large number of nerves in various 
 parts of the body. The following is an abstract of Eichhorst's case which 
 he described under the term acute progressive neuritis: 
 
 " A woman, who was apparently suffering from quotidian intermittent 
 fever, was suddenly paralyzed in the left peroneal nerve, which lost 
 faradic excitability within twenty-four hours. The other peripheral 
 nerves gradually became paralyzed, so that all the limbs were paralyzed 
 in ten days. Amblyopia then developed and finally death. 
 
 "Upon the autopsy no change was found in the brain or cord; the 
 peripheral nerves, however, were all of a dirty grayish red color. The 
 perineurium was very rich in vessels, which were surrounded by lymph- 
 oid cells; the blood-vessels were thickened in places. The nerve-fibres 
 were only degenerated in the neighborhood of the perineurium." 
 
 Leyden's case, which has been referred to above, is somewhat simi- 
 lar to this in its general outlines; it also began suddenly with acute 
 symptoms, but the neuritis afterward passed into a chronic stage. The 
 patient died a year later from urasmia, the result of small contracted 
 kidneys. 
 
 As we shall see further on, these exceptional cases bear very interest- 
 in grelations to the pathology of certain diseases of the spinal cord. 
 
 Chronic Neuritis. 
 
 Chronic neuritis is sometimes an outcome of the acute form of the 
 ■disease. It is also due to direct injury of the nerves, to compression in 
 consequence of various lesions in their vicinity, such as the pressure of 
 tumors, excessive callus, etc., the spread of inflammation from adjacent 
 parts, exposure, etc. An attempt has been made to divide the affection 
 
PERIPHERAL PARALYSIS. I7l 
 
 into two forms, viz., perineuritis or inflammation of the sheath of the 
 nerve, and neuritis proper or inflammation of the nerve itself. Such a 
 distinction is impracticable, however, from a clinical point of view, and 
 very often from an anatomo-pathological standpoint, since both these 
 lesions are often combined. 
 
 When the inflammation is more interstitial in character the sheath of 
 the nerve and the interstitial connective tissue are thickened from an in- 
 crease of spindle cells and new formed fibrous tissue; in consequence of 
 this sclerotic change the nerve-fibres are pressed upon and undergo 
 atrophy; adipose cells sometimes develop between the fibres. In paren- 
 chymatous neuritis the nerve-fibres undergo the most prominent change. 
 The axis cylinders are frequently increased in size, though sometimes 
 they are atrophied; the white substance of Schwann has degenerated in 
 some places and disappeared in others, allowing the sheath to collapse. 
 The blood-vessels are thickened, and may^ be surrounded by capillary ex- 
 travasations of blood. 
 
 The muscles supplied by the affected nerve present th,e same changes 
 as those described on page 1G5, after division of a nerve. 
 
 The symptomatology varies considerabl}^, according to the intensity of 
 the inflammatory process. The disease usually begins by a feeling of 
 numbness and weakness in the distribution of the nerve involved. After 
 a longer or shorter period the patient begins to suffer from pain. In 
 the beginning this consists of mere soreness along the course of the nerve, 
 which soon grows more severe, until finally an intense steady pain is felt. 
 In some cases paroxysms of shooting pain are experienced at longer or 
 shorter intervals; their character is very similar to that of attacks of 
 neuralgia, but the former present a greater tendency to propagation in 
 a centripetal as well as a centrifugal direction. The nerve is always ten- 
 der on pressure (when accessible to the touch), but no circumscribed pain- 
 ful spots are observed, such as we find in true neuralgia. When the 
 nerve is situated directly underneath the skin it is often found to be en- 
 larged. Mistakes are readily made, however, in this respect, and we 
 should therefore always compare the inflamed nerve with the corresponding 
 one on the opposite side of the body. When the inflammatory process is 
 a severe one the integument supplied by the affected nerve is profound- 
 ly anJESthetic; in less marked cases spots of superficial anaesthesia may 
 alternate with patches of hypersesthesia. The patients also complain of 
 sensations of numbness and tingling or a feeling of formication. The 
 muscles undergo a greater or less amount of atrophy, according to the 
 degree of implicatron of the nerve-fibres. Fibrillary twitchings and 
 spasms are often noticeable in the paralyzed and paretic muscles; contrac- 
 ture of these muscles may also take place. 
 
 The electrical reactions present marked variations. Thus the affected 
 nerve, in slight cases, may be more excitable to both the faradic and gal- 
 vanic currents than in the normal condition. As the nerve-changes 
 grow more intense, the excitability to both currents diminishes, and 
 finally disappears altogether. Similar variations are noticeable in the 
 electrical muscular reacrions. Those muscles which have undergone pro- 
 found atrophy always present the degeneration reaction (vide p. 168), 
 while those least affected may react normally to both currents. Erb's 
 so-called " middle forms " of degeneration reaction may also be present. 
 It is not at all infrequent, especially when several nerves are involved, to 
 find all these different varieties of electro-muscular reactions in one 
 individual. 
 
172 FUNCTIONAL NERVOUS DISEASES. 
 
 The trophic changes are sometimes very manifold; and the skin, hair, 
 nails, joints, muscles, and bones, may all be involved in these changes. 
 They are identical in character vv^ith those noticed in severe cases of neu- 
 ralgia, to which we have previously referred. It will therefore be un- 
 necessary to dilate upon them at this time. 
 
 The following case, which I published in the 3fedical Record, April 
 26, 1879, is a good example of chronic neuritis, and also illustrates the ten- 
 dency to the propagation of the inflammation of which we have spoken. 
 
 Case I. — The patient's name is Wm. W., get. 35 years; family his- 
 tory unimportant; married, and has healthy children; he has never had 
 syphilis or other venereal disease; his habits have always been good. 
 The patient was in robust health until the war of the rebellion, when he 
 enlisted as a soldier, and contracted dysentery during his term of service. 
 
 He first came under my notice at the Class for Nervous Diseases of 
 the Bellevue Out-Door Department, on December 13, 1877. The patient 
 was anemic and somewhat emaciated; he complained of slight cough and 
 expectoration in the morning; physical exploration of the chest was not 
 made at that time. A year ago the patient received an injury to the 
 right elbow, resulting in the formation of a boil over the olecranon pro- 
 cess; this healed kindly in two or three weeks, leaving no apparent 
 traces. About five weeks ago he again suffered from a boil, situated 
 in the same locality as the previous one, and coming on without any 
 apparent provocation. The swelling occupied the entire posterior part 
 of the elbow. A month later (nearly two weeks ago), and before 
 the boil had healed, the patient noticed a feeling of numbness and anaes- 
 thesia appearing on the anterior and posterior surfaces of the forearm. 
 This gradually spread downward, involving the anterior and posterior as- 
 pects of the little finger and the ulnar border of the ring finger; these 
 fingers became paretic, pari passu with the anaesthesia. The anaesthe- 
 tic integument soon began to grow dusky red, became somewhat thick- 
 ened, and small, whitish scales developed over its surface. Slight pain 
 and tenderness now appeared in the fold of the elbow and along the 
 course of the ulnar nerve in the forearm. Soon after the patient came 
 under my care the tenderness spread upward in the arm, along the course 
 of the ulnar nerve into the axillary region, and was even present along 
 the course of the brachial plexus in the neck. He was treated by hot 
 douches, actual cautery along the affected nerves, and the descending 
 constant current, as topical remedies; the internal medication consist- 
 ed of iodide of potassium, fifteen grains three times a day, and thirty 
 drops of the fluid extract of ergot three times a day. In the course of 
 two weeks the pain and tenderness along the nerve-trunks had almost 
 entirely disappeared; the skin of the affected region was still insensible 
 to the prick of a pin, but a less intense faradic current than formerly 
 was appreciated. The interosseous muscles are now becoming paretic; 
 the flexors of the little and ring fingers are apparently somewhat stronger 
 than formerly. Treatment was now restricted to the use of galvanism 
 and the iodide of potassium. The patient remained in statu quo until 
 February 10, 1878, when the following notes were taken: general ap- 
 pearance poor; heart-sounds normal; signs of incipient phthisis at the 
 apex of the right lung; good deal of cough and expectoration; pa- 
 tient suffers from profuse night-sweats. Upon examination of the 
 right arm attention is attracted by the dusky redness of the skin in re- 
 gions which accurately represent the distribution of the internal and ex- 
 
PERIPHERAL PARALYSIS. 173 
 
 ternal cutaneous nerves and the cutaneous branch of tlie musculo-spiral. 
 He is unable to feel the prick of a pin in this region even when it draws 
 blood; he does not feel a constant current of thirty-two Stoehrer's cells; 
 feels quite readily a secondary faradic current of moderate intensity. 
 No tenderness on pressure along any of the nerve-trunks; the right 
 hand forces the dynamometer to 46, the left hand to 180°. On inspec- 
 tion it is found that the adductor pollicis can barely adduct the thumb, 
 and the dorsal interossei are considerably atrophied. On asking the pa- 
 tient to move his fingers, it is evident that the palmar interossei and the 
 three inner lumbricales do not act as vigorously as in the left hand, and 
 it is reasonable to suppose that they are also atrophied. The motor 
 nerve affected in the arm is therefore the ulnar. The paralyzed muscles 
 did not respond to the faradic current. In the arm the ulnar nerve can 
 be traced from the groove between the internal condyle and the olecra- 
 non process upward into the axilla as a thick, indurated cord, which is not, 
 however, sensitive to pressure at the present time; the tenderness along 
 the brachial plexus has also disappeared. A red patch is visible on the 
 side of the neck and the tip of the ear (right side). This region, corre- 
 sponding to the auricularis magnus nerve, feels numb, and on testino- it 
 with the festhesiometer, it is evidently markedly anesthetic. The two 
 points of the a^sthesiometer are only distinguished apart at thirty mm., 
 but on the corresponding portion of the left side at fifteen mm. Imme- 
 diately below the inferior angle of the right scapula is a spot nearly as 
 large as a silver dollar, at which the skin presents the same appearances 
 as in the neck and arm; this region is also anaesthetic, and two points can- 
 not be distinguished apart over this spot. To-day the patient informs 
 me, for the first time, of his dysenteric affection. Ordered subnitrate of 
 bismuth, gr. xxx., t.i.d., which, in a few days, reduced the number of 
 passages to two or three per diem, and rendered them healthy in appear- 
 ance; atropia was ordered for the night-sweats with excellent results. 
 The iodide of potassium was continued in the same doses as before, and 
 the constant descending current was passed down the cervical spine, and 
 along the course of the brachial plexus and of the nerves of the arm and 
 forearm, every other day. 
 
 April 2, 1878. — General health greatly improved; coughs very little; 
 no night-sweats; has one or two healthy passages from the bowels daily. 
 The patient is now able to adduct the thumb to the base of the ring fin- 
 ger, and can abduct and adduct all the fingers except the ring finger. 
 The eruption on the forearm has faded a great deal, especially toward its 
 centre. Sensation has improved very little; pain is absent, except in the 
 little finger and the ulnar side of the ring finger (hot, smarting pain). 
 The anfesthesia of the reddened patch on the side of the neck is, perhaps, 
 a little less marked than at the date of the last note, and the eruption is 
 somewhat paler. The patient informs me that he has noticed, since the 
 beginning of the week, a numb, red spot on the middle of the thigh an- 
 teriorly, and about six inches below Poupart's ligament. This patch of 
 eruption, which is as large as a silver dollar, and paler in the centre than 
 at the periphery, is markedly anresthetic; a similar spot, as large as a 
 dime, is found over the left deltoid muscle. He continued to improve 
 very slowly until the winter of 1878, when he returned to work as a night- 
 watchman, and passed out of my observation. 
 
 This case has important bearings upon the question of neuritis ascen- 
 dens and neuritis migrans. During the last twenty-five years there has 
 
174 FUNCTIONAL NERVOUS DISEASES. 
 
 been a strong tendency among neurologists to entirely discard the old 
 doctrine of reflex paralysis, but there is no doubt that in a few cases the 
 theory of reflex inhibitory action is alone sufficient to account for the 
 paralysis produced. Thus Landry reports a case of paralysis, associated 
 with anteversion of the uterus, which disappeared immediately after the 
 organ was replaced in its normal position. M. Rosenthal observed the dis- 
 appearance of a suddenly-developed paraparesis after the extraction of a 
 needle which had been introduced into the vagina. Madge reports a case 
 of paralysis developing during pregnancy, which disappeared after the de- 
 livery of a dead four months fcetus. Fuller ' mentions the case of a boy, 
 cet. 3 years- suffering from paralysis of the right arm and of both legs, 
 which was relieved by the expulsion of fifty-three lumbricoid worms. 
 The theory of reflex inhibition must also be invoked to explain those 
 cases (of which Mitchell has reported several), in which an injury to one 
 nerve has produced paralysis in the distribution of another, and in such 
 a short period of time that no anatomical lesion could have been pro- 
 duced. 
 
 But this theory will evidently not suffice for all cases of this nature. 
 In many instances post-mortem examination revealed the presence of in- 
 flammatory processes in the spinal cord or its meninges, in cases which 
 had been regarded during life as examples of reflex paralysis from blad- 
 der or uterine disease, etc. The histories of the older cases of this char- 
 acter are deficient in microscopical examination of the medullary tissue, 
 and must therefore be discarded. In order to explain the cases included 
 in this category in which anatomical lesions were found in the spinal cord, 
 resort was had to the theory of neuritis migrans, and this doctrine has 
 been favorably entertained by the majority of living pathologists. In 
 addition to the clinical aspects of the question, physiological experiments 
 were also adduced to substantiate it. Thus, Tiesler, Klemm, Feinberg, 
 and Niedick made numerous experiments upon animals by producing ir- 
 ritation of the sciatic nerve in some portion of its course, either by inject- 
 ing a foreign matter into its substance, or by cauterizing it with nitrate 
 of silver or caustic potassa. With the exception of Feinberg, these ob- 
 servers announced as the results of their investigations that the irrita- 
 tion of the nerve in the manner referred to produces neuritis at the irri- 
 tated spot, and that, furthermore, evidences of inflammation appear in 
 the course of the nerves, although the nerve-tissue may be perfectly 
 healthy between two inflammatory foci. In addition, scattered foyers of 
 myelitis were found disseminated throughout the cord. None of these 
 experimenters, however, resorted to microscopical examination of the tis- 
 sues, nor did they compare the appearances presented with those found 
 in healthy animals. Feinberg found, as the result of his investigations, 
 that neuritis was produced at that portion of the nerve which had been 
 irritated, but that the more central parts of the nerve were intact. He 
 nevertheless obtained evidences of myelitis in the cord. This observer 
 is inclined to regard the myelitic process as due to reflex irritation of 
 vasomotor nerves (contraction and secondary dilatation of the medullary 
 vessels). 
 
 In December, 1877, Ottomar Rosenbach published an article in Kleb's 
 " Archiv. f. exp. Path. u. Pharmak.," in which he arrived at entirely- 
 opposite results from those of the observers previously mentioned. Dr. 
 Rosenbach made a series of very careful experiments upon the pneumo- 
 
 ' The Lancet, December, 1865. 
 
PERIPHERAL PARALYSIS. 175 
 
 gastric and sciatic nerves in rabbits, and, although he could develop a 
 perineuritis at the irritated point, in not a single instance was he able to 
 discover any evidences of neuritis migrans or of secondary myelitis. 
 All his experiments were accompanied by careful microscopical examina- 
 tions — a precaution which had been omitted in the above-mentioned re- 
 searches. Rosenbach also calls attention to the fact that no controlling 
 observations were made upon healthy animals by either Klemm,Tiesler, 
 Feinberg or Niedick, and that many of the appearances which the latter 
 regarded as pathological were, in fact, perfectly normal. 
 
 Similar experiments have been made more recently by H. Treub ' and 
 have entirely substantiated the conclusions arrived at by Kosenbach. 
 
 Whether or not the experiments of Rosenbach and Treub dispi-ove 
 the possibility of the production of neuritis migrans, we shall not discuss 
 now. We are, however, warranted in the assertion that its existence has 
 not been experimentally established, and that other and more careful ex- 
 periments are necessary to settle this vexed question. 
 
 We must therefore rely for a solution of the problem upon patholo- 
 gical and clinical data. 
 
 Leyden * reports two cases in both of which the paralyses were secon- 
 dary to disease of the bladder, and in which the autopsy showed the ex- 
 istence of widespread myelitic softening. The myelitis started from that 
 part of the cord in which the nerves supplying the bladder originate, and 
 we are therefore naturally led to suppose that the inflammatory process 
 passed upward from the bladder, and along the nerves, until it reached 
 the cord. But Leyden himself remarks that there is no positive proof in 
 support of this hypothesis. T have been unable to discover any other 
 analogous cases of equal importance after a survey of the medical litera- 
 ture which has appeared since the publication of Leyden's work. 
 
 The case of Wm. W., which I have reported above, appears to me to 
 fill an hiatus in this direction. The primary affection was evidently a 
 neuritis of the internal cutaneous, external cutaneous, and ulnar nerves, 
 caused by an extension of inflammation from the boil situated on the 
 elbow. The fact that the boil was primarily seated over the olecranon 
 process, and from thence spread internally and externally, is a sufficient 
 anatomical explanation of the fact that the three nerves in question were 
 implicated to the exclusion of the other nerves situated in the fold of the 
 elbow. At a later period pain and tenderness became evident along the 
 course of the ulnar nerve in the arm, and the nerve could be traced as a 
 thickened, indurated cord from the back of the inner condyle, along the 
 inner side of the arm into the axillary space. These phenomena undoubt- 
 edly indicated extension of the inflammation along the ulnar nerve. At 
 a still later period tenderness became evident along the course of the 
 brachial plexus in the neck, indicating the further extension of the neu- 
 ritis along the nerve-trunk. 
 
 The next nerve to become involved was the auricularis magnus, as 
 was evidenced by the appearance of anaesthesia and of the trophic erup- 
 tion referred to previously, in its distribution to the lobe of the ear and 
 to the side of the neck. Now the ulnar nerve which had been previously 
 implicated arises from the eighth cervical and first dorsal nerves, while 
 the auricularis magnus is given off from the second or third cervical nerves. 
 If we acknowledge that the implication of the auricularis magnus was sec- 
 
 ' Arch f. exp. Path. n. Pharm., p. 398, 1879. 
 ■ Klinik f. Ilueckenmarkskrankheiten. 
 
176 FUNCTIONAL NERVOUS DISEASES. 
 
 ■ondary to that of the ulnar nerve (and no other explanation is open to 
 us), we are forced to conclude that the affection of the former was caused 
 by some inflammatory process within the spinal canal. This idea is still 
 further strengthened by the subsequent appearance of similar spots of 
 auEesthesiaand of the trophic eruption in other portions of the body (deltoid 
 muscle, scapula, thigh). What the nature of the medullary lesion was 
 we are unable to state. It may have been a disseminated chronic myelitis, 
 or the inflammation may have been limited to the meninges. The spinal 
 symptoms were so slight that it would be rash to venture a differential 
 diagnosis between these two conditions. 
 
 It appears to me that this case demonstrates from a clinical stand- 
 point (and with almost as much positiveness as a successful physiological 
 experiment) that ascending neuritis is capable of developing secondary 
 inflammatory changes in the cord, by means of a simple extension of the 
 neuritic process per contimdtatem. 
 
 This tendency to the upward spread of the chronic inflammatory pro- 
 ■cess along the nerve which was primarily affected, is quite commonly met 
 with in cases which belong to the category at present under discussion. 
 As a rule, however, the spread of the inflammation stops at the nerve 
 plexuses, and does not continue as far as the spinal cord. 
 
 There is also strong reason to believe that neuritis may be propagated 
 downward along the course of the nerve, as appears to have been the 
 case in the following example : A patient fell upon the left shoulder, and 
 this injury was followed by symptoms of neuritis in the circumflex nerv^e. 
 "Within a month pain and tenderness were felt in the brachial plexus, with 
 shooting pains along the circumflex nerve and very marked atrophy of 
 the deltoid muscle. This was followed by the development of pain and 
 tenderness along the nerve-trunks in the arm, and shooting pains along 
 the distribution of the ulnar nerve in the forearm. 
 
 The development of pain and tenderness in the nerves of the arm 
 subsequently to the appearance of these symptoms in the course of the 
 brachial plexus probably indicated a downward spread of the neuritis. 
 
 The results of autopsical examination have also shown the actual ex- 
 istence of neuritis descendens. 
 
 Rheumatic Paralysis. 
 
 Another large category of peripheral paralyses is that which is due to 
 so-called rheumatic or atmospheric influences, and is known as rheumatic 
 paralysis (also called paralysis a frig ore). Our knowledge of the lesions 
 which are produced in this form of the disease is purely hypothetical, so 
 far as regards the milder varieties, which never prove fatal. The paraly- 
 sis was formerly supposed to be reflex, but there is good reason to be- 
 lieve that this view is incorrect. Thus, Frerichs reports a case in which 
 a child, fet. 3 years, became paraplegic after having sat upon a cold stone 
 for several hours. The case terminated fatally, and the autopsy showed 
 the presence of exudative meningitis throughout the entire spinal canal. 
 From certain of the symptoms in the peripheral forms of rheumatic par- 
 alysis, it is supposed that the affection is due to various grades of neu- 
 ritis or perineuritis, which may sometimes be so severe as to lead to 
 degeneration of the nerves and muscles, such as we have described as the 
 result of complete division of the nerve. The modus operandi, however, 
 of the production of such lesions is as little known as is that of the de- 
 
PERIPnERAL PAP.ALYSIS. 177 
 
 velopment of bronchitis after exposure, etc. Rheumatic paralysis develops 
 either as a consequence of cold or from exposure to draughts, especially 
 when the patient is perspiring and is not exercising at the time. In a large 
 proportion of cases the facial and ocular muscles are involved, and as 
 we shall see at a later period, the paralysis may vary greatly in intensity; 
 some attacks recover spontaneously in a few da\'s, others are incurable. 
 Not infrequently rheumatic paralysis occurs during sleep, when the pa- 
 tient is lying in a draught. It may develop within a few minutes after 
 the operation of the exciting cause, or not until the lapse of a couple of 
 days. It is usually unattended with pain or other sensory disturbances, 
 and the duration of the disease generally varies according to the electrical 
 reactions. It was in this form of paralysis that the "degeneration- 
 reaction '' was first observed by Baierlacher. In the most severe cases 
 the degeneration-reaction is as well marked as that described after the 
 complete division of a nerve, and in some all electrical reactions of the 
 nerves and muscles may be entirely lost. But as in paralysis from injuries 
 of nerves, there are numerous gradations between these severe types and 
 tlie slight forms in which the muscular and nervous electrical reactions 
 are entirely normal, and complete recovery occurs within a few days. 
 
 The more intense forms of rheumatic paralysis are not infrequently 
 followed by spasms and contractures of the affected muscles. The lat- 
 ter condition is very liable to lead to permanent deformity, which may 
 seriously interfere with the progress of recovery. 
 
 Atrophy of the muscles does not appear to be as marked as in the va- 
 rieties of paralysis which we have previously described. 
 
 Paealtsis follo^vixg Infectious Diseases, 
 
 The occurrence of paralysis as a sequence of various general diseases 
 had been recognized by a considerable number of clinical observers for a 
 long time, but it is only within the past fifteen years that especial atten- 
 tion has been called to these affections. They were at first regarded as 
 purely functional, i. e,, no anatomical lesion was supposed to be present 
 in these cases; but the pathological investigations of the last decade have 
 shown that they are due, in the majority of instances, to well-defined lesions 
 which are situated sometimes in the brain and spinal cord, sometimes in 
 the peripheral nerves alone. But quite a number of cases have been re- 
 ported very recently in which even the most careful microscopical exami- 
 nation failed to show the presence of any morbid changes. Dejerine gives 
 the results of his examination of three cases of diphtheritic paralysis, in 
 one of which the muscles of the arms and neck, in another both arms, and 
 in the third all the limbs were affected. The morbid appearances were 
 similar in all these instances, and were chiefly confined to the anterior 
 roots of the spinal nerves. The nerve-sheaths and interstitial connective 
 tissue showed a very marked increase of cellular elements, there was a 
 similar increase in the nuclei of the neurilemma, and the white substance 
 of Schwann had degenerated into a sort of granular mass; many of the 
 axis cylinders had entirely disappeared. 
 
 Buhl found, in the same disease, that the roots of the nerves were 
 thickened and had undergone yellow softening in places; the sheaths of 
 the nerves and their interstitial connective tissue showed a cellular infil- 
 tration which Buhl regarded as identical with the diphtheritic infiltration 
 in the mucous membrane of the pharynx. 
 
 Bernhardt describes the following appearances in a case of paralysis 
 12 
 
178 FUNCTIONAL NERVOUS DISEASES. 
 
 of the radial nerve following typhoid fever: the capillaries were moder- 
 ately distended with blood globules, and numerous capillary hemorrhages 
 were noticed along the walls of the vessels; the axis cylinders had disap- 
 pecired in great part, and the white substance of Schwann had undergone 
 fatty and granular degeneration. 
 
 Similar changes have been noticed in the paralyses following dysen- 
 tery, measles, etc. We may also remark that softening and disseminated 
 myelitis have been found in the cord, and capillary hemorrhages, soften- 
 ing, etc., in the brain in cases of central paralysis following acute infec- 
 tious diseases. 
 
 In not an inconsiderable number of autopsies, however, no changes 
 have been discovered, notwithstanding the existence of well-marked paral- 
 ysis (which may even have been the direct cause of death), and we are 
 therefore forced to conclude that some of these forms may be due to the 
 direct paralyzing action of the specific virus upon the nerve-tissues. 
 
 Clinical History . — Paralysis may occur as a sequel of diphtheria, 
 dysentery, whooping-cough, variola, scarlatina, rubeola, typhoid fever, 
 intermittent fever, pneumonia, acute articular rheumatism. 
 
 Some of these affections are much more frequently followed by paral- 
 ysis than others, and diphtheria is by far the most important in this par- 
 ticular. We shall therefore devote our chief attention to a description 
 of diphtheritic paralysis. 
 
 There does not appear to be any special relation between the severity 
 of the primary disease and the frequency of occurrence of post-diphthe- 
 ritic paralysis. All of my own cases have occurred after mild attacks of 
 diphtheria, and it is not infrequent to find the paralysis develop, although 
 the throat trouble was so slight that the case would have been called one 
 of simple pharyngitis, were it not for the existence of undoubted cases of 
 di'phtheria in the immediate neighborhood. 
 
 The loss of motor power usually develops within the first four weeks 
 after the beginning of the disease, although in rarer instances it may not 
 occur until after the lapse of several months. In the beginning the muscles 
 of the velum palati are generally involved; this is shown by the nasal char- 
 acter of the voice, and by the fact that the regurgitation of fluids, which 
 may have been present in the early period of the disease, now reappears. 
 Upon inspection the velum palati and uvula are found to have lost their 
 tonicity, and perhaps one pillar of the fauces hangs lower than the other 
 (we have not met with any reports of cases, however, in which only one 
 pillar was paralyzed). Reflex action from the velum palati is lost, and 
 the parts do not react even to the most energetic stimulation. The elec- 
 trical reactions of the affected muscles vary considerably. In the milder 
 cases they are unaffected, in others there is simple diminution both to the 
 faradic and galvanic currents; a few instances have been reported in 
 which the faradic excitability was abolished and the galvanic excitability 
 markedly increased. The latter condition has been noticed by Leube, 
 Krafft-Ebing, Rosenthal, and Joffroy, so that its occurrence is unques- 
 tioned. 
 
 In the majority of cases some of the muscular structures of the eye 
 are the next to suffer. Within a few days after the development of the 
 faucial disturbance the patients suffer from paralysis of the sphincter of 
 the iris and the tensor muscle of the choroid. This is evidenced by dila- 
 tation of the pupil and loss of the power of accommodation, so that the 
 patient can see distant objects distinctly, while vision for near objects is 
 markedly impaired. 
 
• PERIPHERAL PARALYSIS. 1 79 
 
 More rarely some of the other ocular muscles are also involved, es- 
 pecially the rectus internus and externus. Eulenburg states that he has 
 sometimes noticed a rapid disappearance of the paralysis in one ocular 
 muscle (in from twenty-four to forty-eight hours) and its sudden appear- 
 ance in another. 
 
 Rosenthal reports the occurrence of facial paralysis following diph- 
 theria. " The middle paralyzed muscles of the face had lost their faradic 
 contractility, but preserved their irritability to the continuous current. 
 Even after the disappearance of the paralysis, the same difference existed 
 ■with regard to the action of the two currents." 
 
 Paralysis of the muscles of the limbs and trunk is not infrequently 
 present. It is rarely observed except in cases in which the velum palati 
 has been affected, and usually develops after the latter begins to improve 
 or even after the faucial disorder has entirely disappeared. The paralysis 
 may begin either in the upper or lower limbs, and gradually spreads to 
 the rest of the body. The muscles of the neck and trunk are not very in- 
 frequently involved, and in such cases paralysis of the diaphragm is liable 
 to occur. These forms present naturally a very gloomy prognosis. 
 
 The sensory disturbances are very slight, and usually limited to a feel- 
 ing of numbness, with or without anaesthesia, in the paralyzed parts. 
 The affected muscles are very apt to undergo atrophy, though this trophic 
 change does not develop with any rapidity. In two of my cases loss of 
 power in the lower limbs slowly developed, with considerable wasting of 
 the muscles and some numbness and anaesthesia. In both of these cases 
 incontinence of urine occurred, and the patients did not possess normal 
 control over the rectum. Neither of these individuals had suffered from 
 any faucial paralysis. 
 
 The electrical reactions of the affected muscles present great variations, 
 and various forms of reactions may be observed in the same individual, 
 according to the severity of the paralysis. In a case recently reported 
 by Fritz,* the muscles of the calves of the legs only responded to a 
 very strong faradic current, while the muscles of the ball of the thumb 
 were entirely inexcitable to this current. Exploration with the galvanic 
 current showed the presence of marked degeneration-reaction in the 
 thumb muscles. As the paralysis of the legs increased, the degeneration- 
 reaction also developed in the muscles of the calves. 
 
 As a rule, the prognosis of post-diphtheritic paralysis is very good. 
 The patients usually recover within one to two months, especially when 
 the aft'ection is limited to the muscles of the velum palati or the eye. 
 
 The favorable prognosis, the occurrence of the degeneration-reaction, 
 and the results of autopsical examination (vide p. 177), render it very 
 probable that the majority of cases of post-diphtheritic paralysis, whether 
 circumscribed in character or general, are due to an affection of the peri- 
 pheral nerves (cellular infiltration, etc.). We must remember, however, 
 that no lesions are discovered in a certain proportion of cases. 
 
 Typhoid fever ranks next in importance to diphtheria among infectious 
 diseases as the cause of paralysis. Like diphtheria, it may be followed 
 by paralysis in different parts of the body (ocular muscles, face, paraple- 
 gia, hemiplegia, various nerves). These paralyses develop, as a rule, as 
 a sequence of the disease, but they have also been observed at the height 
 of the affection. They differ from those forms following diphtheria in the 
 fact that they usually run a much more protracted course. With this ex- 
 
 ' Charite-Annalen, p. 255, 1880. 
 
180 FUNCTIONAL NERVOUS DISEASES. 
 
 ception, their clinical history as regards atrophy of muscles, electrical re- 
 actions, etc., is exactly similar to that of the post-diphtheritic affection. 
 AYestphal ' has recently reported a case of post-typhoid paralysis, which 
 is so remarkable, in some respects, that we shall republish a portion of 
 the history in full: 
 
 " The patient, ret. 30 years, recovered from an attack of typhoid 
 fever with a paraparesis of the lower limbs. At the end of nine months 
 she was unable to stand or walk; the peroneal muscles were completely 
 paralyzed, the tibiali antici retained some power. No sensory disturban- 
 ces, no muscular spasms; the bladder and rectum acted normally. 
 
 "The peronei longi and gastrocnemii muscles could be contracted 
 voluntarily and reacted, though very feebly, to the faradic as well as to 
 the galvanic currents. 
 
 " Soth tibiales antici onuscles contracted under the influence of the 
 will cm d of the faradic current, cdthough the strongest galvanic current 
 was unable to jyrochice the slightest contraction. (This remarkable condi- 
 tion is called isofaradic reaction by Westphal.) Under the influence of 
 treatment with the faradic and galvanic currents, this peculiar phenome- 
 non soon disappeared. The tibiales antici muscles gradually began to 
 respond to the galvanic current, in about two months presented the de- 
 generation-reaction, and later became normal." 
 
 Variola, rubeola, scarlatina, dysentery, cholera, erysipelas, pneumonia, 
 and acute articular rheumatism are also followed by paralyses at times, 
 which occur, however, much more infrequently than after diphtheria and 
 typhoid fever. Their clinical history is in all respects similar to that of 
 those described as occurring after the latter diseases, and we shall there- 
 fore refrain from entering into a description, which would be a mere re- 
 capitulation of the remarks previously made. 
 
 Numerous other nervous disturbances, such as acute ascending spinal 
 paralysis, multiple cerebro-spinal sclerosis, locomotor ataxia, etc., have 
 been observed as sequelae of the diseases just mentioned, but their dis- 
 cussion is beyond the scope of this article. 
 
 Toxic Paralysis, 
 
 The next class of cases which require our consideration are the toxic 
 parcdyses, which occur in consequence of j^oisoning with lead, arsenic, etc. 
 Lead is svich an important factor in the production of paralytic and other 
 nervous disorders that we will enter into the discussion somewhat in de- 
 tail. 
 
 This metal may be introduced into the system in a thousand different 
 ways, by inhalation, by the mouth or from external application to the skin. 
 Inhalation may occur from living- in newly-painted rooms, from working 
 in factories in which lead is employed and in which the air is impregnated 
 with the poisonous particles (as in white lead manufactories, in the oper- 
 ation known to painters as flatting, etc.), from taking snuff which has been 
 wrapped in lead foil, etc. It may be swallowed in confectionery colored 
 with lead salts, in articles which have been wrapped in lead foil, in ale 
 drawn through lead pipes (especially that which is drawn early in the 
 morning and has lain in the pipes over night), in water drawn from lead- 
 lined cisterns, in bread, the flour composing which has been ground in 
 
 ' Charite-Annaleu, p. 376, 1880. 
 
PERIPHERAL PARALYSIS. 181 
 
 stones filled with lead, in articles cooked in vessels lined with a lead 
 glaze, etc., etc. It is absorbed through the skin in various trades, such 
 as plumbing, from handling type, using hair-dyes and cosmetic, etc. 
 
 Among 1,213 cases of chronic lead poisoning collected by Tanquerel 
 des Planches, 40G occurred in white lead manufacturers, 305 in house 
 painters, 68 in color grinders, 63 in red lead manufacturers, 54 in earthen 
 pottery manufacturers, 52 in type-founders, 47 in carriage painters, 35 in 
 lapidaries, and 33 in ornamental painters. It is sometimes extremely dif- 
 ficult to determine the source of the entrance of the lead into the system 
 in individual cases, and in several instances we have been unable to dis- 
 cover its origin although the most indubitable evidences of lead poison- 
 ing were present. 
 
 The habits of the patient should be carefully inquired into, and his 
 surroundings examined. Negative statements with regard to the impos- 
 sibility of the entrance of lead into the economy should never be accepted 
 when well-marked symptoms of poisoning are present; the physician 
 should always satisfy himself personally of the condition of affairs. 
 Children are very apt to put into the mouth any substance with which 
 they come in contact, and it is therefore advisable, in cases of lead poison- 
 ing in children, to carefully examine their toys, etc. The determination 
 of the mgde of entrance of the poison into the system is, of course, of the 
 first importance, as we cannot expect any improvement in the symptoms 
 until its further admission has ceased. 
 
 Lead palsy rarely occurs without any previous symptoms of poisoning. 
 The patients have usually suffered for a long time from obstinate consti- 
 pation, the appetite is poor, the skin assumes a peculiar ashen-gray ap- 
 pearance, they complain of a metallic taste in the mouth, the tongue is 
 habitually furred, and the expired air exhales a disagreeable, sickening 
 odor. The pulse is usually slow and hard, the surface of the body is dry, 
 the gums present the blue line. As a rule, the patients have suffered, 
 prior to the paralysis, from one or more attacks of lead colic. Lead pa- 
 ralysis may not occur until the above-mentioned symptoms have lasted 
 for years, in other cases it may develop after a very short exposure to the 
 deleterious influence of the poison. In one case under my own observation 
 the paralysis began to develop within a month after the patient had be- 
 gun work in a white lead factory, although prior to that time he had been 
 in perfect health and had never, so far as I could ascertain, been exposed 
 to the influence of lead. 
 
 Lead palsy is usually bilateral, but in some cases it may be limited to 
 only one side. In the majority of instances the extensor muscles of the 
 forearm are the only ones affected in the beginning of the malady, though 
 other groups of muscles may be involved at a later period. Before the 
 disease develops, the patients usually suffer from tremor of the arms on 
 exertion, and often from neuralgiform pains and anaesthesia. The weak- 
 ness of the muscles generally develops gradually and increases until the 
 production of paralysis. Several months may elapse between the time at 
 which the patients first experience weakness of the limb and the develop- 
 ment of complete paralysis. In exceptional cases, however, the loss of 
 power develops quite suddenly. Thus the patient may retire to bed, feel- 
 ing entirely well, or perhaps complaining of numbness in the arms, and 
 upon waking in the morning, the palsy may be complete or almost so. 
 As we have previously stated, the extensor muscles of the forearm are the 
 ones usually involved, giving rise to the characteristic deformity known 
 as wrist-drop (when the forearm is held horizontal in complete pronation, 
 
182 FUNCTIONAL NERVOUS DISEASES. 
 
 the hand drops down almost at right angles to the arm, and in the sever- 
 est cases not the slightest degree of extension can be performed). It is a 
 remarkable fact, and one which is extremely important from a diagnostic 
 point ol view, that the supinator longus and brevis remain unaffected by 
 the disease, though these muscles, as well as the extensors, are supplied 
 by the radial nerve. 
 
 Lead palsy is usually accompanied by rapid atrophy of the affected 
 muscles so that the appearances presented are very characteristic. Upon, 
 examining the forearm the normal rotundity of its posterior surface is 
 found to be lost, and the atrophy is sometimes so extreme that the finger 
 can be pressed into the interosseous space; immediately adjacent, how- 
 ever, the prominent supinator longus is seen passing down the outside of 
 the forearm in its natural proportions. Although the freedom of the 
 supinator longus from paralysis and atrophy is almost always observed, 
 there are some exceptions to this rule, and I have myself observed two 
 cases in which this muscle was involved to the same extent as the exten- 
 sors. The electrical reactions of the affected muscles vary considerably. 
 In some cases there is merely a diminution of their faradic excitability, 
 in others their galvanic excitability also diminishes. These reactions 
 may continue throughout the entire course of the disease. The degen- 
 eration-reaction is also observed in some cases, and, it is said, always 
 m those forms which are attended with very rapid muscular atrophy. 
 I have at present, however, a case under observation in which the 
 atrophy is so great that the finger can be pressed into the interosse- 
 ous space, but in which the faradic excitability of the muscles, although 
 not very distinct, is entirely proportionate to the small amount of mus- 
 cular fibre left intact; the galvanic excitability is not increased. A num- 
 ber of cases of this kind have come under my notice. Eulenburg has 
 shown that increased mechanical and reflex excitability of the muscles 
 may be present in cases in which their galvanic contractility is increased. 
 
 It has been stated by numerous writers that in cases of wrist-drop the 
 flexors of the arm are also partially paralyzed. This statement is due to 
 a mistake in observation, as can be readily shown. If the hand is flexed 
 upon the forearm, actual measurement will show that the flexor muscles 
 are 1^ to 1^ inches shorter than when the hand is extended (this is read- 
 ily determined by making a mark in the bend of the elbow and measur- 
 ing from it to the tips of the fingers while flexed and extended). But as 
 muscular power is due to contraction of the muscles, the power of the 
 flexors in wrist-drop must necessarily be markedly diminished, since the 
 mere position in this affection causes a shortening, as we have seen, of 
 1^ to 1-^ inches. If the paralyzed hand is held by the observer in a posi- 
 tion of moderate extension and the patient be then directed to exert 
 the flexors, their power will be found undiminished. 
 
 In exceptional cases the paralysis does not begin in the extensors of 
 the forearm. In two of my patients the loss of power began in both del- 
 toids, and had progressed to such an extent that these muscles had almost 
 completely wasted away before the extensors began to be affected. In 
 another case I observed paralysis of the extensors of the feet before those 
 of the arms became implicated. In a not very inconsiderable number of 
 cases the paralysis begins in the usual situation, but then gradually 
 spreads to other muscles of the body, so that the disease may run the 
 course of a progressive muscular atrophy. Buzzard ' mentions an inter- 
 
 ' Brain, p. 121, vol. i. 
 
PERIPHERAL PARALYSIS. 183 
 
 esting- case in which the right hand and the left foot were paralyzed; the 
 supinators were not affected. The faradic excitability of the extensors 
 was lost in the aifected parts, and diminished in the left hand and rig-ht 
 foot; there was increased excitability to galvanism; no blue line on the 
 gums. The diagnosis was chiefly based on the electrical reactions and 
 the freedom of the supinators from paralysis. Careful examination showed 
 that the cistern from which the drinking-water was drawn contained a 
 roll of lead pipe which had been left there while repairs were being made. 
 
 The pathology of lead-paralysis is still very obscure. In cases of 
 chronic lead-poisoning, lead has been found in the brain, cord, muscles, 
 bones, etc., a larger quantity being found in the spinal cord than in the 
 muscles. Hitzig was of the opinion that the paralysis was due to the 
 direct deposit of the metal in the affected muscles, but this view has been 
 successfully combated by Bernhardt, who found that the unaffected su- 
 pinator longus contained proportionally almost the same quantity of lead 
 as the atrophied extensor muscles. 
 
 The anatomical changes in this disease have not been very thor- 
 oughly investigated. Lancereaux reports one case in which the cervical 
 enlargement of the spinal cord presented a soft consistency and was not 
 as large as normally. Some of the nerve-roots springing from this por- 
 tion of the cord were atrophied, and the nerve-fibres had undergone gran- 
 ular degeneration. Vulpian ^ found, in a case of lead-paralysis, marked 
 poliomyelitis with colloid degeneration and atrophy of some of the ganglion 
 cells, an increase in the number of nuclei, and patches of sclerosis in the 
 roots of the cervical enlargement of the spinal cord. C. V. Monakow,' who 
 made an extremely careful examination, corroborates Vulpian's observa- 
 tion in great part. Westphal, Gombault, and Friedlander, on the other 
 hand, found no changes in the spinal cord. Various lesions have been 
 observed in the radial nerve (granular and fatty degeneration, increase 
 of nuclei, etc.), but no definite results have been obtained, and it is unde- 
 cided whether these changes are primary or secondary. Mayor ^ found 
 the following changes in the intramuscular nerves of the extensor com- 
 munis pollicis in a case of lead-paralysis: the myeline in rounded drops; 
 disappearance of the axis cylinders; nuclei of some of the fibres more 
 numerous, with complete disappearance of the myeline; the sheath of 
 Schwann persistent; a large number of the nerve-fibres entirely healthy. 
 
 The paralyzed muscles have been found paler than normal, the trans- 
 verse strife not well marked, and the nuclei of the sarcolemma increased 
 in numbers; there is increase of the interstitial tissue, and a new develop- 
 ment of adipose tissue. 
 
 It is very evident from these manifold changes that pathological anat- 
 omy has not yet determined the real nature of the disease. Hitzig's 
 theory of a local affection of the muscles has been previously referred to, 
 and the weak basis upon which it is founded, pointed out. 
 
 The question as to the peripheral or spinal character of the paralysis 
 is not definitely settled, though there is a strong tendency at present to 
 regard it in the light of an affection of the spinal cord. This view has 
 received additional support from the results of the post-mortem exami- 
 nations made by Vulpian and Monakow, to which we have previously re- 
 ferred. Remak mentions, as one of the strongest arguments in favor of 
 the spinal origin of the affection, the fact that the muscles usuallv in- 
 
 ' Mai. du systems nervenx, 1879, p. 158. ^ j^j.^.^ f_ Psych., 1880. 
 
 ■' Gaz. mt'd. de Paris, 19, 1877. 
 
184 FUNCTIONAL NERVOUS DISEASES. 
 
 volved belong to a single functional group, while the supinator longus, 
 althouo-h it is supplied by the same nerve as the extensors, is not impli- 
 cated except in rare exceptions. It must be remembered, however, that 
 cases have been reported in which the spinal cord presented no changes. 
 
 The theory that the disease is due to an affection of the peripheral 
 nerves is based upon the fact that lesions of the radial nerve have been 
 found, although the spinal cord was intact, and also upon the frequent 
 occurrence of the degeneration-reaction. As we shall see later on, how- 
 ever, this latter phenomenon is not an absolute indication of the peripheral 
 character of the paral3'^sis. 
 
 We must therefore conclude that the true pathology of lead-paraly- 
 sis is still not definitely settled; further investigations may, however, show 
 that the disease is sometimes peripheral, sometimes central in its nature. 
 
 The introduction of arsenic into the system also acts as a cause of 
 paralysis, though much more rarely than lead. Like the latter it may 
 give rise to wrist-drop, due to paralysis cf the extensors with escape of 
 the supinators. Eulenburg has seen several instances of this kind in 
 workers in artificial flowers. My own experience has been exceedingly 
 limited in this respect, the only case of this kind which has come under 
 my own notice being one of paraplegia following acute arsenical poison- 
 ing. As the bladder and rectum were affected in my patient, who is still 
 under observation, I am led to regard the paralysis as probably due to 
 subacute myelitis. The majority of cases of arsenical paral3^sis assume 
 the pai^aplegic form. In those cases in which the paralysis is localized, 
 the symptoms with regard to atrophy of the muscles, electrical reactions, 
 etc., are identical with those observed in lead-palsy. As in the latter 
 disease, also, it is doubtful whether the paralysis is due to a lesion of 
 the peripheral nerves or of the spinal cord, and post-mortem examinations 
 are entirely wanting. 
 
 Mercurial poisoning is rarely a cause of localized paralysis. The 
 long-continued ingestion or inha,lation of mercury gives rise to mer- 
 curial tremor, an affection which is not by any means so frequent now 
 as it was in former times. The limbs which are affected with the tremor 
 are always paretic, and in very exceptional cases the tremor disappears 
 and is replaced by localized paralysis of the muscles. Nothing further is 
 known with regard to the electrical reactions and other phenomena pre- 
 sented in the affected muscles, and the pathology of the affection is equally 
 obscure. 
 
 Ischemic Paralysis. 
 
 A rare but interesting form of disease is that known as ischfemic 
 paralysis, which is due to an interference with the proper supply of arte- 
 rial blood to the affected nerves and nmscies, either from embolism or 
 occlusion of the vessel from the pressure of an aneurism. Very few cases 
 of this character have been observed, and I shall therefore republish the 
 two following examples, the first one being reported by Rosenthal,' the 
 second by Prof. Mannkopf. 
 
 Case III. — "A man, set. 50 years, stated that on October 31, 18G9, 
 he was suddenly seized, while walking, with a violent pain in the left leg, 
 rendering motion impossible, and necessitating the removal of the patient, 
 
 ' Clinical Treatise on Diseases of the Nervous System, p. 422. 
 
PERIPHERAL PARALYSIS. 185 
 
 on the following day, to the Vienna General Hospital. Upon examina- 
 tion, a solid tumor was found in the region of the left obturator foramen, 
 a little larger than a chestnut, pulsating isochronously with the crural 
 artery, and presenting no bruit on auscultation. 
 
 Two days afterward I found the left thigh much colder than the 
 right, the movements of extension scarcely appreciable, and the electro- 
 muscular contractility and sensibility considerably diminished in the ex- 
 tensors of the thigh (upon comparison with the corresponding muscles on 
 the healthy side). Upon November 3d (four days after tlie beginning 
 of the disease), the electro-muscular contractility to faradism was found 
 to be abolished on the anterior surface of the thigh. Gangrene of the 
 limb then set in, followed by chills, and the patient died on November 
 24th. 
 
 Upon autopsy, a sacculated aneurism, as large as a walnut, was found 
 in the neighborhood of the obturator foramen. It originated from the 
 posterior surface of the left crural artery, pushed the vessel upward, and 
 opened into its lumen by an elliptical opening as large as a coffee-bean. 
 The wall of the artery was thickened around this opening, and, on account 
 of the strong tension existing above the neck of the aneurism, the calibre 
 of the artery was narrowed to such an extent that it only permitted the 
 passage of a small-sized sound. The deep femoral artery and the point 
 of emergence of the popliteal artery were obliterated by solid, adherent 
 thrombi.'' 
 
 Case IV. — " The patient was suffering from an attack of acute articular 
 rheumatism, during the course of which an acute pain suddenly devel- 
 oped in the left calf and foot, accompanied by a sensation of cold in this 
 region. Paralysis of motion and sensation developed in the affected 
 parts, and well-marked degeneration-reaction was present in the paralyzed 
 muscles. 
 
 Upon physical examination, mitral insufficiency was found, and there 
 was absence of pulsation in both femoral arteries. 
 
 At the autopsy, fibrinous pJugs were found at the bifurcation of the 
 aorta in the right common iliac and in the left posterior tibial artery. 
 The spinal cord appeared to be intact ; the left tibial nerve, a short dis- 
 tance below its separation from the left peroneal nerve, presented the 
 changes characteristic of parenchymatous and interstitial neuritis ; the 
 muscles were found in a condition of myositis." 
 
 When the occlusion of the artery is not complete, or when the collat- 
 eral circulation is established to a certain extent, the paralysis may be in- 
 termittent in character. 
 
 This was noticed in one of Charcot's patients, in whom paralysis of 
 the right leg occurred from aneurism of the right primary iliac ; the par- 
 alysis always disappeared during repose. 
 
 Physiological experiments have shown that this form of paralysis is 
 due to loss of irritability, occurring first in the nervous structures and 
 then in the muscles, in consequence of the anasmia of these parts. When 
 the abdominal aorta is compressed in animals, paraplegia and anassthesia 
 of the hind limbs is produced. It has been found, in such cases, that 
 the irritability of the spinal cord is very rapidly lost; that of the peripheral 
 nerves in from three-quarters of an hour to an hour after the aorta has 
 been compressed, while the irritability of the muscles persists for a much 
 longer period. 
 
186 FUNCTIONAL NEKVOUS DISEASES. 
 
 Syphilitic Paealtsis. 
 
 In conclusion, we must make a short reference to the influence of 
 syphilis in the production of peripheral paralysis. In very exceptional 
 cases it is said to occur within a short time after the first develop- 
 ment of the syphilitic symptoms, and it is probable that in these cases 
 the paralysis is due to the direct action of the syphilitic virus upon the 
 affected nerves. In the majority of cases, however, syphilitic paralysis 
 occurs in the tertiary stages. It is then due to pressure upon the nerves 
 from adjacent periostitis or exostoses, or to the development of gummata 
 in the nerves themselves. The larger number of these paralyses affect 
 the cerebral nerves, especially those supplying the ocular muscles. Some- 
 times merely a single twig of one of these nerves is implicated, and syphi- 
 litic ptosis (paralysis of the levator palpebrfe superioris) is perhaps one of 
 the most frequent forms of this variety of the disease. Zeissl mentions a 
 case in which a syphilitic exostosis of the greater sciatic foramen pro- 
 duced pressure upon the sciatic nerve and gave rise to paralysis. 
 
 The clinical history of this form is similar to that due to pressure 
 upon the nerves from other causes, and we may therefore refer to the 
 remarks made upon page 166, et seq. Careful examination will, how- 
 ever, usually reveal the existence of other evidences of syphilis, espe- 
 cially in its cerebral forms. We have previously entered so fully into a 
 discussion of these symptoms that it is unnecessary to recur to them at 
 this period. The prognosis of syphilitic peripheral paralysis is usually 
 very good, and the disappearance of the disease under anti-syphilitic 
 measures is an excellent diagnostic sign. 
 
CHAPTER II. 
 
 DIAGNOSIS AND PROGNOSIS. 
 
 The first question to determine is whether the loss of muscular func- 
 tion present in any individual case is really paralytic in its nature. This 
 can only be done by carefully inquiring into the clinical history, and thus 
 excluding those cases in which the loss of motion is due to disease of the 
 muscles, bones, joints, or ligaments. 
 
 Care should also be taken in discriminating between the immobility 
 of a part from loss of power in the muscles, and that occasioned by the 
 production of pain upon movements of the part. This difficulty is fre- 
 quently experienced in severe cases of sciatica, in which the patients are 
 often unable to move the limb on account of the excruciating agony pro- 
 duced by the slightest movement of the parts. 
 
 In infants it is often very difficult to determine the exact location of 
 any paralysis which may be present. This is due to the fact that they 
 are unable to understand our directions, and also because the adipose 
 layer of the skin is frequently so well developed that it hides the pres- 
 ence of muscular atrophy, even though the latter be very considerable 
 in amount. I have very often been unable to detect any difference in 
 the measurements of the limbs in chubby infants, although one of the 
 members was the site of acute infantile paralysis, and the complete loss 
 of power together with the duration of the disease rendered it positive 
 that marked atrophy of the muscles must have occurred. 
 
 If we suspect paralysis of any set of muscles in a child too young 
 to obey our orders, we may often determine its presence by holding a 
 bright object in front of him in such a position that the little patient 
 can only reach it by calling into play the suspected muscles. If this 
 cannot be done by the infant, the position of the object should be changed 
 from time to time, and the movements of the little one in the efforts to 
 reach it carefully watched. Some information may also be obtained by 
 performing various passive movements of the parts, and noting the dif- 
 ferences in the tonicity of the muscles or in the active resistance which is 
 made. 
 
 In some cases of paralysis in infants a mere inspection of the parts 
 will sviffice to make a diagnosis, but in others we must not alone go 
 through all the manipulations mentioned above, but must resort to seve- 
 ral examinations before we arrive at a definite conclusion with regard to 
 the exact location of the disease. I have seen not a few gross mistakes 
 made in the diagnosis of paralysis in children, and I cannot too strongly 
 enjoin the exercise of care and discrimination in the examination of such 
 patients in whom we suspect its presence. 
 
 After having made a diagnosis of paralysis, its character, whether 
 peripheral or central should be then determined. The first inquiry made 
 should be with regard to the cause of the disease. Thus, there can be 
 no question of the character of the affection, if a knife-wound of the 
 
188 PtJNCTlONAL NERVOUS DISEASES. 
 
 ulnar nerve has been followed by paralysis of the corresponding muscles. 
 In very many instances a careful examination into the etiology of the 
 paralysis vv^ill shed full light upon its character, in others no cause can be 
 determined, while in not a few it may have acted upon the central ner- 
 vous system as well as upon the periphery. 
 
 In the majority of cases there are certain distinctive qualities which 
 enable us to distinguish peripheral from central paralysis. In the latter 
 we very rarely find the loss of power limited to a few muscles, and with 
 the exception of the cerebral nerves, the paralysis, as a rule, does not 
 affect an individual nerve, but rather groups of muscles which belong 
 together functionally. In peripheral paralysis, as a matter of course, the 
 loss of power affects those muscles to which the affected nerve is distrib- 
 uted, though, in exceptional cases, the nerve is only partially affected, and 
 only certain of these muscles are involved. In one case, however, which 
 came under my notice, and which I published in the Medical Hecord, Janu- 
 ary 26, 1878, a spinal hemiplegia was, in all probability, due to peripheral 
 causes. This case presents so many points of interest that I shall re- 
 publish it : 
 
 Case V. — Wm. T., fet. 22 years; patient perfectly healthy until 
 March 8, 1876, when he suddenly felt pain in the left shoulder, which soon 
 extended into the other shoulder and into the cervical and upper dorsal 
 regions of the spine; this was attended with strongly-marked torticollis 
 on the left side. The next day, March 9th, he was admitted to Roose- 
 velt Hospital. For permission to publish his history during his stay in 
 that institution, I am indebted to the kindness of Dr. Wm, H. Draper, 
 under whose care the patient was for a part of the time. 
 
 On March 13th a swelling was noticed on the back of the neck, on the 
 left side, and a diagnosis of deep abscess was made. From March 10th' 
 to 20th, the patient's temperature varied irregularly from 100° to 104° F. ; 
 pulse rapid, and an eruption resembling typhoid appeared on the back 
 and chest; he had severe pain in the back and in the left extremi- 
 ties. From March 20th to April 1st, the patient had complete paralysis 
 of the bladder. He now began to suffer from a feeling of " a tight band " 
 around the lower part of the chest; this lasted eight to ten weeks. 
 Paralysis of motion now began to show itself in the left arm, and soon 
 spread to the left leg; there was also some anaesthesia on the left side of 
 the body. At the end of March paralysis was almost complete on the 
 left side. On April 2d the patient began to slowly regain power over 
 the paralyzed parts; the ansesthesia gave way to hypertesthesia. For a 
 week succeeding this date there was intense pain on the left side; the left 
 leg and arm are now slightly contractured; some pain in right arm. Dur- 
 ing the whole illness the temperature did not range above 105°, and was 
 very irregular. 
 
 The patient kept on steadily improving, and was discharged from hos- 
 pital, July 19th. During his sickness he had fibrillary twitchings in 
 the muscles of the left side; was costive from the beginning of the 
 attack; never had headache or other cerebral symptoms; formication 
 and tingling in the left side at times. The patient first came under my 
 own observation about the end of September, 1876. He then had partial 
 left hemiplegia; the left arm and forearm were each half an inch smaller 
 than the corresponding parts on the right side; the movements of the 
 lower limb are much more affected than those of the upper; patient drags 
 the limb very markedly, and must use a cane; he has a feeling of numbness 
 
PERIPHERAL PARALYSIS. 189 
 
 in the adductors of the thigh and flexors of the leg; sensation otherwise 
 normal; reaction of muscles to electricity is normal for both currents. In 
 the left rhomboid minor muscle is found a small, indurated mass, which is 
 very slightly sensitive to pressure. 
 
 The patient was treated by local faradization. About the end of De- 
 cember, 187G, the swelling in the rhomboid muscle became tender; it per- 
 sisted until the middle of January, and then disappeared for a few weeks, 
 to reappear again in various places in the right and left rhomboidei and 
 levatores anguli scapulse. On February 38th he drew my attention 
 to a small abscess situated over the third and fourth dorsal vertebrse; 
 this was opened, and discharged a small amount of thick pus. On March 
 1st a very small piece of bone was discharged through the opening, and 
 the next day the patient entered Bellevue Hospital, where Dr. Jacobi laid 
 open a sinus extending four inches upward along the course of the spi- 
 nous processes; the sinus was probed, but no dead bone was found. On 
 the posterior superior angle of the left scapula I obtained a feeling of 
 crepitus, and the patient winced when this spot was pressed upon. On 
 July 1st he returned to work, feeling quite well. On November 20th he 
 again reported to me with the sinus completely closed, and the swell- 
 ing and induration in the muscle entirely gone; there is still a slight feel- 
 ing of roughness over the posterior superior angle of the scapula. The 
 muscular power on the left side is completely restored. 
 
 The case is evidently one of inflammation within the spinal canal; the 
 exact location of the lesion is a matter of considerable obscurity. In my 
 opinion the diagnosis lies between meningitis spinalis simplex and peripa- 
 chymeningitis spinalis. The latter term implies an inflammation outside 
 of the dura mater of the cord, and any paralysis produced by such a lesion 
 must necessarily be of a peripheral nature. My reasons for adopting the 
 latter view are as follows: 
 
 1. All of the symptoms of the disease can be readily explained on the 
 theory that it was due to a suppurative inflammation in the cellular tissue 
 between the dura mater and the vertebrae. 
 
 2. Some of the characteristic symptoms of meningitis were absent. 
 
 a. There Avere no cerebral symptoms whatever. A case of severe spinal 
 meningitis, especially when the cervical portion of the meninges is affected, 
 without the supervention of any cerebral manifestations, is an exceedingly 
 rare clinical experience. 
 
 b. No tenderness was observed along the spinous processes, and none 
 of the rigidity of the spine so characteristic of spinal meningitis. 
 
 c. There was absence of increased reflex excitability. 
 
 3. Paralysis came on later than is usual in cases of meningitis simplex. 
 
 4. In cases of meningitis, attended with as much paralysis as was pres- 
 ent in this case, there is usually a coexistent myelitis, and recovery is 
 therefore not so complete as in this instance. 
 
 5. If we examine the clinical history carefully we will find that the 
 local symptoms were chiefly confined to the left side of the body. The 
 case was, in reality, a spinal hemplegia, and differs from all others 
 hitherto described in the fact that motion and sensation were affected on 
 the same side. The power of voluntary motion was very much diminished 
 on the affected side, while the disorders of sensation, consisting of formi- 
 cation and tingling, hyperesthesia of the skin, intense pains, and then 
 numbness, were also confined almost exclusively to the left side (with the 
 exception of a certain amount of .pain in tihe right arm during a short 
 period). 
 
190 FUNCTIONAL NERVOUS DISEASES. 
 
 These facts prove conclusively, to my mind, that the diseased process 
 must have produced pressure upon the roots of the nerves on the whole 
 left side of the spinal canal, and while it would be highly improbable 
 that a meningitic process should be limited to the whole length of only 
 one lateral half of the cord, it is readily conceivable that this should take 
 place in the connective tissue surrounding the dura mater, where the dis- 
 ease is not so likely to spread in all directions as on a serous membrane. 
 
 A very interesting question presents itself to our notice when we come 
 to consider the etiology of the affection. Was the inflammatory exuda- 
 tion within the substance of the rhomboid muscle the primary cause of 
 the 23eripachymeningeal inflammation, or was it secondary to this inflam- 
 mation ? 
 
 Although it is impossible to absolutely determine the connection be- 
 tween these two trains of occurrences, I think that the weight of evidence 
 and probability is strongly in favor of the first assumption. 
 
 A review of the biography of the subject will throw some light upon 
 the question. After very diligent search I have been able to find records 
 of only seven cases of this disease,' 
 
 I have found that among the seven cases hitherto reported, five were 
 secondary to inflammation outside of the spinal canal, and two were ap- 
 parently primary. The a priori evidence is, therefore, in favor of the 
 secondary origin of the affection in our case. 
 
 Positive evidence, however, is not wanting to point in the same direc- 
 tion. In the first place, my patient states that he noticed the swelling 
 in the neck on the first day of his admission to Roosevelt Hospital, thus 
 showing that the inflammation in the external tissues was at least coinci- 
 dent, in point of time, with the beginning of the spinal affection, and in 
 all probability antedated it. Secondly, the discharge of a piece of bone 
 from the fistula, together with the fact that I obtained crepitus over the 
 superior posterior angle of the scapula, in the immediate neighborhood of 
 which the swelling first appeared, is quite conclusive to my mind that the 
 morbid process was originally a necrosis of a portion of the scapula, and 
 that the pus, instead of bursting outward, passed inward, through the in- 
 tervertebral foramina, and there set up a suppurative inflammation around 
 the dura mater. 
 
 The occurrence of trophic changes, especially the development of 
 marked atrophy of the muscles, is also a very valuable sign of the periph- 
 eral nature of an attack of paralysis. The only central diseases in which 
 this symptom occurs are acute spinal paralysis of infants and adults (ante- 
 rior poliomyelitis), progressive muscular atrophy, and glosso-labio-laryn- 
 geal (bulbar) paralysis. But these affections are readily distinguished by 
 characteristic symptoms. Acute spinal paralysis frequently begins with 
 fever and symptoms of cerebral or spinal irritation, the paralysis is usually 
 more widespread in the beginning than it is after the lapse of a certain 
 period, and sensory disturbances are generally absent altogether. In pro- 
 gressive muscular atrophy, the course of the disease is slow, the paralysis 
 keeps pace continuously with the atrophy of the muscles, and the latter 
 
 'Mr. John Simon: "Transactions of the London Pathological Society," 1855; 
 Traube : Berlin Medical Society, 1863 (two cases) ; Mannkopf : Berlin Medicinische 
 Wochenschrift, 18G4 ; Mueller: Ueber Peripachymeningitis Spinalis, Koenigsberg-, 
 1868 ; Leyden : Klinik der Rueckenmarkskrankheiten (no autopsy) ; Leyden : Berhn 
 Klin. Wochenschrift, December 17, 1879. 
 
PEKIPHERAL PARALYSIS. 191 
 
 usually pursues a definite course, first affecting certain of the small mus- 
 cles of the hands, then the shoulders or forearms, etc. In this affection, 
 also, sensory disturbances are entirely wanting. In bulbar paralysis the 
 association of facial, glossal, and laryngeal paralysis is so characteristic 
 that the affection cannot readily be mistaken, although a deterniinatinn 
 of the exact location and nature of the primary lesion may be extremely 
 difficult. 
 
 The presence of the degeneration-reaction is another very important 
 sign of peripheral paralysis. This symptom is also observed in the dis- 
 eases which we have mentioned above, with the exception of progressive 
 muscular atrophy. Erb has, however, reported a case of the latter dis- 
 ease in which this symptom was present. Leyden, in his remarks upon 
 the case of multiple neuritis to which we have referred on page 170 
 throws out the suggestion that the degeneration-reaction may only occur 
 in spinal diseases when they are accompanied by descending neuritis, 
 and that Erb's case of progressive muscular atrophy may have been of 
 this kind. However this may be, these diseases of the spinal cord are 
 usually easily recognizable, and we must therefore regard the degenera- 
 tion-reaction as one of the most valuable symptoms of peripheral paral- 
 ysis. 
 
CHAPTER III. 
 
 TREATMENT. 
 
 The therapeutic measures at our command in peripheral paralysis 
 vary with the etiology of the affection, and we shall therefore devote 
 a few words to the treatment of each special variety. 
 
 Acute neuritis, if unchecked, is apt to become chronic, and we should 
 therefore endeavor to cut short the neural inflammation as speedily as 
 possible. One of the main indications is complete rest of the affected part, 
 and when this can be effected in no other way, a splint should be em- 
 ployed. The pain, which is usually intense, may be reKeved by hypoder- 
 mic injections of morphine repeated with sufficient frequency to produce 
 comparative ease. Locally we may employ cold, preferably in the form 
 of an ice-bladder, which is applied continuously (it should not be taken 
 off after a few hours, as the latter plan merely succeeds in increasing 
 the local congestion). Whenever the track of the nerve is swollen and 
 cedematous it is advisable to apply a number of leeches along its course. 
 As soon as the inflammation passes into the chronic stage these meas- 
 ures should be discontinued, as they then become useless. 
 
 In chronic neuritis we have to deal with a very obstinate affection. 
 In this also we should endeavor to secure rest to the parts, though not so 
 complete as in acute neuritis, on account of the long duration of the 
 disease. Counter-irritation often proves very serviceable, especially 
 when there is any tendency to an upward spread of the inflammation. 
 I generally make use of pieces of fly-blister about an inch square, one 
 of which is first applied at the uppermost portion of the nerve, which is 
 found to be tender on pressure. As soon as this begins to heal another 
 square of the blister is applied directly below it, and this plan is con- 
 tinued until the whole course of the nerve has been treated in the same 
 manner. This is very useful in relieving tenderness of the nerve, and it 
 has also seemed to me to be very efficacious in checking the progress of 
 neuritis ascendens. When pain forms a prominent symptom I often re- 
 sort to the actual cautery, applied along the entire length of the affected 
 nerve as far as this is practicable. This measure usually produces con- 
 siderable improvement, but the relief is only temporar}^, as a rule, and 
 the pain soon returns with its former severity. Another excellent palliative 
 is the use of the hot douche. Several pitcherfuls of hot water (as hot 
 as the patient can bear) should be slowly poured upon the affected parts 
 from a height of a couple of feet; this may be done twice a day for sev- 
 eral weeks or even a few months without interruption. This plan is not 
 alone valuable in checking pain, but is also one of the most useful meas- 
 ures at our command for the relief of the contracture of the muscles 
 and the tenderness and partial ankylosis of the joints which are so apt 
 to develop during the course of long-standing neuritis. 
 
 Electricity is also indispensable. The galvanic current should alone 
 
PERIPIIEKAL PARALYSIS. 193 
 
 be used; the anode may be applied over the course of the nerve, and 
 the cathode at some indifferent point farther up the limb; the current 
 should be applied continuously, strong enough to produce decided red- 
 ness of the skin and a smart burning sensation at the situation of the 
 electrodes. The application may be repeated daily or every other day, 
 each sitting lasting four or five minutes. So long as the affected nerve 
 manifests pain and tenderness on pressure the electrical current should 
 only be employed in the manner described. I have seen no good effects 
 under such circumstances from applying electricity directly to the para^ 
 lyzed muscles. The nutritive disturbances in the muscles are due to the 
 condition of the nerves, and we cannot, therefore, hope for much im- 
 provement of the paralysis until the inflammation of the nerves has sub- 
 sided. 
 
 The constant galvanic current is not alone useful in relieving pain 
 and diminishing the severity of the neural inflammation, but also in 
 relieving contracture of the paralyzed muscles. After the neuritis has 
 entirely subsided we may apply the electrical current directly to the 
 paralyzed muscles. In those cases in which the faradic current does not 
 cause contraction of the muscles it is useless to resort to this form of 
 electricity. Galvanism should then be employed, the current being 
 interrupted by means of an "interrupter" in the handle of one elec- 
 trode ; interruption of the current (and therefore contraction of the 
 muscles) may also be obtained by stroking the paralyzed muscles with 
 one electrode, the other being held steadily in one position. The current 
 should be merely strong enough to produce visible muscular contractions, 
 the sittings occurring daily or every other day. When the muscles 
 respond to faradism this current should be employed in preference, the 
 application being made directly over the paralyzed muscles. In severe 
 forms of the disease we must be prepared to exercise great patience, 
 and I have not infrequently employed electricity steadily in these cases 
 for periods varying from six months to a year before any decided im- 
 provement was obtained. 
 
 Passive motion and massage sometimes prove very useful in keeping 
 up the nutrition of the atrophied muscles, in overcoming contracture, 
 and in relieving ankylosis. These latter symptoms may offer some of 
 the most serious obstacles to recovery after the inflammation of the 
 nerve has passed away, and we should therefore direct all our energies 
 toward their removal. 
 
 Very little can be done in chronic neuritis in the way of internal 
 medication. The only internal remedies which I have employed in this 
 affection are iodide of potassium and the fluid extract of ergot, either 
 separately or combined. The doses need not exceed fifteen grains of the 
 former or one drachm of the latter. I am unable to make any positive 
 statements with regard to the efficacy of these drugs, as I have always 
 employed them in combination with some of the measures which have 
 been recommended above. I have often thought, however, that they 
 possess a certain remedial value. No mention has been made of the use 
 of opium in any form to relieve the pain of neuritis, because I am firmly 
 convinced that it should only be employed as a last resort in this 
 disease. 
 
 Any considerable experience with cases of this disease will serve to 
 
 dispel the sanguine expectations which may have been formed with 
 
 regard to the effect of therapeutic measures, but we should not, on the 
 
 other hand, adopt the expectant plan of treatment. The employment of 
 
 13 
 
194 FUNCTIONAL NERVOUS DISEASES. 
 
 persistent and judicious measures will generally produce considerable 
 relief and often furnish very gratifying results. 
 
 When the paralysis is due to compression of the nerves by overlying 
 tumors, exostoses, cicatrices, etc., the pressure may sometimes be relieved 
 by suitable surgical measures. In some cases, as, for instance, when a 
 tumor is directly connected with the tissue of the nerve, it becomes 
 necessary to extirpate a portion of the latter. When the excised por- 
 tion is not too large the cut ends may be brought into coaptation by 
 means of sutures (which are preferably passed through the sheath of the 
 nerve or the connective tissue immediately adjacent), and a proper posi- 
 tion given to the limb. It would appear from the unanimous testimony of 
 surgeons that suture of the nerves will not cause immediate union of the 
 cut ends, though it may hasten regeneration. In cases of this kind 
 considerable room is left for the display of ingenuity on the part of the 
 surgeon, and general rules are of very little value. 
 
 In ischasmic paralysis nothing can be directly done to remove the offend- 
 ing cause, since no internal medication will hasten in the least the ab- 
 sorption of a clot — in reality, a foreign body — in a vessel. The most that 
 can be done in such cases is to keep the parts warm by the application 
 of bottles filled with warm water, or thick rolls of cotton-batting, and to 
 pay careful attention to the general condition of the patient in order to 
 maintain the circulation. The only chance of recovery lies in the pros- 
 pect that the collateral circulation may be re-established with sufficient 
 vigor to nourish the affected nerves and muscles before the structure of 
 the latter has been irreparably impaired. 
 
 The treatment of toxic paralysis turns chiefly upon that of lead pal- 
 sy. The iodide of potassium has been employed in this affection since its 
 introduction by Melsens, but the question of its real utility is still unde- 
 cided. In conformity with the usual practice, however, I have always 
 administered it in small doses in these cases. If it should interfere with 
 digestion it must be discontinued at once, as the disease is usually accom- 
 panied by a certain degree of general cachexia, and nothing should there- 
 fore be done which would interfere in the least with the nutrition of the 
 body. It is unnecessary to state that tonic remedies should be employed 
 to suit the individual case. Warm baths often prove of decided advan- 
 tage in lead paralysis, as they tend to hasten elimination of the poison 
 through the integument. Sulphur baths have also been highly recom- 
 mended for the same purpose, as it was supposed that the lead would 
 combine with the sulphur present in the bath. But this combination 
 could only occur with such portions as had already been excreted, and we 
 therefore believe that the advantage to be derived from a sulphur bath 
 can be obtained with equal readiness from an ordinary warm bath. Elec- 
 tricity also plays an important therapeutical part in the affection under 
 discussion. As a rule, the reaction of the paralyzed muscles to the fara- 
 dic current is diminished, and in severe cases is entirely lost. In these 
 cases the interrupted galvanic current is indicated, the applications be- 
 ing made daily for a period of five to ten minutes. We should not, how- 
 ever, forget to mention that quite a number of cases have been reported 
 in which the persistent application of the faradic current led to recovery, 
 although the paralyzed muscles did not respond, at first, to this current. 
 This is explained by the fact that faradism increases the irritability of a 
 nerve, even when it is insufficient to produce muscular contraction ; this 
 fact has been proven by physiological experiments. We not infrequently 
 observe in lead paralysis that the voluntary power is entirely restored, al- 
 
PEEIPIIERAL PAEALTSIS. 195 
 
 though the electrical reactions of the affected muscles are still below the 
 normal. 
 
 In lead palsy the extensors are kept continuously on the stretch, and 
 this increased tension is an obstacle to the progress of recovery. Various 
 devices have been resorted to in order to overcome this feature, but we 
 shall refer to these measures in the chapter on paralysis of the radial 
 nerve. When very marked atrophy of the muscles has occurred the 
 progress of recovery is usually extremely slow, and in many of these cases 
 a year may elapse before any considerable amount of improvement has oc- 
 curred. In some instances, indeed, the prognosis is extremely unfavor- 
 able, despite the most patient and judicious measures of treatment, and 
 recovery never occurs. Such cases are, however, exceptional. 
 
 Rheumatic paralysis sometimes requires little or no treatment. As 
 we have shown in the course of our remarks on the clinical history of this 
 form of paralysis, the milder varieties may occur spontaneously within a 
 period varying from a few days to two weeks. Of course no treatment 
 whatever is required in these cases. In severe forms, if seen within a few 
 days after the beginning of the paralysis, it is perhaps advisable to apply 
 counter-irritation in the form of a fly-blister, as near the locus morbi as 
 possible, or to place several leeches in the same position. 
 
 Strychnia has been recommended by many authorities in these cases. 
 The high repute of this remedy is undoubtedly due to the fact that it has 
 been frequently employed in those mild forms which recover spontane- 
 ously, and the rapid improvement has then been attributed to the use of 
 the drug. For my own part, I may safely state that I have never seen the 
 slightest good effects from the administration of strychnia in any form of 
 peripheral paralysis. Nor do I well see how it could exert any beneficial 
 action. The effect of strychnia is merely to increase the reflex excitabil- 
 ity of the spinal cord, and physiological experiments have shown that the 
 irritability of the peripheral nerves remains unaffected by its use. 
 
 The good effects of electricity have also been over-estimated, and for 
 the same reason that holds good with regard to the use of strychnia. In 
 severe forms, however, it is the only agent at our command which prom- 
 ises success. The same rules hold good concerning its application as 
 those which we have laid down with regard to lead palsy. In rheumatic 
 paralysis, we should never despair of recovery so long as the slightest 
 muscular reaction is obtained by either current. In fact, improvement 
 may even occur, although the nerves and muscles have ceased entirely to 
 respond to electricity, as I found in one case in which complete recovery 
 was obtained, although all electrical reaction had disappeared for a period 
 of a couple of months. The galvanic current was steadily employed, how- 
 ever, during this entire time, after which faint reactions to this current 
 became apparent. 
 
 The treatment of paralyses following infectious diseases is identical 
 with that of the rheumatic forms. 
 
CHAPTEE lY. 
 
 PARALYSIS OF THE OCULAE MUSCLES. 
 General Remarks. 
 
 We shall devote very little attention to the consideration of paralysis 
 of the ocular muscles, since this affection falls more naturally under the 
 care of the ophthalmologist, and we must therefore refer for fuller details 
 to the standard works on diseases of the eye. 
 
 The slightest amount of paralysis in any of the ocular muscles will 
 give rise to a diminished power of motion of the eyeball in the direction 
 Vi^hich is dominated by the muscle in question. This loss of power gives 
 rise to a diminution of the absolute and of the relative mobility of the globe. 
 The diminution of the former is much slighter than that of the latter, 
 which may be absent altogether when the paresis of the muscle is not 
 well marked. This is due to the fact that in testing the absolute mobil- 
 ity of the eyeball, the paralyzed muscle acts to a certain extent inde- 
 pendently of the corresponding one in the other eye, and as the globe is 
 extremely movable, and very slight force is requisite to turn it in one or 
 the other direction, the affected muscle may be sufficiently innervated by 
 a strong effort of the will to perform the required movement. The dimi- 
 nution of the relative mobility, however, becomes evident even when the 
 muscular paresis is very slight. When the patient is directed to look at 
 an object with both eyes the movements of the globes are always asso- 
 ciated, and the innervation of the paralyzed muscle, as well as its corre- 
 sponding healthy fellow, is equal, and merely sufficient to direct the eye 
 whose muscles are unaffected upon the object. 
 
 The paretic muscle receives an insufficient amount of innervation, and 
 is therefore unable to carry the globe as far as its "fellow. Thus, if we 
 direct a patient whose right external rectus is paralyzed to follow an 
 object, which we hold in the hand, with both eyes, we will find that when 
 the object is held in the right half of the field of vision, it is not followed 
 so far by the right eye as by the left. Upon carefully watching the eye 
 we Vrill also find that the affected muscle appears to act spasmodically, 
 imparting to the eyeball a vibrating movement. In consequence of the 
 insufficiency of the paralyzed muscle, the visual axes of the eyes do not 
 converge upon the object which is looked at, and double vision (diplopia) 
 is therefore the result. This only occurs in that part of the field of vision 
 which is dominated by the paralyzed muscle, and it is also found that the 
 separation of the two images becomes greater, the more the affected mus- 
 cle is brought into play. This is but natural, since the continued move- 
 ment of the normal eye while the affected one remains stationary must 
 result in an increase of the divergence of the visual axes. When the 
 eyes are directed into a portion of the field of vision in which the par- 
 alyzed muscle is not called into play the diplopia disappears. There 
 is, therefore, a distinct portion of the field of vision in which double 
 
PERIPHERAL PARALYSIS. 197 
 
 vision is observed in paralysis of any of the ocular muscles, and a knowl- 
 edge of this fact sometimes enables us to make a diagnosis of paresis of 
 a certain muscle when the loss of power is so slight that it produces no 
 apparent visible effect upon the movements of the globe. The variations 
 in the separation of the two images can be best studied by placing a 
 piece of colored glass before one eye, thus enabling the patient to readily 
 differentiate the images. 
 
 Very frequentl}-, also, the head is placed in a peculiar position in order 
 that the patient may more readily dominate that portion of the field of 
 vision in which the diplopia is not present. This position is also very sig- 
 nificant in making a diagnosis. 
 
 Vertigo is an almost constant concomitant symptom of double vision. 
 It was formerly supposed that this was merely due to the confusion of 
 mind caused by the presence of the two images. J. Hughlings Jackson 
 believes that the vertigo from paralysis of ocular muscles '' is due to a 
 wrong estimation of the position of external objects by the one 63*6 whose 
 muscle is paralyzed." Thus, if the external rectus is paralyzed, the pa- 
 tient imagines that objects in the outer part of the field of vision are sit- 
 uated more to the side than they really are, and if he attempts to seize 
 an object in this position, he will miss it, his hand passing to the outside. 
 This is due to the fact that in the attempt to retain binocular vision, the 
 paralj'zed muscle is innervated more strongly than usual, but without 
 producing an equivalent movement of the globe. The position of objects, 
 however, is determined by experience from the amount of nerve-force 
 which is expended in converging the eyes upon them, and the patient, 
 who expends a large amount of nerve-force upon the paralyzed muscle, 
 therefore thinks that the object is correspondingly far removed from the 
 median line. The apparent motion of surrounding objects which is due 
 to this cause confuses the mind of the patient and gives rise to vertigo. 
 The correctness of this view is substantiated by the fact that the vertigo 
 occurring' in ocular paralysis does not disappear w^hen the healthy eye is 
 closed, but only upon closure of the affected one. After the latter has 
 become accustomed to this condition the vertigo will disappear if the 
 healthy eye be kept continually closed. 
 
 In long-standing paralysis of the ocular muscles contracture of the 
 antagonists is very apt to develop on account of their unopposed action. 
 This condition is always followed by an extension of that portion of the 
 field of vision in which the double images are visible; it also delays the 
 recovery from the paralysis by keeping the paralyzed muscle in a contin- 
 ual state of tension. 
 
 "VYe shall consider separately the clinical history of paralysis of the 
 nerves distributed to the ocular muscles, but the remarks on etiology and 
 treatment will apply equally to all. 
 
 Pakaltsis of the Thikd Nerve. 
 
 The third nerve (motor oculi communis) is distributed to the superior, 
 inferior, and internal recti, the levator palpebraa superioris, inferior ob- 
 lique, the ciliary muscle, and the sphincter of the iris. The paralysis may 
 involve these muscles separately or in combination. In the latter event 
 the symptoms are very characteristic. The paralysis of the levator labii 
 superioris gives rise to drooping of the upper lid (ptosis), so that the e3'e 
 is completely closed, and cannot be opened voluntarily. In some cases. 
 
198 FUNCTIONAL NERVOUS DISEASES. 
 
 however, slight control of the lid is still manifested, but this appears to 
 be due to forced contraction of the corrugator supercilii, which pulls upon 
 the integument, and thus mechanically draws the lid upward. This is 
 readily seen by looking into a mirror and forcibly corrugating the brow; 
 with each movement of the brow, the upper lid will be found to be 
 slightly raised. In complete paralysis of the muscle the patients fre- 
 quently raise the lid with the fingers. The paralysis of the ocular muscles 
 proper causes loss of the power of moving the globe in the directions 
 governed by these muscles. In this case the patient is only capable of 
 turning the eye outward (contraction of the external rectus), and down- 
 ward and outward (contraction of the superior oblique). In fresh 
 cases the antero-posterior axis of the eye is situated in its normal posi- 
 tion, but in old-standing cases contracture of the non-paralyzed external 
 rectus and superior oblique occurs, and the axis of the eye is directed 
 outward and somewhat downward. The paralysis of the muscles also 
 causes slight protrusion of the eyeball, on account of the loss of the 
 tonicity of these muscles, which exercises traction upon the globe, and 
 thus keeps it well within the orbit. When ptosis is present, diplopia 
 does not occur, as a matter of course. But if the levator palpebree is not 
 paralyzed, the diplopia becomes excessively annoying, and is present in 
 all parts of the field of vision except to the outside, and downward and 
 outside. The second image is situated above the first and slightly to the 
 inside, and the distance between the two increases as the object ap- 
 proaches the inner limit of the field of vision. On account of the number 
 of muscles paralyzed the position of all objects except those situated to 
 the outside, and to the outside and downward, is miscalculated, and the 
 patients therefore suffer severely from vertigo, so that frequently they 
 are compelled to walk very slowly. 
 
 The pupil is markedly dilated (mydriasis) on account of the paralysis 
 of the sphincter iridis. Complete dilatation does not occur, and the in- 
 troduction of a solution of atropia into the eye will cause the pupil to 
 dilate still further. The iris does not contract to the stimulus of light, 
 since this act is effected by reflex transmission of an impression upon the 
 optic nerve through the motor oculi communis. Distinct vision is there- 
 fore interfered with to a certain extent, because the dispersion of light 
 upon the retina is not prevented. 
 
 Paralysis of the ciliary muscle causes loss of the power of accommo- 
 dation. This muscle derives its nervous supply from the ophthalmic or 
 ciliary ganglion, the motor root of which is furnished by a branch of the 
 third nerve. The patients are unable to read small print, and the visual 
 limit for near objects is further removed from the eye; vision is unaffected 
 as regards distant objects. 
 
 As we have mentioned in the chapter on etiology, the ciliary muscle 
 may be the only one affected in paralysis after diphtheria. 
 
 When all these symptoms are combined it is impossible to mistake 
 their signification, but a diagnosis sometimes becomes difficult when only 
 a single muscle is paretic. The character of the diplopia varies according 
 to the muscle paralyzed. When the internal rectus is affected the images 
 are placed side by side, the false image being situated to the inside of 
 the true one. When the superior rectus is involved double vision is mani- 
 fested in the upper half of the field of vision — the false image is above 
 and to the outside of the true one. In paralysis of the inferior rectus 
 these conditions are reversed. In paralysis of the inferior oblique muscle 
 the false image would be above the true one, and is slightly inclined from 
 
PERIPHERAL PARALYSIS. 199 
 
 the vertical. It is doubtful, however, "whether this muscle is ever para- 
 lyzed separately. 
 
 These relative positions will vary somewhat when more than one mus- 
 cle is paralyzed, but an accurate knowledge of the action of the ocular 
 muscles will enable us to determine the presence of very slight paresis 
 from the position of the images. Fortunately, however, we are rarely 
 compelled to make a diagnosis in this manner, as the attempt to move the 
 globe in various directions will usually enable us to detect the muscle at 
 fault by mere inspection. 
 
 Pabalysis of the Fourth Nerve. 
 
 The fourth nerve or patheticus is distributed to only a single muscle, 
 viz., the superior oblique. This muscle serves to rotate the eye from 
 without inward, and from below upward, so that the pupil is directed 
 downward and outward. Unless the paralysis is complete, no loss of 
 power in moving the eyeball will be noticeable, as the external and infe- 
 rior rectus perform the work of the affected muscle. The position of the 
 double images is therefore important in making a diagnosis. Diplopia 
 only occurs in the lower half of the field of vision; the images are situ- 
 ated one above the other, the false image being below the true one, and 
 situated obliquely so that its lower end deviates to the outside. The 
 head is usually inclined forward in order to bring objects into the upper 
 half of the field of vision, and thus avoid the development of double im- 
 ages as far as possible. 
 
 Paralysis of the Sixth Nerve. 
 
 Like the fourth nerve, the sixth or motor oculi externus is also distrib- 
 uted to a single muscle, viz., the external rectus. This muscle merely 
 revolves the globe outward, and the effects of its paralysis are very sim- 
 ple. Convergent squint is observed from the unopposed action of the in- 
 ternal rectus, and the eye cannot be turned outward. 
 
 "When the paralysis is slight, strabismus is not present, and the di- 
 minished power of the muscle may only become apparent when an object 
 is brought close to the eye. On account of the paresis of the external 
 rectus, its opponent contracts too strongly, and the eye is therefore re- 
 volved inward. Diplopia occurs in the outer half of the field of vision, 
 the false image being situated to the outside of the true one, and the dis- 
 tance between them increasing as the objects approach the outer limits of 
 the field of vision. The patient therefore imagines objects to be situated 
 to the outside of their true position. 
 
 Etiology. 
 
 In my own experience paralysis of the ocular muscles belongs to the 
 more uncommon varieties of paralysis, but this is probably owing to the 
 fact that the attention of patients is often attracted at first by the diplo- 
 pia, and an ophthalmologist is therefore consulted. The trochlearis nerve 
 is involved much less frequently than either of the others. In paralysis 
 of the motor oculi communis only one or two branches of the nerve are 
 
200 FUNCTIONAL NERVOUS DISEASES. 
 
 usually affected, the entire nerve being less often involved; ptosis is fre- 
 quently the only symptom observed. The paralysis may also affect more 
 than one of the nerves, and sometimes various nerves of both eyes suffer 
 at the same time or in succession. 
 
 The affection is most frequently due to rheumatic causes, such as ex- 
 posure, etc. Patients are, however, very apt to attribute the paralysis to 
 " catching cold," although no definite exposure can be mentioned. 
 
 A considerable contingent of the cases is due to syphilis, which prob- 
 ably gives rise more frequently to parah'sis of the ocular muscles than of 
 any other ; ptosis often develops from this cause. Syphilis may produce 
 lesions of the motor nerves of the eye either wuthin the orbit or in the 
 cranial cavity. In either of these situations it may cause pressure upon 
 the nerves from the development of periostitis, exostoses or gummatous 
 growths growing from the nerves or from adjacent tissues. AVithin the 
 cranial cavity it may also cause pressure upon the nerves by producing 
 pachymeningitis or basilar meningitis wdth subsequent retraction of the 
 tissues. These paralyses, as is evident from the nature of the lesion, 
 occur during the tertiary stage of syphilis. 
 
 A certain proportion of ocular paralyses are due to various forms of 
 traumatism, such as fracture of the skull in its anterior portions, hemor- 
 rhages into the orbit, direct wounds with a knife or other instrument, 
 blows with the fist, etc. A knowledge of the clinical history is always 
 sufficient to enable us to form a correct appreciation of such cases. 
 
 Diphtheria and typhoid fever may also be followed by ocular paralysis, 
 the former often giving rise to uncomplicated paralysis of the ciliary 
 muscle (loss of the power of accommodation). 
 
 Knapp has reported a case of paralysis of all the ocular muscles due 
 to coal-gas poisoning ; this may also be produced by chronic opium- 
 poisoning. 
 
 Various intracranial lesions may give rise to the affection, viz., basilar 
 meningitis, periostitis, and exostoses, tumors growing from the base of 
 the skull, aneurisms of the internal carotids. In some cases tumors of 
 the parenchyma of the anterior portion of the brain may produce peri- 
 pheral paralysis of the motor nerves of the eye by growing downward 
 and thus causing pressure upon the nerves between their exit from the 
 brain and their entrance into the sphenoidal fissure. Tumors of the 
 crura cerebri and pons are also very apt to produce pressure on these 
 nerves. 
 
 DiAG^rosis AND Prognosis. 
 
 In complete paralysis of all the branches of one of the nerves the ap- 
 pearances presented are sufficiently characteristic to enable a diagnosis 
 to be made by mere inspection, except in paralysis of the trochlearis. 
 In this case, and especially when the paralysis is very slight, the diagnosis 
 can only be made with certainty after a careful study of the relative posi- 
 tions of the double images, as we have shown in the remarks on the pre- 
 ceding page. In doubtful cases of paresis of the other nerves this 
 method should also be adopted. 
 
 The mode of development of the paral^'sis will usually enable us to 
 determine its causation. It may be difficult, however, to ascertain the 
 character of the lesion when it is intracranial in its origin. 
 
 In lesions of the base of the brain other cerebral nerves, such as the 
 
PERIPHEEAL PAPwALTSIS. 201 
 
 fifth and seventh, are apt to be implicated, optic neuritis often develops, 
 there is persistent headache, and paralysis of the limbs does not occur 
 until a later period. When the paralysis is due to the presence of tumors 
 growing in the crus cerebri, hemiplegia of motion and sensation occurs, 
 the paralysis of the motor oculi communis occurs on the side opposite to 
 that of the body, and at a later period the opposite third nerve also be- 
 comes affected. 
 
 Temporary paralysis of the ocular muscles may occur in the early 
 stages of locomotor ataxia, and it is very important that its character 
 should be recognized. In such cases careful questioning will usually 
 show that the patient has previously suffered from lancinating pains 
 in the legs, that he finds a little difficulty in walking in the dark, and 
 that there is some numbness in the soles of the feet. The absence of the 
 tendon-reflex, as we have shown previously, is also an important diagnos- 
 tic sign. In addition, one of the pupils may be contracted almost to a pin- 
 point; atrophy of the optic nerves is also noticed at times in the very 
 beginning of the disease. 
 
 The prognosis varies with the nature of the cause. Those varieties 
 which are due to syphilis are usually curable under appropriate treatment, 
 but relapses are not infrequent. Rheumatic cases of recent date also 
 present a favorable prognosis, but the chances of recovery diminish the 
 longer the j^aralysis has lasted; this is especially true of those cases in 
 which contracture of the antagonistic muscles has occurred. 
 
 The paralyses developing after diphtheria and typhoid fever present 
 an excellent prognosis, and recovery often occurs spontaneously. 
 
 When the affection is due to traumatism, hemorrhage, etc., the prog- 
 nosis depends upon the amount of injury which the nerve has sustained, 
 and varies therefore in each individual case. Those forms which are 
 symptomatic of tumors at the base of the brain are, of course, hopeless. 
 
 Treatment. 
 
 The main reliance must be placed on the prolonged use of electricity; 
 it is immaterial which form is employed, some writers preferring the 
 faradic, others the galvanic current. One electrode should be placed 
 upon the corresponding mastoid process or upon the temple, and the other 
 (with a small, olive-shaped tip) upon that portion of the closed lid whicTi 
 is nearest to the insertion of the paralyzed muscle. The ocular electrode 
 is also applied, at times, directly upon the sclerotic coat, close to the in- 
 sertion of the affected muscle. This method is often annoying to the 
 patient, and its advantages do not counterbalance its inconveniences. But 
 with either method of application the current employed should be very 
 mild and never sufficiently intense to give rise to pain. Not infrequently 
 a single application of electricity will suffice to produce a decided and 
 permanent improvement in the power of the muscles. It would seem, in 
 fact, as if the passage of the electrical current through the nerves renders 
 the passage of the stimulus of the will more easy. 
 
 In paralysis of the levator palpebrte superioris, the ptosis may be 
 overcome and the passive elongation of the muscle relieved at the same 
 time by the application of a small bit of rubber which is fastened to the 
 upper lid and forehead by means of a couple of pieces of adhesive plaster. 
 
 The use of prisms, in order to avoid the development of double images, 
 
202 FUXCTIOl^AL NERVOUS DISEASES. 
 
 is not to be recommended, as the separation of the latter varies with the 
 part of the field of vision in which the object is situated. In the second- 
 ary contracture of the antagonist muscles, resort must often be had to 
 suro-ical measures, viz., section of the contractured muscles. 
 
 In those forms which are due to periostitis of the bones of the base of 
 the skull, or to basilar meningitis, some benefit may perhaps be obtained 
 by the long-continued administration of iodide of potassium, and the ap- 
 plication of counter-irritation to the nape of the neck. In tumors of the 
 brain, unless of a specific nature, treatment is of no avail. 
 
CHAPTER V. 
 
 PARALYSIS OF THE NERVE OF MASTICATION. 
 
 (Motor Root of the Fifth.) 
 
 Clinical Histoby. 
 
 This nerve is distributed to the muscles of mastication (temporal, mas- 
 seter, internal and external pterygoid, mylohyoid and digastric), and to the 
 tensor veli palati; it also sends filaments to the buccinator, but these are 
 purely sensory in character, the muscle deriving its motor supply from 
 the facial nerve. The symptoms of paralysis of the nerve of mastication 
 are well shown in the following case which came under my observation, 
 although it was complicated by a lesion of the sensory branches of the 
 trigeminus, and the symptoms of the latter are therefore superadded. 
 
 Case V, — M. E., set. 45 years, married; no history of specific disease; a 
 moderate drinker. The patient had remittent fever six years ago, and 
 has had chills from time to time ever since. Three years ago he began to 
 suffer from pain in the right temple and the right side of the face; the 
 pain extended to the crown of the head, and was very intense from the 
 beginning. For a period of six months the pain was continuous, but 
 since then, although the patient has pain every day, it comes on in par- 
 oxysms lasting three or four minutes, and then disappears for the rest 
 of the day. About a year ago, numbness began to appear in the painful 
 spots and obtained its greatest intensity a week afterward; this has per- 
 sisted ever since. There has been at times a slight purulent discharge 
 from the right ear, and the patient feels easier when this is running; he 
 has not tasted anything on the right side of the tongue since the anaes- 
 thesia appeared in the face. 
 
 Present condition. — There is a depression over the right temple due to 
 atrophy of the temporal muscle. AH the superficial facial muscles on 
 this side act apparently as well as on the other. There is almost com- 
 plete anaesthesia on this side, the anaesthetic zone being bounded ante- 
 riorly by the median line, posteriorly by a line drawn from the front of the 
 ear to the vertex, and below by a line from the front of the ear to the 
 chin, this boundary running a little above the lower border of the jaw. 
 The integument on the right side of the nose, right upper lip, and half of 
 the cheek adjoining is hard, stiff, thickened, and shining. The right ala 
 nasi is drawn upward, thus enlarging the nostril, which bleeds readily 
 when pricked ; the patient cannot taste anything on the anterior half of 
 the right side of the tongue. 
 
 The right lower teeth cannot be carried forward by the patient to a line 
 with the upper row on the right side. When an attempt is made to per- 
 form this movement, the lower jaw projects further forward on the left 
 
204 FUNCTIONAL NERVOUS DISEASES. 
 
 side than it does on the right, moving apparently as if turned on a pivot 
 around the right temporo-maxillary articulation. The jaws cannot be 
 brought firmly against one another on the right side, and the food cannot 
 be chewed on this side. There is no paralysis of the palate or uvula. 
 I am sorry to state that the electrical reactions of the paralyzed muscles 
 ■were not taken, as I only saw the patient once, and he then passed out of 
 my observation. 
 
 The symptoms of this case are readily explained by pressure upon the 
 trunk of the trigeminus, including the sensory as well as the motor 
 branches (probably from periostitis of the petrous portion of the tempo- 
 ral bone). Pressure upon the former accounts for the neuralgic pain, the 
 anjEsthesia and trophic disturbances, w^hile pressure upon the latter ex- 
 plains the motor disorders.' 
 
 Paralysis of the motor root of the trigeminus is usually unilateral, as 
 in the above-mentioned case, but it is bilateral in rare instances. The 
 motor symptoms described above follow naturally from the loss of power 
 in the muscles of mastication. The masseter, temporal, and the two 
 pterygoids combine in the act of raising the lower jaw, and their paraly- 
 sis of course abolishes this mavement on the affected side. Depression 
 of the jaw is chiefly effected by the action of the digastric and mylohyoid 
 muscles, but their unilateral paralysis is insufficient to prevent this move- 
 ment, as the corresponding muscles on the opposite side contract with 
 sufficient vigor to produce depression ; in bilateral paralysis, however, 
 this movement is also abolished. Lateral movements are effected by the 
 alternate action of the pterygoids and the anterior fibres of the temporal 
 and masseter ; these actions are also abolished in this form of paralysis, 
 and the contraction of the corresponding healthy muscles on the opposite 
 side give rise to the peculiar movements which have been described 
 above. As we have previously mentioned, the nerve also sends filaments 
 to the tensor veli palati, but paralysis of this muscle has not been 
 hitherto observed in this affection. 
 
 All the various changes in electrical reactions which we have described 
 as occurring in peripheral paralysis, have been occasionally noticed in the 
 affected muscles in this disease ; very little attention has been devoted, 
 however, to these symptoms. Atrophy of the muscles usually occurs, 
 and that of the temporals can be readily seen upon inspection ; the 
 prominence in the temporal fossa diminishes, and a well-marked depres- 
 sion may even become visible. 
 
 Atrophy of the masseter is also readily recognized by placing one 
 finger in the mouth and another upon the cheek over the position of 
 this muscle, and then making a comparison between the two sides. 
 
 When the motor trigeminal root is alone paral3'zed, the symptoms 
 are restricted to those which we have just described, but some of the 
 other cranial nerves, especially the sensory branches of the fifth, are 
 generally implicated at the same time. The symptoms are then compli- 
 cated with those due to the concomitant affections. 
 
 ' This case is also interesting from a physiological standpoint, as it tends to show 
 that the chorda tympani, which supplies the anterior half of the tongue with the 
 sense of taste, makes its exit from the brain in the course of the trigeminus, as taste 
 was abolished in the distribution of the chorda tympani, although the lesion was un- 
 doubtedly situated in the intra-cranial portion of the trigeminus, and there was no 
 peripheral lesion of the seventh nerve, through which the chorda tympani passes during 
 a part of its course. 
 
PERIPHERAL PARALYSIS. 205 
 
 Etiology. 
 
 This disease is exceedingly rare, especially as a peripheral affection, 
 but it is occasionally met with in alfections of the pons varolii and 
 medulla oblongata. 
 
 The peripheral causes which give rise to it are also usually intra- 
 cranial, and include periostitis and exostoses of the bones at the base of 
 the skull, especially the petrous portion of the temporal, aneurisms of 
 the arteries at the base of the brain, and tumors growing in this reo-ion. 
 Paralysis of this nerve from a lesion involving its extra-cranial course 
 must be extremely rare, as I have not met with any reported cases of 
 this character. This circumstance is due to the deep-seated position 
 which the nerve occupies after its exit from the cranial cavity. 
 
 Diagnosis and Prognosis. 
 
 This affection is not readily mistaken for any other, unless a very 
 careless examination is made. The patient usually complains voluntarily 
 of the disturbance in the process of mastication, and inspection of the 
 parts shows that the corresponding muscles are incapable of performinc 
 their functions. The peculiar position of the lower jaw when the patient 
 is directed to move it from side to side or antero-posteriorly, is a pathog- 
 nomonic sign. 
 
 The prognosis as regards recovery from the paralysis is bad in all 
 cases ; the prognosis as regards life depends upon the character of the 
 primary lesion, whether it is continually progressive, like a tumor or 
 aneurism, or whether its further progress may cease, like that of an 
 exostosis or periostitis. 
 
 Treatment. 
 
 Very little can be done in this direction. "When we suspect that the 
 disease is due to periostitis of the temporal bone, some benefit may 
 perhaps be derived from counter-irritation over the mastoid process, and 
 the internal administration of iodide of potassium. The employment of 
 electricity has also been advised, that current being employed to which 
 the muscles respond most readily. The current must be applied directly 
 to the muscles, as the nerve is so deeply situated that it is not easily 
 reached. 
 
CHAPTER YI. 
 
 FACIAL PARALYSIS. 
 
 Clinical History. 
 
 Facial paralysis * is one of the most interesting, as well as the most 
 frequent of all forms of peripheral paralysis. It is unilateral in the large 
 majority of cases, but in exceptional instances it affects both seventh 
 nerves, and is then sometimes known as diplegia facialis. It may develop 
 suddenly, as when the paralysis immediately follows exposure to a draught,, 
 or occurs very gradually, as in some cases which are due to pressure on 
 the nerve from a slowly growing tumor, etc. At the onset of the disease, 
 the patients, being misled by the appearance of the parts, often believe 
 that the face is swollen, and are astonished upon being informed of the 
 true condition. When the paralysis is complete, the appearances pre- 
 sented are very characteristic, and cannot be mistaken for any other con- 
 dition. The wrinkles in the forehead on the paralyzed side disappear, the 
 eye is widely open and staring, the naso-labiai fold is effaced, the ala 
 nasi is in closer approximation to the septum of the nose than on the 
 healthy side, the angle of the mouth droops and is nearer to the median 
 line than normal. The contrast between the paralyzed and healthy sides 
 of the face becomes much more marked when the patient attempts to 
 perform voluntary facial movements. The paralyzed side then remains 
 motionless, like a mask, and the healthy side becomes distorted, as those 
 muscles which are inserted into the angle of the mouth draw it over to 
 the normal side because- they are unopposed by their antagonists. The 
 eye remains widely open during sleep as well as in the waking condition. 
 When the patient makes a vigorous effort to close the lids the eyeball is 
 rolled upward and slightly inward until the lower border of the cornea is 
 
 ' After emerging from the lateral tract of the medulla oblongata at the lower bor- 
 der of the pons varolii, the seventh nerve passes into the internal auditory canal, and 
 then through the Fallopian canal. It emerges at the stylo-mastoid foramen, im- 
 mediately beneath the lobe of the ear, passes downward and then forward to spread 
 over the surface of the face. At the first bend (genu) which the nerve makes in the 
 Fallopian canal is situated a gangliforra enlargement known as the ganglion genicula- 
 tum. I'rom this enlargement emerges the petrosus superficialis major nerve which 
 goes forward to enter the nasal ganglion, after which it passes downward to supply 
 the levator palati, and perhaps other_ muscles of the velum palati and uvula. It is 
 also supposed that the fibres of the chorda tympani pass through the petrosus super- 
 ficialis major to enter the ganglion geniculatum, after which they pursue the same 
 course as the other fibres of the seventh. The next motor-branch is a small twig which 
 supplies the stapedius muscle. Then the chorda tympani is given off and joins the 
 lingual branch of the trigeminus ; it is the nerve of taste which supplies the anterior 
 third or half of the tongue. At the exit of the nerve from the stylo-mastoid foramen, 
 it gives off the posterior auricular branch, which supplies the muscles of the ear. The 
 nerve then divides into its terminal branches, which supply all the muscles of expres- 
 Bion and one muscle of mastication, viz. : the buccinator ; it also sends filaments to 
 the stylo-hyoid, digastric and stylo -glossus muscles. 
 
PERIPHERAL PARALYSIS. 207 
 
 on a level with the upper lid. During this attempt the upper lid also 
 becomes slightly lowered, but the mechanism of this action is not clearly 
 understood; it has been supposed that the levator palpebrai superioris, 
 the unopposed action of which causes the lids to be continually open, be- 
 comes relaxed during the effort to close the eye. Epiphora, or overflow 
 of tears, is a constant symptom in this condition. This is due to the fact 
 that on account of the paralysis of the lower segment of the orbicularis 
 palpebra?rum, especially that portion known as Horner's muscle, the 
 lower lachrymal point is not kept applied against the eyeball, and the 
 tears are not able, therefore, to escape by the usual channel; overflow 
 then occurs as a natural consequence. On account of the exposed con- 
 dition of the globe of the eye, and the inability to wash away foreign 
 particles by the act of winking, a certain amount of conjunctival irrita- 
 tion is usually present, unless precautions are adopted to shield the 
 eye. A few cases have been reported in which opacity and ulceration 
 of the cornea, etc., occurred, as in cases of severe disease of the trigemi- 
 nus, but it is extremely questionable whether these symptoms were the 
 result of facial paralysis. The speech of the patient is indistinct on ac- 
 count of his inability to close the lips properly; the imperfection is 
 therefore chiefly noticeable in the pronunciation of labials. He is also 
 unable to whistle, purse the lips, etc., and, in infants, suckling is inter- 
 fered with; when an attempt is made to distend the cheeks the air es- 
 capes through the unclosed angle of the mouth on the paralyzed side, 
 and the cheek flaps as if it were perfectly limp. One of the muscles of 
 mastication, viz. : the buccinator, is also supplied by the facial, and its 
 paralysis therefore interferes to a certain extent with this function. The 
 flaccid condition of this muscle prevents the cheek from being closely ap- 
 plied against the teeth and alveolar processes, and particles of food, there- 
 fore, slip in between the teeth and cheek and must often be removed from 
 this position by the aid of the finger. 
 
 Some observers state that the tongue deviates to one side when pro- 
 truded, but this statement is based on an error of observation. The angle 
 of the mouth on the paralyzed side is nearer to the median line than on 
 the sound side, and the tip of the tongue therefore approaches the for- 
 mer. The absence of deviation of the tongue is one of the differential 
 signs between peripheral and cerebral facial paralysis. 
 
 In the majority of cases, the uvula and velum palati are not involved, 
 but exceptionally they are also paralyzed on the affected side. The para- 
 lyzed half of the velum hangs lower than on the healthy side, and does 
 not contract so readily during phonation; its reflex excitability is also 
 impaired and may be entirely wanting. When the azygos uvuloe muscle 
 is affected, deviation of the uvula occurs; the tip has been found de- 
 flected sometimes toward the paralyzed, sometimes toward the healthy 
 side. But certain sources of error should be excluded before making a 
 diagnosis of paralysis of the uvula and velum palati. In the first place, 
 one pillar of the fauces may normally hang lower than its fellow, and 
 thus simulate paralysis; but, in such a case, its curve is found to be 
 sharply defined, and upon irritating the fauces with any foreign substance, 
 it will draw up as forcibly as the opposite one. The uvula also is not 
 unfrequently deflected in health; in some cases, also, when it is long and 
 pendulous, as after any pharyngeal inflammation, it will topple over to- 
 ward that side to which the face happens to be turned, and may thus simu- 
 late paralysis. I saw this mistake made by a distinguished physician of 
 this city, in a case in which the prognosis depended very considerably upon 
 
208 FUNCTIONAL TirERYOUS DISEASES. 
 
 the occurrence of this symptom, as indicative of the peripheral nature 
 of the affection. Paralysis of the velum palati is supposed to be due to 
 implication of the nervus petrosus superficialis major, vphich passes from 
 the sranglion geniculatum of the seventh nerve to the spheno-palatine or 
 Meckel's ganglion, and thence to the levator palati and probably other 
 muscles of the velum palati. But this question in physiology is still not 
 definitely settled. 
 
 The special senses may also be affected as the result of this dis- 
 ease. Thus, the sense of smell is very often less acute in the nostril of 
 the paralyzed side, though this is not due to any specific influence of the 
 seventh nerve upon the function of smell; its causes are purely mechani- 
 cal. In the first place, the cessation of the respiratory movements of the 
 ala nasi and the closer application of the ala to the septum of the nose, 
 prevents the introduction of the proper quantity of air, and therefore of 
 a sufficient number of odoriferous particles. Furthermore, the paralysis 
 of the orbicularis palpebrarum and the consequent epiphora result in an 
 insufficient flow of tears through the nasal duct, and then over the 
 Schneiderian membrane. The latter therefore becomes dry and the ter- 
 minal filaments of the olfactory nerve are, accordingly, not in the proper 
 condition to receive odoriferous impressions. 
 
 The sense of taste is also impaired, at times, and the majority of 
 authors agree in the statement that this symptom is quite rare. My own 
 experience has been different, and I have found, after examining a con- 
 siderable number of patients, that a certain diminution in the sense of 
 taste is present in quite a large proportion of cases taken indiscriminate- 
 1}^ Upon testing with various sapid substances, a diminution in the 
 sense of taste will be noticed on the anterior third of the tongue on the 
 affected side. This examination must be conducted carefully, as the 
 patients are apt to give misleading statements. In more exceptional 
 cases, they state that they have various curious subjective sensations of 
 taste in the above-mentioned portion of the tongue. All the symptoms 
 are due to an implication of the chorda tympani (which is contained in the 
 trunk of the seventh nerve during a part of its course) in the primary lesion. 
 
 The sense of hearing sometimes presents peculiar disturbances. We 
 do not now refer to those cases in which the paralysis is secondary to a 
 disease of the ear, and in which the auditory phenomena are merely symp- 
 tomatic of an organic affection. The phenomena in question consist of 
 a disagreeable sensation within the ear, which is experienced whenever 
 the patient hears sounds of any considerable intensity; auditory hyperass- 
 thesia is also present, and is characterized by an increased perception of 
 very high and very low notes. These symptoms were first noticed by 
 Roux upon himself, while suffering from facial paralysis, and have been 
 since confirmed by other observers. Wolff has applied to this condition 
 the term oxyokoia. 
 
 These symptoms are attributed to paralysis of the stapedius muscle, 
 which is supplied by a small twig passing off from the facial nerve during 
 its course through the Fallopian canal; the paralysis of this muscle causes 
 increased tension of the membrana tympani on account of the unopposed 
 action of the tensor tympani. 
 
 The secretion of saliva on the affected side is usually diminished, and 
 the mucous membrane of the mouth is therefore drier than on the oppo- 
 site side. Physiological experiments have rendered it probable that the 
 chorda tympani nerve sends secretory fibres to the submaxillary and sub- 
 lingual glands, and it is supposed that the irritation of these fibres causes 
 
PERIPIIERAL PARALYSIS. 209 
 
 a diminution of the salivary secretion. There is no doubt, however, that 
 the increased dryness of the mouth on the affected side is partly due to 
 the fact that the mouth cannot be completely closed upon that side, and 
 that the consequent exposure to the air causes an increased evaporation 
 of fluid. 
 
 The electrical reactions of the paralyzed muscles vary according to the 
 severity of the paralysis. It was in this affection that the degeneration 
 reaction was first observed by Baierlacher. In the most severe cases the 
 irritability of the nerves rapidly diminishes after a few days, and is soon 
 entirely lost to both the faradic and galvanic currents (in some cases it is 
 slightly increased for the first few days). Within a few days the farado- 
 muscular excitability begins to diminish, grows gradually less, and within 
 two or three weeks has entirely disappeared. The galvano-muscular ex- 
 citability is undisturbed for the first few days, and then begins to increase 
 so that finally the muscles react to a very mild current. The difference 
 between the contractions of the healthy and paralyzed muscles can be very 
 beautifully shown in this affection. If one electrode is placed at some in- 
 different spot, such as the nape of the neck, and the other over the median 
 line, upon the forehead or chin, so that the electrode covers muscles on 
 both sides of the face, and a mild current is allowed to pass, it will be 
 found that the healthy muscles remain quiet while the paralyzed ones 
 contract vigorously. 
 
 Thus, the affected muscles may react to two cells although it re- 
 quires ten or twelve to produce any response from the healthy ones. 
 After a variable duration of the degeneration-reaction, lasting from a few 
 weeks to several months, it usually begins to disappear, and as the nor- 
 mal galvanic reactions reappear, the farado-muscular contractility also 
 redevelops, and increases until recovery occurs. The irritability of the 
 nerves now also reappears, first to the galvanic and later to the fara- 
 dic current. Cases of this character usually last at least six months, and 
 often as long as a year, or even more. It is also not very infrequent to 
 find that voluntary power is completely restored, although the electrical 
 irritability of the nerves and muscles is still below the normal. 
 
 As the severity of the paralysis varies, in different cases, we may no- 
 tice all the various forms of changed electrical reactions which we have 
 previously described. The extent of the deviation of these reactions 
 from the normal is usually a good indication of the probable duration of 
 the disease. Those in which the reactions are normal or are only some- 
 what diminished in quantity, not in quality, will probably recover within 
 a couple of weeks. In exceptional cases, however, these reactions per- 
 sist for several months, and the disease may run a tedious course. Fi- 
 nally, Brenner has reported cases in which the irritability of the nerves 
 to both currents is heightened for several weeks. It is also stated that 
 electrization of the healthy muscles will sometimes give rise to contraction 
 of the paralyzed ones; this may, however, be due to diffusion of the cur- 
 rent. In cases of long standing, and in all incurable cases, the muscles, 
 and apparently also the skin, undergo a certain amount of atrophy. 
 This is frequently so slight that careful scrutiny is necessary to detect it. 
 The entire paralyzed side of the face appears to be smaller than the un- 
 affected, the bones are more prominent, and the integument appears to be 
 thinner. This is not pathognomonic of a peripheral affection, as I have 
 sometimes observed the same condition in facial hemiplegia, which was 
 undoubtedly due to a cerebral lesion acquired in early life. In cerebral 
 facial paralysis of adults these changes are never observed. 
 14 
 
210 FUNCTIONAL NERVOUS DISEASES. 
 
 Sensory disturbances are extremely rare in the disease under considera- 
 tion, and their occurrence has been disputed. I have noticed, however, in 
 a few severe cases of rlieuinatic facial paralysis that the patients complain- 
 ed of numbness of the cheek, and have found that tactile sensation was 
 not as distinct as on the opposite side, though no change could be detect- 
 ed with the aesthesiometer. These symptoms are undoubtedly due to 
 implication of some of the recurrent fibres of the trigeminus by the pri- 
 mary lesion. 
 
 An interesting, though infrequent, feature of facial paralysis is the 
 occurrence of spasms and contractures in the affected muscles. The 
 spasms may be either of a tonic or clonic character, and are usually the 
 precursors of contracture. 
 
 The muscular spasms generally affect only a few muscles at a time, 
 and may occur spontaneously or during mental emotion, attempted volun- 
 tary action, etc. They are not infrequently accompanied by increased 
 mechanical irritability of the parts. When the spasmodic movements 
 are well marked and general, they simulate facial tic. 
 
 Contracture of the paralyzed muscles is generally preceded, as we have 
 stated above, by tonic or clonic spasms. Duchenne * states that the 
 rapid development of tonicity in a completely paralyzed muscle which has 
 lost its faradic excitability, is an indication that it will become contrac- 
 tured at a later period. Either a single muscle or the entire group of facial 
 muscles may be affected. When all are involved, the eye appears slightly 
 smaller than its fellow, the ala nasi is drawn upward, the naso-labial fold is 
 deeper and higher than the one on the normal side, the upper lip is drawn 
 upward and a little outward, so that a portion of the teeth is continually 
 exposed, and the lower lip is everted. These changes are not so general, of 
 course, when only a few muscles are contractured. In the larger number 
 of cases the affected muscles are also subject to tonic or clonic spasms. 
 This condition not infrequently leads to mistakes in diagnosis, since, at first 
 sight, the deepening of the naso-labial fold on the affected side may lead 
 to the suspicion that the opposite side is paralyzed. I remember a case 
 in which a well-known neurologist of this city fell into this error and mis- 
 took a paralysis of the left lower facial muscles for an affection of the 
 right side. At first sight I was also of the opinion that the affection was 
 on the right half of the face, but upon asking the patient to move the 
 muscles, I found that those on the right side could be contracted with 
 perfect facility, while those on the left, and apparently healthy side, were 
 immovable. Upon questioning the patient as to the history of the dis- 
 ease, it became evident that the left half of the face had been at first com- 
 pletely paralyzed, and that contracture developed at a later period. 
 Trousseau also mentions a case of this kind, in which the paralysis was 
 supposed to be on the healthy side of the face by several medical men 
 who had seen the patient. Careful examination of the motility of 
 both halves of the face will, however, always enable us to make a cor- 
 rect diagnosis with regard to the seat of the disease. The contracture 
 of the muscles is probably due to atrophy of the muscular fibres and to 
 retraction of the newly formed interstitial connective tissue, which thus 
 causes shortening. If this process ceases before it becomes excessive, it 
 may entirely overcome the deformity caused by the paralysis, so that no 
 difference is observed in the two halves of the face unless the movements 
 of the healthy side are very marked. 
 
 ' Electrisation localisee. 
 
PERIPHERAL PARALYSIS. 211 
 
 Double facial paralysis (diplegia facialis) is extremely rare as a peri- 
 pheral affection, though it is not very uncommon as the result of central 
 diseases. But, as we shall see in the chapter on diagnosis, the latter 
 usually affect only the lower facial muscles. The appearances presented 
 in diplegia facialis are very striking. All expression, except that of the 
 eyes, is lost; the natural folds and wrinkles of the face are entirely 
 effaced. The lower lip droops and the saliva dribbles down the chin. 
 The eyes' are widely open and staring, and remain so even during sleep. 
 Though the patient laugh ever so heartily, the features remain perfectly 
 immovable. The disturbances of speech are much more marked than in 
 unilateral paralysis, and the interference with deglutition is also very 
 annoying on account of the passage of food between the cheeks and 
 teeth. The electrical reactions vary in no respect from those observed 
 in like cases of unilateral paralysis. The duration and course of the 
 disease is also entirely similar to those already described in the unilateral 
 variety. 
 
 Etiology. 
 
 The majority of cases of this disease are due to so-called rheumatic 
 causes. They occur from exposure to a draught and sometimes while 
 merely working or playing in the open air. The paralysis develops imme- 
 diately after the exposure, or a period of one or two days may elapse; in 
 all cases, it attains its greatest severity within a short period after its in- 
 ception. A considerable proportion of these cases are attended with loss 
 of taste in the anterior third of the tongue on the affected side; the velum 
 palati and uvula are, however, rarely implicated. It is presumed that in 
 this form a certain degree of neuritis develops in that portion of the facial 
 nerve which passes through the Fallopian canal, and that the severity of 
 the paralysis varies with the amount of plastic exudation into the tissue 
 of the nerve. 
 
 Light forms of facial paralysis may disappear in from twelve to 
 twenty-four hours, and it is extremely improbable that any inflammatory 
 exudation could be absorbed in this short space of time. We are there- 
 fore led to suppose that a simple congestion of the nerve may give rise 
 to temporary loss of power. 
 
 Inflammatory diseases of the middle ear or carious or necrotic proces- 
 ses of the petrous portion of the temporal bone in the neighborhood of 
 the Fallopian canal also act as frequent causes of the disease. In such 
 cases the paralysis usually develops slowly, one twig of the nerve being 
 affected after the other. In some of these cases it is probable that the 
 paralysis is due to a direct spread of the inflammation from the middle ear 
 to the adjacent nerve, giving rise to various grades of neuritis or perineu- 
 ritis. In the milder forms, it is probable, as in mild rheumatic paralysis, 
 that there is simple congestion of the nerve. The sense of taste is fre- 
 quently implicated in facial paralysis from ear disease, but the velum 
 palati and uvula are rarely, if ever involved. Disturbances of hearing due 
 to the primary aural disease are, of course, always present; but, in addi- 
 tion, the hyperakusis which was described on page 208, is often noticeable. 
 
 Quite a number of cases are due to a lesion of the nerve after its exit 
 from the stylo-mastoid foramen. This category includes direct injury to 
 the nerve by a knife or bullet wound, blow upon the face with the fist, a 
 stone, etc., compression of the nerve by the forceps during delivery, the 
 spread of inflammation from abscesses of the parotid gland, implication 
 
212 l^UNCTIOFAL NERVOUS DISEASES. 
 
 of the nerve in new-growths developing in the gland or in the adjacent 
 tissues, division of the nerve by the knife of the surgeon in opening ab- 
 scesses, extirpating tumors, etc. A characteristic phenomenon in this 
 variety of the disease is the fact that only a few of the muscles are usually 
 involved, and even when all are affected, the paralysis travels gradually 
 from one muscle to the other. This is due to the anatomical arrangement 
 of the nerve-fibres after their exit from the stylo-mastoid foramen, the 
 nerves spreading out and becoming separated from one another. The 
 paralysis is usually severe, the muscles undergo atrophy, present the degen- 
 eration-reaction, and often remain paralyzed irremediably; contracture of 
 the affected muscles is not an infrequent result. The chorda tympani is 
 not involved in this variety, and implication of the velum palati and uvula 
 is also absent. Paralysis from pressure of the forceps during delivery was 
 first described by Osiander and Landouzy. When the infant is quiet, it is 
 very difficult and often impossible to detect any paralysis, as the natural 
 folds of the face are very poorly marked in the young. As soon as the 
 child begins to cry, however, the immobility of the paralyzed side and the 
 consequent deformity become very distinct. The affection is usually mild 
 and recovers spontaneously within a few weeks. 
 
 Intracranial diseases may also produce peripheral paralysis of the sev- 
 enth nerve; we exclude from this variety all those cases which are due 
 to an affection of the central nervous system. This category includes 
 basilar meningitis, the exudation in which produces pressure and atrophy 
 of the nerve, periostitis of the petrous portion of the temporal bone, ex- 
 ostoses and tumors growing from the base of the skull, aneurisms of the 
 vessels at the base of the brain. The nerve is paralyzed, in these cases, 
 in its entire distribution. It appears, however, from the history of re- 
 ported cases (and I can substantiate this by my own experience in several 
 cases) that the sense of taste is not impaired. This fact seems to in- 
 dicate that the chorda tympani does not leave the brain with the seventh 
 nerve, but enters the latter in some of the numerous anastomoses which 
 it forms with the trigeminus, giosso-pharyngeal and vagus. It is charac- 
 teristic of this variety of facial paralysis that it is always attended with 
 paralysis of some of the other cranial nerves, or perhaps with irregularity 
 of the pupils, double vision, amaurosis, headache, and later with paralysis 
 of the limbs. The electrical reactions of the muscles vary with the se- 
 verity of the disease, and present as many variations as are produced in 
 the rheumatic form. Like the paralysis produced by middle-ear trouble, 
 this variety is also produced slowly, as a rule, the loss of power gradually 
 deepening, and one mmscle sometimes becoming affected after the other. 
 The disease is naturally very chronic, its recovery depending upon the 
 curability of the primary disease. 
 
 Syphilis generally gives rise to peripheral facial paralysis by producing 
 lesions similar to those of the intracranial diseases mentioned above. 
 Thus, it may produce periostitis, exostoses, gummata, or chronic basilar 
 meningitis. In rare instances the syphilitic lesions are situated along 
 the course of the nerve through the Fallopian canal, or even after its exit 
 from the stylo-mastoid foramen. The paralysis is general (affecting all 
 branches of the nerve) and usually develops slowly. The disease gener- 
 ally disappears promptly under appropriate treatment. 
 
 Finally, we must refer to the development of peripheral facial paraly- 
 sis as a sequela of certain of the infectious diseases (diphtheria, variola, 
 scarlatina). These cases are very rare, and their clinical history differs in 
 no respect from that described on page 178. 
 
PERIPHERAL PARALYSIS. 213 
 
 Diplegia facialis results most frequently from some affection at the 
 base of the brain which gives rise to pressure on both seventh nerves at 
 their exit from the lower border of the pons (basilar meningitis, tumor). 
 It may also be produced by an injury which has given rise to an extrava- 
 sation of blood into each middle ear, or by the presence of double otitis 
 media. A few cases have also been reported in which it was of a purely 
 rheumatic origin, the paralyses usually developing at an interval of a 
 couple of days. In still another series of cases the affection may have a 
 different origin on the two sides. Thus, it may be due to middle-ear dis- 
 ease on one side, and be of a rheumatic character on the other, etc. 
 
 Diagnosis and Prognosis. 
 
 The diagnosis of facial paralysis is extremely simple; in addition to 
 noting the absence of the naso-labial fold and the wrinkles on the fore- 
 head, the drooping of the angle of the mouth, it is merely necessary to 
 direct the patient to laugh, when the characteristic deformity will imme- 
 diately appear. In those cases in which contracture of the muscles has 
 occurred, and the folds of the face have therefore been restored, we must, 
 in addition to making a careful inspection of the parts, obtain a history 
 of the beginning of the affection and of the appearances then presented. 
 The exercise of a moderate amount of care in the examination will always 
 enable us to avoid making a mistake in these cases (vide page 210.) 
 
 After having made a diagnosis of paralysis, we must determine whether 
 it is of peripheral or central origin. The history of the case is of great 
 importance in this respect. The fact that the affection developed after 
 exposure to a well-defined peripheral cause (exposure, blow, etc.), its 
 occurrence without any cerebral symptoms or without the presence of 
 paralysis in any other portion of the body, the implication of the orbicularis 
 palpebrierum, occipito-frontalis and corrugator supercilii, diminution in 
 the electrical reactions of the nerves and muscles, and, not infrequently, 
 the presence of the degeneration-reaction, the disturbance of taste in the 
 distribution of the chorda tympani (anterior third of tongue), the paraly- 
 sis of the velum palati and uvula — all these symptoms are valuable indica- 
 tions of the peripheral nature of the affection. But certain central 
 paralyses of the seventh nerve, due to affections of the pons varolii, are 
 differentiated with great difficulty from the peripheral forms. Tumors, 
 hemorrhages, abscesses, etc., of the pons varolii may be symptomatized 
 by facial paralysis, in which all the facial muscles are affected, as in the or- 
 dinary peripheral variety, and in which the electrical reactions correspond 
 to those observed in the latter. Two cases of this kind are reported by 
 Rosenthal.' As a rule, however, some of the other cranial nerves are 
 implicated either simultaneously with the facial or after a variable period, 
 and, in addition, the limbs become paralyzed on the side of the body op- 
 posite to the paralysis (crossed paralysis). 
 
 The peculiar anatomical arrangement of the seventh nerve and its 
 branches enables us, in very many instances, to determine the exact site 
 of the lesion which has given rise to the affection. 
 
 When the lesion is situated between the exit of the seventh nerve 
 from the brain and the ganglion geniculatum, the paralysis involves all 
 the facial muscles, the velum palati and uvula are implicated, but the 
 
 > Clinical Treatise on Diseases of the Nervous System, pp. 126 and 127. 
 
214 FUNCTIONAL NERVOUS DISEASES. 
 
 sense of taste is not affected; the disturbances of audition (oxyokoioa) to 
 ■which we have previously referred are also present. The absence of any 
 disturbance of taste appears to corroborate the theory of Schiff, v\^ho 
 states that the chorda tympani enters the seventh nerve in the petrosus 
 snperficialis major, and any lesion situated above the genu would there- 
 fore not interfere with gustation. If the lesion is situated between the 
 ganglion geniculatum and the point at which the chorda tympani leaves 
 the Fallopian canal, the symptoms will vary slightly from those described 
 above. The velum palati and uvula will be unaffected; there will be an 
 interference with gustation, however, in the anterior third or half of the 
 tongue on the paralyzed side. When the lesion is outside of the Fallo- 
 pian canal, the only symptoms present are those dependent on paralysis 
 of all the facial muscles; in such cases there is no interference with any 
 of the special senses. 
 
 In addition to determining the seat of the lesion, we should also en- 
 deavor to ascertain its nature. This is usually done with readiness, and 
 is determined by a knowledge of the history of the case and of the pre- 
 existing diseases from which the patient has suffered. Caution must be 
 exercised, however, in pronouncing the affection of a syphilitic nature, as 
 there is a tendency to consider all nervous diseases as syphilitic which 
 occur in a patient who suffers from this affection. It is therefore well to 
 exclude all other causes before attributing the paralysis to syphilis. 
 
 The prognosis depends, of course, upon the nature of the cause. 
 When it is due to some irremediable organic lesion, the paralysis will not 
 disappear, and will usually be followed by atrophy and contracture of the 
 muscles. The electrical reactions of the nerves and muscles are a valua- 
 ble indication of the probable duration of the disease, as we have shown at 
 length in our general remarks on peripheral paralysis. But even in those 
 cases in which the electro-muscular contractility to both currents has en- 
 tirely disappeared, we should not abandon all hope of final recovery, as a 
 case of this kind has come under my notice in which persevering treat- 
 ment led to a favorable termination. 
 
 Teeatment. 
 
 In syphilitic facial paralysis, the use of anti-syphilitic remedies alone 
 is sufficient, in the majority of cases, to cure the disease. In those rare 
 forms which occur in the early secondary stage, mercurials are indi- 
 cated ; in the commdner varieties, due to tertiary lesions, the mixed 
 treatment should be employed. The iodide of potassium, as we have so 
 frequently insisted, should be administered in continually increasing 
 doses until the desired effect is produced. 
 
 When the disease is due to otitis media or some other affection of the 
 middle ear, the chief attention should be devoted to the treatment of the 
 latter. Great importance must be attached to the frequent use of mild 
 injections into the ear, the treatment of any pharyngeal catarrh which 
 may be present, etc., etc. For further details on this subject we must 
 refer to the text-books on otology. This variety of paralysis is usually 
 very chronic, and electrical treatment, employed in the manner which we 
 shall describe later on, becomes very important. 
 
 Surgical measures become necessary where the affection is due to the 
 presence of abscesses, tumors, etc., in the vicinity of the nerve after its 
 exit from the stylo-mastoid foramen. No general advice can be given with 
 
PERIPHERAL PARALYSIS. 215 
 
 regard to the treatment of this form, as everything depends upon tlie pecu- 
 liarities of the individual case. When resort is had to the knife, however, 
 the incisions should be as small and superficial as possible, in order to ob- 
 viate division of the nerve, regeneration of which does not readily occur 
 in this situation. 
 
 In some forms of rheumatic paralysis no treatment is required, as the 
 affection disappears spontaneously within a period of one or two weeks ; 
 tlie majority of cases, however, demand careful attention. Within the 
 first few days it is advisable to place two or three leeches behind the ear 
 and then apply a blister over the mastoid process. It is doubtful, how- 
 ever, whether any decided benefit is obtained from these measures. The 
 use of strychnia is also recommended, but I have never seen the slightest 
 advantage from its administration, and have long since discontinued this 
 remedy. It is advisable to keep the eye covered with a shade in order 
 to prevent irritation from foreign particles. This simple measure often 
 prevents serious annoyance from this cause. 
 
 Practically, our only resource consists in the application of elec- 
 tricity. When the muscles react to faradism, this current should be 
 used in preference, an ordinary electrode being placed over the mastoid 
 process, and the other smaller one (about the size of a five-cent piece), 
 being placed over the various paralyzed muscles. The current should 
 merely be strong enough to produce visible muscular contractions, and 
 three sittings weekly, of four to five minutes' duration, are amply suffi- 
 cient. In milder cases, or when recovery is almost complete, the nerves 
 also react to faradism ; in this event, one electrode is placed in the mas- 
 toid fossa, and the other is slowly passed up and down the face in a line 
 passing from a point a little behind the outer angle of the eye to the 
 angle of the jaw. In this manner all the branches of the nerve are sub- 
 jected to the action of the current. When the nerves are insensible to 
 faradism but react to galvanism, the latter current should be employed 
 in the same manner, the positive electrode being placed in the mastoid 
 fossa and the negative passed over the trunks of the nerves. When the 
 electrode is moved to and fro in this way, it is unnecessary to inter- 
 rupt the current, as the mere passage of the electrode over the muscles 
 suffices for this purpose. When the muscles alone react to galvanism, 
 the positive pole is retained in the mastoid fossa, the negative being 
 placed over the individual muscles (vide Fig. 1). In this case it is neces- 
 sary to interrupt the current, and this is readily effected by pressing upon 
 an interrupter placed in the handle of one of the electrodes. Here, again, 
 it is merely requisite to obtain a visible muscular contraction. Even when 
 the electrical irritability of the nerves and muscles is entirely abolished, 
 treatment should be steadily continued unless the nature of the cause of 
 the paralysis precludes the possibility of recovery. It is preferable, in 
 these cases, to employ the uninterrupted constant current through the 
 nerves, and the sittings may be held daily. 
 
 Dr. Seguin' has described an intra-buccal method of applying elec- 
 4;ricity to the lower facial muscles. The electrode " consists of an ordi- 
 nary interrupting handle, armed with a rod-like electrode of moderate 
 length, bent at a right angle near its extremity, and terminating in a ball 
 five millimetres in diameter. The whole of the rod or stem, except the 
 ball, should be completely insulated." This may be used upon all the 
 lovver facial muscles, the ball being placed on the buccal mucous mem- 
 
 ' Archives of Medicine, Feb., 1880. 
 
216 FUJJ^CTIONAL NERVOUS DISEASES. 
 
 brane at parts corresponding to the motor points externally. Dr. Seguin 
 claims to be thus able "in the stage of recovery of rheumatic facial 
 paralysis, to obtain distinct contractions with faradism when the strong- 
 est currents which could be tolerated on the skin of the face did not 
 produce them." 
 
 It is held that the slow progress of recovery in many cases of facial 
 paralysis, as in various other peripheral paralyses, is very materially , 
 retarded and often entirely stopped on account of the elongation of the 
 muscles, which is caused by the unopposed contraction of the antago- 
 nists. Various devices have been suggested in order to overcome this 
 feature. The most effective is one recommended by Dr. Van Bibber of 
 Baltimore, who advises the following plan : a metallic hook is introduced 
 into the angle of the mouth, and ia connected with a piece of india rub- 
 ber which is fastened around the ear. By means of this the desirable 
 amount of traction can be exercised upon the angle of the mouth and 
 the elongation of the muscles thus obviated. 
 
 The treatment of facial paralysis following acute infectious diseases 
 is identical with that of the rheumatic forms. Various measures have 
 been recommended in the treatment of contracture of the affected 
 muscles, none of which, however, offer much chance of success ; these 
 include galvanization of the contractured muscles, the application of 
 faradism to the antagonistic healthy ones, mechanical elongation of the 
 affected parts by stretching them with the fingers, or keeping a rubber 
 ball in the cheek, and even incision of the muscles. The latter plan 
 should not be adopted under any circumstances, as it will only serve to 
 increase the deformity after reunion of the divided parts has occurred. 
 
PERIPHERAL PARALYSIS. 
 
 217 
 
 CoTTugator snpercilii- 
 
 Compressor nasi 
 Orbicularis palpebrsemm 
 Levator labii sup. alseque. 
 
 nasi. 
 Levator labii sup. proprius- 
 Zygomatic. minor 
 
 Dilator narium , „ 
 
 I post. 
 
 Zygomatic, major 
 
 Orbicularis oris 
 
 Frontal muscle. 
 
 Attrahens & attolens aurem. 
 
 Retrahens aurem. 
 
 Occipital mu'scle. 
 Facial nerve. 
 Posterior auricular nerve. , 
 
 branches of the faciaL 
 
 N. to Irianga^larifi & lev. menti 
 Levator menti 
 Qnadratus 
 Triangulari: 
 
 Cervical branches of facial- 
 nerve. 
 
 utan. branch of inf. maxillary. 
 Spinal accessory nerve. 
 Branch to stemo- mastoid. 
 Branch to trapezius. 
 
 Stemo-mastoid. 
 Levator anguli scapulae. 
 
 •Phrenic nerve. 
 
 Posterior thoracic nerve 
 (serratus magnus). 
 
 Axillary nerve. 
 
 PlO. 1. — Motor points of the face, showing the position of the electrodes in electrization of the facial 
 nerve and muBcles. The anode is placed in the mastoid fossa, and the cathode upon the part indicated ia 
 the figure. 
 
CHAPTEE YII. 
 
 PAEALYSIS OF TKE SPINAL ACCESSORY.' 
 Clinical Histoet. 
 
 This form of paralysis is extremely rare, but the symptoms produced 
 are very characteristic, and agree in all respects with those observed after 
 extirpation of the nerve in physiological experiments. The external or 
 muscular branch is much more frequently affected than the internal. 
 Paralysis of the former nerve gives rise to partial loss of power in the 
 sterno-cleido-mastoid and trapezius. 
 
 When the former muscle is paralyzed, the head is drawn by the unop- 
 posed action of the corresponding healthy one in such a manner that 
 the mastoid process on the unaffected side is brought closer to the sternum 
 and the chin is carried horizontally toward the paralyzed side. If con- 
 tracture of the healthy sterno-mastoid develops (and this may occur after 
 the paralysis has lasted for a long time), the head is permanently fixed in 
 this abnormal position. When atrophj* of the muscle occurs, the normal 
 protrusion of its belly is lost, and the diminution in size can also be ap- 
 preciated by rolling it between the fingers and comparing it with the 
 healthy one. The power of flexing the head and at the same time ap- 
 proximating the chin to the opposite shoulder is lost. Paralysis of the 
 trapezius, when accompanied by atrophy, may also be visible to the naked 
 eye upon comparing the muscle with its fellow, especially when the pa- 
 tient is directed to elevate both shoulders. The scapula is lower upon 
 the paralyzed than upon the healthy side, and its posterior border is 
 drawn farther away from the spine on account of the unopposed action of 
 the serratus magnus. The elevation of the shoulder is diminished though 
 not entirely prevented, as the levator anguli scapulse and rhomboidei are 
 brought more vigorously into play, and thus partially supply the deficiency 
 of the trapezius. In addition, the power of raising the arm above the hor- 
 izontal is somewhat impaired, as the trapezius aids the serratus magnus 
 in this action by the contraction of its anterior fibres which elevate the 
 acromial end of the scapula. As in paralysis of the sterno-cleido-mas- 
 toid, the antagonist muscle (in this case the serratus magnus) may be- 
 come contractured, and this will result in drawing the scapula perma- 
 nently downward and away from the spinal column. 
 
 More commonly the external branch of the spinal accessory is alone 
 affected; at times, however, the internal anastomotic branch is also in- 
 
 ' The spinal accessory nerve divides into two branches, the internal or anastomotic, 
 and the external or muscular. The I'ormer passes to the pneumojjastric. and supp'.ies 
 some of the muscles of the velum palati, the coastrictors of the pharynx, and all the 
 muscles of the Inryux which are concerned in phonation ; this branch also possesses 
 an inhibitory influence upon the heart. The external branch is distributed to the 
 Bterno-cleido-mastoid and trapezius, but these muscles also receive a portion of their 
 nerve-supply from the two up2>er cervical nerves. 
 
PEEIPHEKAL PAEALTSIS. 219 
 
 volved. On account of the fact that the innervation of these muscles is 
 derived from various sources, it is sometimes found that the muscles are 
 not paralyzed in their entirety, but that only a few bundles are affected. 
 
 The electrical reactions have not been inquired into very thoroughly, 
 but in most of the cases in which attention has been paid to this point, 
 thev were simply diminished, Erb reports a case, however, in which the 
 degeneration-reaction was present. Lesion of the internal branch of the 
 spinal accessory gives rise to paralysis of the velum palati, the muscles 
 of the pharynx, and those muscles of the larynx which are engaged in 
 phonation. In paralysis of both nerves, the velum palati has been found 
 completely motionless; the voice in consequence has a nasal twang, and 
 fluids are apt to regurgitate through the nose. The loss of power in the 
 constrictors of the pharynx causes difficulty in swallowing, the food " sticks 
 in the throat," and the patient exerts unusual effort in forcing it down- 
 ward. Unilateral paralysis of the muscles of the larynx causes hoarse- 
 ness and huskiness of the voice, which is not as loud as usual; upon ex- 
 amination with the laryngoscope, the vocal cord on the affected side is 
 found to be motionless during an attempt at articulation, while that of 
 the opposite side often passes beyond the median line. When both vocal 
 cords are paralyzed, complete aphonia is produced. The incomplete 
 closure of the glottis often allows particles of food to enter the larynx, 
 and thus gives rise to paroxysms of cough. 
 
 The spinal accessory nerve also possesses an inhibitory influence upon 
 the action of the heart, but no effect is produced upon the character of 
 the pulse when only one nerve is affected; when both are involved, the 
 pulse may be increased in frequency. The following case, which was re- 
 ported in detail by Seeligmueller, ' illustrates most of the symptoms to 
 which we have referred. 
 
 Case VL — Amelia F., jet. 24 years; the patient was healthy until nine 
 years ago, at which time she was compelled to carry very hea'^^y vessels of 
 water upon the back. These often spilled, the water running down the 
 neck and back. Shortly afterward, cough and pain developed on the right 
 side. At the same time the neck became very much swollen on both sides, 
 and the patient experienced considerable difficulty in swallowing; the lat- 
 ter symptom did not disappear after the swelling had subsided, and was 
 therefore unconnected with it. The solid food frequently " stuck in the 
 throat," and fluids were regurgitated through the nose. The patient ex- 
 perienced a certain amount of difficulty in speaking, and the respiration 
 was stertorous. Four years ago the preceding symptoms became compli- 
 cated with gradually increasing weakness of the left arm. About the 
 same time the patient noticed bilateral atrophy in the region of the neck. 
 
 Present condition. — Upon inspection, the facial muscles appear nor- 
 mal and can be well contracted. The uvula is not in the median line, 
 but is deflected considerably toward the right side, so that the right arch 
 of the palate is much narrower and hig'her than that on the left side; the 
 velum palati and uvula remain motionless when irritated or when an at- 
 tempt is made at phonation. Upon laryngoscopic examination, the rima 
 glottidis is found to be widely opened, and the vocal cords do not change 
 their position during respiration or when the patient is directed to artic- 
 ulate. 
 
 The sterno-cleido-mastoids are markedly atrophied, but unequally in 
 
 1 Arch, t Psych. Bd. ni., p. 433. 
 
220 FUNCTIONAL NERVOUS DISEASES. 
 
 different portions of the muscles; the bundles which are inserted into the 
 clavicles are very much atrophied, while those inserted into the sternum are 
 somewhat better developed. The clavicular portion of the trapezius has 
 entirely disappeared on the left side, but is retained on the right; the re- 
 maining portions of the trapezius are moderately atrophied on both sides. 
 The temperature is normal, but the pulse is somewhat accelerated (ninety 
 per minute). 
 
 The left arm is paralyzed; the deltoid muscle is very markedly atro- 
 phied, and the other muscles of the limb are also considerably reduced in 
 size. 
 
 This case was probably due to a chronic inflammatory process which 
 began around the medulla, compressing the bulbar origin of the spinal 
 accessory nerves, and then spread downward, involving the spinal roots 
 of origin of both nerves, and then also affecting the origin of the left bra- 
 chial plexus. In a somewhat similar case which came under my own 
 notice, and which was due to an injury to the back of the neck, only the 
 spinal roots of the accessory nerves were affected. This was shown by 
 the fact that the patient could swallow normally and the muscles of the 
 larynx were also in a normal condition. Both sterno-cleido-mastoids were 
 very markedly atrophied, especially those portions which are inserted into 
 the clavicle; the sternal bundles of fibres were also considerably smaller 
 than usual, and the functions of the muscles were correspondingly lost. 
 The trapezii were also very much atrophied, and the power of elevating 
 the shoulders diminished. On the left side, which was more severely af- 
 fected, the scapula was lower than on the right side, its posterior border 
 was further removed from the spinal column, and the arm could not be 
 raised to the vertical position. 
 
 Etiology. 
 
 Paralysis of the external branch of the nerve is not very infrequent, 
 and may be due to a great variety of causes; paralysis of both branches, 
 however, is extremely rare. The latter variety may be due to tumors of 
 the posterior cerebral fossa, exostoses in this region, or exposure to a 
 draught, as in a case reported by Fraenkel.' Paralysis of the external 
 branch may be caused by blows upon the neck, wounds of various kinds, 
 exposure, pressure of tumors or enlarged glands, and neuritis. It also 
 occurs not infrequently during the course of progressive muscular atrophy. 
 The latter disease is usually regarded as a central process (degeneration of 
 the anterior horns of the spinal column) but within the last two or three 
 years considerable doubt has been cast upon this view of its pathology, 
 and well-known authorities are accepting the doctrine that certa n forms, 
 at least, must be regarded as peripheral in their nature. 
 
 Diagnosis and Prognosis. 
 
 "When the velum palati, constrictors of the pharynx and laryngeal 
 muscles of phonation are paralyzed, there can be no doubt with regard to 
 the affected nerve, as the spinal accessory alone supplies these parts (with 
 
 ' BerL Klin. Wschrft. I. 1876. 
 
PEPaPHEllAL PARALYSIS. 221 
 
 the exception of the velum palati which is also innervated through other 
 paths). Paralysis of the sterno-cleido-mastoid and trapezius muscles is, 
 however, not infrequently mistaken for other affections. Paralysis of 
 the sterno-mastoid may be mistaken for torticollis or spasmodic contrac- 
 tion of the opposite sterno-mastoid. In the paralytic affection, however, 
 the head can be easily restored to its natural position ; in addition, the 
 atrophy of the muscle is usually distinctly perceptible to sight as well as 
 to touch. After the loss of power has lasted for a long time, contracture 
 of the opposite muscle may occur, and a correct diagnosis can only be 
 made, in such cases, from a knowledge of the previous clinical history. 
 Paralysis of the trapezius is most apt to be mistaken for contracture of the 
 serratus magnus, as this will also interfere with the elevation of the 
 shoulder, and will cause the scapula to be depressed and removed from the 
 spinal column. This affection can be readily excluded by the fact that 
 the scapula can be freely moved in all directions by the hand of the phy- 
 sician. Inspection of the parts will often, also, show atrophy of the mus- 
 cle when it is compared with the opposite side. 
 
 Paralysis of the internal branch of the nerve usually presents a very 
 unfavorable prognosis, as the disease, under such circumstances, is due to 
 intracranial or intraspinal processes, which are generally of an incurable 
 character. Fraenkel's patient, in whom the disease was due to rheumatic 
 influences (exposure to a draught), made an excellent recovery. 
 
 In paralysis of the external branch the prognosis varies with the etiol- 
 ogy. In the rheumatic forms, which are perhaps the most frequent, the 
 chances of recovery are usually good. If the disease has lasted for a long 
 time, however, and is complicated by contracture of the opposing mus- 
 cles, treatment generally proves unavailing. Those cases which are due 
 to injury, neuritis, or the pressure of enlarged glands, may also recover 
 under appropriate treatment, though improvement usually occurs slowly. 
 When the paralysis is caused by compression of the nerve by means of a 
 tumor, the disease may be relieved if the tumor is situated in such a po- 
 sition that it can be removed by surgical measures. 
 
 Treatment. 
 
 In all cases, electricity constitutes the chief and sometimes the only 
 plan of treatment. Either the faradic or galvanic current may be em- 
 ployed according as the muscles respond to one or the other. The deep 
 position of the internal branch of the nerve as well as of the muscles sup- 
 plied by it (velum palati, pharynx, and larynx) prevents the direct appli- 
 cation of the current to this portion of the nerve. The electrodes are 
 therefore best applied upon each side of the neck, underneath the angle 
 of the jaw in order to influence the muscles of the velum or pharynx, 
 and upon each side of the larynx to affect the muscles of the latter. 
 Faradization of the sterno-mastoid and trapezius can be readily performed 
 by placing one electrode over the origin of the muscles and stroking va- 
 rious portions of the bodies of the muscles with the other. 
 
 In applying the galvanic current to the sterno-mastoids one electrode 
 should be placed over the anterior border of the sterno-mastoid about an 
 inch below the lobe of the ear, and the other at the lower border; to gal- 
 vanize the trapezius, one electrode is placed over the entrance of the 
 nerve into the muscle (at its anterior border, half-way between the occi- 
 put and clavicle), and the other over that portion in which we desire to 
 
222 FUI^CTIOITAL NERVOUS DISEASES. 
 
 produce contraction. When we have reason to suspect a chronic inflam- 
 matory process around the spinal roots of origin or compression of the 
 trunk of the nerve by an enlarged gland, counter-irritation by means of 
 fly-blisters or compound tincture of iodine may prove of service. Treat- 
 ment is usually of no avail when the paralysis is due to an intracranial 
 or intraspinal affection. 
 
 When contracture of the opposite sterno-mastoid, or of the serratus 
 magnus occurs, improvement may perhaps be obtained by the steady use 
 of the continuous galvanic current through the contractured muscles. If 
 no relief is obtained in this manner, the former condition may some- 
 times be relieved by tenotomy of the muscle, and the subsequent ap- 
 plication of an orthopaedic apparatus to the head in order to prevent a 
 re-development of the contracture. 
 
CHAPTER YIIL 
 
 PARALYSIS OF THE HYPOGLOSSUS.i 
 Clinical History. 
 
 Paralysis of the tongue is not an infrequent complication of the 
 most varied central diseases, but it is extremely rare as a peripheral 
 aSection. • The latter may be due to the pressure of tumors growing 
 from the medulla (in which event the paralysis may be bilateral), to a 
 gunshot wound of the neck, or to injury of the nerve during various 
 operations in this region. 
 
 In unilateral paralysis of the tongue, the organ when protruded from 
 the mouth, is deflected toward the paralyzed side on account of the un- 
 opposed action of the normal genio-glossus muscle. The lateral move- 
 ments (toward the affected side) are also seriously interfered with or 
 completely abolished. After the paralysis has lasted for a certain length 
 of time, the affected half of the tongue is found to be smaller than the 
 opposite side, the mucous membrane covering it looks wrinkled, and fibril- 
 lary contractions may be visible underneath the surface. When the 
 paralysis is bilateral, the tongue lies in the floor of the mouth and cannot 
 be moved in any direction. In such cases, there is marked disturbance 
 of the functions of mastication and articulation. The former is inter- 
 fered with because the alimentary bolus cannot be readily moved from 
 one side of the mouth to the other by the contractions of the tongue 
 muscles; in addition, the bolus is not forced properly into the fauces nor 
 can the tongue be contracted in such a manner as to separate the buccal 
 cavity from that of the pharynx; in the act of deglutition, therefore, some 
 of the food will regurgitate into the mouth. The articulation of linouals 
 may be entirely abolished, and indeed the pronunciation of all the letters 
 of the alphabet is usually impaired to a certain extent. These disturb- 
 ances are naturally greater when the paralysis is bilateral and complete, 
 and in such cases it is almost impossible to understand a single word 
 uttered by the patient. 
 
 In pure examples of hypoglossal paralysis, there are no disturbances 
 of taste or sensation in the tongue. 
 
 The following illustrative case is taken from Weir Mitchell's work on 
 "Injuries of Nerves." 
 
 " Alonzo B. Rogers, a colored lad, aged nineteen, was admitted into 
 the Pennsylvania Hospital, November 24, 1871, suffering from a gunshot 
 wound of the neck. The ball entered the left side of the neck, one and 
 a half inch behind and a little below the angle of the jaw. 
 
 ' This nerve is distributed to all of the muscles in the infra-hyoid region, which 
 depress the larynx and the hyoid bone after the passage of the alimentary bolus 
 through the pharynx ; to one of the muscles in the supra-hyoid region, the genio- 
 hyoid ; to most of the muscles which move the tongue ; and to the muscular fibres of 
 the tongue itself. 
 
224 FUNCTIOIS'AL NERVOUS DISEASES. 
 
 "The tongue was found paralj^zed on the left side as regards motion, 
 but not sensation. When protruded, it turned toward the left or wound- 
 ed side, and could not be held against the upper lip without the aid of 
 the under. When the tip was pressed against the roof of the mouth, it 
 turned toward the left side. The patient could readily press the tip 
 against any point on the right side of the mouth, but on the left the at- 
 tempt was attended with difficulty. There was no trouble in swallowing, 
 but the patient thought he could not articulate as distinctly as formerly. 
 
 *' Sensation was not at all impaired. Several tests were made at dif- 
 ferent times, but the result was always the same. The right side of the 
 tongue readily responded to the electric current, the wounded side did 
 not, but seemed the more sensitive under the current. The wounded 
 side of the tongue was notably atrophied before the patient was dis- 
 charged. Several attempts were made to find the bullet, but all were 
 unsuccessful. The wound healed without any difficulty, and the patient 
 left December 12, 1871, the paralysis continuing unaltered." 
 
 Diagnosis. 
 
 The diagnosis of paralysis of the hypoglossus is readily made from a 
 mere inspection of the parts upon directing the patient to move the 
 tongue in various directions. It is sometimes difficult to determine 
 whether the paralysis is of a peripheral or central nature. The most im- 
 portant points in this respect are the etiology of the affection (whether 
 the lesion is situated in the course of the nerve after its exit from the 
 skull) and the implication or non-implication of other nerves, or of one 
 or more limbs. The hypoglossi are affected in glosso-labio-laryngeal pa- 
 ralysis, but this disease runs such a typical course that it is impossible to 
 make a mistake. The prognosis is usually very poor as regards recov- 
 ery of the paralysis. When the disease is due to an intracranial process, 
 whether central or peripheral, death generally results on account of the 
 secondary implication of other of the bulbar nerves. 
 
 Treatment. 
 
 Electrical treatment offers the only chance of success, that current 
 being employed to which tlie muscles respond most readily. The elec- 
 trodes may be applied directly to the tongue itself, although this is very 
 inconvenient, or one pole is placed above the cornu of the hyoid bone 
 above which the hypoglossal nerve is found in its passage to the tongue. 
 
CHAPTER IX. 
 
 PARALYSIS OF THE SERRATUS JLVGNUS. 
 
 Clinical Histoky, 
 
 The paralysis of this muscle, which is supplied by the posterior tho- 
 racic nerve' (external respiratory nerve of Bell) is extremely inteiesting- 
 on account of the peculiar deformity to which it gives rise. Quite an 
 extensive journal literature has been published on the subject, but the 
 question as to the real cause of the deformity still remains undecided. 
 The paralysis is of comparatively rare occurrence, and is usually unilat- 
 eral, the large majority of cases having been observed upon the right 
 side. A good idea of the usual course of the disease may be formed 
 from the following history of a case under my observation : 
 
 Case VI. — Annie B., ret. 20 years, a servant by occupation; no his- 
 tory of traumatism, though she has been in tlie habit of lifting heavy 
 weights; no history of syphilis. About four months ago the patient 
 began to suffer from intense darting pains along the outer side of the 
 riglit arm; these continued for two weeks and were uniformly worse at 
 night; prior to the appearance of the pains in the arm, she also suffered 
 intensely in the anterior part of the right thigh, but these pains only 
 lasted for a few hours. There was no history of any previous exposure. 
 After the neuralgic pains in the arm had lasted for two weeks, she lost 
 the power of raising the arm into a vertical position. Two months later, 
 her friends noticed that the shoulder-blade projected very markedly on 
 the right side, though the patient, who is rather stupid, had been unaware 
 of this fact. 
 
 Upon inspection, the patient's hands being held loosely at her sides, 
 very little deviation from the normal can be observed. Upon carefully' 
 comparing both scapulae, however, the inferior angle on the right side is 
 found to be somewhat nearer to the spinal column than on the left; the 
 posterior border is slightly deflected, the upper jiortion being- farther re- 
 moved from the spinal column than the lower part; the lower angle of 
 the scapula projects very slightly from the wall of the chest; these changes 
 are so slight that they can only be noticed on close observation. When 
 the patient endeavors to raise the arm, the peculiar " angel-wing " de- 
 
 ' The posterior thoracic arises from the fifth and sixth cervical nerves, passes down 
 in front of the scalenus medius muscle, and then along the lateral aspect of the 
 thorax to supply the serratus magnus. The nerve can be most easily reached a little 
 above the clavicle at the posterior border of the sterno-cleido-mastoid. The serratus 
 magnus " arises by nine fleshy di.Liitatious from the outer surface and upper border of 
 the eight upper ribs and from the aponeurosis covering the upper intercostal spaces, 
 and is inserted into the whole length of the inner margin of the posterior border of the 
 scapula. " 
 
 15 
 
226 FUNCTIONAL NERVOUS DISEASES. 
 
 formity starts out in bold relief, and the arm can only be raised to the 
 horizontal position. At the same time that this is done, the posterior 
 border of the scapula begins to move away from the walls of the chest, 
 and when the arm has been raised to the horizontal, the separation of the 
 scapula is so great that almost the entire fist can be introduced between 
 the anterior surface of the bone and the chest-walls. The faradic reac- 
 tion of the paralyzed muscle was entirely lost in the beginning, and the 
 galvanic excitability was very markedly diminished. The latter current 
 %vas steadily employed, and the patient advised to exercise the muscle. 
 Within two months recovery had made considerable progress, and when 
 the patient ceased her attendance at the clinic, the cure was practically 
 complete. She again called, after an interval of a couple of months, to 
 report herself entirely well. 
 
 The paralysis is very often preceded by neuralgic pains in the arm or 
 shoulder, and sometimes by anesthesia or hyperesthesia in these regions. 
 It develops slowly, as a rule, though such a long interval as was appar- 
 ently present in the case reported above, between the beginning of the 
 affection (neuralgic pain) and the production of the paralysis, is very un- 
 usual. Not infrequently other muscles are also affected, such as the in- 
 fraspinatus, supraspinatus, trapezius, levator anguli scapulae. The reason 
 for this combination will become evident when we consider the etiology 
 of the disease. 
 
 In lon^- standing cases, atrophy of the muscle can be detected if we 
 direct the patient to raise both arms, and carefully compare the appear- 
 ances presented at the upper and lateral portions of the thorax. If the 
 panniculus adiposus is not too thick, the digitations of the muscle at 
 their origin from the ribs will be found much smaller on the affected 
 side. The electrical reactions to both currents are simply diminished in 
 the majority of cases, though the degeneration-reaction has also been 
 observed. 
 
 There ^s a difference of opinion with regard to the position of the 
 scapula when the arm is held loosely at the side. Some maintain that no 
 deformity whatever is perceptible under these circumstances, while the 
 majority of observers mention the appearances noted in the case which I 
 have reported above, viz., a closer approximation of the lower angle of 
 the scapula to the spinal column, a change in the direction of the posterior 
 border of the scapula from vertical to upward and outward, and slight 
 separation of the lower angle of the bone from the walls of the thorax. 
 In the few cases which have come under my notice, these appearances 
 have always been presented. According to Berger, these changes in the 
 position of the bone are due to the unopposed action of the trapezius, the 
 levator anguli scapulas and the rhomboidei muscles. The angel-wing de- 
 formity, which is produced when the attempt is made to raise the arm, is 
 very difficult of explanation. The simplest view appears to us to be that 
 of Duchenne, which has recently been revived by Lewinski.' According 
 to these authors it is merely the result of the contraction of the deltoid. 
 When the arm has been brought into a horizontal plane, it cannot be 
 raised any further by the unassisted efforts of the deltoid. This muscle 
 will therefore exert traction upon the scapula, which is no longer held 
 against the thorax by the serratus magnus; the mere contraction of those 
 
 ' Arch. £. Path. Anat., 1878, pp. 473-500. 
 
PEKIPnEKAL PARALYSIS. 227 
 
 fibres of the deltoid which take their origin from the spine of the scapula 
 (the insertion of which into the humerus now forms the poi7it cVappui) will 
 naturally cause the posterior border of the scapula to revolve outward 
 and thus become separated from the chest-walls. 
 
 The inability to raise the arm to the vertical position also requires a 
 few words of explanation. The serratus magnus muscle is inserted into 
 the entire posterior border of the scapula; when the muscle contracts, it 
 therefore pulls upon the bone and, as the lower angle of the bone is not 
 held so firmly in position by muscular action as the upper, the contraction 
 of the scapula causes the inferior angle to turn forward and upward, and 
 thus, in some sort, to revolve around the superior posterior angle. This 
 causes the anterior angle of the bone to move upward, and the humerus, 
 which is firmly held against the latter by the contraction of the deltoid, 
 is thus pushed upward into the vertical position. This action of the ser- 
 ratus magnus may be readily imitated in cases in which the muscle is 
 paralyzed. The patient is directed to hold the arm steadily in the hori- 
 zontal position, and the physician then makes forcible pressure forward 
 upon the prominent inferior angle of the scapula; in proportion as the 
 bone is pushed forward, the arm will be found to rise and will finally 
 reach the vertical position. 
 
 Erb mentions a case in which a patient, suffering from this affection, 
 could nevertheless raise the arm to the vertical position by bending the 
 chest backward and then swinging the humerus forcibly forward; its 
 inertia carried it past the horizontal into the vertical position, a luxation 
 of the head of the humerus downward being produced at the same time. 
 An exactly similar case has fallen under my own observation. 
 
 Baeumler ' reports a case in which the arm could be almost complete- 
 ly raised into the vertical position by gradual muscular contraction. He 
 found that the deltoid, supraspinatus and infraspinatus muscles were 
 considerably hypertrophied, and by their contraction fixed the arm firmly 
 at a right angle to the axis of the scapula; the trapezius was then brought 
 into action, and by its contraction tilted up the scapula sufficientlv to 
 raise the arm almost into a vertical position. 
 
 In exceptional instances the paralysis is bilateral, though such cases 
 Are usually of a central, not peripheral, origin. A case of this kind has 
 come under my notice in which the paralysis of both muscles was un- 
 doubtedly due to a syphilitic lesion of the posterior thoracic nerves. In 
 the patient in question the paralysis of one muscle was well advanced 
 toward recovery when the other became involved. Under the use of 
 anti-syphilitic remedies, the affection was entirely relieved. 
 
 The nerve supplying the serratus muscle was called the external re- 
 spiratory nerve by Bell, under the erroneous impression that the muscle 
 was actively engaged in ordinary inspiration. This notion is refuted by 
 the case to which we have just referred, in which no disturbance of respi- 
 ration could be detected, although both muscles were completely paralyzed. 
 
 Etiology. 
 
 The most frequent causes of the disease are traumatism and over- 
 work. For this reason we find that the right side is almost invariably 
 affected, and that it occurs much more frequently in males than in 
 
 ' Deutsches Archiv f. klin. Med. 1880, p. 305. 
 
228 
 
 FUNCTIONAL NE.llVOUS DISEASES. 
 
 females. The nerve may be injured by falls and blows upon the shoulder^ 
 by direct division of the nerve by gunshot or other wounds, by compres- 
 sion from bearing heavy weights upon the shoulder. It may also, though 
 rarely, be due to rheumatic influences (sitting in a draught, lying u})on 
 the affected side when exposed to wet, etc.). As in the case of bilateral 
 paralysis, which we have mentioned above, the disease may be due to 
 syphilitic lesions. This appears to me, however, to be a unique obser- 
 vation, as I have not found, in the literature of the affection, any report 
 of a similar causation. 
 
 Berger, and a few other authors, have also reported paralysis of the 
 serratus magnus as one of the sequences of typhoid fever. Finally, this 
 muscle not infrequently becomes paralyzed during the course of progres- 
 sive muscular atrophy, and it is especially in this affection that both sides 
 are apt to become involved. 
 
 Diagnosis and Prognosis. 
 
 The diagnosis of paralysis of the serratus magnus muscle is made 
 with extreme ease. It is merely necessary to direct the patient to raise 
 the arm, when the peculiar deformity (angel's wing) which we have 
 
 Posterior thoracic nerve. 
 
 Intercostal nerves. 
 
 '-^^Serratus magnus. 
 Latissimus dorsi 
 
 Intercostal nerves. 
 
 Transversalis. 
 
 Fig. 2. — Motor points of the trunk. 
 
 described, immeJliately becomes apparent and cannot possibly be mis- 
 taken as the result of any other affection. It should be remembered, 
 also, that there is very little change in the position of the scapula during 
 rest. The other muscles of the scapula and shoulder should also be care- 
 fully examined as we not infrequently find that the same cause which 
 
PERIPHERAL PARALYSIS. 229 
 
 has produced the affection under consideration, has also given rise to 
 paralysis of some of the other adjacent muscles. 
 
 It is sometimes difficult to make a differential diagnosis between the 
 peripheral form of the disease and that occurring in progressive muscular 
 atrophy. In exceptional cases the latter disease begins in the serratus 
 magnus, and the diagnosis then becomes very puzzling. In the peri- 
 pheral form, however, the affection is usually preceded by darting pains, 
 and sometimes by anresthesia or hypenesthesia, in the neighborhood of 
 the shoulder. In addition, the faradic excitability is usually normal (when 
 compared with the number of muscular fibres which are still retained) in 
 progressive muscular atrophy ; in paralysis of peripheral origin it is 
 diminisiied or lost. When numerous other muscles of the body are 
 paralyzed, the diagnosis of progressive muscular atrojjhy is rendered 
 very easy. 
 
 Treatment. 
 
 The treatment of paralysis of the serratus magnus muscle is very 
 simple indeed, consisting merely in the administration of an electrical 
 current to the nerve or muscle, according as one or the other reacts. 
 One electrode is pressed firmly behind the sterno-cleido-mastoid muscle, 
 immediately above its insertion into the clavicle, as the nerve is most 
 accessible in this region after it passes through the scalenus medius 
 (Fig. 2.). The other electrode is placed along the course of the nerve 
 in the middle of the axillary space upon the chest-walls, or upon the 
 origin of the muscle from the ribs. When no response could be obtained 
 in this manner, I have sometimes succeeded in producing contractions by 
 placing one electrode upon the origin of the muscle, then directing the 
 patient to elevate the arm, and when the angel-wing deformity had thus 
 been produced, pressing the other electrode firmly between the chest- 
 walls and the anterior surface of the scapula, and thus passing the cur- 
 rent directly through the muscle itself. When the affection is attended 
 with considerable pain in some of the cutaneous filaments supplying the 
 shoulder and arm, great relief may sometimes be procured by applying 
 counter-irritation over the course of the nerves ^i the brachial plexus. 
 It is rarely necessary to resort to the administration of morphine for 
 this purpose. 
 
CHAPTEE X. 
 
 PAKALYSIS OF THE PHRENIC NERVE. 
 Clixical History. 
 
 Peripheral paralysis of this nerve, which is distributed to the dia- 
 phragm, is an extremely rare affection; it may be due either to rheumatic 
 causes or to wounds of the nerve in the neck. The diaphragm some- 
 times loses its contractile power in severe cases of pleurisy or perito- 
 nitis, but this is due to a spread of the inflammation from the serous 
 membranes to the structure of the muscle itself, and cannot therefore be 
 regarded as a true paralysis. Paralysis and atrophy of the diaphragm 
 also occur in the last stages of progressive muscular atrophy, and its de- 
 velopment is then ominous of approaching death. 
 
 The symptoms of this form of paralysis are very characteristic. 
 When the patient makes an inspiration, the epigastrium sinks in instead of 
 becoming more prominent; this is due to the fact that the capacity of the 
 tliorax is increased by the contraction of the intercostal muscles and the 
 diaphragm is therofore forced upward to fill up the space. During tlie 
 act of expiration, the opposite phenomenon is observed, the epigastrium 
 being elevated. During rest, the patient experiences no difficulty in res- 
 piration, but as soon as he attempts to perform any active exercise, the 
 breathing becomes labored and the dyspnoea soon becomes extreme, the 
 auxiliary muscles of respiration being called into play. All reflex acts 
 whose performance requires the contraction of the diaphragm, such as 
 coughing, sneezing, etc., are interfered with or entirely abolished, and in 
 this very fact lies one of the chief dangers of the disease. Thus a patient 
 suffering from ordinary bronchitis, whose diaphragm is paralyzed at the 
 same time, will be unable to expectorate the secretion of the bronchial 
 tubes, and is therefore placed in imminent danger of death from suffoca- 
 tion. 
 
 The diagnosis of this affection is very simple, as the sinking of the 
 epigastrium during inspiration, and its protrusion on expiration are 
 pathognomonic of this form of paralysis. The cause of the disease is 
 also readily determined from the clinical history of the case. 
 
 Treatment. 
 
 The treatment consists almost solely of faradization or galvanization 
 of the phrenic nerve or diaphragm. This is effected by pressing one elec- 
 trode deep into the neck at the anterior border of the sterno-cleido-mas- 
 toid immediately above the sternum, and the other along the insertion of 
 the diaphragm into the costal cartilages of the false ribs. In almost all 
 cases the paralyzed muscle reacts well to both currents, but one case has 
 been reported in which the electrical excitability of the muscle was di- 
 minished. If the paralysis is due to some inflammatory lesion in the neck 
 along the course of the nerves, counter-irritation is indicated. It is im- 
 portant in these cases to keep the bowels regular and. avoid the develop- 
 ment of tympanites, as very slight disturbances of this nature will inter- 
 fere seriously with the proper performance of respiration. 
 
CHAPTER XL 
 
 PARALYSIS OF THE NERVES OF THE ARM. 
 
 Paralysis of the Circumflex. 
 
 Clinical History. 
 
 This nerve supplies the deltoid and teres minor muscles, ajid sends sen- 
 sory filaments to the integument of the shoulder; it is very frequently 
 paralyzed either alone or in combination with other nerves. Tiie deltoid 
 raises the arm from the thorax to the horizontal position; the teres minor 
 assists in rotating the arm outward. The paralysis may develop suddenly 
 or very gradually, according to its causation. When it is due to neuritis, 
 it is frequently accompanied by a feeling of numbness or shooting pains 
 in the shoulder; these sensory disturbances are often combined with an- 
 a?sthesia of the integument in this re^aion. The paralytic symptoms 
 simply consist of the inability of the patient to raise the arm from the 
 side; the action of the teres minor is so slight, and is so thoroughlv com- 
 pensated by other muscles, that we can disregard it altogether. If the 
 lesion of the nerve is a severe one, atrophy of the muscles develops more 
 or less rapidly. "When this occurs, the diminished rotundity of the shoul- 
 der is readily perceptible, and in extreme cases the finger may be pressed 
 between the humerus and the glenoid cavity of the scapula. In such cases 
 the arm is somewhat longer than its fellow, because the tonicity of the 
 deltoid, which serves to hold the head of the humerus snugly against the 
 scapula, is lost, and the arm therefore droops more than in the normal 
 condition. The electrical reactions vary considerably ; only in the mild- 
 est cases are they normal. In the majority of cases which have come 
 under m}'' observation, the excitability of the muscle was simply dimin- 
 ished to both currents; in rarer instances, well-marked degeneration- 
 reaction is observed. I have noticed with special frequency in this form 
 of paralysis that the electrical excitability of the muscle may still be con- 
 siderably lowered, even after it reacts with normal promptitude to the 
 stimulus of the will. 
 
 Etiology. 
 
 Traumatism constitutes probably one of the most frequent causes of 
 deltoid paralysis. The injury may be of various kinds, such as a fall upon 
 the shoulder, a blow with a blunt instrument (in one of my patients the 
 paralysis was caused by a blow with the fist, which struck immediately 
 above the clavicle over the course of the brachial plexus), pressure from 
 a dislocated or fractured humerus, pressure from sleeping on the shoulder, 
 or the injury produced in version by the arm during delivery, an example 
 of which has come under my notice. In some of these cases, inflamma- 
 tion of the circumflex nerve may be produced, and, as I have noticed in 
 
232 FUNCTIONAL NERVOUS DISEASES. 
 
 several cases, the neuritis may spread upward to the brachial plexus, and 
 thus involv^e other nerves in the paralysis. Rheumatic influences, such 
 as exposure, also constitute a not very infrequent cause of deltoid par- 
 alysis; it may also be produced by overstretching of the muscle. A 
 few cases have been repoited in which the affection followed certain of 
 the infectious diseases, such as scarlet fever, small-pox, etc. Finally, 
 deltoid paralysis (usually bilateral) may usher in an attack of lead-palsy, 
 and may be restricted to these muscles, though it generally spreads, after 
 a short interval, to the extensors of the forearm. On account of the in- 
 teresting character of this modification of lead-palsy, I will give a brief 
 abstract of the history of a patient now under my observation in Ran- 
 dall's Island Hospital : 
 
 Case VIII. — Laurence Clooney, ast. 37 years, house painter; entered 
 the hospital. May 13, 1880. He has worked at his trade for eighteen years; 
 two years ago he had an attack of lead colic. The patient continued 
 well since then until January 6, 1880, when he suddenly noticed while 
 at work that he could not lift his arms from the side (paralysis of the 
 deltoids). Two days afterward he again had an attack of colic, and pains 
 began to be felt in both arms. He kept on working until April 25th, 
 when, on attempting to wash his hands, he found that they were also 
 paralyzed; two days later an attack of colic occurred, and five days later 
 another attack. 
 
 Present condition. — The patient has a sallow-complexion ; he thinks 
 he has lost flesh ; marked blue line on the gums. No loss of sensibility 
 can be discovered in any part of the body. The deltoid muscles are com- 
 pletely paralyzed (he is unable to lift the arm from the side of the chest) 
 and are markedly atrophied, the right to a greater extent than the left; he 
 presents weakness with some atrophy of the biceps ; the triceps is not 
 appreciably affected. Paralysis of the extensors of the wrist, more marked 
 on the right side, with very considerable atrophy of these muscles is also 
 noticeable. The supinator longus of the right arm is paretic and small- 
 er in size than the left. All the affected muscles present a diminished 
 react on to the faradic current. 
 
 Diagnosis. 
 
 The diagnosis of deltoid paralysis is very readily made from the loss 
 of function of the muscle. In two of my cases, occurring in a child (in 
 whom all forms of paralysis are detected with much greater difficulty than 
 in the adult), a diagnosis had been made of dislocation of the humerus. 
 This mistake is readily obviated by placing the hand of the affected side 
 over the opposite shoulder. In paralysis of the deltoid, the elbow can 
 be brought in apposition with the chest, while the arm is in this position ; 
 in dislocation of the humerus this cannot be done. Another patient 
 was referred to me by a surgeon, who thought the case was one of del- 
 toid paralysis. A very slight examination, however, served to show 
 that the patient was suffering from fracture of the humerus, A mistake 
 of this kind can only result from sheer carelessness. 
 
 In rare instances infantile paralysis affects the deltoid without involv- 
 ing any other muscles, and it may then be very difficult to decide whether 
 the paralysis is of a pw ipheral or central nature. The distinguishing fea- 
 
PEPJPIIEUAL PARALYSIS. 233 
 
 tures of the latter are : its occurrence in childhood, the frequent develop- 
 ment of febrile symptoms prior to the paralysis, the rapid atrophy of the 
 muscle, the absence of any determinable cause, and the almost absolutely 
 unfavorable prognosis as regards recovery from the paralysis. 
 
 Tkeatment. 
 
 Electricity furnishes our chief resource in the treatment of paralysis 
 of this nerve. As a general thing that current should be employed to 
 which the muscle responds most readily, but it is found, in exceptional 
 cases, that recovery occurs under the continued employment of faradism 
 altliough the paralyzed muscles do not react to this current. In apply- 
 ing electricity to the deltoid, one electrode should be placed upon its ante- 
 rior fibres below the clavicle and the other slowly moved across the body 
 of the muscle. This method is applicable to both currents, and does not 
 require the use of the interrupting handle. When, the paralysis is due 
 to neuritis, which is still present in an active stage, it is doubtful whether 
 electrization of the muscle itself is attended with much benefit. In such 
 cases it is well to pass the uninterrupted constant current through the 
 nerve, one electrode being placed upon the brachial plexus in the neck, 
 and the other near the insertion of the muscle into tlie humerus. There 
 appears to be a special tendency for neuritis of the circumflex to spread 
 upward and secondarily involve other branches of the brachial plexus. 
 Counter-irritation (in the form of fly-blisters) is useful in combating this 
 tendency; the blisters should be applied upon any painful spots which 
 may be present in the muscle, and also along the course of the plexus in 
 the root of the neck (at the anterior border of the trapezius). 
 
 When the paralysis is due to pressure upon the nerve from disloca- 
 tion or fracture of the humerus, etc., the appropriate surgical measures 
 must, of course, be adopted. 
 
 Paralysis of the Musculo-Cutaneous Nerve. 
 Clinical History. 
 
 This nerve supplies the biceps, brachialis anticus, and coraco-brachialis 
 muscles, and is also distributed to the integument of the outer and an- 
 terior aspects of the forearm and ball of the thumb, and the lower third 
 of the posterior surface of the forearm. It is very rarely paralyzed after 
 leaving the brachial plexus, as it is situated very deeply and therefore 
 not liable to injury. Even when a trauma affects the plexus, this nerve 
 usually escapes on account of its protected position. I have a case un- 
 der observation, however, at present, in which this nerve alone became 
 paralyzed while the individual was on a drunken debauch ; the patient 
 is unable to give an account of the nature of the accident, but it probably 
 occurred from injury of some kind. 
 
 The symptoms of this form of paralysis consist merely of partial loss 
 of the power of flexing the forearm upon the arm and loss of sensation 
 on the anterior and posterior aspects of the outer side of the forearm. 
 Flexion of the forearm is not entirely lost because the supinator longus 
 
234 
 
 FITNCTIOKAL NERVOUS DISEASES. 
 
 acts as flexor as well as supinator. As this disease usually forms part 
 of paralysis of the entire brachial plexus, its etiology and treatment are 
 similar to those of the latter. (Fig. 3.) 
 
 Paralysis of the Median Nerve. 
 Clinical History. 
 
 This nerve supplies the deep and superficial flexors, the flexor carpi 
 radialis, the muscles of the ball of the thumb with the exception of the 
 adductor poilicis, both pronators, and the first three lumbricales; it is 
 also distributed to the integument of the anterior surface of the thumb, 
 the first two fingers and outer half of the ring finger, and the dorsal aspect 
 of the second and third phalanges of the index and middle fingers and 
 outer half of the ring finger. 
 
 Paralysis of the deep and superficial flexors causes loss of the power 
 of flexion of the second and third phalanges; it does not affect the first 
 
 JIusculo-cutaneous nerve. Biceps. 
 
 Mnscnlo-cutaneous Branch to Median BrachialiB Ulnar nerve, 
 
 nerve. long head nerve. antions. 
 
 of triceps. 
 
 Fig. 3. — Motor points of inner aspect of arm. 
 
 phalanges as they are flexed by the contraction of the interossei mus- 
 cles, which, at the same time, produce extension of the second and third 
 phalanges. When the paralysis of the flexor muscles is complete and 
 long-continued, the unopposed action of the interossei may permanently 
 cause flexion of the first phalanges and hyperextension of the second and 
 third. Paralysis of the pronators of the forearm (which are also supplied 
 by the median nerve) interfere with pronation to a certain extent, though 
 not completely, as this function is performed in part by the supinator 
 longus, when the forearm is flexed upon the arm. 
 
 Flexion of the wrist cannot be performed normally, on account of the 
 paralysis of the flexor carpi radialis. The paralysis of the muscles of 
 
PERIPHERAL PARALYSIS. 235 
 
 the thumb, with the exception of the adductor pollicis, causes loss of the 
 power of touching the tips of the fingers with the thumb and of pressing 
 the thumb firmly against the forefinger. The unopposed action of tlie 
 extensor longus pollicis produces hyperextension of the thumb, and at 
 the same time cause a disappearance of the natural projection of the 
 ball of the thumb anteriorly, thus flattening the entire anterior surface 
 of the hand. 
 
 Where the entire trunk of the nerve is wounded, sensation may be 
 lost on the anterior surface of the thumb, the first two fingers, outer half 
 of the ring finger, the dorsal aspect of the second and third phalanges 
 of the index and middle fingers, and the outer half of the ring finger. 
 The distribution of the sensory disturbances, is however, subject to very 
 great modification, and indeed Richet has reported a case (to which we 
 have previously referred) in which division of the median nerve was not 
 followed by any loss of sensation in the hand. This peculiar phenome- 
 non is explained by the presence of Arloing and Tripier's recuz-rent sen- 
 sory fibres, which pass from the ulnar and radial nerves to the median, 
 and to Avhich reference has been so frequently made in the article on 
 neuralgia. Various trophic disturbances, which are entirely similar in all 
 respects to those which have been mentioned as occurring in traumatic 
 neuralgia of the upper limbs, are also observed in severe paralysis of this 
 nerve. 
 
 Etiology. 
 
 Median paralysis is due to a great variety of causes, especially to 
 traumatism, including gunshot wounds, incised wounds with a knife, 
 pieces of glass, etc., blows with a club; to pressure from tumors of va- 
 rious kinds, from excessive development of callus after fracture, from the 
 bands of a strait-jacket when drawn too tightly; from neuritis in conse- 
 quence of exposure, or as a sequel of certain infectious diseases. 
 
 This nerve is, however, rarely paralyzed separately and, indeed, it is 
 unf requently met with even in combination with paralysis of other nerves 
 of the arm. 
 
 Treatment. 
 
 The remarks made on the treatment of deltoid paralysis also hold 
 good with reference to this form of jDaralysis. In applying electricity to 
 the median nerve, one electrode is placed in the fold of the elbow to the 
 inside of the median line (vide Fig. 4) and the other electrode is ap- 
 plied above the wrist directly in the median line. The muscles of the 
 ball of the thumb and the lumbricales may be electrized through the nerve 
 by placing one electrode over the lower portion of the nerve above the 
 wrist, and the other (a small olive-pointed electrode) upon the motor 
 points shown in Fig. 4, or the current may be passed through the 
 muscles (usually more effectual), the olive-pointed electrode being re- 
 tained in the position just described, and the other being placed on the 
 dorsum of the hand. 
 
 Surgical measures frequently prove of decided relief when the paral- 
 ysis is due to compression of the nerve by an old cicatrix, a foreign body 
 in a wound, etc. These cases are often attended with considerable pain, 
 which is sometimes so severe as to necessitate the hypodermic adminis- 
 tration of morphine. 
 
236 
 
 FUNCTIONAL NEEVOUS DISEASES. 
 
 Paealysis op the Ulnar Nerte. 
 
 Clinical History. 
 
 The motor fibres of the ulnar nerve are distributed to the flexor carpi 
 ulnaris and a portion of the flexor digitorum profundus, the interossei 
 (both pahuar and dorsal), first two lumbricales, the adductor pollicis and 
 the muscles of the hypothenar eminence; the sensory fibres ai"e distribu- 
 ted to the ulnar third of the palm of the hand, the flexor aspect of the 
 
 Median nerve. . . 
 Palmaris longis. 
 
 Flexor carpi ulnaris, 
 
 Flexor sublimis digitorum 
 Ulnar nerve 
 
 Flexor sublimis digitorum. 
 
 Volar nerve 
 
 Palmaris brevis 
 
 Abductor minimi digiti 
 Flexor minimi digiti, 
 Opponens minimi digiti, 
 
 Lumbricales 2d, 3d, 4th..-' 
 
 S ■ Flexor carpi radialis. 
 
 J 
 
 S- Flexor profundus digitorum. 
 
 Flexor sublimis digitorum. 
 
 Flexor longUB pollicis.J 
 
 Median nerve. 
 
 Abductor pollicis. 
 
 -Opponens pollicis. 
 Flexor brevis pollicis. 
 ..Adductor pollicis. 
 ^.. 1st Lumbricalis, 
 
 Fig. 4. — Motor points of flexor aspect of forearm. 
 
 little finger, ulnar half of the ring finger, and the dorsal aspect of the lit- 
 tle and ring fingers and the ulnar half of the middle finger, with the ex- 
 ception of the first phalanx, which is supplied by the median nerve. 
 
 Paralysis of this nerve, therefore, leads to partial loss of the power of 
 flexion of the wrist and fingers. The paralysis of the interossei causes 
 loss of power of adduction and abduction of the fingers, and also of flex- 
 
PERIPHERAL PARALYSIS. 287 
 
 ion of the first phalanx and extension of tlie second and third phalanges. 
 When the paralysis is complete and long-continued, a very peculiar and 
 characteristic deformity is produced, on account of the unopposed action 
 of the antagonists of the interossei, viz., the superficial and deep flexors, 
 which flex the second and third phalanges, and the common extensor, 
 which extends the first phalanx. The contraction of the latter muscle 
 causes hyperextension of the first phalanges; the action of the former 
 produces complete flexion of the second and third phalanges, thus giving 
 rise to what is known as the " claw-hand." 
 
 In addition, paralysis of the adductor pollicis causes diminution in 
 the power with which the thumb can be pressed against the index finger; 
 paralysis of the muscles of the hypothenar eminence interferes with the 
 various movements of the little finger. In severe forms of paralysis, the 
 muscles undergo atrophy, and this is very readily detected when the dor- 
 sal interossei are affected; the metacarpal bones then project prominent- 
 ly and depressions are visible between them. 
 
 There may be considerable loss of muscular power without any affec- 
 tion of sensation ; when present, the latter usually affects the integu- 
 ment in the manner referred to in describing the distribution of the 
 nerve, but variations are also observed in the case of this nerve, though 
 not so marked as in paralysis of the median. The only variation which 
 has come under my own notice has been that the loss of sensation has 
 extended over the outer half of the flexor aspect of the ring finger, and 
 has affected half instead of a third of the palm. 
 
 When the paralysis is due to an irritative lesion of the nerve, it is 
 not infrequently complicated with numbness and tingling, or lancinating- 
 pains in the anaesthetic regions. The trophic and vaso-motor disturb- 
 ances which are noticeable are similar to those occurring in other par- 
 alyses of the arm. 
 
 Etiology. 
 
 This form of paralysis is due in the majority of cases to traumatic 
 influences, to which the nerve is often subjected on account of its ex- 
 posed position. These include blows upon the forearm, sleeping on the 
 arm, wounds with a knife or other sharp instrument, pressure of a straight- 
 jacket, pressure of a crutch upon the nerve in the axilla. It is also pro- 
 duced by neuritis due to exposure or to the propagation of inflammation 
 from surrounding parts, and to the pressure of a neuroma or other form 
 of tumor. 
 
 The peculiar claw-shaped hand is not pathognomonic of this form of 
 paralysis, but is also observed at times in progressive muscular atrophy. 
 But other characteristic symptoms then serve to differentiate the two 
 affections. Thus, in the latter the atrophy often begins in the muscles 
 of the ball of the thumb, it gradually spreads up the arm, and then 
 travels to the trunk and lower limbs, involving the muscles irrespective 
 of their nervous supply, sensory disturbances are entirely absent and the 
 loss of power keeps pace^:>«r4^jass<6 with the muscular atrophy. 
 
 Treatment. 
 
 The treatment of ulnar paralysis is similar to that of the other nerves 
 of the arm. Electricity is employed in this affection by applying one 
 electrode upon the fold of the elbow over the inner condyle, and the 
 
238 FUNCTIONAL NERVOUS DISEASES. 
 
 other upon the inner side of the wrist (Fig. 3). The interossei are 
 electrized by placing one electrode over the nerve at the wrist and the 
 other over the motor points of the muscles as shown in Fig. 4, or by 
 placing one electrode in the palm in the manner described on page 335, 
 in speaking of electrization of the lumbricales. 
 
 When there is a tendency to the development of the " claw-hand," 
 the contracture of the muscles should be overcome by the application of 
 a straight splint to the palm of the hand and fingers. Galvanization of 
 the opposing muscles is also said to be useful under these circum- 
 stances. Too much must not, however, be expected from the employ- 
 ment of these measures, as the peculiar deformity may develop despite all 
 treatment, and render the hand entirely useless. 
 
 Paralysis of the Musculo-spiral Nerve. 
 Clinical History. 
 
 During its course through the spiral groove of the humerus, this 
 nerve is distributed to the triceps, anconeus, supinator longus, and exten- 
 sor carpi ra.dialis longior ; it also supplies the integument of the outer 
 and posterior aspect of the lower half of the arm, and the upper two- 
 thirds of the posterior aspect of the forearm. The nerve divides into 
 the radial and posterior interosseous nerves, the former being distributed 
 to the integument of the outer half of the dorsum of the hand and the 
 dorsal aspect of the thumb, the index finger and outer half of the mid- 
 dle finger, with the exception of the third phalanges (which are supplied 
 by the median). The posterior interosseous nerve is distributed to all 
 the muscles on the posterior aspect of the forearm. 
 
 This form of paralysis of the nerves of the arm is much more com- 
 mon than the varieties previously described, and also differs from the 
 other varieties in the fact that it very often occurs separately, though 
 the branch above the elbow is rarely involved except in combination with 
 other nerves of the brachial plexus. 
 
 The branches supplying the triceps and the integument of the arm are 
 so rarely involved apart from paralysis of the other nerves of the plexus, 
 that it is unnecessary to consider them in this connection. 
 
 Paralysis of the extensors gives rise to the characteristic appearance 
 known as wrist-drop, the hand and first phalanges being flexed, the 
 second and third jDhalanges extended. The patients are unable to extend 
 the wrist voluntarily, and for this reason the flexors of the forearm are 
 also apparently weakened (vide page 182). When the paralysis is com- 
 plete and affects both arms, the patients are rendered almost entirely 
 helpless, as the loss of power of the extensors not only prevents the per- 
 formance of extension, but the inability to steady the wrist also interferes 
 with flexion of the fingers. Paralysis of the supinator longus causes 
 partial loss of the power of supination of the forearm (this is partially ef- 
 fected by the biceps) and also, to a certain extent of flexion, as this func- 
 tion is assumed by the supinator when the forearm is maintained in a 
 semipronated position. A very characteristic appearance is presented 
 when the paralysis is attended with muscular atrophy; the prominence 
 upon the outer side of the forearm, produced by the bellies of the exten- 
 sor muscles is lost, and in extreme cases the finger may be pressed deep 
 into the posterior interosseous space. 
 
PERIPHERAL PARALYSIS. 239 
 
 In lead paralysis, as we have previously pointed out, the supinator 
 longus is only exceptionally affected, and we therefore find that tliis mus- 
 cle stands out prominently, while the other extensors may be wasted to 
 such an extent that they are detected with difficulty. 
 
 This form of paralysis has appeared to me to he more frequently com- 
 plicated with trophic disturbances than the other paralyses of the nerves 
 of the arm. 
 
 Its etiology embraces the entire list of causes which have been de- 
 scribed as productive of ulnar and median paralysis. In addition, lead 
 palsy is usually localized in the distribution of this nerve. The majority 
 of cases of musculo-spiral paralysis, however, are due to sleeping upon 
 the arm, allowing it to hang over the edge of a chair, etc. Among up- 
 ward of twenty-five of my cases due to the latter cause, in all but two 
 the paralysis developed while the patients were sleeping off the effects of 
 a heavy debauch. It occurs with so much greater frequency under these 
 conditions, because the patients sleep more heavily and change their posi- 
 tion less frequently. Gowers ' reports two cases in which paralysis of the 
 musculo-spiral nerve occurred from violent contraction of the triceps 
 muscle. 
 
 Diagnosis. 
 
 The diagnosis ef this form of paralysis is readily made from the posi- 
 tion of the hand and the inability to perform extension. It is often diffi- 
 cult, however, to determine whether the paralysis is due to lead poison- 
 ing or to other causes. In the former event, there is usually a history of 
 the entrance of lead into the system in some manner, the patient has suf- 
 fered from one or more attacks of lead colic, a blue line is present upon 
 the gums, and the supinator longus is unaffected in the large majority of 
 cases. In addition, the paralysis generally involves both arms, and, in 
 fact, any bilateral paralysis of the extensors, in which a cause cannot be 
 determined, should lead us to suspect the presence of lead in the system. 
 
 In one case under my observation bilateral paralysis of the extensors 
 was due to rheumatic influences, viz.: exposure to a high wind. The 
 patient, a washerwoman, hung clothes upon the roof in a strong wind, her 
 arms being wet at the time, and upon the following morning awoke with 
 wrist-drop in both arms. The disease was differentiated from lead-palsy 
 by the fact that there was no history of lead-poisoning, no blue line on 
 the gums, the supinators were affected to the same extent as the exten- 
 sors, and the paralysis ensued shortly after the action of a sufficient ex- 
 citing cause. 
 
 In rare cases some difficulty is experienced in differentiating the dis- 
 ease from progressive muscular atrophy, but the latter is generally accom- 
 panied by atrophy of muscles in other parts of the upper limbs, especially 
 in the interossei and muscles of the ball of the thumb. 
 
 Treatment. 
 
 The treatment is, in general terms, the same as that of ulnar and me- 
 dian paralysis. The extensor muscles are electrized by placing one elec- 
 trode over their general origin from the external condyle of the humerus 
 
 ' Medical Times and Gazette, 1877, p. 475. 
 
240 FUNCTIONAL NERVOUS DISEASES. 
 
 and gently stroking the posterior surface of the forearm with the other; 
 in this manner all the muscles are successively brought into play, and 
 this method may be employed for both currents. (Figs. 5 and 6.) Gal- 
 vanization of the nerve may be effected by placing one electrode in the 
 fold of the elbow over the external condyle and the other at the back 
 of the wrist in the median line. In the treatment of lead-palsy recovery 
 is sometimes obtained under the use of the faradic current, although 
 the muscles no longer respond to this form of electricity. In all cases 
 of lead-paralysis, however, it is more advisable to use the interrupted 
 galvanic current. 
 
 When wrist-drop develops, the extensor muscles, as we have previously 
 Been, are put upon the stretch, and this condition interferes, to a certain 
 extent, with the progress of recovery. Various devices have been re- 
 sorted to in order to obviate this difficulty, the simplest being that in- 
 vented by Dr. Van Bibber, and which may be modified in various ways. 
 
 External head of triceps 
 
 Musculo-spiral nerve., 
 Brachialis anticns. . . . 
 
 / 
 
 Supinator longus 
 
 Extensor carpi radialis longior.. 
 
 Extensor carpi radialis brevier. / 
 
 / 
 
 Fig. 5. — Motor points of outer aspect of arm. 
 
 A fingerless glove is worn upon the paralyzed hand, into the back of which 
 is inserted a wire loop in the median line. Another loop is inserted over 
 the posterior surface of the elbow by means of a piece of moleskin plas- 
 ter, which adheres to the back of the arm; an artificial muscle, consisting 
 of simple rubber tubing, is then introduced between the two wire loops, 
 and should be drawn sufficiently tight to keep the hand continually in 
 slight extension. A rubber ring or band of any description may be 
 placed around the wrist (allowing the artificial muscle to pass between it 
 and the skin), thus preventing the apparatus from rubbing against the 
 clothes and becoming displaced. When the apparatus has been properly 
 adjusted the patient is often enabled to perform movements with the 
 hand which were previously impossible, and the relief of the muscular 
 tension undoubtedly facilitates recovery. 
 
PERIPHERAL PARALYSIS. 
 
 241 
 
 Whenever this form of paralysis (as well as all the other varieties of 
 paralysis of the nerves of the arm) is attended with trophic changes in the 
 joints (pain, swelling of the ends of the bones, ankylosis), considerable 
 benefit is often derived from the persistent use of hot douches, applied 
 half an hour daily, lu severe cases the constant galvanic current may be 
 
 Supinator longns 
 
 Extensor carpi radialis longior.. . . 
 
 Extensor carpi radialis brevior. 
 Extensor communis digitorum.. 
 
 1st dorsal interosseous.u 
 
 2d dorsal interrosseous 
 
 3d dorsal interrosseous ' 
 
 i-SM Extensor carpi ulcarig. 
 
 I :iXi'|f|^L Extensor minimi digiti. 
 
 m ^l^'K^^ Extensors of the thumb. 
 
 1 Extensor indicis. 
 
 Abductor minimi digriti. 
 4th dorsal interosseous. 
 
 Fig. 6. — Motor points of extensor aspect of forearm. 
 
 employed, the current being passed directly through the affected joint, 
 and a sufficient number of cells being used to cause considerable pain and 
 decided redness of the integument. The applications should be made 
 daily, the duration varying from ten to fifteen minutes. 
 
 In lead-paralysis constitutional treatment is also required, but this has 
 been referred to with sufficient detail on page 194. 
 
 Combined Paralysis of the Nerves of the Arm. 
 
 With the exception of paralysis of the circumflex and musculo-spiral 
 nerves, which often occur separately, several of the nerves of the brachial 
 plexus are usually affected at the same time. This is due to the fact that 
 16 
 
242 FUNCTIONAL NERVOUS DISEASES. 
 
 the nerves are situated so closely together in their passage down the 
 neck and arm, and also to the tendency — more marked in this than in any 
 other part of the body — of the spread of neuritis along the course of the 
 nerve-trunks, thus leading to the secondary implication of other branches 
 of the plexus. As we have shown in the course of our general remarks 
 on peripheral paralysis, neuritis descendens as well as ascendens are ob- 
 served in the nerves of the upper limbs, and in some cases, indeed, the 
 inflammatory process extends to the spinal cord. 
 
 Erb first described a peculiar form of paralysis in which the deltoid, 
 biceps, brachialis anticus and supinator longus were paralyzed, and, at 
 times, the muscles supplied by the median nerve in the forearm. Erb 
 believed that this form of paralysis was due to a lesion situated at the 
 exit of the sixth cervical nerve from the scalenus muscle, as the application 
 of the faradic current to this spot will produce contraction of the above- 
 mentioned muscles. These observations have been since confirmed by 
 Ernst Remak ^ and H. ten Gate Hoedemaker.* As Erb has pointed out, 
 the same group of muscles are sometimes affected in the paralysis of the 
 upper arm occurring during parturition, which was first described by 
 Duchenne. This combination does not, however, always occur under 
 such circumstances; a case of this kind has been reported by Bailly and 
 Onimus, and another has come under my observation, the following being 
 a short abstract of the history: 
 
 Case IX. — Julius H., set. 3 months, in robust health; the head was 
 delivered by forceps, and the shoulders were then found to be tightly 
 wedged in the pelvis, so that the accoucheur had great difficulty in dis- 
 engaging them, and exerted considerable force in this manipulation. 
 Immediately after delivery it was noticed that the left arm hung limp by 
 the side, and the only movement observed in the limb was the power of 
 flexion of the fingers. The measurements of the arms are exactly the 
 same, and the child is so plump that it is impossible to tell whether the 
 muscles are atrophied. When the arm is raised to the horizontal it drops 
 down perfectly limp; irritation of the limb gives rise to no movements 
 except flexion of the fingers. Examination shows that there is no frac- 
 ture or dislocation of the humerus. None of the muscles, with the ex- 
 ception of the flexors of the fingers, react to the faradic current, and only 
 slight contractions are observed on the application of the interrupted 
 galvanic current; sensation appears to be normal. 
 
 In comparatively rare cases the entire limb is paralyzed as the result 
 of a lesion to the peripheral nerves, usually from tumors growing from 
 the brachial plexus, from the pressure of the dislocated head of the hu- 
 merus, or from direct injury received during falls, etc. When the paraly- 
 sis of the arm is complete, the prognosis is very gloomy, and complete 
 recovery rarely, if ever, occurs. 
 
 Two cases of paralysis of the entire plexus are under my observation 
 at present, one of which is due to a fall upon the shoulder, the exciting 
 cause of the other being unknown. In the former, the circumflex and 
 musculo-spinal nerves are chiefly affected (the degeneration-reaction is 
 present in the corresponding muscles), in the latter the median and ulnar 
 nerves are most seriously implicated. 
 
 ' Berl. klin. Wschrft. No. 9, 1877. ^ Arch. f. Psych. IX. p. 738. 
 
CHAPTER XII. 
 
 PARALYSIS OF THE NERVES OF THE LOWER LIMBS. 
 
 Paealtsis of the Obturator Nerve. 
 
 Clinical History. 
 
 This nerve supplies the adductors of the thigh, the obturator muscles, 
 and the gracilis and pectineus ; it is also distributed to the integument 
 of the inner aspect of the thigh in its lower two-thirds. This form of 
 paralysis is extremely rare and its symptoms are not very marked ; they 
 consist merely of loss of the power of adduction of the thigh (adductors, 
 gracilis, pectineus) and to a certain extent of external rotation (obturators). 
 The paralysis may develop either on one or both sides, and occurs more 
 frequently in combination with crural paralysis than separately. The 
 loss of power is rarely very great and does not cause the patient very 
 much inconvenience. 
 
 Etiology. 
 
 This form of paralysis may occur as the result of tumor growths upon 
 the Cauda equina, wounds of the lower portion of the spinal cord, psoas 
 abscesses, pressure upon the nerve during forceps delivery or by a large 
 fcetal head, wounds of the nerve after its exit from the pelvis. In one 
 unique case, the notes of which were furnished me by Dr. V. P. Gibney, 
 the paralysis was apparently due to over-exertion of the muscles, the re- 
 sult of excessive coitus. 
 
 Case X. — " Minnie M., set, 19 years, a prostitute. Two years ago, the 
 patient, according to her own account, had a vaginal abscess on the left 
 side. Last July another abscess developed in the same locality, and this 
 was opened. Upon attempting to get out of bed she found herself una- 
 ble to walk and suffered from pains in the lower limbs ; there were no 
 cincture pains or d sturbance of the functions of the bladder. Two 
 months elapsed before she began to go about, and she then could only 
 walk very slowly ; she has been gradually getting better. She now 
 walks pretty well on a level, but gets upstairs with great diflSculty ; she 
 is unable to adduct the thighs and carry one across the other. 
 
 " November 29th. The vagina was examined quite carefully (though 
 the light was not good) but no cicatrix of an abscess could be found ; ilie 
 uterus appears to be in the normal position ; no evidences of specific dis- 
 ease. 
 
 " The adductors of the thigh are found to be very feeble, especially in 
 the right limb ; these muscles are also very flabb}'' ; there is also some 
 paresis of the extensors of the thigh. The faradic excitability is dimin- 
 ished in the adductor group of the right limb. The patient suffers from 
 
244 
 
 FUNCTIONAL NERVOUS DISEASES. 
 
 pain at the knee and inner aspect of the thigh {distribution of the obtu- 
 rator). 
 
 " December 15th. The patient has been receiving faradism to the 
 affected muscles three times a week and thinks she can walk much bet- 
 ter. February 15th reports herself entirely well. 
 
 " Upon inquiry it was found that the patient had had coitus, for the 
 past two years, about seven or eight times a week, and that she had been 
 
 Crural nerve _.., i_ ''T 
 
 Obturator nerve /S|y 
 
 Sartorius ■ 
 
 Adductor longus _.,. _ 
 
 Branch of crural nerve to com. exteu- „ 
 
 sor. l/f S 
 
 Crureus _ \. 
 
 |— ^ 
 
 Vastus intemus _ <; ^ 
 
 \'' 
 
 \ 
 
 \ 
 I 
 f 
 
 . Rectus f emoris. 
 
 ^^ 
 
 . Vastus extemus. 
 
 Fig. 7. 
 
 , — Motor points of anterior region of thigh. 
 
 very much addicted to performing intercourse in " fancy positions." As 
 the affected muscles were the ones which would be chiefly strained in such 
 manoeuvres, it is reasonable to conclude that the disease was brought 
 about in this manner." 
 
 Treatment. 
 
 The treatment consists simply in the application of electricity, one 
 electrode being applied to the inner side of the thigh, a little below Pou- 
 part's ligament, in the position indicated on Fig. 7, and the other being 
 moved to and fro over the adductor group near their insertion into the 
 femur. 
 
 Paralysis of the Anterior Crural Nerve. 
 Clinical History. 
 
 This nerve supplies the iliacus, quadriceps femoris, sartorius, and pec- 
 tineus muscles. The sensory filaments are distributed to the inner half of 
 the anterior surface of the thigh, and the inner aspect of the leg and foot. 
 Paralysis of this nerve, though rare, occurs with greater frequency than 
 
PERIPHERAL PARALYSIS. 245 
 
 that of the obturator, but is sometimes combined with the latter. Its 
 etiology is entirely similar, in all respects, to that of obturator paralysis, 
 though it is more frequently caused by traumatism, on account of the 
 more exposed position of the nerve. 
 
 Paralysis of the anterior crural gives rise to serious disturbances, es- 
 pecially when both nerves are affected. Paralysis of the iliaci causes 
 partial loss of the power of maintaining the erect position, as these mus- 
 cles produce fixation of the pelvis upon the femur; it also interferes with 
 flexion of the thigh upon the trunk; the latter effect is still further in- 
 creased by paralysis of the sartorius, which is also a flexor of the thigh. 
 Paralysis of the quadriceps extensor femoris interferes very decidedly 
 with the power of walking, elevating the foot, etc.; this muscle, taking 
 its origin from the femur and the anterior inferior spinous process of the 
 ilium, extends the leg upon the thigh and thus takes an active part in the 
 act of walking. The affected muscles are usually markedly atrophied, 
 and this is readily determined when compared with the healthy limb. If 
 the patient is very obese, careful measurements of the thighs may become 
 necessary in order to detect the presence of the muscular atrophy. The 
 sensory disturbances are usually of a slight grade, and consist of numb- 
 ness and tingling in the cutaneous distribution of the nerve. 
 
 The diagnosis is readily made by inspection of the parts and by direct- 
 ing the patient to extend the leg upon the thigh. In rare cases acute 
 infantile paralysis is localized in the distribution of this nerve, and the 
 differentiation of this affection from peripheral paralysis may require some 
 care. In the former disease the paralysis often begins with constitutional 
 disturbance, the loss of power is more general in the beginning than it is 
 after the lapse of a few days, the muscular atrophy occurs very rapidly, 
 and no sensory disturbances are observed. 
 
 Treatmext. 
 
 The treatment, as in paralysis of the obturator nerve, consists merely 
 of electrization, one electrode being placed over the middle of the base 
 of Scarpa's triangle and the other one passed to and fro over the anterior 
 muscles of the thigh; the muscles can be stimulated separately by placing 
 the latter electrode in the positions shown on Fig. 7. 
 
 Paralysis of the Sciatic Nerve. 
 Clinical History. 
 
 The sciatic nerve supplies the integument of the entire leg and foot, 
 ■with the exception of the internal portion which is supplied by the inter- 
 nal saphenous. Before its division into the internal and external poplit- 
 eal, it sends branches to the biceps, semi-tendinosus, semi-merabranosus 
 (flexors of the leg), and to the adductor magnus. The internal popliteal 
 is distributed to the gastrocnemius, soleus, popliteus, and plantaris, tibi- 
 alis posticus, flexor longus digitorum, flexor longus pollicis, and the small 
 muscles of the sole of the foot. The external popliteal or peroneal nerve 
 is distributed to the tibialis anticus, extensor longus digitorum, extensor 
 proprius pollicis, the peronei, and extensor brevis digitorum. 
 
 Paralysis of this nerve is much more frequent than that of the other 
 
246 FUNCTIONAL NERVOUS DISEASES. 
 
 nerves of the lower limb, on account of its great length and more exposed 
 situation. It is comparatively infrequent, hov^ever, when compared with 
 paralysis of the nerves of the upper limb. It may be due to hemorrhages 
 within the spinal canal, to the pressure of tumors upon the cauda equina, 
 to fracture of the lower lumbar vertebrge (in one case under my observa- 
 tion both sciatics were completely paralyzed in consequence of fracture 
 of the second lumbar vertebrae with forward dislocation) ; it may also be 
 caused by the pressure of intra-pelvic tumors, of the forceps or a large head 
 during a severe and protracted delivery. After the exit of the nerve 
 from the pelvis, traumatism plays a prominent part in the production of 
 peripheral paralysis, and the nerve is usually involved after its bifurcation 
 into the internal and external popliteal, the latter being most frequently 
 affected. The injury may consist of a bullet or knife wound, blow with 
 a club, a fall upon the buttocks, the pressure of a strait-jacket or, as in 
 one interesting case which I observed, kneeling upon a ridged tin roof, 
 which caused paralysis of the muscles supplied by the anterior tibial 
 nerve; paralysis of the nerve after its exit from the pelvis may also be 
 due to rheumatic influences (exposure to wet or cold). In rare cases, lead 
 palsy or paralysis after acute infectious diseases may involve the muscles 
 supplied by the sciatic, the former being restricted almost exclusively to 
 the distribution of the anterior tibial nerve (extensors of the foot). Fi- 
 nally, a few cases have been reported in which paralysis occurred in the 
 distribution of the sciatic nerve as the result of version by the foot during 
 transverse presentation. I once saw a case of this kind in consultation, in 
 which the paralysis was bilateral, and in which the accoucheur confessed 
 tliat he had used great violence during version. In this case, however, 
 the other nerves of the lower limbs were also paralyzed, and it seemed to 
 me probable that the lesion consisted of a hemorrhage around the cauda 
 equina. 
 
 Paralysis of the branches distributed to the biceps, semi-membranosus 
 and semi-tendinosus, causes loss of the power of flexion of the leg upon 
 the thigh. When the biceps contracts alone, it produces slight rotation 
 of the leg outward; contraction of the semi-membranosus causes slight 
 rotation inward. These movements are also lost in paralysis of the nerve 
 above its bifurcation. 
 
 Paralysis of the internal popliteal gives rise to well-marked symp- 
 toms. Paralysis of the gastrocnemius, soleus, and plantaris causes loss 
 of the power of raising the heel from the floor in walking, and therefore 
 interferes very materially with locomotion. In severe forms contracture 
 of the opposing extensor muscles of the foot develops, and gives rise to 
 the production of talipes calcaneus. After this condition has continued 
 for a long time, changes occur in the joint surfaces, but the consideration 
 of these symptoms belongs to the orthopedic surgeon. Paralysis of the 
 tibialis posticus interferes with extension of the tarsus upon the leg, 
 inversion of the sole of the foot, and adduction of the foot. This gives 
 rise to the production of calcaneo-valgus. Paralysis of the flexor longus 
 digitorum and flexor longus pollicis causes loss of the power of flexion 
 of the second and third phalanges. When the small muscles of the sole of 
 the foot are paralyzed, their function is undoubtedly lost, but we possess 
 such little voluntary power over the individual muscles, and the latter are 
 so much engaged in the performance of reflex acts, that it is difficult and 
 in many cases impossible to differentiate the action of one from the other. 
 The muscles supplied by the internal popliteal are almost invariably par- 
 alyzed together. 
 
PERIPHERAL PARALYSIS. 
 
 24^ 
 
 Paralysis of the external popliteal is much more frequent than that 
 of the internal popliteal or of the trunk of the nerve, as it is more exposed 
 on account of its position in the anterior portion of the leg. Paralysis 
 of the tibialis anticus interferes with flexion of the foot and with adduc- 
 tion to a certain extent, and also allows the antero-posterior arch of the 
 foot to sink. When contracture of the antagonists occurs, therefore, 
 pes equinus is produced. Paralysis of the extensor longus digitorum, 
 extensor pollicis proprius and peroneus tertius also interferes witVi flexion 
 of the foot, and at the same time, with abduction; contracture of the 
 antagonists therefore leads to pes equino-varus. The peronei longus and 
 brevis are extensors of the foot upon the leg, acting in combination with 
 
 Gluteus maxiimis 
 
 Sciatic nerve 
 
 Biceps (long head) 
 
 Biceps (short bead) 
 
 „| "■■s/3l:~i;'®fflS ,— Adductor magnua. 
 
 ■• •vTj^^—- — Semitendinosus. 
 
 "Semimembranosus. 
 
 Tibial nerve 
 
 Peroneal ner\'e 
 
 External head of gastrocnemius.. 
 
 Soleus _ 
 
 — Internal head of gastrocnemius. 
 
 Fig. 8. — Motor points of posterior region of thigh. 
 
 the tibialis posticus in this respect. The peroneus longus also abducts 
 the foot, and, at the same time, everts it. In addition, this muscle, as 
 Duchenne has shown, holds the transverse arch of the sole of the foot in 
 place by pressing the base of the first metatarsal bone against the adja- 
 cent bones. Its paralysis therefore gives rise to a certain degree of flat 
 foot, which becomes complete if the tibialis anticus is also paralyzed. 
 
 Diagnosis. 
 
 In these cases, also, it is often difficult to differentiate peripheral 
 paralysis from infantile paralysis limited usually to the group of muscles 
 supplied by the external popliteal nerve. It must be remembered that 
 the analogous disease may also occur occasionally in the adult, and a case 
 
248 
 
 FUNCTIONAL NERVOUS DISEASES. 
 
 of this kind has come under my notice in which it was difficult to exclude 
 the peripheral character of the affection. The differential symptoms have 
 been so often mentioned, that it is unnecessary to refer to them again. 
 
 If the entire nerve is paralyzed, and especially if the other nerves of 
 the limb are implicated, we should make a careful examination of the 
 pelvic viscera and also of the spinal column, in order to determine 
 whether the paralj'sis may not be due to an affection of these organs. 
 
 We should also be on our guard against mistaking contracture of the 
 muscles for paralysis, as such an error may be fraught with serious con- 
 
 Peroneus longus- 
 
 Tibialis anticus 
 
 Extensor longus digitorum — 
 
 Extensor brevis digitorum- 
 
 Dorsal interossel 
 
 Peroneal nerve. 
 
 External head of gastroc- 
 nemius. 
 
 ?1^: -a.....Soleus. 
 
 ■— Exten-or communis digito- 
 rum longus. 
 
 _.Peronens brevia. 
 
 g Soleus. 
 
 Plexor longos digitorum. 
 
 ^ — Extensor communis digito- 
 rum brevis. 
 
 ■Abductor minimi digiti. 
 
 Fig. 9.— Motor points of outer side of leg. 
 
 sequences in regard to treatment. A mistake of this nature can only be 
 obviated by a careful examination of the affected parts, by observing 
 which muscles are atrophied, and especially by noting the mobility of 
 the parts. When the joints are very tender, it may become necessary to 
 place the patient under ether in order to make a careful examination. 
 
 Treatment. 
 
 When the paralysis has been of longstanding, and is complicated with 
 contracture qf unparalyzed muscles and with the various forms of talipes. 
 
PERIPHERAL PARALYSIS. 210 
 
 the treatment belongs properly in tlie hands of the orthopaedic surgeon. 
 The medical treatment consists entirely of the application of electricity, 
 the current being varied according to the rules so often laid down. One 
 electrode should be placed over the nerve, the other passed along the 
 muscles. In the thigh, the nerve is readily found below the gluteal fold 
 a little to the outside of the median line of the limb (Fig. 8); in the leg 
 the external peroneal is found to the outside of the popliteal space, 
 whence it winds over the head of the tibula; the internal popliteal is a 
 little to the inside of the former (Fig. 9). The motor points of the muscles 
 are very well shown upon these figures and need no further explanation. 
 In paralysis of the anterior group of muscles, considerable improve- 
 ment in the power of walking maybe obtained immediately by the appli- 
 cation of an artificial muscle, in the manner employed by Dr. Sayre in the 
 treatment of club-foot. 
 
INDEX. 
 
INDEX. 
 
 Accommodation, paralysis of, 198 
 
 Actual cautery, 116 
 
 Acute neuritis, 1G9 
 
 Agraphia, 45 
 
 Alveolar neuralgia, 124 
 
 Angel-wing deformity, 236 
 
 Anterior crural nerve, paralysis of, 244 
 
 clinical history, 244 
 
 treatment, 245 
 Arm, combined paralysis of nerves of, 241 
 Arsenic paralysis, 184 
 Athetosis, 14 
 
 case of, 14 
 
 lesions of, 16 
 Aura, psychical, 45 
 
 sensory, 45 
 
 motor, 46 
 
 vaso-motor, 46 
 
 Bladder, chorea of, 6 
 
 case of, 6 
 Brachial neuralgia, 136 
 
 cUnical history, 136 
 
 etiology, 139 
 
 diagnosis and prognosis, 140 
 
 treatment, 140 
 Brodie's joint, 158 
 Bromide of potassium, 87 
 Bromism, 87 
 
 Carcinoma op the vertebrae, 145 
 Caries of the vertebrae, 144 
 Causalgia, 136 
 Cerebral ansemia, 109 
 Cerebro-spinal sclerosis, 35 
 Cervical caries, 134 
 Chorda tympani, course of, 203 
 Chorea. 1 
 
 clinical history, 1 
 
 etiology, IS 
 
 pathological anatomy, 24 
 
 Chorea — pathology, 30 
 
 diagnosis and prognosis, 35 
 
 treatment, 38 
 
 condition of pupils in, 7 
 
 electrical reactions in, 5 
 
 embolismic theory of, 32 
 
 thrombotic theory of, 33 
 
 experiments on production of, 30 
 
 heart-murmurs in, 6 
 
 insanity in, 8 
 
 sensation in, 7 
 
 spinal tenderness in, 7 
 
 gravidarum, 11 
 
 nutans, 1 
 
 syphilitic, 22 
 Chronic cervical pachymeningitis, 139 
 Chronic neuritis, 170 
 Ciliary neuralgia, 123 
 Circumflex nerve, i^aralysis of, 231 
 
 clinical history, 231 
 
 etiology, 231 
 
 diagnosis, 232 
 
 treatment, 233 
 Clarus hystericus, 126 
 Claw-hand, 237 
 Compression of nerves, 166 
 Congenital chorea, 18 
 Convulsive centre, 75 
 Cooper's irritable breast, 142 
 Counter-irritation, by electricity, 116 
 Crural neuralgia, 147 
 
 Degeneration-reaction, 168 
 Diet of epileptics, 86 
 Diphtheritic paralysis, 177 
 Diplegia facialis, 211 
 Diplopia, 196 
 
 Eclampsia infantum, 79 
 Electrical reactions in peripheral paralysis, 
 168 
 
254 
 
 IKDEX. 
 
 Epilepsia gravior, 43 
 Epilepsy, 43 
 
 clinical history, 43 
 
 etiology, 61 
 
 pathological anatomy, 73 
 
 diagnosis and prognosis, 77 
 
 treatment, 83 
 
 death in, 81 
 
 examination of urine in, 51 
 
 experimental pioduction of, 75 
 
 nervous discharges in, 76 
 
 sphygmographic tracings in, 48 
 
 spasm of the glottis in, 48 
 
 petechial eruption in, 48 
 Epileptic coma, 49 
 
 cry, 47 
 
 insanity, 59 
 EpUeptic paroxysms, apparent volition in, 
 
 56 
 Epileptic physiognomy, 58 
 Epileptics, marriage of, 85 
 Epileptiform neuralgia, 1 23 
 Epileptic vertigo, 54 
 Epileptogenic zone, 67 
 Epileptoid states, 56 
 Erysipelas in neuralgia, 94 
 £tat de mal epileptique, 51 
 
 Faciax, paralysis, 206 
 
 clinical history, 206 
 
 etiology, 211 
 
 diagnosis and prognosis, 213 
 
 treatment, 214 
 
 sense of smell in, 208 
 
 sense of taste in, 208 
 
 sense of hearing in, 208 
 Feigned epilepsy, 77 
 
 Galvanism in neuralgia, 117 
 Glossy skin, 137 
 Glycosuria in sciatica, 154 
 Grand mal, 43 
 
 Hair, trophic changes of, 95 
 Headache of Bright' s disease, 127 
 Hemichorea, 3 
 Hemicrania, 126 
 Heredity, 01 
 
 in neuralgia, 97 
 Herpes ophthalmicus, 123 
 
 zoster, 95 
 Hypoglossus, paralysis of, 223 
 
 clinical history, 223 
 
 Hypoglossus — diagnosis, 224 
 
 treatment, 224 
 Hysterical convulsions, 80 
 
 joints, 158 
 
 Ilio-inguinal neuralgia, 147 
 Injuries of nerves, 165 
 Insanity, epileptic, 59 
 Intercostal neuralgia, 142 
 
 clinical history, 142 
 
 etiology, 143 
 
 diagnosis, 144 
 
 treatment, 145 
 Irradiated neuralgia, 93 
 Irregidar epilepsy, 54 
 Ischsemic paralysis, 184 
 
 Joint changes in brachial neuralgia, 138 
 
 Kidneys, cirrhosis of, 79 
 Kleptomania, 56 
 
 Larvated epilepsy, 54 
 
 Laryngeal chorea, 2 
 
 Lead paralysis, 180 
 
 Ligature of the carotid in neuralgia, 120 
 
 Locomotor ataxia, pains of, 110 
 
 Lumbar neuralgia, 147 
 
 cliuical history, 147 
 
 etiology, 149 
 
 diagnosis, 149 
 
 treatment, 150 
 
 Malarial chorea, 22 
 Mammary neuralgia, 142 
 Masturbation ra epilepsy, 65 
 Median nerve, paralysis of, 234 
 
 clinical history, 234 
 
 etiology, 235 
 
 treatment, 235 
 MeduUa oblongata, lesions of, in epilepsy, 
 
 74 
 Melancholia in neuralgia, 96 
 Menopause neurosis, 100 
 Mercurial paralysis, 184 
 Migraine, 126 
 Morbus coxae, 158 
 
 Motor oculi communis, paralysis of, 197 
 Multiple neuritis, 170 
 Multiple sclerosis, 35 
 Muscular rheumatism, 108 
 Musculocutaneous nerve, paralysis of, 233 
 
 clinical history, 233 
 
INDEX. 
 
 255 
 
 Musculo- spiral nerve, paralysis of, 238 
 
 clinical liialory, 288 
 
 diagnosis, 239 
 
 treatment, 239 
 Myalgia, 108 
 
 Nails, trophic changes of, in neuralgia, 
 
 95 
 Nerves, compression of, 1G6 
 
 injuries of, 165 
 Nerve-stretching, 120 
 Nervous discharge, 76 
 Neuralgia, 91 
 
 clinical history, 91 
 
 etiology, 97 
 
 pathology, 105 
 
 diagnosis and prognosis, 108 
 
 treatment, 112 
 
 Anstie's theory of, 105 
 
 Uspensky's theory of, 106 
 
 Benedikt's theory of, 107 
 
 motor complications, 93 
 
 vaso-motor complications, 94 
 
 secretory complications, 94 
 
 trophic complications, 94 
 
 periodicity of, 91 
 Neurectomy, 120 
 Neuritis, acute, 169 
 
 chronic, 170 
 
 ascendens, 174 
 
 multiple, 170 
 Neurotomy, 120 
 
 Obturator nerve, paralysis of, 243 
 
 clinical history, 243 
 
 etiology, 243 
 
 treatment, 244 
 Occipital neuralgia, 132 
 
 clinical history, 132 
 
 etiology, 133 
 
 diagnosis and prognosis, 134 
 
 treatment, 134 
 Ocular muscles, paralysis of, 196 
 
 general remarks, 196 
 
 etiology, 199 
 
 diagnosis and prognosis, 200 
 
 treatment, 201 
 Orchiepididymitis, neuralgia in, 104 
 Osteocopic pains, 109 
 Oxyokoia, 208 
 
 Painful points, 92 
 
 Pains of locomotor ataxia, 110 
 
 Paralysis agitans, 36 
 
 after arsenical poisoning, 184 
 
 after mercurial poisoning, 184 
 
 df rigor e, 176 
 
 definition of, 1G3 
 
 diphtheritic, 177 
 
 following infectious diseases, 177 
 
 following typhoid fever, 179 
 
 ischasmic, 184 
 
 in children, diagnosis of, 187 
 
 in chorea, 3 
 
 lead, 180 
 
 of the fourth nerve, 199 
 
 of the nerve of mastication, 203 
 
 of the ocular muscles, 19G 
 
 of the sixth nerve, 199 
 
 of the third nerve, 197 
 
 reflex, 174 
 
 rheumatic, 176 
 
 syphilitic, 186 
 
 toxic, 180 
 Paresis, definition of, 163 
 Patheticus, paralysis of, 199 
 Periodicity of neuroses, 92 
 Petit mal, 52 
 Perineuritis, 171 
 Peripheral paralysis, 163 
 
 clinical history, 163 
 
 diagnosis and prognosis, 187 
 
 treatment, 192 
 Physiognomy, epileptic, 58 
 Points apophysaires, 92 
 Pott's disease, 144 
 Post-hemiplegic chorea, 13 
 
 lesions of, 13 
 Pregnancy, chorea of, 11 
 Pre-hemiplegic chorea, 13 
 Prodomata, epileptic, 44 
 
 remote, 44 
 
 immediate, 45 
 Prophylaxis of neuralgia, 113 
 Prosopalgia, 122 
 Psychical degeneration, epileptic, 59 
 
 disturbances, transitory, in epileppy, 
 59 
 Psychoses, epileptic, 60 
 Ptosis, 197 
 Puncta dolorosa, 92 
 
 theory of, 107 
 Phrenic nerve, paralysis of, 230 
 
 clinical history, 230 
 
 treatment, 230 
 
256 
 
 INDEX, 
 
 Reflex epilepsy, 66 
 
 neuralgia, 103 
 
 paralysis, 174 
 Rheumatic paralysis, 176 
 Rheumatism and chorea, 20 
 
 Sciatica, 151 
 
 clinical history, 151 
 
 etiology, 154 
 
 diagnosis and prognosis, 157 
 
 treatment, 159 
 Sciatic nerve, paralysis of, 245 
 
 clinical history, 245 
 
 diagnosis, 247 
 
 treatment, 248 
 Serratus magnus, paralysis of, 225 
 
 clinical history, 225 
 
 etiology, 227 
 
 diagnosis and prognosis, 236 
 
 treatment, 229 
 Skin, atrophj^ of, 94 
 
 hypertrophy of, 94 
 Skull, malformation of, in epilepsy, 73 
 Sleep-states, 57 
 Spinal accessory, paralysis of, 218 
 
 clinical history, 218 
 
 etiology, 220 
 
 diagnosis and prognosis, 220 
 
 treatment, 221 
 Spinal hemiplegia, peripheral, 188 
 
 irritation, 109 
 Spinous points, 92 
 
 Spondylitis deformans, 133 
 Status epilepticus, 51 
 
 convulsive stage, 51 
 
 meningitic stage, 52 
 
 temperature in, 52 
 Sweating, epUeptic, 57 
 Sympathetic system in epilepsy, lesions of, 
 
 74 
 Syphilitic epilepsy, 71 
 Syphilitic paralysis, 186 
 
 Tic douloureux, 122 
 Toxic paralysis, 180 
 Trachelismus, 47 
 Trephining, 83 
 Trigeminal neuralgia, 122 
 
 clinical history, 122 
 
 etiology, 124 
 
 diagnosis and prognosis, 126 
 
 treatment, 127 
 Trochlearis, paralysis of, 199 
 
 Ulnar nerve, paralysis of, 236 
 clinical history, 236 
 etiology, 237 
 treatment, 237 
 
 Vertebra, caries of, 144 
 
 carcinoma of, 145 
 Vertigo, epileptic, 54 
 
 in ocular paralysis, 197 
 
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