^°H^rT^H'ts*Hi:i?^S' 'HX64i 23707 RC341 .P31 1904 a practical treatise intl)eCttpofJlm|ork CoUege of ^fjpsiiciang anb ^urgcong Hibrarp A PRACTICAL TREATISE ON NERVOUS DISEASES Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/practicaltreatisOOpear < ■ ^ r— 1J A PRACTICAL TREATISE ON NERVOUS DISEASES FOR THE MEDICAL STUDENT AND GENERAL PRACTITIONER BY F. SAVARY PEARCE, M.D. PROFESSOR OF NERVOUS AND MENTAL DISEASES IN THE MEDICO-CHIRURGICAL COLLEGE OF PHILADELPHIA; FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; NEUROLOGIST TO THE PHILADELPHIA AND HOWARD HOSPITALS; MEM- BER OF THE AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION, AND OF THE AMERICAN CLIMATOLOGICAL ASSOCIATION; CHAIRMAN OF SECTION ON NERVOUS AND MEN- TAL DISEASES OF THE AMERICAN MEDICAL ASSOCIATION COLOURED FRONTISPIECE NINETY-ONE ILLUSTRATIONS IN THE TEXT, MANY IN COLOURS NEW YORK AND LONDON D. APPLETON AND COMPANY 19 04 Copyright, 1904, bt D. APPLETON AXD COMPANY PRINTED AT THE APPLETON PRESS NEW TORK, U. S. A. DEDICATED TO S. WEIR MITCHELL, M.D., LL.D. WHOSE LIFE HAS BEEN AN INSPIRATION FROM CHILDHOOD AND WHOSE FRIENDSHIP HAS BEEN OP VALUE SINCE EN MEDICINE PREFACE This text-book on Nervous Diseases has been written for the student and general practitioner. It has ever been the object to curtail details of the doubtful points in neurology and to make' most in small compass of practical facts in the study of nervous disorders. We believe that this is the surest method of instilling knowledge of so intricate a subject. The chapter on anatomy and physiology has been blended, so that its study will insure a pretty clear understanding of the anatomy and functions of the various parts of the nervous system. I have to thank my col- league. Prof. Isaac Ott, for the physiological details given. I beg to acknowledge, among many other authorities, special reference to the works of Gowers, Mills, Dana, Barker, Osier, and Striim- pell, to the latter three of which the author is also indebted for several cuts, for which credit is given in the text. I gratefully acknowledge the kindness for the use of illustrations from The Diagnostics of Internal Medicine, by Dr. G. E. Butler, and Acci- dent and Injury, by Dr. Pearce Bailey, respectively; also to Dr. M. K. Kassabian and Dr. G. E. Pfahler for the X-ray produc- tions and some of the photographs. It is the purpose of the author to follow this contribution by a similar treatise on Mental Diseases, so that the two works can be used in consonance by the medical student and busy practi- tioner. F. S. P. 1409 Locust Street, Philadelphia, Pa, CONTENTS CHAPTER I PAGE Section I. — Anatomy : Classification of Nerves — Nerve centres . 1 Nerve cells — varieties 2 Nerve fibres — incisions of Lautermann 4 Arrangement of nerve fibres 5 Nerve centres in general . 5 Differentiation of tracts (three methods) 9 Names of tracts 11 to 13 Degenerations . ." 13 Tracts of descending degeneration ....... 13 and 14 " ascending " 14 and 15 Medulla oblongata 15 and 16 Centres in medulla 17 Pons Varolii, etc 17 and 18 Cerebral peduncles .18 Capsules of brain 91 Cerebellum . . . 19 and 20 Cerebrum 20 and 21 Optic thalami 21 and 21 Corpora quadrigemini, etc. 22 Corpus striatum 23 Membi-anes of brain and cord 22 Section II. — Physiology : ^ Functions of spinal cord 22, 23 and 24 Pfluger's laws 24 Inhibition of reflexes ■ 24 Brown-Sequard on reflex activity . " 25 Reflexes of spinal cord 25 and 26 Excitability of spinal cord . 26 and 27 Paths of spinal cord 27 and 28 Nerve-fibres, functions of 28 Irritability and stimuli of nerves .... 29, 30, 31 and 32 Transmission of nerve impulses > . . . . . . .33 Relay stations of motor and sensory fibres 33 Chemical and mechanical properties of nerve substance ... 33 Physiology of the cerebellum 33 and 34 CONTENTS Section II. — Physiology: Functions of medulla .... " " pons Varolii . . , " " cerebral peduncles " " corpora quadrigemina . " " corpora striata " " optic thalami The capsules, functions of, etc. . Functions of cerebral hemispheres Sleep and waking .... H3-pnotics Strength and liminal intensity of stimuli Weher-Fechnef s law .... After sensations .... Functions of the sympathetic system Other non-nervous tissues (blood-vessels, neuroglia) Section III. — Chemistry 39 34, 85 and 36 . 36 . 36 36 and 37 37 and 38 . 38 38 and 39 40 and 41 42 and 43 . 43 . 43 45 and 46 . 46 . 46 . 47 47, 48 and 49 CHAPTER II General pathology 50 Sclerosis 50 Degenerations . . .50 and 51 Gliosis 51 Inflammations (varieties) 51, 52 and 53 CHAPTER III General symptoms and methods of examination, diseases Guide to note-taking The reflexes recapitulated .... Trophic, vaso-motor and secretory phenomena Examination of the patient .... Gait and station (Romberg's sign) Grasp — dynamometer .... Pathologic gaits Physiognomy Temperaments Decubitus .. = ... Examination for sensation (aBsthesiometer) " " motion Contraction and contracture . Hemiplegia, monoplegia, paraplegia, diplegia Ataxic and other movements, static ataxia . Table of tremors nomenclature in nervous 54 and 57, 58, 59 60 and 61 and 56 55 61 62 . 62 . 62 . 63 63 and 64 . 64 65 64 and 65 and 67 67 67 68 68 CONTENTS xi PAGE Conjugate deviation 69 Pressure sense 69 Muscular sense . . . . ^ 69 Weight sense 69 and 70 Sensations of motion 70 Ocular disturbances 70 and 71 Colour changes 71 Pupillary symptoms (Argyll Robertson pupil) . . .71, 72 and 73 Hearing, smell, taste 73 and 74 Reflexes again studied 74, 75, 76 and 77 Surface temperature 77 " " in erythromelalgia 77 " thermometer (Mattson's) 77 CHAPTER IV General therapeutics and prevention of nervous disease, and the acquire- ment of nervous health , . : . . . . . . .77 Hygiene . . . " 78, 79, 80 and 81 Exercise 81 and 82 Hydrotherapeutics in nervous diseases 82 and 83 Turkish bathing 82 and 83 Details of Turkish bath 83 and 84 Charcot douche, Scottish douche 85 Drip sheet , 86 Massage — five sets of movements in 86 and 87 How to " rub " a patient 88 and 89 Salient points of massage 89 and 90 Contra-indicatiqns to massage 90 Muscular movements 90 Exercises for hands and feet 90 and 91 " " body and lower limbs 91 and 92 Electricity 92 Physics of . . ' . 92 and 93 Physiology of , . . 92 and 93 Diagnosis and prognosis by 94 Quantitative change 94 and 95 Qualitative " 95 Reaction of degeneration and examination for . . .95 and 96 Generation of electricity for practical therapy .... 97 Some practical indications for galvanism . . . .97 and 98 Regulations of galvanic current — axioms ... 99 and 100 Stabile — labile — nodal point and sinusoidal current . . . 160 Faradic electricity (induction current) 101 Uses of Faradic electricity 102 and 103 Franklin or static electricity , . . , . . . 105 xii CONTENTS PAGE Hypnotism 105 and 106 " Rest " treatment of Weir Mitchell .... 107 and 108 Object of the " rest " treatment ....... 103 Care and treatment in convalescence from functional nervous' disease 108 and 109 Physical care, adjunctsand medication . . 110, 111 and 112 Climatology of nervous disease = . . . ... . 113 CHAPTER V Symptomatic disorders 114 Vertigo 114 and 115 Insomnia ' . . 116 and 117 Neuralgia 118 Facial neuralgia 118 Tic douloureux 118 and 119 Intercostal jaeuralgia 119 and 120 Sciatic neuralgia 120 Anterior crural neuralgia 120 Visceral neuralgia 121 Neuralgia of heart (angina) 121 Headache 121 " causes of 122 " megrim . . 132 and 123 Meniere's disease 124 and 125 CHAPTER VI Diseases of the cranial nerves 126 Olfactory nerve 126 Optic nerve . . . . . ■ 126 and 127 Oculomotor nerve 128 Patheticus (or fourth nerve) 129 Trifacial n. '. . 129 Abducens n * . 129 and 130 Facial n 130 and 131 Auditory n. 131 and 132 Grlosso-pharyngeal n 132 Pneumogastric n. 133 Spinal accessory n 133 and 134 Hypoglossal n 135 and 136 CHAPTER VII Diseases of peripheral nerves ...,.,... 136 Origin of nerves 136 Pathology of nerves 137 Neuritis , , . 137, 138 and 139 CONTENTS xiii PAGE Multiple neuritis, special forms of 140 Recurrent multiple neuritis 144 Leprous neuritis 144 and 145 Sciatic neuritis 145, 146 and 147 Tumours of nerves . ' 149, 150 and 151 CHAPTER VIII Diseases of other spinal nerves 152 Cervical plexus 152 Long or posterior thoracic n 153 and 154 Cervico-occipital neuralgia 155 Infrascapular nerve 155 Musculo-spiral nerve 155, 156 and 157 Ulnar nerve 157 and 158 Median nerve 158 and 159 Combined palsies of nerves of arm 160 and 161 Brachial neuritis ■_ . . . 161 and 162 Nerves of the trunk 163 " " " lower extremity 164 Anterior crural n 164 and 165 Obturator n 165 Superior gluteal n. , . . . " 165 Great sciatic n. . 165 and 166 Internal popliteal n. 166 Metatarsalgia {Morto7i's disease) 166 and 167 Rhizomelique spondylitis 168 to 170 CHAPTER IX Diseases of membranes of brain . . . -. 171 Pachymeningitis externa 171 Meningitis ... 171 and 172 Acute cerebral pachymeningitis .... 172, 173 and 174 Cerebral pachymeningitis haemorrhagica (or haematoma dura) 175 and 176 Cerebral leptomeningitis 177 Hydrocephalus (acute and chronic) .... 177, 178 and 179 Meningitis serosa 182 CHAPTER X Diffuse and local disease of brain 183 Cerebral localization (epitomized) 183 Occipital lobe .._... = . o .. . 183 Temporal lobe 184 and 185 Prefrontal region 186 Centrum ovale 186 Corpus callosum . . • 186 " striatum ...,,,,,., 186 XIV CONTENTS PAGE Optic thalamus 186 Internal capsule 187 Crus cerebri . 188 Pons or bulb 188 Cerebellum 188 Medulla oblongata 188 Aphasia (varieties) 189, 190 to 194 CHAPTER XI Other diseases of brain and membranes General symptomatology Malformations of brain and membranes Meningocele Apoplexy (cerebral hfemorrhage) " diagnosis .... " prognosis .... " treatment and nursing Encephalitis Brain tumour (cerebral neoplasm) " symptoms and localization " pathology, diagnosis, prognosis and treatment 198, . 195 . 195 196 and 197 197 and 198 199, 200 and 204 .' 205 . 205 205 and 206 307 and 208 209 and 210 210 and 211 211 and 212 CHAPTER XII Inflammations of membranes of cord and unclassified diseases . . . 213 Inflammations of spinal dura (pachymeningitis) . 213, 214 and 215 " " " pia (leptomeningitis) . . . 215 and 216 Caisson disease (divers' disease) 217 and 218 Landry's disease (acute ascending paralysis) . . . 219 and 220 CHAPTER XIII Diseases of the spinal cord 221 General considerations 221 Special diseases 222 Malformations : Heteropia, meningocele, amyelia, double cord, split- ting of cord, agenesis, micromyelia . . 223, 224, 225 and 226 System diseases (sensory and motor neurons) . . . = . 226 Locomotor ataxia (tabes) ; (symptoms, diagnosis, prognosis and treatment) . . " 226, 227 to 233 Primary lateral sclerosis 234 to 236 Spastic spinal paralysis 236 to 238 Hereditary spastic spinal paralysis 238 Friedreich's disease (hereditary ataxia) .... 238 and 239 Cerebellar ataxia 240 Functional disorders of spinal cord . , 240 Cauda equina — diseases of 241 and 242 CONTENTS XV CHAPTER XIV PAGE Diffuse and local disease of spinal cord . . . . . , . 243 Spinal anaemia ; spinal haemorrhage (spinal apoplexy) . . . 244 (1) Haematorrhachis ; (2) hasmatomyelia. .... 244 to 247 Syringomyelia 247, 248 and 249 Muscular dystrophies (varieties) . , = . . 250 to 252 (1) Pseudohypertrophic paralysis . . , . 250, 251 and 252 (2) Idiopathic muscular atrophy 252 (a) (Pacio-scapulo-humeral) 252 (b) (Juvenile form of Erb) 254 (3) Neuritic type 254 and 255 Anterior poliomyelitis acuta (infantile palsy) . . 255, 256 and 257 Glosso-labio-phai'yngeal palsy (bulbar palsy) ; (1) acute ; (2) chronic ; (3) asthenic ; (4) pseudo 257 and 258 Combined scleroses 260 (1) Hereditary ataxia (see p. 238) 260 (2) Type of Putnam-Lichthein-Dana . . • . . . 260 to 262 Myelitis : Causes, types, symptoms, prognosis, pathology and treat- ment . . . 262, 263, 264 to 266 CHAPTER XV Diffuse diseases of brain and cord 267 Multiple or insular sclerosis : Symptoms, diagnosis, prognosis and treatment 267, 268 and 269 Paralysis agitans (Parkinson's disease) . . . 269, 270, 271 and 272 Nervous syphilis 272 General considerations 272 Pathology 273 and 274' Diagnosis 275 Pi'ognosis 275 Treatment 275 and 276 CHAPTER XVI General and functional nervous diseases 277 Classification 277 Chorea minor (St. Vitus's dance) : Types, symptoms, diagnosis, prognosis and treatment 278 to 282 Habit chorea (habit spasm) 283 and 284 Hereditary chorea {Huntingdon's disease) . . 284, 285 and 286 Convulsive tic {Giles de la Totirette's disease) . . . 286 and 287 Saltatory spasm (jumpers' disease) 287 and 288 Myotonia congenita (Thomsen's disease) .... 288 and 289 Epilepsy 289 and 290 Definition, aetiology, symptomatology, pathology, diagnosis, prognosis and treatment 289 to 295 Neurasthenia (nervous exhaustion) 295 xvi COJS' TENTS PAGE Symptoms, astiology., pathology, diagnosis, prognosis and treat- ment . 295 to 302 -Hysteria 302 Symptoms, aetiology, pathology, diagnosis, prognosis and treat- ment 302 to 308 Traumatic hysteria (railway spinej 308 Symptoms, aetiology, diagnosis, prognosis and treatment . 309 to 312 Saltatory spasm 312 Salaam convulsions 312 Writer's cramp (artisan's jaalsy) : Symptoms, types, prognosis, treat- ment 313 and 314 CHAPTER XVII Vasomotor and trophic disorders 316 Exophthalmic goitre (Graves' disease) : Causes, symptoms, prog- nosis and treatment 316 to 319 Glass-blowers' disease 319 Sudden changes in the hair 320 and 321 Hyperostosis cranii (cephalomegaly) 333 and 324 Adiposis dolorosa 324 and 325 Facial hemiatrophy 326 " hemihypertrophy 326 Dermatitis gangrenosa nervosa 327 and 328 Mysoedema and cretinism . . . . . . . 328 and 329 Scleroderma . 329 and 330 Ainhura 330 Acromegaly .......... 331 to 333 Hypertrophic pulmonary osteo-arthropathy . . . 333 and 334 Arthritis deformans (rheumatoid arthritis) 334 to 340 Heat exhaustion 340 and 341 Sunstroke (insolation) ~. . 341 and 342 Myasthenia gravis 342 and 343 Family periodic paralysis 343 and 344 CHAPTER XVIII General toxsemic diseases of the nervous system 845 Hydrophobia (rabies) ........ 345 and 346 Tetanus (lockjaw) 347, 348 and 350 ■ Tetany (tetanilla) , . 350, 351 and 353 . CHAPTER XIX Drug intoxications 354 Alcoholism (alcoholic insanity) . . . . . 354, 355 and 356 Tobacco poisoning 356 and 357 Tea and coffee poisoning. 357 CONTENTS xvii PAGE Lead, mercuiy, and arsenic poisoning .... 357 and 358 Opium poisoning 358 and 359 Cocaine liabit 359 and 360 Coal-tar-products intoxication 360 and 361 CHAPTER XX General paresis (paresis) : Types : symptoms, aetiology, pathology, diag- nosis, prognosis and treatment 362 to 366 Syphilitic pseudo-paresis 366 Alcoholic pseudo-paresis 366 Treatment of all forms 368 APPENDIX Disorders of sleep 369 (a) Wakeful disorders 370 and 371 (h) Somnolent " 372 and 373 Additional figures 373 to 384 Tables 385 and 386 Formulary 387 to 390 LIST OF ILLUSTRATIONS FIG. PAGE Ervthromelalgia of right foot Frontispiece 1. The neurone (diagrammatic) . . . 3 2. Functions of the fibres of the anterior and posterior roots, etc. . . 6 3. The parts and columns of the spinal cord, and some of the diseases which affect them 6 4. Tracts of the spinal cord and their varied nomenclature ... 8 5. Functions of the various tracts of the spinal cord 10 6. The relation of the segments of the spinal cord, etc., to the spinous processes of the vertebrae . . . 12 7. Sensory pathways 44 8. Motor pathways 45 9. The relation of the spinal cord to the dorsal surface of the trunk, etc. 47 10. Position of hand in local tonic hysterical spasm 56 11. Krauss's plessimeter 57 12. The Jendrassik method of obtaining the knee-jerk .... 58 13. Taylor knee-jerk hammer 59 14. Showing the method of obtaining the triceps and supinator jerk. . 60 15. Weir Mitchell's apparatus for clinical observations of station . . 62 16. Dynamometer 62 17. Hand-dynamometer 63 18. Carroll's ^sthesiometer 66 19. Diagram of visual paths 73 20. Mechanism of deep reflexes ; also the two main types (spastic and flac- cid) of paralysis 75 21. Complete galvanic dry-cell battery 100 22. Combination dry-cell galvanic and faradic battery .... 101 23. Complete electric cabinet . . . 102 24. Static machine and complete series of electrodes 104 25. Congenital nystagmus 128 26. Facial palsy, left side 130 27. Attitude in spasmodic torticollis 184 28. Supranuclear palsy of the right hypoglossal nei've .... 135 29. Bedridden case of multiple neuritis 141 30. Wrist drop from musculo-spiral alcoholic pressure palsy . . . 157 31. Distribution of the sensory nerves of the skin of the arm, anterior aspect 159 33. Distribution of the sensory nerves of the skin of the arm, posterior aspect . 159 xix XX LIST OF ILLUSTEATIOXS 33. Distribution of the sensory nerves of the skin of the leg, posterior aspect 34. Distribution of the sensory nerves of the skin of the trunk and leg, anterior aspect 35. Distribution of the sensory nerves of the skin of the trunk, posterior aspect 36. Distribution of the sensory nerves of the skin of the foot 37. Ehizomelique spondylitis 38. Haemorrhagie pachymeningitis interna (alcoholic) 39. Brain ; case of hydrocephalus in a child of five years . 40. Spastic diplegia from chronic hydrocephalus (adult male) . 41. Schematic reiDresentation of the cerebral cortex and its centres . 42. View of the right cerebral hemisphere from the median side 43. Diagram of motor and sensory representation in the internal capsule 44. Zones and centres. External aspect. Cerebrum .... 4*5. Zones and centres. Mesal aspect. Cerebrum .... 46. Fleehsig"s association areas, lateral aspect . * . 47. " *■ " mesal aspect 48. Lack of development. Left half of cerebrum .... 49. Arteries at the base of the brain 50. The portions of the cerebral hemisphere supplied by the anterior middle and posterior cerebral arteries 51. Area of thrombosis and haemorrhage motor area cerebrum. X-ray photograph 52. Hyperpyrexia in cerebral haemorrhage ; male, aged sixty-one years 53. Chronic cervical tubercular external pachymeningitis . 54. Atrophy of interossei, thenar and hypothenar muscles of both hands 55. Agenesis and micromyelia of spinal cord in a male aged forty years • 56. Standing posture, static ataxia in tabes dorsalis .... 57. Charcot joints in tabes 58. Tumour (psaramoma) springing from dura, lower dorsal cord 59. Atrophy of intrinsic muscles of the hand with thermo-aneesthesia 60. Pseudohypertrophic paralysis showing atrophy of shoulders, girdle and thighs 61. Progressive muscular atrophy of spinal origin 62. Combined sclerosis of the type Putnara-Lichthein-Dana, followed by left hemiparesis 63. Expression " pill-rolling" hands and attitude in paralysis agitans 64. Communications of the nervous system to the genital organs 65. Hysterical paralysis; braces and wheel-crutch applied to assist in walking 66. Exophthalmic goitre. Prominent eyes and thyreoid gland 67. Trophoneurosis of the hair, showing change from dark to white 68. Universal alopecia of nervous origin .... 69. Hyperostosis cranii 70. Skull-cap from same case of hyperostosis cranii . 71. Adiposis dolorosa in a colored woman .... 72. Dermatitis gangrenosa nervosa, showing scars on left hand 159 162 164 167 169 176 180 181 184 185 187 190 192 193 194 197 199 200 201 203 214 216 225 • 228 230 241 248 251 253 2G1 269 296 306 316 320 321 322 323 325 327 LIST OF ILLUSTEATIONS xxi FIG. PAGE 73. Sporadic cretinism 328 74. Acromegaly in a woman, showing enlarged supra-orbital ridges, infe- rior maxilla and hands 332 75. Agglutination of patella to tibia and subluxation of knee in rheuma- toid arthritis ; X-ray photograph 335 76. Erosion joints of hands, Rlieumatoid arthritis. X-ray photograph . 33G 77. Hheumatoid arthritis with contractures 338 78. Rheumatoid arthritis, after operation and braces are applied . . 339 79. Paretic dementia, ordinary type, second stage 363 80. Spastic and athetoid movements in face, tongue, and pharyngeal muscles 373 81. Attitude in a case of general athetosis in cerebral palsy of childhood 374 83. Secondary contractions of face, arm, hand, foot, and leg in case of chronic left hemiplegia 375 83. Tumour (endotheliouia), inner surface cerebral dura .... 376 84. Horizontal linear light shadow (radiograph), showing result of specific meningitis and erosion of inner plate of parieto-frontal bones . 377 85. Showing motor points (head and neck) 378 86. Showing motor points (shoulder and arm) anterior aspect . . . 379 87. " " " " " " posterior "... 380 88. " " " (leg) . .381 89. Showing the effects of various lesions of the motor path in the brain and spinal cord 382 90. Diagram of skin areas corresponding to the different spinal segments (anterior aspect) 383 91. Diagram of skin areas corresponding to the different spinal segments (posterior aspect) 384 A PRACTICAL TREATISE ON NERVOUS DISEASES CHAPTEE I GENERAL ANATOMY, PHYSIOLOGY, AND CHEMISTRY OF THE NERVOUS SYSTEM Section" I. — Anatomy The structure of the nervous system may be distinctly divided into five parts, as follows : 1. ISTon-medullated nerve-fibres. 2. Mednllated nerve-fibres. 3. Neuroglia. 4. Supporting connective-tissue framework^ besides the neu- roglia. 5. Nerve-cells. Classification of Nerves. — Nerve-fibres may be classified into three main groups, according to the direction in which they con- vey normally nervous impulses. These three divisions are: 1. Efferent nerve-fibres. 2. Afferent nerve-fibres. 3. Intercentral nerve-fibres. Ejferent or centrifugal nerves are those which conduct nerv- ous impulses from the central nervous system (brain and spinal cord) to other parts of the body. Afferent or centripetal nerves are those which conduct nervous impulses in the opposite direction — namely, from all parts of the body to the central nervous system. Intercentral nerves are those nerves which connect nerve-cen- tres together; they connect different parts of the brain and of the cord to one another. Nerve-Centres. — Nerve-centres are composed of white and gray matter. In the brain the gray matter is on the outside, and in 1 1 2 TEEATISE ON NEEYOUS DISEASES the spinal cord it is on the inside. The white matter is made up of nerverfibres, and the gray matter of cells and an interposing cement substance called neuroglia. It is expedient to here explain Avhat is meant by the neuroglia. This is the cementing tissue ol the nervous system, of ectod.ermic origin — differing from connect- ive tissue, which is solely derived from the mesoderm — and in the spinal cord it arises in part from the pia mater and passes into the white matter, carrying with it blood-vessels, and forming ssepta which separate the nerve-fibres into bundles. Neuroglia proper is made up of a delicate reticulum, holding in its meshes the small glia cells. Nerve-Cells. — Nerve-cells differ greatly in size and shape. The nucleus is generally large and spherical, containing a dis- tinct nucleolus. They may be roughly divided into three groups, according to the number of protoplastic processes they possess, into imijwlar, bipolar^ and multipolar cells. Unipolar cells are found in the spinal ganglia. They are spherical in shape, are inclosed in a nucleated sheath, and the single process after a short course joins one of the nerve-fibres traversing the ganglion by a T-shaped junction. Bipolar cells are cells with two branches or processes. The embryonic condition of the cells of a spinal ganglion is one ex- ample of these. Multipolar Cells. — Here the cell becomes angular or stellate. It was formerly thought, in some instances, as in the cells of the sympathetic ganglia, that all the processes become nerve-fibres, but this is not so, for here, as well as in the large cells of the gray matter of the spinal cord, only one process becomes the axis cylin- der of a nerve-fibre, the others dividing and subdividing in a ramified manner until they end in an arborescence of fine twigs. The nerve-cell is the fundamental characteristic unit of the gray matter, and is known as a neuron (Waldeyer, 1891). Some of these cells are coloured or pigmented, such as in the locus niger, where they are black; nucleus ruber, where they are red, as its name would imply, etc. Every nerve-cell has an axis-cylinder proc- ess, which has been variously called the axis cylinder, neurit, ax- one, or neuraxon. The protoplasmic prolongations of the nerve- cells are called dendrons. According to the number of these proc- esses, the nerve-cells are termed, as before stated, unipolar, bipolar, and multipolar. DENDRITES' N E U R N B ^ Carry impulses to the cell Degenerate if separated from It Is the container and generator of nerve force Is trophic for dendrites and axones Carries impulses from the cell body Degenerates if separated from it A " Upper or cerebral motor NEURONE Exercises an inhibitory con- trol OVER B ( Intermingles but does not unite with ■< dendrites of neurone, to which it ( carries impulses 6 = Lower OR peripheral mo- tor NEURONE Exercises trophic influence OVER AND maintains TONUS of muscles End organ In muscular fibre Fig. 1. — The neurone (diagrammatic). (From Butler's Diagnostics of Internal Medi- cine, 1902.) 4 TREATISE OX XERVOUS DISEASES The nerve-cells vary from ^o¥ ^° j¥o of an inch in diameter. The lai'gest nerve-cells are found in the anterior horns of the spinal cord and in the vicinity of the fissure of Rolando. Nerve-Fibres. — The nervous system is composed of two parts — the central nervous system and the peripheral nervous system. The central nervous system consists of the brain and the spinal cord: the peripheral nervous system consists of the nerves which conduct the nervous impulses to and 'from the central nervous system^ and thus bring the nerve-centres in relation with other parts of the hody. Xerve-fibres are of two histological kinds, viz., medullated and non-medullated. Medullated nerve-fibres are found in the white matter of the nerve-centres and in the nerves originating from the brain and spinal cord. Xon-medullated nerve-fibres occur in the sympathetic system. The medullated or vjlvite fibres are characterized by the sheath of white colour, fatty in nature, and stained black with osmic acid; it is called the medullary sheath or white substance of Schwann; this ensheaths the essential part of the fibre, which is a process from a nerve-cell, and is called the axis cylinder. Ac- cording to Piersol, the axis cylinder is covered by a thin, trans- parent, elastic sheath, called the axilemma. The substance of Schwann is ensheathed by a thin, homogeneous membrane of an elastic nature, called the neurilemma. The axis cylinder is made up of a number of small fibrils, which are held together by a cement substance called the neuroplasm. Along the course of a medullated nerve-fibre there are numer- ous constrictions called the annular constrictions or nodes of Ran- vier. At these constrictions the neurilemma lies in direct conta-ct with the axis cylinder of said nerve. According to some author- ities, the axilemma lies interposed. The stretch of nerve between two nodes is called an internode, and in the middle of each node is a nucleus which belongs to the primitive sheath. The nucleus is not necessarily always in the middle, for in some cases it is found to be variously distributed. Incisures of Lantermann. — In each interannual segment in a nerve that is stretched there will be noticed a number of oblique lines running across the white substance of Schwann. This indi- cates that the segments of Schmidt are built up of a series of conical sections, each of which is bevelled at its ends, while the AXATOMY, PHYSIOLOGY, AXD CHEMISTRY 5 sHglit interval between them appears as an incisure of Lanter- mann. The iibres of the nerve-centres differ from the preceding in that they have no neurilemma and no annular constrictions. When a nerve enters the spinal cord or brain it loses its neurilemma. The non-meduHated fibres or filjres of Remak have no medul- lary sheath, and are therefore devoid of the double contour of the medullated fibres, and are unaffected in appearance by osmic acid. They consist of an axis cylinder covered by a nucleated fibrillated sheath. These nerves branch very frequently. They are princi- pally found in the sympathetic system, a few being found in the spinal nerves mixed with the medullated fibres. Arrangement of Nerve-Fibres. — The arrangement of nerve- fibres is best seen in transverse section. The nerve is composed of a number of bundles of funiculi of nerve-fibres bound together by connective tissue. The sheath of the whole nerve is called the epineurium : that of the funiculi the perineurium; that which passes between the fibres in a funiculus the endoneuriurn. The size of a nerve-fibre is from -g-oVo" "to ti'Vo' ^f an inch in .diameter. Nerve-Centres in General. — The nerve-centres in general are the spinal cord, medulla ohlongata, pons varolii, cerebellum, and cerebrum. Spinal Cord. — The spinal cord is enclosed in the bony canal formed by the spinal vertebrae; it extends from the margin of the foramen magnum to the lower border of the first lumbar vertebra, terminating in a slender filament of gray substance, the filum terminale, which lies in the midst of the roots of many nerves forming the cauda equina. It does not fill the canal altogether, but is suspended in the cerebro-spinal fluid. It has two enlarge- ments, one in the cervical, the other in the lumbar region. These are the situations whence the large nerves for the supply of the limbs issue. The spinal cord is from 15 to 18 inches in length and weighs about one ounce. It is composed of white and gray matter; the white matter is situated externally, and constitutes its chief portion; the gray matter is in the interior, being so arranged that in a transverse section of the cord it appears like two crescentic masses which are connected together by a narrower portion which is known as PAIN AND TEM- PERATURE SENSE, TACTILE SENSE REFLEX AND VISCERAL Fig. 3. — Showing the functions of the fibres of the anterior and posterior roots, and their relations to the horns and columns of the spinal cord. (Redrawn and modi- fied from Dana.) Fig. 3. — Showing the parts and columns of the spinal cord and some of the diseases which aflfect them. (From Butler.) a ANATOMY, PHYSIOLOGY, AND CHEMISTRY 7 the posterior commissure. In the centre of this narrow portion is located the central canal. Directly in front of the posterior commissure is located the anterior commissure, which is composed of white matter. The spinal cord consists of two lateral halves, separated an- teriorly by the anterior median fissure, which extends from the front surface of the spinal cord to the anterior or white commis- sure. Posteriorly it is separated indistinctly by the posterior me- dian fissure, which extends from the posterior surface of the spinal cord to the posterior or gray commissure. The posterior fissure is deeper than the anterior, but it is not as wide nor is it so dis- tinct. The posterior fissure extends from the calamus scriptorius in the fourth ventricle above to the termination of the cord below. On the lateral surface of the cord are noticed two longitudinal furrows, which divide each half of the cord into three columns, viz., anterior, lateral, and posterior. From the furrow between the anterior and lateral columns spring the anterior (motor) nerves; from the furrow between the lateral and posterior col- umns spring the posterior (sensory) nerves. The cord is composed of a cortical white substance and a cen- tral gray matter. The white matter is made up of medullated nerve-fibres of different sizes, arranged longitudinally, and of a supporting material of two kinds, viz. : (a) Ordinary fibrous con- nective-tissue sgepta with elastic fibres, which is connected with ssepta from the pia mater, passing into the cord to carry blood- vessels; (h) neuroglia; the processes of the neuroglia cells are arranged so as to support the nerve-fibres which are without the usual external nerve-sheaths. The gray matter of the cord con- sists of nerve-fibres, most of which are very fine and delicate, of nerve-cells with branching processes, and of an extremely delicate network of the primitive fibrillse of axis cylinders. This fine net- work is called Gerlaclt's netioorh, and is mingled with the meshes of neuroglia. The neuroglia of the gray matter resembles that in white matter, but instead of everywhere forming a close network to support the nerve-fibres, here and there it is in the form of a more open sponge-work to support the nerve-cells. It is espo- cially well developed around ibo central canal, l)eing called here tlie suhstantia gclatinosa centralis. At the tip of the posterior horn it is also well developed, and is called suhstantia gelatinosa lateralis of Rolando. The latter is well developed in the cervical 1* MARGINAL ZONE, C OR LISSAUER'S TRACT. Fig. 4. — Showing the tracts of the spinal cord and their varied nomenclature. Red = motor (or efferent). Blue = sensory (or afferent). (Butler.) 8 ANATOMY, PHYSIOLOGY, AND CHEMISTEY 9 region. The gray substance is thicker in the lumbar and cervical regions than anywhere else. The gray substance of the horns or cornua causes the anterior horns to be thicker than the posterior. The anterior horns do not quite reach the free surface of the cord, while the posterior horns do. The groups of cells in the gray matter are either scat- tered singly or arranged in groups, of which the following are to be distinguished on either side. The nerve-cells in the anterior horn of gray matter are principally large, multipolar, ganglion cells. They are arranged as a mesial group, near the inner aspect of the horn, and an anterior and a lateral group. The column of Clarke is a column of nerve-cells situated at the junction of the posterior horn with the gray commissure. These latter cells are seen only in the thoracic portion of the cord. The smallest nerve-cells are found in the posterior horns of the cord. The fibres of the spinal cord are of two kinds — the extrinsic and intrinsic. The extrinsic fibres begin in the cerebrum of the braiii, perhaps in the cerebellum, and run down the spinal cord to cells therein. The intrinsic fibres connect different parts of 'the spinal cord with each other. Differentiation of Tracts. — The white matter can be systemat- ically divided into different tracts by the following methods of observation : 1. Emhrijological Method. — It has been found by examining the spinal cord at different stages of its development that certain groups of fibres put on their myelin sheath at earlier periods than others, and that the different groups of fibres can therefore be traced in various directions. This is sometimes called the Flechsig method. 2. Walleriaii or Degeneration Method. — This method depends upon the fact that if a nerve-fibre is separated from its nerve- cells it wastes or degenerates. It consists in tracing the course of tracts of degenerated fibres which result from an injury to any part of the central nervous system. When fibres degenerate below a lesion, the tract is said to be descending degeneration, and when the fibres degenerate in an opposite direction, the tract is one of ascending degeneration. 3. Another method is by removing an organ of special sense, and then tracking the degenerated fibres. Fig. 5.-Showing the functions of the various tracts of the spinal cord. Red = n.otor (or efferent). Bhie = sensory (or afferent). Compare with Fig. 4. (Butler.; 10 ANxVTOMY, PHYSIOLOGY, AXD CHEMISTRY 11 Tracts discovered by the above Methods of Determination. — The spinal cord may be considered as a series of segments super- imposed one upon the other, corresponding to the pairs of spinal nerves. Each of these sections is a complete centre, is sup- plied with nerve-cells and with motor and sensory nerves. The nerve-cells are grouped into motor and sensory fields, united by the intraspinal fibres. These commissures or fibres are very short. 1. Anterior Column. — This is composed of fibres known as the commissural fibres, and the innermost contribute to the for-- mation of the white commissure of the cord. There are two tracts located in the anterior column, viz. : on either side of the anterior median fissure a portion of the column is taken up by the direct pyramidal tract (fasciculus of Turk), which can be traced to be continuous with the non-decussating fibres of the pyramid of the medulla. The rest of the anterior column is composed of fibres of the anterior lateral ground hundle. The anterior column would be bounded in the following manner: internally by the an- terior median fissure, externally by the anterior horn and nerves springing from same, and anteriorly by the free surface of the cord. It may be stated that it is more or less triangular in shape. Some observers claim that the anterior lateral ground hundle is wholly situated in the lateral column. 2. Lateral Column. — This column is composed of fibres which are larger on the surface of the cord and smaller in the deeper portions. There is no decussation in the spinal cord of these fibres. It is made up of the following tracts, viz. : crossed ■pyram- idal, direct cerebellar, anterior lateral ascending, sometimes called , tract of Gowers, anterior lateral descending, sometimes called tract of Lowenthal ; Lissauer, mixed lateral tract, and the an- tero-lateral ground hundle. The direct cerebellar, or tract of Flechsig, is situated at the posterior superficial part of the lateral column. This extends downward as far as the second lumbar nerve, and upward as far as the restiform body, with which fibres it passes into the cerebellum. Gowers's tract occupies the anterior superficial surface of the lateral column. It commences in the lumbar swelling and terminates in the cerebellum, passing through the superior peduncles. The lateral column would be bounded in the following manner: internally by the anterior and posterior horns and nerves leading from, the anterior horn ; externally the ROOTS SPINOUS PROCESS EXITS C I ARISES ABOVE ATLAS II ARISES OPPOSITE ATLAS III ARISES AT ATLAS IV ARISES BETWEEN 2nd & 3rd SPINE V ,/ OPPOSITE 3rd SPINE VI u Til VIII « D I II III .? TV a V „ VI VII VIII IX X XI XII LI ) II [ '. Ill-, IV ^ „ V ) S I II III IV 4th Sih 6th 6th 7th ,. . 1st DORSAL SPIN£. '2nd « 3rd „ II 4th 5th ,1 6th 7th ,. 8th 9th 10th 11th ■^\ Black Dots == Points of Origin. Circles- Points of Exit, C = Cervical, D = Dorsal. 1, = Lumbar. S = Sacral. BETWEEN ATLAS & OCCIPUT ABOVE ATLAS ABOVE 3rd CERVICAL SPINE 4th i-i 5th ,■> II 6th .. 7th II 1st DORSAL SPINE BETWEEN 1st & 2nd DORSAL SPINE 2nd II 3rd II 3rd II 4th 4th „ 5th 1, II 5th ,, 6th 1. 6th 11 7th 1, 7th „ 8th 1, 8th „ 9th 9th ,. 10th ,1 If 10th ,, 11th II 11th & 12th „ BETWEEN 11th DORSAL & Ist LUMBAR i, 1st & 2nd 1, 2ndi 3rd 1. 3rd 1 4th 4th 1 5th BETWEEN 5th' LUMBAR & 1st SACRAL ,i 1st & 2nd 2nd, 3rd II 3rd, 4th „ 4th , 5th Fig. 6.— Diagram showing the relation of the segments of the spinal cord, and of the roots and exits of the spinal nerves, to the spinous processes of the vertebrse. 18 ANATOMY, PHYSIOLOGY, AND CHEMISTRY 13 lateral column is comprised between the lines of implantation of the anterior and posterior roots. 3. Posterior Column. — This column is composed of fine fibres, and is remarkable for its abundance of neuroglia. It is made up of the following tracts — GolVs and Burdaclis. The internal col- umn, near the posterior fissure,, is apparent at the upper part of the cord in the form of a slight enlargement. It is formed of long commissural fibres. The fibres rise as low down as the cauda equina, and run up to the nucleus of Goll in the medulla oblongata. The tract of Burdach is developed before the tract of Goll. Bur- dach's tract terminates in the nucleus of Burdach. The poste- rior column would be bounded in the following manner : inter- nally by the posterior median fissure, externally by the posterior horn, and posteriorly by the free margin or surface of the spinal cord. The gray columns of cells of the cord are ClarTie's, and inter- medio-lateral tracts. Degenerations. — TTe now pass from this to consider the tracts of degeneration that occur when the spinal cord is cut right across in the thoracic region. Some tracts will be found degenerated in the piece of cord below the lesion; these consist of nerve-fibres that are connected with the nerve-cells in the brain ; they are called the pyramidal tracts. Other tracts are found degenerated in the piece of cord above the lesion ; these consist of fibres that are con- nected with the nerve-cells of the spinal ganglia, or with the cells of the spinal cord itself below the lesion, and are passing upward. The tracts which degenerate downward are the motor tracts; the tracts that degenerate upward are the sensory tracts. Tracts of Descending Degeneration. — 1. Crossed Pyramidal Tract. — This tract is situated in the lateral column on the outer side of the posterior cornu of gray matter. At the lower part of the spinal cord it extends to the margin, but higher up it becomes displaced from this position by the interpolation of an- other tract of fibres, viz., the direct cerebellar tract. The crossed pyramidal tract is large, and may touch the gray matter at the tip of the posterior cornu, but is separated from it elsewhere. Its shape on cross-section is somewhat like a lens, but varies in dif- ferent regions of the cord, and diminishes in size from the cervical region downward, its fibres passing off as they descend, to arborize around the nerve-cells and their branchings in the gray matter 14 TEEATISE ON NERVOUS DISEASES of the cord. The fibres of which this tract is composed are mod- erately large, but are mixed with some that are smaller. 2. Direct Pyramidal Tract. — This tract is situated in the an- terior column by the side of the anterior fissure. It is small in some animals, but is quite conspicuous in the human spinal cord. It can be traced upward to the brain, and downward as far as the mid or lower thoracic region, where it ends. The two pyramidal tracts come down from the brain; in the medulla oblongata, the greater number of the pyramidal fibres cross over to the other side of the cord which they descend, hence the term " crossed pyramidal '" tract ; a smaller collection of the pyramidal fibres goes straight on on the same side of the cord, and these cross at different levels in the anterior commissure of the cord lower down ; hence the disappearance of the direct pyramidal tract in the lower part of the cord. 3. Anterior Lateral Descending Tract. — An extensive tract, elongated but narrow, and reaching from the crossed to the direct pyramidal tract. It is a mixed tract, since not all of the fibres degenerate below the lesion. 4. Comma Tract. — This is a small tract of fibres which degen-: erate below section or injury of the cord. It is only found for a few millimetres below the actual lesion, though it degenerates downward; it is in reality a sensory tract, being composed of the branches of the entering posterior root-fibres which pass down- ward on entering the cord. Tracts of Ascending Degeneration. — 1. Gall. — This degenerates upward on injury or on section of the cord, as well as on section of the cord from below upward, and can be traced into the bulb. It is made up of very fine fibres. 2. Direct Cerebellar Tract. — This tract is situated on the outer part of the cord between the crossed pyramidal tract and the margin. It is found in the cervical, thoracic, and upper lum- bar regions of the cord, and increases in size from below upward. It degenerates on injury or section of the cord itself, but not on section of the posterior nerve-roots. As its name implies, it passes up into the cerebellum. Its fibres are large, and originate from the cells of Clarke's column of the same side of the cord. 3. Anterior Lateral Ascending Tract.— Thh tract is situated at the margin of the cord outside the corresponding descending ANATOMY, PHYSIOLOGY, AND CHEMISTEY io tract. Its fibres are of various sizes, and originate from cells situated in the base of the anterior horn of the opposite side of the spinal cord, and in the lower thoracic and lumbar regions; the fibres pass through the gray matter or commissure and anterior horn of the opposite side, and travels up as the tract of Gowers to terminate above, principally in the cerebellum. 4. Lissaue7''s Tract. — This is a small tract of ascending fibres, situated at the outer side of the tip of the posterior cornu. It is made up of fibres of the posterior nerve-roots. Complete section of the spinal cord (transverse) leads to: (a) Loss of motion of the parts supplied by the nerves below the section on both sides of the body. The paralysis is not con- fined to the voluntary muscles, but includes the muscular fibres of the blood-vessels and viscera. Hence there is a fall of blood- pressure, paralysis of sphincters, etc. (6) Loss of sensation in the same regions. (c) Degeneration, descending and ascending, on both sides of the cord. Hemisection. — If the operation performed is not a complete cutting of the spinal cord across transversely, but a cutting of half the cord across, it is termed hemisection. This operation leads to : {a) Loss of motion of the parts supplied by the nerves below the section on the same side of the body as the injury. (6) Loss of sensation in the same region. The loss of sensa- tion is not a very important symptom, and is limited to the sense of localization and the muscular sense. The animal can still feel sensations of pain and of heat and cold. (c) Degeneration, ascending and descending, nearly entirely confined to the same side of the cord as the injury. A lesion of the pyramidal tract in the cord may cause liemi- plegia or paralysis of one arm or leg, called monoplegia. When the motor decussation takes place in the anterior pyra- mids, it cuts off the anterior horns of the spinal cord, forming a number of nuclei which give origin to motor fibres of the cranial nerves. The posterior horns are cut off by the decussation of the fillet and give sensory nuclei which form origins to the cranial nerves. Medulla Oblongata. — The medulla oblongata is the upper ex- pended part of the spinal cord. It connects the upper part of the 16 TEEATISE OX XEEYOUS DISEASES spinal cord with tlie pons varolii. The weight of the medulla is about 100 grains. In the medulla, the fibres from the cord are rearranged, the gray matter is also much changed, while new gray matter is added. Each half of the medulla consists of the follow- ing parts, from before backward: anterior pyramid, olivary body, restiform body, funiculus gracilis, and funiculus cuneoius. By the divergence of the posterior columns and the restiform bodies, the floor of the fourth ventricle is formed. At the anterior lower border of the medulla we find the decussation of the pyramids, where the fibres cross over to the lateral columns of the cord. The anterior pyramid receives the direct pyramidal tract of the anterior column of the cord from its own side, and the crossed pyramidal tract from the lateral column of the cord of the oppo- site side. Most of the pyramidal fibres pass through the pons directly to the cerebrum, a few fibres passing to the cerebellum. The anterior median fissure of the spinal cord terminates at the foramen caecum, just beneath the pons. In transverse section at the level of the inferior olive we see the pyramids in front. Ex- ternal to the pyramid, on either side, is the inferior olive with its contained nucleus of gray matter called the dentate nucleus. The formatio reticularis is seen in the centre of the section. Formatio reticularis is an association system of short fibres which is to be met with at any point between the spinal cord and the thalamus. These fibres run at right angles to each other. Imbedded in it are nerve-cells. The restiform body is composed of fibres from the following sources : From the superior olive. From lateral nucleus. From the direct cerebellar tract of the same side. From the nucleus gracilis and nucleus cuneatus of the same side (posterior superficial arcuate fibres). From the nucleus gracilis and nucleus cuneatus of the opposite side (anterior superficial arcuate fibres). From lateral nucleus of opposite side. From the olivary nucleus by fibres which pass through the opposite olive, superficial to the opposite olive, and deeper than the opposite olive. The funiculus gracilis of the medulla is composed of fibres which occupy the column of Goll in the spinal cord. AXATOMY, PHYSIOLOGY, AND CHEMISTRY 17 The funiculus cuneatus is composed of fibres wliicli occaipy tlie column of Burdach in the spinal cord. The funiculus of Rolando is the continuation upward into the medulla of the geUitinous substance capping tlie posterior horns in the spinal cord. The medulla is about 1 inch in length, f of an inch in width, and ^ an inch in thickness. It has four faces. The triangular space between the restiform bodies is a part of the floor of the fourth ventricle. Eunning transversely across the floor of the fourth ventricle are a group of fibres which give partial origin to the auditory nerve. They form the " beard " of the fourth ventricle. Just at the divergence of columns of Goll is the nib of the fourth ventricle, called the calamus scrip- torius. Centres found in the Medulla. — Eespiratory, cardio-inhibitory, diabetic, deglutition, vaso-motor, cardio-accelerator, vomiting, salivation, mastication. Pons Varolii, Etc. — This is situated between the medulla and the crura cerebri. It is a white body in the form of a half ring. Its size depends upon the size of the hemisphere with which it has to do. It weighs about 250 grains. It has six faces. The anterior face rests upon the basilar process of the occipital bone, and presents a median groove for the basilar artery. The posterior surface of the pons forms a part of the floor of the fourth ven- tricle. The pons is formed of scattered nerve-fibres and cells. The transverse fibres which form the cortex go for the most part through the cerebellar peduncles to the hemispheres. There are three planes of transverse fibres: first, the super- ficial, which covers the pyramidal columns ; second, the one known as the deep stratum, which separates the pyramidal tracts from the fillets; and the third, known as the complex, which separates the different tracts. On transverse section we see that the organ is divisible into an anterior portion or crusta, and a posterior por- tion or tegmentum. The superior olive is a collection of gray matter. The trapezium is a prominent group of transverse fibres running from the accessory nucleus and tuberculum acusticum to the superior olive situated in front of the tegmentum. Numerous small masses of gray matter are found in the pons, which are known as the pontine nuclei. 18 TEEATISE OX XERVOUS DISEASES The pons is a cross-way for the conduction of motion in one direction and sensation in the opposite; and besides this function of the pons there is a co-ordination centre in the pons for reflex actions. Irritation of the pons will cause convulsions; therefore it contains a convulsive centre. Cerebral Peduncles. — The cerebral peduncles extend from the superior part of the pons to the optic thalami, and their size is in direct relation with the size of the brain proper. They are about f of an inch in length. After leaving the pons they are separated from each other, each going to the hemisphere of the respective sides. The space between them is known as the inter- peduncular space. The cerebral peduncles have an anterior face, which presents a longitudinal groove. The external face is em- braced in great part by the hippocampal convolution. Upon transverse section we see a black-looking structure which separates the crusta from the tegmentum and is known as the locus niger, dividing the pes or crusta from the tegmentum. The tegmentum consists of masses of gray matter and fibres extending through the posterior end of the medulla oblongata, pons, and crura up to the optic thalami. The crusta is composed of two bun- dles, the internal or cortico-pontal, which goes to the anterior por- tion of the brain, and which might be considered as a commissure of the brain, connecting that portion with the gray nuclei in the medulla and pons and the cerebellum; and another, the external bundle or voluntary motion bundle, which comes from the ascend- ing frontal and ascending parietal convolutions, and ends in the anterior horns of the spinal cord. The external bundle contains the geniculate bundle. This starts in the cortex around the speech centre, and ends in the hypoglossal, facial, and trigeminal nuclei. In the peduncle is seen the nucleus ruler, which is composed of a mass of red fibres and cells, and in which ends the superior cerebellar peduncle. In the tegmentum of the peduncle are also sensory fibres. In the tegmentum are three masses of longitudinal fibres, viz., the posterior, the central, and superior. There are three fillets. The median or upper, which rises from Goll and Burdach's nuclei and runs on through the teg- mentum chiefly, and in lateral nucleus of optic thalamus, and then enters the cortex of the brain. The lateral -fillet, which starts from Goll and Burdach's nuclei, runs to the superior olive and ANATOMY, PHYSIOLOGY, AND CHEMISTRY 19 ends in the posterior corpus quadrigeminum. It is composed of fibres concerned in hearing. The mesial fillet comes from the same source as the others. It terminates in the base of cerebrum. Capsules of the Brain. — They are the internal and external. The internal capsule is composed of a band of white fibres, being divided into an anterior and a posterior segment. The point where the segments are united is known as the genu. The internal cap- sule is bounded internally by the optic thalamus and caudate nu- cleus, externally by the lenticular nucleus. The fibres composing the anterior segment of the internal capsule are the cortico-pontal fibres anteriorly and the geniculate tract posteriorly. In other words, the geniculate tract lies just in front of the genu. The posterior segment of the internal capsule is made up of motor fibres for its anterior two-thirds, and sensory for the posterior one- third. The motor tract has the following origin and distribution : From ascending frontal, ascending parietal convolutions (motor area), through anterior two-thirds of posterior segment of internal capsule, thence through crura, pons, anterior pyramids of medulla, and there decussate. Crossed pyramidal portion goes down oppo- site lateral column; direct pyramidal portion goes down the same side, both tracts ending finally in the anterior horns for further distribution. The sensory tract is traced as follows: From occip- ital, parietal, and temporal lobes, through posterior third of in- ternal capsule (posterior segment) into peduncle, divides, the main part goes through tegmentum to nuclei of Goll and Burdach, down posterior columns through ganglion of posterior root to skin. The rest or remainder of the sensory fibres go through the lateral columns for further distribution. The external capsule is a band of fibres bounded laterally or internally by the lenticular nucleus and externally by the clau- strum. Cerebellum. — The cerebellum is composed of an elongated cen- tral portion or lobe, called the vermiform process, and two lateral hemispheres. Each hemisphere is connected with its fellow not only by means of the vermiform process, but also by a bundle of fibres called the middle peduncle (the latter forming the greater part of the transverse fibres of the pons), while the superior peduncles, which decussate in the micl-brain, connect it with the cerebrum, and the inferior peduncles (restiform bodies) connect it with the medulla oblongata. 20 TEEATISE OK NERVOUS DISEASES The cerebellum is composed of white and gray matter, the latter being external, like that of the cerebrum, and, like it, in- folded so that a larger area may be contained in a given space. The tree-like arrangement of the white matter has given rise to the name arho7' vitce. Besides the gray matter on the surface, there are in the centre of the white substance of each hemisphere small masses of gray matter, the largest of which is called corpus dentatum. The others are called nucleus glo'bosus, nucleus fastigii, and nucleus emholiformis. If a section is taken through the cortical portion of the cere- bellum, the following distinct layers can be seen by the micro- scope. Underneath the pia mater is the external layer of gray matter ; it is formed chiefly of fine nerve-fibres with small nerve-cells scat- tered through it. Into its outer part processes of pia mater pass vertically; these convey blood-vessels. There are also here numer- ous long tapering neuroglia cells. The internal or granular layer of gray matter is made up of a large number of small nerve-cells mixed with a few larger ones, and some neuroglia cells. Between the two laj'ers is an incomplete stratum of large flask-shaped cells called the cells of Purhinje. Each of these gives off from its base a fine process which becomes the axis cylinder of one of the medullated fibres of the white matter; the neck of the flask passing in the opposite direction breaks up into dendrites, which pass into the external layer of gray matter. Each cell of Pur- kinje is further invested by arborizations of two sets of nerve- fibres. One of these (originating from the fibres of the white matter which are not continuous as axis cylinders from the cells of Purkinje) forms a basket-work round the dendrons; the other (originating as axis-cylinder processes from the nerve-cells of the external layer) forms a felt-work of fibrils round the body of the cell. The cells of the internal layer of gray matter are small ; their dendrites intermingle with those of neighbouring cells ; their ax- ones penetrate into the external layer, but their final destination is uncertain. Ramifying among these cells are fibres characterized by possessing bunches of short branches at intervals. Cerebrum. — The cerebrum consists of two halves called cere- bral hemispheres, separated by a longitudinal fissure and con- nected by a large band of transverse commissural fibres known as AXATOMY, PHYSIOLOGY, AXD CHEMISTRY 21 the corpus callosum. The interior of each hemisphere contains a cavity of complicated shape called the lateral ventricle. Each hemisphere is covered with gray matter^ which passes down into the fissures that abound on it? exterior. The amount of this gray matter varies directly with the amount of convolu- tions of the surface. Under it white matter is situated, and at the hase there are masses of gray matter ; parts of these basal gan- glia are seen forming part of the wall of the ventricles. The an- terior basal ganglion is called the corpus striatum : it is divided into two parts, called the lenticular nucleus and the caudate nu- cleus. The posterior basal ganglion is called the optic thalamus. Passing between the basal ganglia are the white fibres, which enter the cerebral hemispheres from the crus; these constitute the internal capsule (already explained). The brain cortex has four layers, as follows : 1, molecular layer, containing caudal cells; 2, lajer of small pyramidal cells; 3, layer of large pyramidal cells and cells of Martinotti whose axones run upward to the first or molecular layer: 4. layer of polymorphous cells. The outer or external surface of the brain presents numerous depressions and elevations, the. latter being known as convolutions. Each cerebral hemisphere is divided into lobes, which are further divided by many depressions or fissures into convolutions. The cause of folding of the cerebral substance is due to the rigidity of the cranium during development. There are five great fissures, viz., the great longitudinal, the great transverse, fissure of Sylvius, fissure of Eolando, and the occipito-parietal. The fissure of Eolando commences at the great longitudinal fissure, and runs downward, terminating above the horizontal limb of the fissure of Sylvius. The weight of the brain is about 52 ounces. In rare cases it may reach 65 ounces. It is heavier in civilized than uncivilized races ; greater in the male than in the female. Optic Tlialami. — The optic thalami are about the size of pig- eons' eggs, and are directed obliquely forward and inward, and approach each other at their anterior extremities. Between them lies the third ventricle. The thalami have three nuclei, viz.. external, or lateral nu- cleus of Flechsig, internal, and anterior. The lateral nuclei are 3 22 TREATISE OX XEEVOUS DISEASES the points of attachment of the posterior roots. The other nuclei do not have anything to do with the posterior roots. There are some cells between the pulvinar and the origin of the peduncle of the pineal gland, called the hahennla. There is also a nucleus known as the nucleus of the habenula. Corpora Quadrigemina, Etc. — These are four small bodies, sepa- rated from the aqueduct of Sylvius by the lamina quadrigemina. The anterior pair are connected by the superior brachia with the external geniculate todies. The posterior pair are connected by the inferior brachia to the internal geniculate bodies. The anterior corpora quadrigemina are principally concerned in sight, while the posterior are concerned principally in hearing. Corpus Striatum. — This is so called from the fact that white fibres of the internal capsule pass through it. They are situated a little in front and slightly outward from the optic thalami. The nuclei composing these bodies, as before stated, are the lentic- ular and caudate. Membranes of the Brain and Cord. — The brain and spinal cord are enveloped in three membranes: 1, dura mater; 2, arachnoid; 3, pia mater. 1. The dm'a mater or external covering is a tough membrane composed of bundles of connective tissue which cross at various angles, and in whose interstices branched connective-tissue cor- puscles lie; it is lined by a thin, elastic membrane on the inner surface of which is a layer of endothelial cells. , 2. The arachnoid is a more delicate membrane, very -simple, and similar in structure to the dura mater, and lined on its outer free surface by an endothelial membrane. 3. The pia mater consists of two chief layers, between which numerous blood-vessels ramify. Between the arachnoid and the pia mater is a network of fibrous tissue trabeculas sheathed, with endothelial cells; these suharachnoid traheculce divide up the sub- arachnoid space into a number of irregular sinuses. There are some similar trabecul^e, but fewer in number, traversing the sub- dural space, i. e., the space between the dura mater and arachnoid. Section II. — Physiology Physiology of the Nervous System. — Functions of the Spinal Cord. — It is a great conducting medium, carrying impulses up- AXATOMY, PHYSIOLOGY, AND CHEMISTRY' 23 ward and downward, and within itself from side to side; it is the. great reflex centre, or rather series of so-called reflex centres. Im- pulses originate within it a function of minor importance, how- ever. Spinal Reflexes. — By reflex action or movement is meant a movement caused by the stimulation of an afferent (sensory) nerve. The simplest definition is ; a reflex action is an afferent impulse followed by an efferent impulse. Another definition is : a reflex act is the transmission of irritation by the neuraxone of a sensory neurone to the dendrones of the motor neurone, and by its neuraxone to the muscle. The stimulus, on being applied to an afferent nerve, sets up a state of excitement (nervous impulse) in that nerve, which state of excitement is transmitted or conducted in a centripetal direction along the nerve to the centre (spinal cord) ; where the nerve-cells represent the nerve-centre in the cord, the impulse is transferred to the motor, efferent, or centrifugal channel. Three factors, therefore, are essential for a reflex motor act — afferent fibre, a transferring centre, and an efferent fibre; these together constitute a reflex arc. In a purely reflex act all voluntary activity is excluded. Ee- ilex movements may be divided into three classes, as follows : a. The simple or partial reflexes, which are characterized by the fact that stimulation of a sensory area discharges movement in one muscle only, or at least in one limited group of muscles. h. The extensive inco-ordinate reflexes, or reflex spasms. These movements occur in the form of clonic or tetanic contrac- tions; individual groups of muscles, or all the muscles of the body may be implicated. c. Extensive co-ordinated reflexes are due to stimulation of a sensory nerve, causing the discharge of complicated reflex move- ments in whole groups of different muscles, the movements being "" purposive " in character, i. e., as if they were intended for a particular purpose. If an electric irritant is applied to a motor nerve there will be a greater contraction of the muscle than if the irritant was applied directly to the muscle itself. In reflex action are three elements : first, the external irrita- tion; second, excitation of nerve-centres themselves; third, con- tractions of the muscles. 24 TREATISE O^t NERVOUS DISEASES The seat of reflex action is mainl}^ in the cord, although some centres are found in the medulla and pons varolii. PflUger's Laws of Reflex Action. — 1. The reflex movement oc- curs on the same side on which the sensor}^ nerve is stimulated, while only those muscles contract whose nerves arise from the same segment of the spinal cord. ' 2. If the reflex occurs on the other side, only the corresponding muscles contract. 3. If the contractions be unequal upon the two sides, then the most vigorous contractions always occur on the side which is stimulated. 4. If the reflex excitement extend to other motor nerves, those nerves are always affected which lie in the direction of the me- dulla oblongata. Lastly, all the muscles of the body may be thrown into contraction. In the spinal cord reflex impressions pass at the rate of 20 feet per second. Inhibition of the Reflexes. — Within the body there are mechan- isms which can suppress or inhibit the discharges of reflexes, and they may therefore be termed mechanisms inhibiting the reflexes. These are : 1. Voluntary Inliihition. — Reflexes may be inhibited voluntar- ily, both in the region of the spinal cord and brain. Example : Keeping the eyelids open when the eyeball is touched; arrest of movement when skin is tickled. We must observe, however, that the suppression of the reflexes is possible only up to a certain degree. 2. Setsclienow's Inhibitory Centres. — They are located in the corpora quadrigemina and the optic thalami. 3. Strong stimulation of a sensory nerve inhibits reflex move- ments. The reflex does not take place if an afferent nerve be stimulated very powerfully. Example: Suppressing a sneeze by friction of the nose: suppression of the movements produced by tickling, by biting the tongue. 4. Poisons. — Chloroform diminishes the reflex excitability by acting upon the centres. A constant current of electricity passed longitudinally through the cord diminishes the reflexes, especially if the direction of the current is from above downward. Some drugs affect the reflex excitability directly by acting on ANATOMY, PHYSIOLOGY, AND CHEMISTKY 2o the spinal cord — e. g., niethylconine — but other drugs may produce the same result indirectly by affecting the heart and the blood supply to the cord. If the abdominal aorta be compressed for a few minutes to cut off the blood supply to the cord and lower limbs, paraplegia is temporarily produced. Blood is absolutely necessary for the maintenance of function in the cord. If the sup- ply 'be cut off from the brain, the person will lose consciousness in four seconds. Anaemia will stimulate reflex actions for a cer- tain time. If the excitation is carried to a great degree the cord will become fatigued. If the spinal cord is cut in the lumbar region there will be a rhythmic action of the sphincters. Strych- nine is poisonous to every nerve-cell, while cliloroform is poisonous to every cell both of plants and animals. According to Broivn-Sequard, reflex activity is most marked in birds, amphibians, reptiles, next in mammals and fishes. In the new-born it is always very great. The physician, by studying the condition of the reflexes, can form an idea as to the condition of (practically) every inch of the spinal cord. The following reflexes have been noted: 1. Plantar Refl.ex. — Obtained by tickling the sole of the foot. Centre in the lumbar region. 2. Patellar Reflex. — Obtained by striking the tendon above or below the patella. Centre between second and third lumbar nerves. ' 3. Cremasteric Reflex. — Obtained by tickling or pinching the inside of the thigh ; the testicle is drawn up. Centre in the lumbar .region, between second and third lumbar nerves. 4. Abdominal Reflex. — Obtained from a sharp push in the ab- domen, causing contraction of the abtlominal muscles. Centre between eighth and twelfth dorsal nerves. 5. Epigastric Reflex.— li the skin is excited between the fourth, fifth, and sixth intercostal spaces, there will be a contraction of the rectus abdominis. Centre between fourth and eighth dorsal nerves. 6. Scapular Reflex. — On irritating the skin over the scapula there will be a contraction of the shoulder muscles. Centre be- tween seventh and eighth cervical and second dorsal nerves. 7. Cilio-spinal Reflex. — If the skin of neck is pinched there will be a dilatation of the pupil. Centre between sixth cervical and third dorsal nerves, 26 TREATISE OX XERVOUS DISEASES Other Reflex Centres in the Spinal Cord. — a. Ano-spinal cen- tre, or centre controlling the act of defecation. t. Vesicospinal centre for regailating micturition. c. Erection or genito-spinal centre, located in the lumbar re- gion. The afferent nerves are the sensory nerves of the penis; the efferent nerves for the deep arterj^ of the penis are the vaso-dilator nerves arising from the first to the third sacral nerves. d. Ejaculation Centre. — The afferent nerve is the dorsal nerve of the penis; the centre lies at the fourth lumbar vertebra; the motor fibres of the vas deferens arise from the fourth to the fifth lumbar nerves, which pass into the S3'mpathetic, and from thence into the vas deferens. The motor fibres for the bulbo-cavernosus muscle, which ejects the semen from the bulb of the urethra, lie in the third and fourth sacral nerves. e. Vaso-rnotor Centres. — Both vaso-constrictor and vaso-dilator centres are distributed throughout the whole of the spinal axis. /. Siveat Centres. — These are located in the spinal cord. g. Parturition Centre. — This lies at the first and second lumbar vertebra ; the afferent fibres come from the uterine plexus, to which also the motor fibres proceed. Goltz observed that a bitch became pregnant after its spinal cord was divided at the first lumbar vertebra. Excitability of the Spinal Cord. — Even at the present time ob- servers are by no means agreed whether the spinal cord, like the peripheral nerves, is excitable, or whether it is distinguished by the remarkable peculiarity that most of its conducting paths and gan- glia do not react to direct electrical and mechanical stimuli. It is contended by most observers that if stimuli be cautiously ap- plied either to white or gra}^ matter, there is' neither movement nor sensation. As the spinal cord conducts to the brain impulses communicated to it from the stimulated posterior roots, but does not itself respond to stimuli which produce sensations, Schiff has applied to it the term cesthesodic. Further, as the cord can con- duct both voluntary and reflex motor impulses without, however, itself being affected by stimuli applied to it directly, he called it hinesodic. The following views have been expressed: 1. In the posterior columns the sensory root-fibres of the pos- terior root which traverse these columns give rise to painful im- pressions, but the proper paths of the posterior columns them- ANATOMY, PHYSIOLOGY, AND CHEMISTEY 27 selves do not do so. Eemoval of the posterior column produces ancEsthesia (loss of tactile 'sensation). Algesia (or the sensation of pain) remains intact, although at first there may even be hyperalgesia. The trophic centres of posterior roots are the posterior root ganglia. 2. The anterior columns are non-excitable, both for striped and non-striped muscle, as long as the stimuli are applied only to the proper paths of these columns. But movements may follow either when the anterior nerve-roots are stimulated or when, by the escape of the current, the posterior columns are affected, where- by reflex movements are produced. The trophic centres of anterior roots are the anterior horns. 3. The vaso-constrictor nerves^, which proceed from the vaso- motor centre and run downward in the lateral columns of the cord, are excitable by all stimuli along their whole course; direct stimulation of any transverse section of the cord constricts all the blood-vessels below the point of section. In the same way, the fibres which ascend in the cord and increase the action of the vaso- motor centre are also excitable. Stimulation of these fibres, al- though it affects the vaso-motor centre reflexly, does not cause sensation. 4. Chemical stimuli, such as the application of salt or wetting the cut surface with blood, appear to excite the spinal cord some- . what, 5. The motor centres are directly excited by blood heated to about 40° C, or by asphyxiated blood, or by sudden and complete anaemia of the cord produced by ligature of the aorta, and also by certain poisons. Picrotoxin, nicotine, and compounds of bari- um seem also to produce the effect. Paths of Spinal Cord for Pain, Heat, and Cold; Muscular and Tactile Sensations. — Pain, heat, and cold impressions pass through the gray matter of the spinal cord from cell to cell. Muscular and tactile sensations are transmitted through or by the white matter of the cord. Vaso-motor nerves come down the lateral columns in the gray substance to the anterior roots. The nerves from the centre of respiration run through the lateral columns and then enter the gray substance of the anterior liorns and leave by the anterior roots. 38 TREATISE ON NERVOUS DISEASES The s7/jeat and inJiihitory fibres runniiag down the lateral col- umns hoth decussate, the former in the cord and the others in the medulla. The sweat fibres pass out from the anterior roots, also the branches which make up the splanchnics. There is one sensory decussation in the fillet fibres. There are two motor decussations : the lower one is in the cord, in the anterior commissure, while the higher is in the anterior pyramids. Locomotor Ataxia. — In locomotor ataxia there is a degenera- tion of the lower part of the posterior column. Tactile and mus- cular sensations are abolished. Pain, heat, and cold sensations, however, are still transmitted, as a rule. Syringomyelia. — This is a disease of the gray tract, with gliosis arnd final cavity formation. Sensations of heat, pain, and cold are abolished, while tactile and muscular sensations are still transmitted. When there is a lesion in the jons, there is a paralysis of the face on one side and of the arm and leg on the opposite side. This is known as crossed hemiplegia. Monoplegia is paralysis of certain areas alone, as in the leg, arm, etc., due to haemorrhage in the brain or disease of certain parts of the motor area. There is a plentiful supply of blood-vessels in all portions of the brain. Both the caudate and lenticular nuclei are supplied by ' the middle cerebral artery. There are three lenticular branches ; one of these is known as the lenticulo-striate artery of cerebral haemorrhage. It is sometimes called Charcot's artery of cerebral hsemorrhage. The brain has no true lymphatics, but both in the brain and cord are the perivascular lymph spaces of His which carry the lymph. Nerve-Fibres, runction of. — A nerve wave is a transmission of nerve force through the axis cylinder of a nerve. This brings out the properties of nervous excitability. The laws of nervous con- ductivity are : First, the integrity of the nerve ; the neuraxone must be intact. Second, isolated conduction ; a nerve-fibre carries an im- pression without its being diffused to other nerves. Third, the law of conduction in both directions; if a nerve is irritated, the im- pression may be carried both ways. Sensory and motor nerves are of the same nature and structure, but they are attached to different forms of -apparatus. AI^ATOMY, PHYSIOLOUY, AND CHEMISTEY 29 Electricity travels ten million times faster than nerve waves. Irritability is a fundamental property of nerves. After a nerve is cut and separated from the circulation, it will retain its irrita- bility for some time, but eventually loses it. The Esmarch bandage will cause this phenomenon. When a nerve is cut, the first thing is a rise of irritability, soon followed by its loss. Woorara para- lyzes the terminations of the motor nerves in the muscles. In sym- metrical gangrene there is a slow stoppage of the circulation, and the pain is very acute. The patient suffers first from hyperses- thesia, but this soon disappears. When a mixed nerve is irritated, there is first an anaesthesia and then a paralysis. Heat causes nerv- ous excitability and cold renders a part insensible, and if carried to excess causes temporary paralysis. Inflammation causes great irritation to the nerves. When such nerves are incised there is much more pain than in healthy tissue. Nerves possess the prop- erty of being thrown into a state of excitement by stimuli, and are therefore said to be excitable. The stimuli may be applied to and may act upon any part of the nerve. The following are the various kinds of stimuli — i. e., modes of motion — which act upon the nerves : 1. Mechanical stimuli act upon nerves when they are applied with sufficient rapidity to produce a change in the form of the nerve particles, such as pressure, pinching, tension, puncture, etc. In the case of sensory nerves, when they are stimulated pain is produced, as is felt when a limb " sleeps," or when pressure is ex- erted upon the ulnar nerve at the bend of the elbow. When a motor nerve is stimulated, motion results in the muscle attached to the nerve. If the continuity of the nerve-fibres be destroyed, the conduction of the impulse across the injured part is interrupted. Continued pressure upon a mixed nerve paralyzes the motor fibre sooner than the sensory fibres. 2. Thermal Stimuli. — If a frog's nerve be heated to 45° C, its excitability is first increased and then diminished. The higher the temperature, the greater is the excitability and the shorter is its duration. If a nerve be heated to 50° C. for a short time, its excitability is abolished as well as its conductivity. Sudden cooling of a nerve to 5° C. acts as a stimulus, causing contraction in a muscle. 3. Chemical Stimuli. — These excite nerves when they act with a certain rapidity and thereby alter the condition of the nerve. 30 TKEAT18E OX NERVOUS DISEASES Most chemical stimuli act by first increasing tlie nervous excita- bility and then diminishing or paralj-zing it. Chemical stimuli^ as a rule, have less effect upon the sensory than upon the motor fibres. The following chemical stimuli excite nerves : alkaline salts, sugar, urea, glycerin, and some metallic salts. Atropine diminishes the action of the pneumogastrics and the glandular nerves, etc. Pilo- carpine has the opposite action. Free alkalies, mineral acids (not phosphoric), acetic, oxalic, tartaric, and lactic acids dimin- ish the excitability of nerves, as well as most salts of the heavy metals. 4. Physiological or normal stimuli excite the nerves in the normal body. Its nature is entirely unknown. The " nerve motion " thereby set up travels either in a '"' centrifugal '" or out- going direction from the central nervous system, giving rise to motion, inhibition of motion, or secretion, or in a " centripetal " or ingoing motion or direction from, the specific end organs of the nerves of the special senses or the sensory nerves. 5. Electrical Stimuli. — The following forms of electrical stim- uli may be used: a. A constant current, which may be made or broken, h. Induction shochs, either make or break shocks, c. An, interrupted current. Constant Current. — If the constant current be used as a nerve stimulus, the stimulating efl^ect on the sensory nerves is most marked at the moment of making and breaking the current; dur- ing the time the current passes only slight excitement is perceived, but even under these circumstances very strong currents may cause very considerable, and even unbearable, sensations. If a constant current be applied to a motor nerve, the greatest effect is produced when the current is made or closed and when it is broken or opened. But while the current is passing, the stimu- lation does not cease completely; for, with a certain strength of stimulus the muscle remains in a state of tetanus. An irritation of sensory nerves, except nervous depressor, pro- duces increase of blood pressure. Induction Current or Shocl:. — If a galvanic element is closed by means of a short arc of wire, at the moment the circuit is again opened or broken a slight spark is noticed. If, however, the cir- cuit is made or closed by means of a very long wire rolled in a coil, then, on breaking the circuit, there is a strong spark. If the wires be connected to two electrodes, so that a person can hold ANATOMY, PHYSIOLOGY, AND CHEMISTRY 31 one in each hand, the cnrrent at the moment it is opened must pass through the person's body — then there is a violent shock communicated to the hand. This phenomenon is due to a current induced in the long spiral of wire which has been called the extra current. Interrupted or Faradic Current. — If a very long insulated wire be coiled into the form of a spiral roll, which is called the secondary spiral, and if a similar spiral, the primary spiral, be placed near the former, and the ends of the wire of the primary spiral be connected with the poles o£ a constant battery, every time the current in the primary circuit is made (closed), or broken (opened), a current takes place, or, as it is said, is induced, in the secondary spiral. If the primary circuit be kept closed, and if the secondary spiral be brought nearer to or removed farther from the spiral (primary), a current is also induced in the secondary spiral. The current in the secondary circuit is called the Faradic current. When the primary circuit is closed, or when the two spirals are ' brought nearer each other, the current in the secondary spiral has a direction opposite to that in the primary spiral, while the cur- rent produced by opening the primary circuit or by removing the spirals farther apart has the same direction as the primary. Dur- ing the time the primary circuit is closed, or when both spirals remain at the same distance from each other, there is no current in the secondary spiral. When a galvanic current is passed through a nerve, it is said to be in a state of electrotonus, because its irritability is modified. In this condition, the vital properties of the nerve are modified — i.e., its electro-motivity, its excitability. If a nerve be so arranged upon the electrodes that its trans- verse section lies on one and its longitudinal on the other elec- trode, then the galvanometer indicates a strong current. If, now, a constant current be transmitted through the end of the nerve projecting beyond the electrodes, and if the direction of the cur- rent coincides with that in the nerve, then the magnetic needle gives a greater deflection, indicating an increase of the nerve current — the positive phase of electrotonus. The increase is greater the longer the stretch of nerve traversed by the current, the stronger the galvanic current, and the less the distance be- tween the part of the nerve traversed by the constant current and that on the electrodeSo 33 TEEATlSE ON NERVOUS DISEASES If in the same length of nerve the constant current passes in the opposite direction to the nerve current, there is a diminution of the electro-motive force of the latter — negative phase of elec- trotonus. If two points of the nerve equidistant from the equator be placed on the electrodes, there is no deflection of the galvanometer needle. If a constant current be passed through one free pro- jecting end of the nerve, then the galvanometer indicates an elec- tro-motive efEect in the same direction as the current (constant). These experiments show that a constant current causes a change of the electro-motive force of the part of the nerve in- directly traversed by the constant current — i. e., in the intra- polar area — and also in the part of the nerve outside the elec- trodes — i. e., in the extrapolar area. This condition is called electrotoniis. Muscle Current during Electrotonus. — The constant current also produces an electrotonic condition in the muscle; a constant current in the same direction increases the muscle current, while one in an opposite direction weakens it, but the action is rela- tively feeble. Cause of Electrotonus. — If a certain stretch of a living nerve be traversed by a constant electrical current, it passes into a con- dition of altered excitability which is known as electrotonus. This condition of altered excitability extends not only over the part actually traversed by the current, but it is communicated to the entire nerve. At the positive pole or anode the excitability is diminished; this is the region of anelectrotonus. At the negative pole or cathode the excitability is increased; this is the region of cathelectrotonus. The changes of excitability are most marked in the regions of the poles themselves. Transmission of Nervous Impulses. — If a motor nerve be stiniu- lated at its central end (1) a condition of excitation is set up, and (2) an impulse is transmitted along the nerve to the mascle with a certain velocity. The latter depends upon the former and represents the function of conductivity. According to Helmholtz the velocity for a human motor nerve-wave is about 100 feet per second. In the sensory nerves of man, the velocity of the impulse is probably about the same as in motor nerves. The rates usually given are about 150 feet per second. AXATOMY, PHYSIOLOGY, AND CHEMISTRY 33 Relay Stations of Motor and Sensory Fibres. — The optic thai- ami are the relay stations of the sensory tract. The caudate nuclei are the relay stations for the motor tract. Chemical and Mechanical Properties of Nervous Substance. — Specific gravity of white substance, 1.040; gray substance, 1.050. The reaction is sometimes slightly alkaline and sometimes slightly acid. It contains a varying amount of water and solid substances ; 75 per cent water and 25 per cent solid matter is about the average. Proteids. — Albumin occurs chiefly in the axis cylinder and in the substance of the ganglionic cells. Some of this proteid sub- stance represents characters not unlike those of myosin. Dilute solution of common salt extracts a proteid from nervous matter, which is precipitated by the addition of much water and also by a concentrated solution of common salt. Potash albumin and a glohulin-like substance are also present. Nuclein occurs especially ^in the gray matter, while neuro-heratin, a body containing much sulphur and closely related to keratin, occurs in the neuroglia. Fats and other allied substances soluble in ether, more espe- cially in the white matter : a. Cerehrin, free from phosphorus. It is a white powder com- posed of spherical soluble granules (in hot alcohol and ether), but insoluble in cold water. When boiled for a long time with acids, it splits up into a left rotatory body like sugar and another unknown product. h. Lecithin and its decomposition products — giycero-phosphoric acid and oleo-phosphoric acid. c. Protagon, which contains nitrogen and phosphorus, is sim- ilar to cerebrin and lecethin combined. d. Leucin, inosite, etc. The physical properties of nerve tissue are cohesion and elas- ticity. Physiology of the Cerebellum. — Irritation of the cerebellum will cause no contractions or pain, but if it be deeply injured there will be a tottering of the animal called a cerebellar tottering. If the cerebellum is entirely removed the animal will live for quite a time, and will soon learn to co-ordinate its movements. The cerebellum is the centre of co-ordination of muscular move- ments. It is probable that the co-ordinating fibres go through the descending antero-lateral tract. 34 TliEATISE ON NERVOUS DISEASES Irritation of the cerebellum will not only cause a tottering walk, but also may cause a tendency to vomit, on account of the irritation of the vomiting centre in the medulla. Injury of the middle cerebellar peduncle causes a tendency for the animal to go to one side {circus movements). It also brings on internal squint on the same side and superior squint on the opposite side. Lesions of one hemisphere may not give rise to any symptoms; but if the middle lobe is involved, there is inco-ordination of move- ments, especially a tendency to fall, unsteady gait, and pronounced vertigo. Irritative lesions of the middle peduncle cause complete gyrating movements of the body around its axis, together with rotation of the eyes and head. Functions of the Medulla Oblongata. — The medulla oblongata, which connects the spinal cord with the brain, has many points of resemblance with the former. Like the cord, it is concerned in the conduction of impulses. In it numerous reflex centres are present — e. g., for simple reflexes similar to the nerve-centres in the spinal cord. There are other centres present which seem to dominate or control similar centres placed in the cord — e. g., the great vaso-motor centre, pupil-dilating centres, and the centre for combining the reflex movements of the body. Some of the centres are capable of being excited reflexly. It is also said to contain automatic centres. The normal functions of the centres depend upon the exchanges of blood and gases effected by the circulation of the blood through the medulla. If this gaseous exchange be interrupted or interfered with — as asphyxia, sudden anaemia, or venous congestion — these centres are first excited, and exhibit a condition of increased excitability, and at last, if they are over- stimulated they are paralyzed. An excessive temperature also acts as a stimulus by an action on the polypnoeic centre in the tuber cinereum which drives the respiration centre into activity. All the centres, however, are not active at the same time, and they do not all exhibit the same degree of excitability. Normally, the respira- tory centre and the vaso-motor centre are continually in a state of activity. The centres found in the medulla have been given under the anatomy of same. The respiratory centre lies in the m.edulla behind the super- ficial origin of the vagus, on both sides of the posterior aspect of the apex of the calamus scriptorius, between the nuclei of the ANATOMY, PHYSIOLOGY, AND CHEMISTRY^ 35 vagus and accessorius. It consists of two parts, which are in a state of activity alternately, an inspiratory and an expiratory:, each one forming the motor central point for the acts of inspira- tion and expiration. Some observers claim that this is an auto- matic centre, for after section of all the sensory nerves which can act refiexly upon the centre, it still retains its activity. The degree of excitability and the stimulation of the centre depend upon the state of the blood, and chiefly upon the amount of blood gases. The Cardio-inhibitory Centre. — The fibres of the vagus, when moderately .stimulated, diminish the action of the heart; when strongly stimulated, however, they arrest its action and cause it to stand still in diastole; they are supplied to the vagus through the spinal accessory nerve, and have their centre in the medulla oblongata. Gaskell has shown that stimulation of the vagus not only influences the rhythm of the heart's action, but modifies the other functions of the cardiac muscle. Stimulation of the vagus influences the automatic rhythm — i. e., the rate at which the heart contracts automatically; the force of the contractions, more espe- cially the auricles, although in some animals — e. g., the tortoise — the ventricles are not affected ; the power of conduction — i. e., the capacity for conducting the muscular contractions. This centre may be excited directly in the medulla, and also reflexly by stimu- lating certain efferent nerves. Stimulation of the trunk of the vagus from the centre downward, along its whole course, and also of certain of its cardiac branches, causes the heart either to beat more slowly or arrests its action in diastole. The result depends upon the strength of the stimulus employed; feeble stimuli slow the action of the heart, while strong stimuli arrest it in diastole. Cardiac- Accelerating Centre. — This centre is also located in the medulla oblongata, which sends accelerating fibres to the heart. They pass from the medulla through the spinal cord, and leave the cord through the rami communicantes of the lower cervical and upper six dorsal nerves to pass into the sympathetic system. If the vagi of an animal be divided, stimulation of the medulla oblongata, of the lower end of the divided cervical spinal cord, even of the lower cervical ganglion, or of the upper dorsal gan- glion of the sympathetic, causes acceleration of the heart-beats in the dog and rabbit without the blood-pressure undergoing any change. The inhibitory fibres of the vagus lose their excitability 36 TREATISE ON" NEEVOUS DISEASES more readily than the accelerating" fibres^ but the vagus fibres are more excitable than those of the accelerans. Vaso-motor Centre and Nerves. — The chief dominating centre, which supplies all the non-striped muscles of the arterial system with motor nerves, lies in the medulla oblongata at a point which contains ganglionic cells. The nerves passing from this centre are known as the vaso-motor nerves, there being two kinds of them — vaso-constricior and vaso-dilator. The vaso-constrictor nerves, as their name implies, constrict the arteries, or rather reduce their mean diameters, thus causing an increase of blood-pressure, result- ing in the swelling of veins and the heart. The vaso-dilator nerves, as their name implies, cause a dilatation of the arteries and a de- crease in blood-pressure. Functions of the Pons Varolii. — This is seated in front of the medulla, and is the centre of convulsive movements. In epi- lepsy there is a lesion of the cortex of the brain, and the im- pressions are conveyed to the convulsive centre. It is also a path for the conduction of sensibility and motion. If there is a lesion in the pons, there is a paralysis of the face on one side and of the leg and arm of the opposite side. This is due to a lesion helow the facial decussation and above the motor decussation of the fibres in the pons. The convulsion centre can be excited by ex- cess of carbonic acid, lack of oxygen, anaemia, etc. Functions of Cerebral Peduncles. — They are about f of an inch in length, and contain fibres which connect the brain with the structures at its base. In the locus niger there is located the high detrusor centre of the bladder, although the proper detrusor centre is located down in the cord. Injury to one cerebral peduncle causes, in the first place, violent pain and spasm of the opposite side, while the blood-vessels on that side contract and the salivary glands secrete. These phenom- ena of irritation are followed by paralytic symptoms of the oppo- site side — viz., anaesthesia and paresis. In afl:ections of the cerebral peduncle in man, we must remember the relation of the oculomo- torius to it, as the latter is often paralyzed on the same side, while the extremities, tongue, and half the face are paralyzed on the opposite side from the lesion. Functions of the Corpora Cluadrigemina. — Destruction of these bodies on one side in mammals causes actual blindness, which may be on the same or the opposite side, according to the relation ANATOMY, PHYSIOLOGY, AI^D CHEMISTEY 37 of the fibres crossing at the optic chiasm. Total destruction causes blindness of both eyes. At the same time, the reflex contraction of the pupil, due to the stimulation of the retina with light, no longer takes place where the optic is the afferent and the oculo- motorius the efferent nerve. If the cerebral peduncles are left in position and the cerebral hemisphere alone be removed, the pupil still- contracts to light, as well as after mechanical stimulation of the optic nerve. Destruction of the corpora quadrigemina inter- feres with the complete harmony of the motor acts; disturbance of equilibrium and inco-ordination of movements occur. In man very little is known regarding the effects of disease of the corpora quadrigemina, interference with the ocular mus- cles being the most marked symptom; but the inco-ordination of movement which has been observed may be due to pressure upon the superior cerebellar peduncle, while it is by no means certain that the defects of vision are directly due to lesions of these bodies. Forced Movements. — It is evident from what has been said regarding the importance of the corpora quadrigemina for the harmonious execution of movements, that unilateral injury of such parts as are connected with them by conducting channels must give rise to peculiar unilateral disturbance of the equilibrium, causing variations from the symmetrical movements of both sides of the body. These are called " forced movements." Strabismus and Nystagmus. — Among the forced movements may be reckoned deviation of the eyeballs, strabismus or squinting, and involuntary oscillation of the eyeballs, constituting nystagmus. The latter condition occurs after superficial lesions of the resti- form bodies, as well as of the floor of the fourth ventricle. ■Contraction centre of iris is in the anterior corpora quadri- gemina. Functions of the Corpora Striata, — Lenticular and Caudate Nu- clei. — Electrical stimulation of these nuclei causes general con- tractions in the opposite half of the body which are due to simul- taneous stimulation of the neighbouring cortico-muscular paths. There is no sign of pain. Lesions of the lenticular nucleus or of the caudate nucleus do not seem to give rise to any permanent symptoms, provided the internal capsule is not injured. If the corpus striatum is destroyed on one side, there is paralysis of the opposite side of the body. This body holds the same relation to 38 TEEATISE OX NERVOUS DISEASES the motor tract that the optic thalami bear to the sensory tracts; on the other hand, or in other words, the corpora striata are the relay stations of the motor tracts. These bodies also contain a thermogenic centre, and if section is made of both the temperature will rise to 110.5° F. If section be made of the tuher cinereum there will be a great increase of temperature. Functions of Optic Thalami. — Ferrier did not observe any movements on stimulating the optic thalami with electricity. As the puhinar or the posterior extremity of the optic thalamus is in part the origin of the optic nerve, and is also connected by fibres with the cerebral cortex, it is probably related to the sense of sight. Injury to its posterior third in man results in disturbance of vision. Ferrier surmises that the sensory fibres pass through the optic thalami on their way to the cortex, so that M^hen they are destroyed insensibility of the opposite half of the body is produced. Thus these bodies are called relay stations for the sensory tracts. The Capsules: Functions, Etc. — In connection with the func- tions of the basal ganglia it is most important to remember their relation to the internal capsule. The anterior segment of the internal capsule sweeps between the caudate and lenticular nuclei, while the posterior segment lies between the optic thalamus and the lenticular nucleus. External to the first division of the lenticular nucleus is the external capsule, whose function is unknown. Ex- ternal to this latter structure is the claustrum, whose function also is unknown. It is evident that hsemorrhage into or about the basal ganglia is apt to involve the fibres of the internal capsule. When the " artery of hsemorrhage " ruptures it may not only destroy the lenticular nucleus, but the internal capsule will be compressed, and the same is the ease with the I enticulo -thalamic artery — the external capsule will tend to force the blood inward. We know that in the posterior segment of the capsule the voli- tional or pyramidal fibres lie in the following order from before backward: those for the face (and tongue) in the knee; in the anterior third, those for the arm and hand; and in the middle third, for the leg, and perhaps behind these those for the trunk; so that a very small lesion in this region will affect a large num- ber of these fibres, converging as they do like the rays of a fan from the motor cortical areas, where the arrangement of these centres is a supero-inferior one, to become an antero-posterior one ANATOMY, PHYSIOLOGY, AND CHEMISTEY 39 in the knee and posterior limb of the internal capsule. The- pos- terior third of this limb is sensory, and is the sensory cross-way. Destruction of the internal capsule causes paralysis of motion or sensibility, or both, on the opposite side of the body, according to the part of it which is injured. Functions of Cerebral Hemispheres. — The cortical motor areas for the face, arm, and leg are grouped around the fissure of Ro- lando, including the ascending frontal, ascending parietal, and paracentral lobules. The centre for the face occupies the lowest third of the ascending frontal convolution, and reaches also to the lowest fifth of the ascending parietal. The arm centre occu- pies the middle third of the ascending frontal and middle three- fifths of the ascending parietal convolutions, while the leg centres lie at the upper end of the sulcus and extends backward into the parietal lobule. The leg centre is continued over on to the para- central lobule, opposite the upper end of the fissure of Eolando, i]i the marginal convolution on the mesial aspect of the hemi- sphere, where the centres for the muscles of the trunk also exist. The motor areas are supplied by branches of the Sylvian artery. To locate the fissure of Rolando on the cranium, a line is drawn from the glabella to the external occipital protuberance. Divide the distance into two equal parts, and ^ an inch behind the middle point is the top of the fissure of Eolando. The cortical sensory areas are distributed very irregularly. There must be some connection between the surface of the brain and the afl:erent channels through which sensory impulses pass inward; and although the channels for these impulses are, perhaps, not so well known, it must be that sensory impulses fgr the opposite half of the body travel upward through the posterior third of the posterior limb of the internal capsule, to radiate in all probability into the occipital, temporal, and parietal lobes. Parts of these different convolutions are sometimes spoken of as sensory centres. Extirpation and stimulation are the methods employed to de- termine the different areas on the brain. Hemiplegia consists of motor paralj^sis of one-half of the body, although, as a rule, all tlie muscles are not paralyzed to the same extent; in some there may be complete paralysis — i. e., they are entirely removed from voluntary control — while in others there is merely impaired voluntary control. It may be caused by affec- tions of the cortical areas or by lesion of the motor tracts above 40 TREATISE ON NEEYOUS DISEASES the medulla ; and the paralysis is alwaj^s on the side opposite to the lesion, owing to the decussation of the motor paths in the medulla. If the case be a severe one, there is a complete hemiplegia due to lesion of the cortical centres for the face, arm, and leg. While the arm and leg are completely paralyzed, the lower part of the face is more affected than the upper half, which is usually not affected. The arm recovers more quickly than the leg. Conjugate deviation of the eyes, with rotation of the head, is frequently present in the early period of hemiplegia, although it usually disappears. When a person turns his head to one side there is an associated movement of certain of the ocular muscles with those of the neck. The head and eyes are usually turned to the side of lesion; this is termed conjugate deviation, so that the power of voluntarily moving the eyes and head to the para- lyzed side is temporarily lost. The unopposed muscles rotate the head and eyes to the sound side. If a lesion be in the posterior part of the pons, the deviation is to the paralyzed side. Irritation of the Motor Centres. — If the motor centres are irri- tated by pathological processes, such as hypersemia, inflammation in a syphilitic diathesis, tumours, tubercles, cj^sts, fragments of bone, etc., there arise spasmodic movements in the corresponding muscle groups. This condition of a sudden discharge of the gray matter resulting in local spasms is called Jachsonian cerebral epilepsy. The Centre of Speech. — The investigations of Broca and others liave shown that tlie third left frontal convolution of the cerebrum (Broca's area) is of essential -importance for speech, while prob- ably the island of Eeil is also concerned. Three activities are required for speech: (1) the normal move- ment of the vocal apparatus; (3) a knowledge of the signs for objects and ideas; (3) the correct union of both. Aphasia. — Injury of the speech centre causes either a loss or more or less considerable disturbance of the power of speech. The loss of the power of speech is called aphasia. Aphasia, as usu- ally understood, means the partial or complete loss of the power of articulate speech from cerebral causes. A person may compre- hend what he sees or hears, yet he is imable to speak. Ataxic Aphasia. — Here there is loss of speech owing to inability to execute the various movements of the mouth necessary for speech and co-ordinated grimaces. He can utter inarticulate words or ANATOMY, PHYSIOLOGY, AND CHEMISTEY 41 sounds. The muscles concerned in articulation are not paralyzed, but there is an absence of co-ordination of these muscles due to dis- ease of the cortical centre. Hence the patient cannot repeat what is said to him. Nevertheless, the psychical processes necessary for speech are completely retained, and all words are remembered ; and hence these persons can still give expression to their thoughts graphically by writing. If, however, the finely adjusted movements necessary for writing are lost, owing to an affection of the centre for the hand, then there arises at the same time the condition of agraphia, or inability to execute those movements necessary for writing. Such a person, when he desires to express his ideas in writing, only succeeds in making a few unintelligible scrawls on the paper. In ivord blindness, the person cannot name a letter or a word, so that he cannot understand symbols, such as printed or written words, or it may be a familiar object ; although he can see quite well, while he can speak fluently and write correctly. In wo7'd deafness, the person hears other sounds and is not deaf, but he does not hear and understand words. (See Aphasia.) An animal or person can live with only one cerebral hemisphere intact; but if both are removed, the animal lies still, remaining in one position, and will not move. Seats or centres of consciousness and volition (ivill) are lo- cated in the cerebral cortex. The cerebrum contains the centres of intelligence. There are many ways of measuring the grade of intelligence of a man; the important is the facial angle measurement, explained as follows: The facial angle (Camper) is the divergence between a line drawn from the inferior anterior nasal ridge of upper jaw to the gla- bella, and another drawn from the nasal ridge to the external audi- tory meatus. In the Caucasian race it is 80° ; in the Mongolian, 75°; in the Ethiopian, 70°; and in apes, 40°. The Visual Centre. — According to Munk, this includes the occipital lobes (cuneus), while, according to Ferrier, it also in- cludes the angular gyrus. In cases of long-standing blindness there has been noticed to be a consecutive disappearance of the occipital convolutions on both sides of the parieto-occipital fis- sure. Stimulation of the centre gives rise to the phenomena of light and colour. Injury causes a disturbance of vision, especially hemiopia of the same side, to be further explained under the eye. 42 TEEATISE 0^ NERVOUS DISEASES When one centre is the seat of irritation, there is a photopsia- of the same halves of both eyes. Stimulation of both centres causes the occurrence of the phenomena of light or colour or visual hallucinations in the entire field of vision. The auditory centres are found in the superior temporal con- volutions. When this is completely removed, deafness is the re- sult, while partial injury causes psychical deafness. It has been found that softening of the first temporal convolution is the cause of these phenomena. The centres of taste and smell are located in the gyrus unci- natus. The centre of tactile sensibility is located in the gyrus forni- catus, according to some observers; by others, in the motor area. Sleep and Waking. — In sleep and waking we observe the peri- odicity of the active and passive conditions of the brain. During sleep there is diminished excitability of the whole nervous system, which in turn is partly due to fatigue of the afferent nerves, though largely due to the condition of the central nervous system. During sleep we require to apply strong stimuli to produce reflex acts. In the deepest sleep the mental processes seem to be completely in abeyance, so that a person asleep might be compared to an ani- mal with its cerebral hemispheres removed. Towards the approach of the period when a person is about to waken, psychical activity may manifest itself in the form of dreams, which differ, however, from normal mental processes. They consist either of impressions, where there is no objective cause, or of voluntary impulses which are not executed, or trains of thought where the reasoning and judging powers are disturbed. Often, especially near the time of waking, the actual stimuli may so act as to give rise to im- pressions which become mixed with the thoughts of a dream. The pupils are contracted during sleep in proportion to its depth ; so that in the deepest sleep they do not become contracted on the application of light. The pupils dilate when sensory or audi- tory stimuli are applied, and the lighter the sleep the more easily is it accomplished — they are the widest at the moment of awaking. The soundness of sleep may be determined by the intensity of the sound required to awaken a person. Some observers find that at first sleep deepens very quickly, then more slowly, and the maximum is reached after one hour ; it then rapidly lightens, until several hours before waking it is very light. We therefore sleep ANATOMY, PHYSIOLOGY, AND CHEMISTEY 43 soundest the first two hours, and weakest towards morning. Tlie deei^er the sleep tlie longer it lasts. The cause of sleep is the using up of the potential energy, especially in the central nervous system, which renders a restitu- tion of energy necessary. Perhaps the accumulation of the decom- position products of the nervous activity may also act as a sleep- producer. Sleep cannot be kept up for above a certain time, nor can it be interrupted voluntarily. Many narcotics rapidly pro- duce sleep. Hypnotics, such as opium, morphine, potassium bro- mide, and chloral, are drugs which induce sleep. Strength and Liminal Intensity of Stimuli. — Homologous stim- uli act upon the sensory organs only within certain limits as to strength. Very feeble stimuli at first produce no effect. The strength of stimulus which is just sufficient to cause the first trace of sensation is called by Fechner the " liminal intensity " of the sensation. As the strength of the stimulus increases, so also do the sensations, but the sensations equally increase when the strength of the stimulus increases in relative proportions. Thus, we have the same sensation of equal increase of light when, instead of 10 candles 11, or instead of 100 candles 110 are lighted — the pro- portion of increase in both cases is equal to one-tenth. As the logarithm of the numbers increases in an equal degree when the numbers increase in the same relative proportion, the law may be expressed thus : " The sensations do not increase with the absolute strength of the stimuli, but nearly as the logarithm of the strength of the stimulus." This is Fechner's " psycho-physical law," but its accuracy has lately been challenged by Hering. It holds good only with regard to stimuli of medium strength. If the specific stimulus be too intense, it gives rise to peculiar painful sensations — e. g., a feeling of blindness or deafness, as the case may be. The sense organs respond to adequate stimuli, but only with cer- tain limits of the stimulus — e. g., the ear responds only to vibra- ting bodies, emitting a certain range of vibrations per second; the retina responds only to vibrations of the ether between red and violet, but not to the so-called heat vibrations or to the chemically active vibrations. It was Weber who worked out the relation between the intensity of stimuli and the changes in the quantity of the resulting sensations. He used the method of " least observable differences," as applied to sensations of pressure and the measurements of lines by the eye. Hence it is called CORTEX. OPTIC THALAMUS. HORIZONTAL SECTION OF CRUS. HORIZONTAL SECTION OF SPINAL CORD ANTERO-LATERAL - ASCENDING TRACT. DIRECT CEREBELLAR COLUMN. SENSORY BRANCH TO MOTOR CELL IN ANTERIOR HORN. GANGLION OF POSTERIOR (SEN SORY) ROOT. ■ DENDRITES Each cell of the ganglia of the posterior roots of the spi- nal cord (or of the cranial nerve nuclei) gives off two main processes. One, the den- drite, goes to the sensory end organ in the skin or elsewhere, bringing impressions to the cell, and constituting the pe- ripheral sensory nerve-fibre; the other, the axone, enters the cord through the poste- rior root (or runs from the cra- nial nerve nuclei inward), com- ing into relation with other neurones. BLUE" = DIRECT SETvlSORY PATHWAY. RED = INDIRECT SENSORY PATHWAY, Pig. 7.— Sensory Pathways. The direct sensorij path (in blue) (for touch, pain, and temperature) runs f lom posterior root across the cord to antero-lateral column, to tegmentum of crus, to optic thalamus, to cortex. The indirect senwry 2Jaths{in red) (for co-ordinative sensations from muscles, joints, and viscera) run upward on same side, via the direct cerebellar tract and the posterior column, decussating at UDDer iiart of cord, to cereliellum. to ontic thalamus, to cortex. (From Butler.) HORIZONTAL SECTION OF THE LEFT INTERNAL CAPSULE VERTICAL SECTION OF INTERNAL CAPSULE. HORIZONTAL SEC- TION OF CRUS. CEREBELLUM AND INDIRECT MOTOR PATHWAY. MOTOR DECUSSATION N MEDULLA. HORIZONTAL SECTION OF THE SPINAL CORD. DIRECT PYRAM< IDAL TRACT. ANTERIOR ROOT OF SPINAL i L NERVE. O' ANTERIOR ROOT OF SPINAL NERVE. BLACK FIBRES = INDIRECT PATHV\/AY. '■J[. BUJt^ PtRIPHeRAL ;Luv RED = CENTRAL fUPPER) NEURONE FiQ 8. — Motor Pathways. Direct motor path (in red) (for voluntary impulses, runs from cortex, via corona radiata, internal capsule, crus, pons, medulla, crossed and direct pyramidal columns, to motor cells of anterior horn ; the cranial nerve motor fibres" (in red) cross at various levels in crus, pons, and medulla. Indirect motor path (in black) (for muscul:. co-ordination and higher reflex and automatic movements) runs from cortex to pons nuclei, to cerebellum, to lateral fundamental column, via the peduncles, the fibres terminating at various levels in the anterior horn. (From Butler.) 45 46 TEEATISE ON NERVOUS DISEASES Weber's law; but Fechner expanded it, and assumed that all Just observable differences are equally great, and so the law is some- times called by his name. Generally speaking, it is called Weher- Fechners law. After-Sensations. — The term "after-sensation" is applied to the following phenomenon : viz., that, as a rule, the sensation lasts longer than the stimulus producing it; thus there is an after- sensation after pressure is applied to the skin. Subjective sensa- tions occur when stimuli due to internal somatic causes excite the nervous apparatus of the sense organ. The highest degrees of these, depending mostly upon pathological stimulation of the sen- sory cortical centres, are characterized as hallucinations — e. g., when a delirious person imagines he sees figures or hears sounds which have no objective reality. In opposition to this condition, the term illusion is applied to modifications by the sensorium of sensations actually caused by external objects — e. g., when the rolling of a wagon is mistaken for thunder, etc. In other words, an illusion is' the misinterpretation of an objective stimulation. Ideation is the forination of ideas caused by cerebral activity. The Sympathetic Nervous System: Function, Etc. — It consists of a double chain of ganglia on each side of the spinal column and visceral plexuses. It is chiefly composed of non-medullated nerve- fibres. Its chief function is vaso-motor. Its ganglia are readily paralyzed by nicotine. OTHER NON-NERVOUS TISSUES Blood-Vessels. — The nerves are richly supplied with blood. The peripheral nerves also are supplied from different arterial branches, but always from one general source. The artery passes to the nerve-sheath obliquely, then divides dichotomously, -send- ing branches for a long distance up and domi the sheath. It may pierce the sheath first, however, then divide as above de- scribed. The dichotomous branches send off arterioles and capil- laries which form plexuses about the nerve fascicles, the so- called "interfascicular arcades." This division of the arteries subserves the function of preventing large and sudden impact of blood into the parenchyma of the nerves. This resembles also the brain and cord distribution of the blood. The veins subdivide dichotomously like the arteries, and freely ANATOMY, PHYSIOLOGY, AND CHEMISTEY 47 anastomose with the veins of the muscles, so that muscular action is in close sympathy with nerve function and circulation. Veins of superficial nerves thus also connect with the deep nerve veins. Lymphatic vessels and spaces are found in the epineurium and perineiirium. There are no demonstrable lymphatic vessels in the fasciculi of nerves, but lymph spaces probably exist. Neuroglia. — In addition to connective tissue, the central nerv- ous system has another substance not found in the peripheral Fig. 9. — Showing the relation of the- spinal cord to the dorsal surface of the trank the relative length of the cervical, dorsal, lumbar, and sacral portions; and the position of the cervical and lumbar enlargements. nervous system. It is called the neuroglia and is derived from the epiblast. Its cells are very numerous and are finely ramified together, in the which they support the nerve-cells. They are also called " spider cells " and consist of a large nucleus and proc- esses. Section III. — Chemistry Neuroglia, — One point in the chemistry of the neuroglia should preface this section — i. e., the processes of these cells be- 48 TREATISE OX XERVOUS DISEASES come charged in their chemical and physical characters so that they take on different stain from that of the cell body itself (Weigert). The scavenger cells of Lewis are the neurogliar cells produced by inflammatory irritation which carry off irritating products; and this must he some form of chemical combination as yet awaiting the physiological chemist to solve. Nervous Tissue. — According to Krause and Bischoff, the spe- cific gravity of nervous tissue is 1.036; that of the brain 1.038, of the spinal cord and nerves 1.034. The reaction is alkaline owing chiefly to the production of lactic acid. Water makes up three-fourths of nervous tissue. There is more water in the gray than in the white matter, and least water in the sympathetic nerves. Inorganic salts are about 5 per cent of the total constituents of nerve-tissue. According to Breed, phosphorus is the largest single element, and it is combined with calcium, magnesium, sodium, potassium, and iron-forming phos- phate salts. Chloride of potassium is the most unportant of the other constituents. Table of Chemical Constituents of Nervous System (Baumstark — quoted by Hammerstein and by Dana) Gray matter. Water in 1,000 parts Solids " " " T, , ( cerebrin Protagon j j^^-^j^.^ ^^^^^-^^^ Insoluble albumin and connective tissue Cholesterin Nuclein Neurokeratin , Inorganic salts 769.97 230.03 10.08 60.79 23.81 1.99 10.43 5.63 Protagon is a complex substance of .atty matter containing nitrogen, united with glycerin-phosphoric acid instead of glyc- erin. This protagon is made up of two bodies, cerehrin and leci- thin, the latter of which contains an ammonia compound called neurin. Protagon is especially abundant in the white matter. The gray matter contains nuclein, important in cell metabolism. Kuclein (C29H49N9P3O22 Miescher) consists of nucleic acid, a sub- stance rich in phosphorus and a various amount of albumin. The Qerve-cells (gray matter) also contain various amounts of albumi- ANATOMY, PHYSIOLOGY, A^B CHEMISTRY 49 nous substances. According to Halliburton, nuclein and its con- gener nucleo-aJbumin are designated alluminoids. They both con- tain albumin and are found chiefly in the nucleus. The albu- minous substances are also called proteids and contain little or no pliosphorus and make up most of the cytoplasm or cell body. CHAPTEE II GENERAL PATHOLOGY Ti-iE nervous system, composed as it is of nerve-cells and fibres forming the neurones, the connective tissue, the neuroglia, blood-vessels, and lympliatics, must have in it^ pathology disease of one or many of these structures. Most diseases affect the blood-vessels, connective tissue, or neuroglia primarily, and paren- chyma secondarily, although in many affections it still remains doubtful which is first diseased. Forms of disease which affect the nervous system are, there- fore, as follows: 1. Functional and nutritive disorders, including those of meta- bolic and glandular defects as in exophthalmic goitre, cretinism, or myxoedema and acromegaly. 2. Malformations, lack of proper development or agenesis; de- fective development or dysgenesis. 3. Anfemia, ha?morrhage, and arterio-venous disease. 4. Atrophy, degeneration, softening, gliosis, and sclerosis. 5. Hyperemia, oedema, and inflammations. 6. Tumours, parasites (echinococcus, etc.). 7. Syphilis, tuberculosis. Under nutritive and functional disorders of the nervous system come defects in metabolism, as uric-acid diathesis causative of a certain number of cases of neurasthenia; also under this .comes, as Just mentioned, other autochthonous poisons such as leuco- maines. Then come the extrinsic poisons, as ptomaines developed from intestinal intoxication, etc. Sclerosis is a process of connective-tissue ^Drolif eration in which the normal parenchymatous tissue is supplanted by connective tis- sue. This is the result of degeneration (next to be considered). Neuroglia overgrowth also usually occurs in sclerosis. Degenerations may be divided as follows, into acute and chronic; and these again are subdivided into primary and secondary 50 GEKEEAL PATHOLOGY 51 and mixed. Under primary come the progressive muscular atro- phies of spinal origin^ myelomalacia and tabes dorsalis, or any of the system diseases of the cord. Under secondary degenerations, we may give as examples secondary lateral sclerosis as in that fol- lowing upon hemiplegia of cerebral origin or in degeneration (diffuse) of the cord following chronic myelitis or syringomyelia. Acute degeneration usually brings about a softening or necrosis. If repair occurs a cicatrix is formed. Primary degenerations are, of course, due to inherent defect in nutrition or to some poison (as that of syphilis in the fourth stage) acting directly on the fibre or cell. Secondary degenera- tion is per contra due to separation of the nerve-fibre or cell from its trophic centre, or to cutting off of its vascular supply, or to injury as in pressure neuritis, etc. The most usual extrinsic poisons that cause degenerations are arsenic, lead, phosphorus, or the poisons of infectious diseases as of la grippe. Endarteritis and arteriosclerosis of old age also cause degenerations by obliterating tlie lumen of vessels, and thus preventing proper nutrition of the part beyond. There is a legion of causes which with all our scientific advancement are as yet unknown, but are productive of premature death of the cell. Whether certain scleroses are forms of proliferative inflammation is as yet also a debated question by pathologists, although the tend- ency is now to term the so-styled chronic inflammations as really degenerative processes, and that, as indicated above, the primary trouble is in the parenchyma. Gliosis. — Dejerine is the leader of the French school who be- lieves that some of the chronic degenerative diseases are due to proliferation of neuroglia. This overgrowth of neurogliar tissue rather than connective tissue is termed gliosis. Inflammations. — Since the pathology of most of the types of disease above outlined are given under their respective heads, we shall dwell upon the main pathologic changes only in this chapter. Inflammation should be understood as to its nature, as the student should also have a clear comprehension of degeneration of nerve-tissue. Inflammation has primarily to do with blood-vessels, then lymphatics, and finally formation of connective tissue. It is the reaction of an organism to an irritant, so that wherever there is inflammation there has been irritation. Products of growths of micro-organisms, or some irritant the product of tissue change, are 5^ TEEATISE OK KERVOUS DISEASES usually the immediate causes of the irritation. But certain chem- ical substances^ as alcohol, lead, or arsenic, as previously men- tioned in this section, may produce inflammations directly; al- though they are more apt to be causative of primary or degener- ative (destructive) processes. When the irritant is removed, inflammation tends to subside — i. e., it is then regressive not a progressive process. Inflammations are further divided into — 1, Productive forms (Delafield). 2. Exudative forms — these forms may be simple inflammations, vs^ithout necrosis or with necrosis, purulent or purulent and ne- crotic. Productive or proliferative inflammation is a process in which there is little congestion and exudation, but new connective tissue sloivly forms. It is usually chronic. Examples of this form are syphilitic or tubercular inflammations (producing specific granu- lomata or tubercles). Lead, alcohol, arsenic may also produce this form, as may the poisons of rheumatism, gout, diabetes, states of inanition (^^sewiio-palsies of rickets, etc.). Exudative inflammation is associated with first a congestion, then stasis, exudation of white blood corpuscles (amoeboid move- ment), diapedesis of the red blood cells, transudation of blood serum, the final formation of fibrin; the complete result being an exudate containing white blood cells, now called pus cells, and fibrin. In some instances there is no destruction of tissue in this form of inflammation, and after its subsidence the tissues affected return to the normal state. In other cases the nerve tissue is partly destroyed. In the purulent form there is great increase of pus cells and but little fibrin. If the tissue is also destroyed it is a purulent and necrotic form of inflammation. In some forms of exudative inflammation increase of connective tissue takes place from the outset, and this latter continues until the inflammation subsides. Most forms of this exudative type are acute or subacute. Inflammatory oedema, so called, is of this type of inflammation. ISTerve-cells proper once destroj^ed never re-develop. This is not true of nerve-fibres, and while these frequently develop again, they but seldom do so within the tracts of the central nervous sys- tem. The peripheral nerves when regenerating always grow from their trophic centre. ISTerve-tissue in brain, cord, or nerve will not reunite, after section, by direct union. With but very few excep- GENEEAL PATHOLOGY 63 tions there is a primary degeneration of the cut ends, which is then followed by regeneration. JSTervons tissue is further dependent upon its blood supply and its trophic connection for its vitality. The nerve-cell is absolutely dependent on the blood supply, while the neuraxone is dependent upon the trophic influence of its con- necting cell, though it can survive for a time the simple exclusion of its blood supply. If the neuraxone is injured it affects the cell, which can be repaired, however. Tumours will be described under the heading of Neoplasms. CHAPTER III GEXERAL SYMPTOMS AXJJ METHODS OF EXAMIXATIOX NOMENCLATURE IN NERVOUS DISEASES Neurosis applies to a functional condition of the nervotis S5's- tem, wherein the higher centres (of the mindj are not involved, snch as in neitrasthenia. "Where the higher faculties of mind are involved the name psy- chosis is given, as in hysteria or insanity. Stupor is that state of nnconscionsness in which the patient can he partially or completely aroused; and in "which the reflexes are preserved. Coma is that state of nnconscionsness from which the patient cannot he aroused and wherein the reflexes are ahsent. HypercEstJiesia is a term used to indicate increased sensibility. Hypcesthesia applies to decrease of sensation. Parrpsfhesia is a perversion of common sensation, such as ting- ling, nunibness. or formication, which latter is a sensation as though ants were crawling over the body. Spasm or convulsion is a sjTnptom in which there is violent contraction of the muscles, and may he localized or general. Fre- quentlv spasm is used in the sense of a localized convttlsion alone, although this is not technically correct, and local spasm is prop- erly called "tic,"^ such as "tic"" of the face — a spasm of the seventh nerve. Convulsions are further divided into clo?iic and tonic. In the former the movements are in rapid succession, and in the latter the contraction is maintained for a long period of time. Hysterical convulsions are partienlarly apt to be of a tonic nature. (See illustration, p. 56.) There are certain definite affections of different tracts of the central nervous system which are given special prominence in the > Tic may also apply to a painful paroxysm in neurological nomenclature; bat then the Tpre&x painful is used in explanation, or an afl&x as in '[tic doulou- reux.'^ 54 GUIDE TO XOTE-TAKIXG IXFIRMARY FOR XERVOUS DISEASE, PHILADELPHIA Xo. of Case. Xame of Book. Date. Service of Doctor. Xame. Eesidence. Age. Sex. Eace. General Statement to Aid in Classifying Case. Family History: Hereditary Tendencies — Healtli of Parents — Syphilis— Gout — Diabetes, etc. Personal History : Married or Single — Children — Relation of Work to Present Trouble — ■ Illnesses — Injuries — Syphilis — Xervous Diseases — Habits — Tempera- ment — -Life, Active or Sedentary — Occupation — Exposure to Poisons — Malaria — Lead — Tobacco — Alcohol — Xarcotics— Opium, etc. — Usual Weight — Height. Date of Onset of Present Trouble : Supposed Cause — ]\[ode of Onset and Outline of Course. General Aspect : Weight now— Colour — Skin — Hair — Eyes — Scars on Head, etc. State of Organs: Present — Comparing Pa"fet. 1. Digestion: Tongue — Bowels — Appetite — Rectum — Teeth — Liver — Spleen — Taste. 2. Eespiration : Lungs — Throat — Xose — Smell. 3. Circulation: Heart — Pulse — Arterial Tension — Blood — CEdema. 4. Uro-Genitory : Catamenia — Leucorrhoea — Displacements — Phimosis Scars — Sexual Functions — Power, etc. — Urinalysis — Colour — Sp. Gr. — Albumen — Sugar — Uric Acid — Oxalates — Urates. 5. iSTervous System : (a) Motility — Voluntary Movements — Strength — Grasp — Co-ordination — Spasms — Reflex Capacity — Knee-Jerk — Arm-.Jerk — -Jaw-Jerk — Skin — Cremaster, etc. — Muscle- Jerks— Clonus — Station — Sway — Bladder Con- trol. (6) Sensibility — Subjective Sensations — Hyperfesthesia — Anaesthesia, etc. — To contact (^l^sthesiometer), to pain, to temperature — Intellectual Functions^Hallucinations — Delusions — State of Will — Predominant Ideas — Specify Insane Acts — Sleep — Vertigo — Tenderness over Xerves — Headaches — Electrical Examination — Trophic Alterations — Vaso-motor Activities. 6. Sight: Vision (Type — Fingers — Colours) — Field — Fundus — Ocular Muscles — Pupils. 7. Hearing: Deafness — Wax — Tinnitus. 55 56 TEEATISE OX NERVOUS DISEASES study of diseases of the nervous system, and lead to assist in the diagnosis through knowing the results of anatomical or physiolog- ical perversions in them. In the sensory tracts we have mani- fested pain, dull or shooting in character; parcesthesia, or numb- ness of a part; causaJgia, or burning pain, frequently occurring in peripheral neuritis — all due to irritative lesions of these tracts. A diminution of the function of the sensory tracts will produce hypsesthesia, angesthesia. Different distributions of anesthesia are of nerve- trunJc, the circumscribed, the s'igmental or glove-like — ^where the anaesthesia ex- tends up an entire extrem- ity, such as from the finger- tips to the elbow, as in cases of hysteria. Hemian- esthesia is a condition where half of the body is in- \ volved — this being of two % different kinds — organic and functional, a point of difference being that func- tional or hysterical anses- ^^^^ thesia, so called, has a dis- ^HHB^I^ tinct dividing line in the ^^^^^1*^^ median line of the body — ■ ^mMB ^^'hereas organic hemianses- ■ .^A.E» thesia will extend slightly Fig. 10.— Position of Hand in Local Tonic j^evond the median line, due Hysterical Spasm . " ,^ t _l i • f to the distal crossing ot nerve-fibres beyond the median line ; or, better, this latter is anges- thesia from the centre to the ultimate end of the nerve-twigs. The destructive lesion of the spinal cord involving one-half of it will produce symptoms of complete hemiangesthesia and slight motor loss below the site of lesion on the opposite side, with complete motor loss on the side of lesion. Tsually it is only pain and temperature sense that are lost, since the lesion is, as a rule, limited. This is called Brown-Sequard paralysis, named for him who first described it, and is due to the fact that the sen- SYMPTOMS AND METHODS OF EXAMINATION 57 sory fibres upon entering the cord cross to the opposite side, then pass up. In pontine lesions we may have a hemiansesthesia of same side of the face with motor and sensory palsy on the opposite side of the' body to the lesion. Algesia refers to the pain produced in a part either by external or subjective stimulation of sensory nerve-fibres or neurones. Muscle sense is that phenomenon by which we distinguish space, shape, size ; also the location of parts of the body. Asteriognosis refers to the inability to appreciate dimensions, density, and shapes of objects. Fig. 11. — Krauss's Plessimeter. By unscrewing the caps C and D it may be used as an sesthesiometer, or as a brush for testing tactile sensibility. Temperature sense is the faculty of appreciating temperatures of bodies^ such as heat and cold. Reflexes are phenomena produced by irritation or by stimu- lants of some sort either from within or from without. Ordinarily, the reflex consists of an afferent impulse, which is carried over the sensory tract to the nerve-centre in the cord or brain. The impulse is then transmitted to the centre, which consists of a collection of nerve-cells within the cord or brain; and finally the efferent impulse completing the reflex is carried over the motor tract or fibres from the nerve-centre, producing motion, secretion, and various physiological phenomena of the body, depending upon the nature of the reflex action. Eeflexes are divided into superficial and deep and visceral. Superficial are those occurring upon the surface of the body, such as skin and mucous membranes. We have among them the pupil- lary sTcin reflex, which consists of a dilatation of a pupil, produced by the irritation of the skin of the neck, as in pinching the same, the impulse being carried up by the cervical sensory nerves, and down as a motor impulse through the motor sympathetic nerve- fibres to the dilator muscles of the pupil. The pectoral reflex con- TEEATISE ON NERVOUS DISEASES sists in contraction of the pectoral muscles through the skin over them. The epigastric reflex consists in a contraction in the epi- gastric region through the fibres of the recti muscles. The abdom- inal reflex consists of contraction of the abdominal muscles when the abdomen is irritated. The supra-orhital reflex of McCarthy consists in elevation of the lower lid when the supra-orbital region is gentty tapped. There are a number of others not of practical importance to the student. r ' ^™ Fig. 12.— Showing the Jendrassik Method of Obtaining the Knee-Jerk. The cremasteric reflex consists in retraction of the testicle when the skin of thigh is irritated. The plantar reflex consists of flexion of the toes when sole of the foot is irritated. The palmar reflex consists in jerking of hand and closing of the fingers upon irritating the skin. The infra-orbital reflex consists of the elevation of the lower eyelid when the supra-orbital region is irritated by a blow. SYMPTOMS AND METHODS OF EXAMINATION 59 Deep reflexes or muscle reflexes are produced by tapping a muscle or tendon and causing contraction of the muscle. The knee-jerk is produced by tapping the ligamentum patella, the leg being loosely pendant at right angles to the thigh. There is extension of the leg. The tendo-Achillcs reflex is produced by tapping the tendo- Achilles, when extension of the foot will occur, due to the con- traction of the gastrocnemius group of muscles. The contra-lateral or adductor femoris reflex is one pro- duced by tapping the ligamentum patella on one side, the patient sitting on the edge of a chair with both limbs loosely resting on the feet. If this reflex is present adduction of the opposite thigh will occur. This is an inconstant reflex, and although it cannot be said to be pathological in significance, it is much increased in cases of spastic disease, as a rule, especially when involving the lateral columns of the cord. Anlde clonus is a deep reflex, always pathological, and is produced by sudden flexion of the ankle, the physician support- Tatlor Knee-Jerk Hammer. ing the calf with one hand and firmly pressing on the sole or ball of the foot quickly. If present there will be a to-and-fro clonic involvement of the foot due to contraction of the soleus ^ and gastro-intestinal muscle. This is called true ankle clonus. A psuedo-anhle clonus is that inconstant clonic contraction of the same muscle group, occurring in neurasthenia or hysteria. It is also called abortive ankle clonus, since it is soon exhausted. It does not signify organic disease of the cord, as the true form always doee. The elhoiv-jerh consists in the extension of the elbow, produced by tapping the tendon of the triceps muscle when the arm is held pendant over the table or other object. » Weir-Mitchell believes it is entirely due to action of the soleus. 60 TREATISE OX is^EEYOUS DISEASES The hiceps-jerh corftists in flexion of the elbow, when the biceps tendon or muscle is suddenly tapped. The extensor reflex of the wrist consists of the extension at the wrist when the extensor group of muscles are tapped. The icrist reflex proper consists in flexion when the flexor mus- cles are tapped. Fig. 14.— Showing Method of Obtaining the Triceps and Supinator Jerk. The jaw-jerk consists in sudden closing of the mouth when tapping over the mental process of the inferior maxilla. Paradoxical contraction consists of a tonic contraction of the anterior tibial muscles, produced by a sudden flexion of the foot or the leg. This sudden shortening of the- muscles indicated causes the tonic spasm which is always pathological. Superficial and deep reflexes are said to be increased when there SYMPTOMS AND METHODS OF EXAMINATION 61 is a decided increase of tiie movement over the normal; lessened when there is a lessening of the normal amount of movement upon its development. Of course reflexes are absent where no response occurs. The two extremes of reflex action are spastic where the reflexes are greatly increased, and absent when there is no reflex at all produced on external stimulation. Several other terms are used in describing reflexes, such as moderately increased and greatly increased, and related to the spastic as described. Also the other extreme — slightly diminished and greatly diminished, exists before abolition of the reflexes occurs. Visceral reflexes is the third group, and consists of the ac- tion of the various viscera, etc., induced by irritative phenom- ena; as the peristaltic movements of the stomach, after taking of food. The Eye. — The light reflex is produced by throwing a bright light into the eye, causing contraction of the pupil. Accommoda- tion reflex is brought out by causing the subject to look at a near object when the pupil also suddenly contracts. When the light reflex is lost and accommodation is still present the Argyll-Robert- son pupil is said to exist. Eeflexes of the bladder, rectum, and sexual apparatus are also important; the two former being under control of the higher centres. 'If the tone of the compressor urethra is intact, the reflex being lost, we have incontinence of overflow as a sign. Damage to the genital reflex arc causes loss of erection and sexual desire. Loss of inhibition may cause priapism. TROPHIC, VASO-MOTOR AND SECRETORY PHENOMENA By trophic disturbances we refer to certain conditions, as the wasting of muscles, false hypertrophy of muscles, bedsores, joint disease, trophic changes in same, such as the arthropathies, brittle- ness of the nails, hypertrophy of bone, such as in Paget's disease, where the cranial bones are enlarged. Vaso-motor disturbances refer to the conditions dependent upon disease of the nervous system, as flushing, cedema, angeio- neurotic oedema, coldness and clamminess of the extremities. Secretory phenomena and disturbances thereof, consists of, among others, retention, or too much elimination of certain secre- tions; in the former in the case of the thyreoid gland, we have 62 TREATISE OK KERYOUS DISEASES developed a disease to be studied in another chapter — cretinism and myxcedema. Excess of thyreoid secretion probably occurs in exophthalmic goitre. EXAMINATION OF THE PATIENT Examination of the patient for nervous disease includes a study the most thorough in general medicine, in order to^ exclude other maladies; and specifically, of course,, for the deter- mination of the status of the nervous system. It will be in keeping with the book to pass by intricate medical meth- ods, therefore, insisting upon their im- portance, however, and to hasten on to the examination of the nervous system itself. Gait and Station. — Station is the attitude, the manner of holding the body in the upright posture, the feet being in the position of "atten- tion." The station is said to be normal when the patient but slightly deviates from the erect posture while standing, the sway tending towards no particular direction. The station is said to be ah normal when the patient does sway markedly. In designating this symp- FiG. 15. — Weir Mitchell's APPARA.TUS FOR CLINICAL OB- SERVATIONS OF Station. torn, right, left, forward or backward are used to indi- cate the direction of the abnormal deviating move- ment. An unsteady sta- tion is called Romberg's sign, particularly found in tabes. The sway should also be tested with the eyes open and with the eyes closed, since it will always be found more perverted when the eyes are shut, especially in diseases where muscular sense is much dfsturbed, as in tabes, referred to above. Fig. 16. — Foot Dynamometer. SYMPTOMS AND METHODS OF EXAMINATtON 63 Gait is the manner of progression of the individual. It is to be noted that there is a difference between the normal gaits of the two sexes. The female, due to the breadth of the hips, has a more or less waddling progression, whereas the male movement is more directly forward in walking. Patients should not deviate from the direct line of progression in any one direction more than another, although a natural sway does occur, and there are particular family types of normal pro- gression. Grasp is determined by the dynamometer. It is of use to compare palsy of the hand and forearm muscles. PATHOLOGIC GAITS 1. Hemiplegic, or that type in whiclifthe individual carries one side of the body forward with the muscular action of the unaf- fected side, plus gravity. The patient brings the affected leg Fig. 17. — Hand Dynamometer. forward in flail-like fashion, using the opposite foot as a pivot, the toe of the affected side dropping to the ground before the step is completed, so that a tracing of this gait will present a short stride of the affected side, followed by the longer stride of the healthy limb. 2. Spastic is one characterized by the forcing of the toes down- ward in flexion during progression. In its incipiency the wearing out of the toe of the shoe may be the most prominent sign. Later the ball of the foot is " dug " into the floor, the patient stumbling over the slightest impediment. The knee-jerk is found to be in- 64 TREATISE Oif NEEVOUS DISEASES creased, though it may be difficult to elicit on account of flexor contractions. 3. Ataxic is one where the patient throws the limb outward, forward, and downward, the heel dropping first, and all the move- ments being inco-ordinate. This gait is decidedly worse when the patient is in the dark or when closing his eyes. The knee-jerk is usually absent. It is increased in ataxie-paraplegia. 4. Titubation is characterized by a rather sudden deviation to right or left during progression. As a rule, the patient " catches " himself before more than one or two steps away from the normal are made. This gait is rather characteristic of the inco-ordination produced by cerebellar disease where centres for balance lie. 5. Steppage gait is that in which the patient lifts the toes high from the surface, such as normally is done in ascending stairs. The cause for this exaggeration lies in the fact that there is palsy of the anterior muscles of the leg. This gait occurs in neuritis and the muscular dystrophies. It is almost pathogno- monic of these conditions. 6. Festinating gait (or running gait). Here the patient tends to go forward rapidly, as in paralysis agitans, in which disease a sensation of falling forward (propulsion) or backward (retro- pulsion) may also occur. PHYSIOGNOMY Physiognomy of the patient has much to do with the deter- mination of certain features of the nervous malady. Besides the final delineations of feature, showing depressive mental states or the opposite, a temperament is shown by the examination of the facies, of which the following are of some worth in stud3dng the case — namely: Lymphatic temperament, in which the face, along with other structures, presents a pale and waxy sallow aspect, and in which the subcutaneous tissues are flabby and the skin is unduly wrinkled. Such persons are apt to be large of skeleton, out of proportion to the musculature, and their circulation is sluggish. Sanguineous temperament is characterized by the face present- ing a florid complexion. Prominence and tension of the sub- cutaneous tissues, with perhaps excessive development of fat SYMPTOMS AIsTD METHODS OF EXAMINATION 65 cells, is seen; the neck usually appearing short and the chest broad, out of proportion to the general physique. It should be stated that this type is predisposed to apoplexy among nervous diseases. Bilious temperament is, typically, found in those with dark hair .and complexion. The salient features are tendency to jaun- dice, to a melancholy physiognomy, the tongue being usually coated and bowels constipated. Such types are likely subject to nervous depressive diseases, such as hypochondriasis and melan- cholia, or to the neurasthenias dependent upon gastro-intestinal auto-intoxication in some measure. Nervous Temperament. — Here the individual expression is one of vivacity, eyes are alert, movements quick; with a miisculature that is not large, but the muscles are distinctly outlined, as in the thoroughbred, the bellies being prominent. These people are most likely to come under the list of nervous patients, because they do the world's work. Neuro-Bilious Temperament. — This is a type we can well des- ignate in America, since our methods of life conduce to modifica- tion of the other temperaments towards the nervous ; and since the bilious temperament, as indicated, is not itself an important factor in nervous disease, but when added to by the nervous element there is reason to make the above designation. This type is the most difficult to manage in any case of nervous or mental disease. DECUBITUS In neurology the position of the patient, as he lies in bed, is important to note in making an examination. In decubitus of meningitis, as a rule, the patient lies supine, or on his side, with retraction of the head and hyperextension of the back, plus general muscular rigidity. In hemiplegia the patient usually lies upon the back, the one side of the body being assisted by the normal extremities. In tetanus and hydrophobia the decubitus is not consistent, but is somewhat like that of meningitis, the patient more frequent- ly remaining on the side, however. Tonic and clonic convulsions occur spontaneously or with the slightest reflex excitement. In both of these diseases there is frothing at the mouth. Decubitus of an epileptic attack consists of the patient lying on 5 66 TEEATISE OK NERVOUS DISEASES . the back usually in the typical convulsion, with conjugate devia- tion of the eyes and dilated pupils. Following the attack the patient remains limp, supine. He may, of course, fall upon his face in exceptional instances. Decubitus of neuritis is not constant, depending upon the degree and extent of nervous inflammation and palsy. The pa- tient always tends to protect the extremity or part affected, and this will extend to the guarding of the extremity from any injury or contact, as of the bed-clothing, when there is active neuritis. EXAMINATION FOR SENSATION This is done by means of the sesthesiometer, to determine the presence, absence (anaesthesia), or diminution (hypassthesia), or exaggeration (Ii3^per8esthesia) of common sensations. Dysesthesia is an abnormal sensation, such as a feeling of discomfort pro- duced by ordinary tactile or painful impres- sion. Parsesthesia is a subjective sensation, such as a feeling of pins and needles prick- ing the affected part, and occurs frequently in early neuritis, as in pressure palsy. Causalgia is a "burning" sensation found in some cases of neuritis of chronic type, as in erythromelalgia. Formication is the sensation as of ants crawling over the surface of the skin; often a delusion of mental disease. For the finest determination of sense of touch, a piece of cotton twirled at the end will be found efficacious; or better the fes- thesiometer. In testing, it should always be done symmetrically, since one person may differ from another, according to the tem- perament, so that a standard cannot be set for all persons from one case. It should be remembered, too, that special parts of the body are more sensitive than others, such as the face and the lips, tongue, and palms of the hands and feet. To test the thermic sense, heat and cold are applied through water in test-tubes. The absence of thermic sense (thermo-anses- FiG. 18.— Carroll's ^STHESIOMETER. SYMPTOMS AND METHODS OF EXAMINATION 67 thesia) is to be expected in cases of syringomyelia, where the touch sense may he retained in tlie absence of thermic sensation — the so-called disassociaiion of sensation. Algesia or pain sense is tested by means of a sharp instrument, as the Eesthesiometer. This, also, may be absent (analgesia) with preservation of the other forms of sensation in some eases of hys- teria, etc. EXAMINATION FOR MOTION The motor phenomena are examined for, first, as to palsies. These "can be tested by means of the hand or foot dynamometer, which is an instrument by which record is made on a dial of the amount of force used to compress the oval spring. In testing the strength of the lower extremity, the instrument is suspended from the shoulder, and by means of a strap, attached also to the dynamometer, the amount of pressure can be regis- tered. This should be used bilaterally, since the record is only for comparison. The palsy in other parts is noted by the strength shown in movement of the part of the muscles, as in effort to lift some object, etc. Individual muscle palsies are noted by obser- vation, the anatomical position of the part involved, and in rela- tion to the motor nerve supply, thus giving way to opposing normal muscles. The opposite of paralyses, convulsions, are determined by means of the sense of sight. A contraction is a shortening of the muscle of a part, which cannot be forcibly extended even under etherization of the patient. A contracture is the shortening of a muscle, which can be re- lieved by firm extension, the muscle therefore not being actually organically diseased. It may be necessary to etherize the patient to accurately test this. Paralysis may be partial or complete, the former scientifically being designated paresis. The forms of paralysis are: Hemiplegia, involving one-half of the body. Monoplegia, where the palsy is confined to one limb of the body. Paraplegia, where both the lower extremities are affected. Diaplegia, where the palsy involves corresponding extremities, as the two legs, two arms. Or all four limbs. 68 TREATISE ON NEEVOUS DISEASES Loss of the special sensibility of the muscles, articular sur- faces, and tendons produces ataxic movements. Ataxic movements are inco-ordinate movements, as in loco- motor ataxia; or in cerebellar disease or in neuritis. Apprecia- tion of weight and position of limbs are lost in ataxia. Static ataxia consists in loss of equilibrium when the patient or part is at rest. Cerebellar ataxia is produced by cerebellar disease. Motion of an unparalyzed limb or a limb that is partially paralyzed will occasionally produce movements in the correspond- ing paralyzed extremity. This is designated as associated move- ment. A forced movement is one produced in spite of the patient's will, as when the patient is suddenly whirled about in various directions. Some other abnormal movements are tremors, spasms, and choreiform convulsions. Tremors are fine, coarse, intentional, and continual. The following table gives the various causes of tremor and their character : Cause. Toxic. Neuroses f Arsenic. Lead. Alcohol. Tobacco. Tea. Coffee. Hysteria. Neurasthenia. Exophthalmic Goitre. Senility , Heredity Any disease of brain, spinal cord, or periphe- ral nerves, excepting multiple sclerosis and paralysis agitans. Paralysis agitans Type of tremor. Intention in early stages : later may become con- stant ; may then be in- creased by exertion. Ibid. Multiple sclerosis. Ibid. Ibid, Ibid. Often ceases for a few seconds after muscular exertion. Intention only. Rapidity. Rapid. That of hysteria some- times is slow; others always rapid. Rapid. Rapid. May be slow or rapid, or both combined. - Slow. Slow. Spasms may be tonic or clonic, the latter consisting in rapid movements; but when the contraction persists it is designated tonic; when permanently persisting, it produces what is called muscular rigidity, as in the extremities, neck, or trunk. SYMPTOMS AND METHODS' OF EXAMIXATIOX 69 Choreic movements are sudden, or jerking, irregular inco-ordi- nate movements. Convulsive tic is a form of choreic movement confined to cer- tain groups of muscles and limited to muscles physiologically grouped for certain functions, as the respiration, or expression, or locomotor. Athetosis is the vermicular movement described first by Ham- mond, observed in cerebral disease, as in porencephaly. Conjugate deviation is a phenomenon that is frequently pres- ent in diseases of one side of the brain. In this the eyes are directed towards one side (of lesion), with or without the corre- sponding rotation of the head. If the lesion is a simj^le irritative one the deviation is away from the side of the lesion. The first is paralytic, the latter spas- modic. PRESSURE SENSE Pressure sense is determined by means of weights, alternating one with the other, until the power of discrimination is nicely met with the least amount of weight. Differences of temperature should be excluded, also the prevention of the displacement of the weights in this test, and the area or part tested should be held in relaxed position. For making the finer tests bits of cork are used. MUSCULAR SENSIBILITY This test depends somewhat upon idiosyncrasy of the individ- ual. To exclude surface differences in testing by balancing weights, they can be suspended in a towel or by cords. By re- peated experiments, it is thus possible to determine as between the cutaneous sensibility (which will interfere with the test to the extent of two or three ounces pressure) and the muscular sense. The pressure sense is a composite physiological phenomenon, consisting of the sense of coarse movements of the limb, the pos- ture sense and the pressure sense. SENSE OF THE APPLICATION OF WEIGHT This is determined by the piesmeter of Beard and Eockwell, which instrument is made up of a cylinder, f of an inch in diam- eter and 3 inches long, in which is a piston kept pressed back to 70 TEEATISE OX XEEYOUS DISEASES its fullest extent by a spring. At the end of the piston rod is a flat disk which is pressed against the skin. The physician then presses against the end of the cylinder, forcing the piston into the barrel, and the amount of pressure made before it is recognised by the patient is indicated by a scale on the instrument. In this connection it should be stated that there is a similar instrument, which is called the algometer, devised by Dr. Arthur MacDonald, by which pain is tested in a similar manner to that of the above instrument. Instead of the plain disk, however, a sharpened point is forced upon the part to be tested. SENSATIONS OF MOTION It may be necessary- to diagnosticate diseases of the semi- circular canals, the vestibular nerve and its terminations, from affections of the cochlear nerve, which latter is the true nerve of hearing. Since the two nerves are so closely approximated in most deaf jDersons, it will be found that sensations of motion are also affected in them. So that it is chiefly where the periphery of the vestibular nerve is affected, the patient not being deaf, there- fore, that abnormal sensation of motion are produced in hearing individuals. In this test, deafness or not should, of course, be first determined. Then rapidly rotate the table upon which the patient stands, the top of which is placed upon a pivot, as suggested by Sanford. In health the direction of rotation can be recognised when the rate is as low as two degrees per second, or even lower. In some deaf-mutes the sense of motion is entirely absent. This latter is probably a reason why deaf people seldom get seasick. OCULAR DISTURBANCES In this we examine for changes in the optic nerve, such as neuritis, atrophy, occurring in brain tumour, meningitis, etc. ; also for changes in the retina, especially concerned in specific disease of the nervous S3'Stem. Eefractive errors are not a part of neuro- logical examination. Nystagmus or involuntary oscillation of the eyes, usually bilateral aud horizontal, is present iu affections of the cerebellum and in dissem-iuated scleroses. It is irregular or rotary in type in blind persons. N'ystagmus may also be congenital. TJemxanopsia is loss of one side of the visual field, whereas Jiemiopia refers to loss of visual power in one-half of the retina. SYMPTOMS AXD METHODS OF EXAMIXATIOX Tl The latter term is generally used in describing peripheral dis- turbances, whereas hemianopsia is used in the study of brain dis- eases. The lesion causing hemianopsia is situated anywhere from the cortical centres of vision in the occipital lol)e to the optic chiasm. In rare cases it may be necessary to study areas of ob- scuration of vision, as cjuadrants or irregular areas. Hemianopsia may be vertical, horizontal, bilateral, binocular, or lateral ho- monymous. Homonymous hemianopsia indicates blindness of the inner half of one field and the outer half of the other field of vision. Amblyopia indicates dimness of vision. Amaurosis indicates total blindness. Hemianopsia can be roughly determined by having the patient look at a fixed point, then by moving an object from without in, in all portions of the visual field, when, if it is not present, the moving object Avill be perceived at the proper limit. The perim- eter of Emerson is also used by the ophthalmologist to make these tests. Errors of refraction and exophthalmos should also he noted. Wernicl-e's liemiopic pupillary inaction consists in lack of con- traction of the iris when a ray of light is thrown on the blinded side of the retina. Since the reflex centre of this arc is located in the primary optic centres in the pregeminum and pregenie- ulum, if the lesion is behind these centres, the reaction does not occur. If the lesion is in front of the primary centres, the inac- tion occurs. Colour Changes. — Occasionally subnormal colour perception exists with hemianopsia or v/ith sector defects of the eye. Con- centric restriction in the field of vision and reversal of the order of colour field may be present and may be tested for with colour disks in the slide of the perimeter. Abnormalities of the visual fields may occur in functional disease; thus, in hysteria we may have complete reversal of the colour field with a constriction of the field of vision. The condition is likely due to defect of perception in this disease, as described by De Schweinitz and J. K. Mitchell. The test for colour is made by means of coloured yarns. Pupillary Symptoms. — We note under this if the pupils are dilated, contracted, or irregular; also seek for abrupt and frequent changes in the pupil and also for spasms or paralysis of accom- modation, etc. n TREATISE ON NERVOUS DISEASES Argyll-Hobertson pupil is one in Avhicli there is wanting re- sponse to light, the power of accommodation remaining. A phenomenon called Jiippus is produced when the hand cov- ering the eye, directed towards the light, is removed, the pupil at usu^ 'SU A^ Pig. 19.— Diagram of Visual Paths. (Prom Vialet, modified.) OP. N., Optic nerve. OP. C, Optic chiasm. OP. T., Optic tract. OP. R., Optic ra- diations. GEN., Genicnlate body. THO., Optic thalamus. C. QU., Corpora quadrigemina. C. C, Corpus callosum. V. S., Visual speech centre. A. S., Audi- tory speech centre. M. S., Motor speech centre. A lesion at 1 causes blindness of that eye ; at 3, bi-temporal hemianopia ; at 3, nasal hemianopia. Symmetrical lesions at 3 and 3 would cause bi-nasal hemianopia ; at 4, hemianopia of both eyes, with hemianopic pupillary inaction ; at .5 and 6, hemianopia of both eyes, pupillary reflexes normal ; at 7, amblyopia, especially of opposite eye ■, at 8, on left side, word- blindness. SYMPTOMS AND METHODS OF EXAMINATION 73 first contracts^ and then slightly dilates, and thus oscillates until it settles to the original size. During the testing for mobility of the iris the eye must be fixed upon a distant point, if not, the influence of accommodation and convergence will prevent accuracy. Hearing. — This is tested by means of a watch brought towards the ear, the point at which it is first heard to tick being recorded. The eye should be closed when this is being done. This test shows the extent of air conduction. Bone conduction is tested by using watch or tuning-fork. The patient being deaf, a tuning-fork struck, then placed over the mastoid process is heard better than by aerial conduction in an ear that is diseased in the middle portion. Disease of the labyrinth or nerve will, of course, destroy bone con- duction as well as aerial. Galton's whistle is a piece of brass tubing, with an internal diameter of less than ^ of an inch, into which a plug can be fitted and drawn in or out at will. This is used in determining pitch. Deafness is of different degrees. We speak of this as a person being totally deaf, partially deaf, or having impaired hearing. The three terms indicate the degree of defect in the order men- tioned. Smell. — In testing the efficacy of the olfactory nerve, and in distinguishing acuteness, we should avoid, first, the use of any irritating substance, and, secondly, select pleasant odours; thus, the odour of violets, musk, camphor, oil of cloves, etc., should be placed upon cotton and applied to one nostril while the other one is held closed at the time. The loss of the sense of smell may be due either to a functional or an organic disease. Of the former, hysteria is an example. Anosmia is the name given to that condi- tion where there is loss of the sense of smell. Fracture through the ethmoid may cause organic anosmia. Hyperosmia is increased acuity of the sense of smell. Parosmia is the perversion of the sense of smell. Taste. — This is tested for by means of a sweet solution, or of something sour or bitter. In making the test the patient should be asked to protrude the toncjne, the solution being dropped upon one side of the tongue, and the patient again asked to record the sensation before retracting the tongue into the mouth, otherwise the sensation will be perverted by impingement of the test solution upon adjacent parts of the mouth. A test should be applied to the 74 TKEATISE OX XERVOUS DISEASES sides, back, tip, and middle of the tongue, according to the part desired to be tested, and is indicated upon each half separately. The sense of taste can be tested electrically by an instrument invented by Xewman consisting of a long stem carrying two wires isolated from each other, at the ends of which are two little balls, forming the poles. The current being applied, the sense of taste, if present, is readily perceived in a sapid and metallic sense of taste. In order to prevent confusion, smell, touch, or taste, the eyes should be shut and the nostrils held in difficult cases. Ageusia is absence of taste. Hypergeusia is increased sensibility of taste. Parageusia is perversion of the sense of taste. Reflexes. — Since these are most important they will be gone over again from a different viewpoint. The reflexes are divided into cutaneous, deep, and visceral, as noted in a previous section. Exaggerated responses of skin reflexes will be produced if the special sense organ is in an irritated or inflamed condition, or if they are cut off from central control, or if cerebral sensory areas are diseased. The lack of response would indicate that the nerve- tracts in the periphery or in the cord are injured, or that the special sense organs are destroyed or impaired. The skin reflexes have been divided in accordance with the areas most conveniently tested, as the supraorhiial, the epigastric, over the epigastric re- gion: cremasteric, brought out by irritation over the inner part of the thigh; the abdominal, over the sides of the abdomen; the plantar, obtained by irritating the sole of the foot. In the trunk and upper extremities we have the intercostal, the interscapular, the palmar, the bicipital, and in the head the conjunctival and pliaryngeal. The skin reflexes are very easily exhausted even in very sensitive individuals. Therefore, the test should be mad.e quickly and recorded at once before the loss occurs. Deep Reflexes. — These deep reflexes are muscle or tendon re- flexes. The knee-jerk or patellar reflex is that produced by tap- ping the ligamentum patella, which by stimulating contraction of the erector femori group of muscles, produce extension of the leg. The jerk is due, first, to the direct stimulation of the muscles, and, secondly, to reflex influences. The elbow-jerk is produced by tapping the triceps tendon, the arm being pendant over some object, as the back of a chair. Extension of the forearm occurs. The biceps-jerk is produced upon striking the biceps tendon of the arm, the member being held in semi-flexion. This produces SYMPTOMS AXD METHODS OF EXAMIXATION^ 75 flexion of the forearm upon the arm. JerTcs or reflexes can also be obtained over some of the muscles of the neck^ as well as from NHIBITING FIBRES! FROM > CEREBRUM. j DISEASE AFFECTING THESE ALLOWS EXAGGERATED REFLEXES [-CORTICAL LESIONS. SPASTIC PARALYSIS DISEASE OF MOTOR END-PLATES SHOWING THE MECHANISM OF THE DEEP REFLEXES AND EXAMPLES OF THE LESIONS WHICH MAY INCREASE OR ABOLISH THEM AS ILLUSTRATED BY THE KNEE-JERK. DOTTED CIRCLES = LESIONS ABOLISHING THE REFLEXES. BLACK C1RCLES = LESI0NS EXAGGERATING THE REFLEXES. Fig. 20. — Showing mechanism of deep reflexes ; also the two main types (spastic and flaccid) of paralysis. (From Butler's Diagnostics ) 76 TEEATISE ON NERVOUS DISEASES the tendons. The reflexes may be exaggerated, depressed, or abol- ished in nervous diseases. In making a test the part should he well suj^ported and voluntary effort on part of the patient avoided. The cliin or jaw-jerk is that produced by tapping the mental proc- ess of the inferior maxillary bone, the mouth being held loosely open, when contraction of the temporal muscles occurs to the closure of the mouth. It is diminished in neurasthenia. Muscle- jerks are the same as deep reflexes and are also obtained by striking the muscle, when shortening occurs. If disease or an injur}^ severs the nerve supplying the muscle, the tendon reflex is absent, but " humping " from a direct blow over the belly of the muscle may remain for a time. Ankle clonus is produced by "sudden flexion of the ankle, when a rapid clonic movement will follow if the phenomenon be present. Paradoxical contraction is the sudden contraction as of the ante- rior tibial muscles, when the said muscles are suddenly shortened by movement of the extremity. These two reflexes are always abnormal, and indicate excess of irritability of an organic nature. Bulbo-cavernous reflex consists in sudden contraction of the ischial and bulbo-cavernous muscles caused by mechanical excita- tion of the glans penis. It is produced by placing the left index finger on the bulbous portion of the penis, and with the right hand striking, with a piece of paper, the dorsal surface of the glans. Onanoff believes that its absence is the sign of an organic lesion. If the sexual function is impaired and the reflex is present, the disease is probably of dynamic origin, and favourable prognosis can be given. This reflex is also styled virile reflex by Hughes of St. Louis. The anal reflex has its centre in the third sacral segment. It is found increased in neurasthenia and in myelitis high up, but is diminished in sacral neuritis and posterior scleroses. - Visceral Reflexes. — Eye. — The liglit reflex is produced by throwing a ray of light into the eye, when the pupil contracts, to dilate again when the light is removed. The accommodation reflex is brought about by causing the patient to look at a near and a far object. In the former case the pupil contracts; in the latter it dilates. One eye should be covered in examining for the reflex of the pupil. When the light reflex is lost and accommo- dation remains, we have what is known as the Argyll-Robertson pupil. SYMPTOMS AXD METHODS OF EXAMINATION 77 Reflexes of the Bladder, Rectum, and Sexual Apparatus. — Urination and defecation are reflex acts under control of higher centres. If the inhihitory influence is removed and voluntary control over the sphincters is lost, urine and faeces are expelled as soon as bladder and rectum are full. Disturbance of function of the pyramidal tracts will bring about this condition. The bladder walls may become weak, and if the compressor' urethrce remains intact the bladder becomes distended, and we have in- continence of overflow. If any of the components of the reflex are involved, incontinence will occur. If the motor part is dis- eased, the sphincters are relaxed. In case of the rectum, if the rectal sphincter is relaxed it is due to (as can be shown by digital examination here) disease of the motor part of the arc. If the sensory part of the arc is diseased, the patient is unaware that the bladder or rectum is full. Damage to arc of genital functions may bring about loss of sexual power and desire. The Surface Temperature. — It is desirable to note the local temperature in many diseases, in some of which this symptom is of special value, as in cerebral haemorrhage, infantile palsy, and in the various vaso-motor and trophic disturbances. In cerebral diseases we may find an increase or a diminution over some por- tion of the scalp. In erythromelalgia the surface temperature is increased, espe- cially when the affected limb is pendant. This can be detected by a thermometer, which was first invented and constructed by Seguin. The Mattson's surface thermometer is an instrument consisting of a coil containing the mercury and extending up a tube at right angles to the coil. It is the best instrument that we have used. CHAPTEE IV GENERAL THERAPEUTICS AND PREVENTION OF NERV- OUS DISEASE AND THE ACQUIRE 2IE NT OF NERVOUS HEALTH — HYDROTHERAPEUTICS — MASSAGE — ELEC- TRICITY — HYPNOTISM — CARE AND TREATMENT IN CONVALESCENCE FROM FUNCTIONAL NERVOUS DIS- EASE—CLIMATOLOGY OF NERVOUS DISEASE TREATMENT AND PREVENTION OF NERVOUS DIS- EASE AND THE ACQUIREMENT OF NERVOUS HEALTH Ix the treatment of nervous disease the physician should at- tempt to relieve distressing symptoms, or better, to secure an out- and-out cure, or to prevent return — prophylaxis being always the ideal, but which it is difficult to inculcate into the minds of or enforce upon people who have not once gone through suffering. General measures to be instituted in the care of nervous dis- ease are, first hygiene, then exercise, rest, diet, climate, hydro- therapy, massage, electricity, external and internal applications and measures, surgical procedures, and finally, the judicious use of drugs and of other remedial measures. Hygiene. — To maintain normal nervous sy.stems in the present social life led by Americans would require extreme alterations in method of living of the majority, though gradually the cultured educated classes are beginning to appreciate this, and are adopt- ing more common-sense methods of living, which wise scientific doctors have been advising for so long. Methods here detailed are particularly applicable to the neuropathic individual, but it must be remembered that the nervous predisposition does not start de novo, and hence the suggestions to be here made can apply in proper measure to all active people. Thus, persons of neuropathic stock should- not intermarry. Consanguinity should be avoided; nor should intermarriage take place betweeen, families of highly nervous temperaments. Chil- dren should live much in the open air to develop themselves by 78 GENERAL THERAPEUTICS AND PREVENTION 79 natural methods of physical exercise, such as walking, boating, horseback-riding. The overdoing of many so-called medical gym- nastic exercises should be prevented. People should be taught to eat slowly, masticate and insalivate thoroughly, and to live on a wholesome mixed diet of fats, carbohydrates, and proteids. Self- control and obedience should be inculcated into children from an early age. This particularly prevents the development of hysteria, that disorder of the emotions. Systematic study and work is essen- tial; never overwork in growing youth. All reflex causes, such as by eye-strain, through poor light, or errors in refraction, should be looked to. Ventilation, if poor, will have a baneful influence through preventing proper oxidation and growth and nutrition of nerve and other tissues in the economy. The occupation should be carefully selected for the young ; overeducation is to be avoided, since it brings about stress upon the growing brain and its highest function, the mind. Weak children should indeed, be especially educated in accordance with their physical development and nerv- ous capacity. Precocious children are only more apt to develop breakdowns because they do overwork. The queer or eccentric child is the one, however, that must be well guarded if a nervous wreck is not to develop at adolescence. Mental overwork in them should largely be substituted by physical exercise. Even this can easily be overdone. Many people of this stamp would make excellent artisans or mechanics, or even labourers, and enhance the value of the race by such manual labour rather than by being advised or set to do the work of the mind such as is compassed in the professions. " Moderation in all things '' is an old adage that amply applies to prophylaxis of nervous disease. This applies to sexual indulgence in adults in particular. Exercise is a very valuable prophylactic measure for them. Luetic infection is the one prominent single misfortune that can happen to an individual; for even if treated to the full, there still lurks remote toxines within the blood which at the degenerative period of life cause neurasthenia, hysteria, or grave organic or suborganic disease, which seldom can be entirely relieved. The overuse of tea, coffee, condiments, tobacco, or alcohol must be remembered as causes of various functional and organic diseases, such as optic atrophy or chronic neuritis. Mental and physical trauma; poisons, as lead or mercury; or the infective fevers, are all causes of various nervous disorders. Alcoholic abuse, it should be repeated, stands 80 TEEATISE ON NERVOUS DISEASES next to syphilis as a cause of a legiori of diseases of the nervous system. At least eight hours of sleep should be had in twenty- four hours by every healthy man. Diet. — As indicated above, nitrogenous food should be given in abundance to the nervous, since there is waste in them of nu- clein and other proteid substances from the nerve-cells. Fats are next in importance; carbohydrates least, and they also fre- quently interfere with digestion, since it requires more caloric, and therefore nervous energy to oxidize this class of foodstuffs. Water should be drunk freely between meals, and even a glass of water at the meal is a desideratum, since certain salts of food need the chemical action of water to convert them into soluble chem- ical substances. The obese should not eat or drink as freely as a spare person. If muscular exercise is indulged, then the total amount of food should be increased. If the patient is consti- pated, green vegetables, farinaceous foods, or an orange before breakfast are valuable remedial measures in dietary. The best foods are meats — beefsteak and fowl; also eggs, fish, milk, but- termilk, and cocoa; stale bread, to which can be added plenty of butter. Metal workers .should have plain drinks and alkaline waters. It must be remembered that adults cannot take so copi- ously of milk as children. The use of alcohol is baneful for the nervous body. Some claim it may increase capacity for work, but I am perfectly sure this is not the case. In disease with tempera- ture it is, of course, of value. " Generally nervous " still applies to a class of irritable persons anno5^ed by trifles, yet not truly neurasthenic nor hysterical. In all three of the latter states, however, the patients can and should take large quantities of proteid food, to which should be added the heat-giving foodstuff fats as much as can be easily digested, since these patients always complain of being cold or chilly at the slightest exposure. Some nervous persons cannot take sweets with- out producing headache, rheumatic pains, or disorders of digestion, due to the fermentation produced and acid condition of the blood (uricacidsemia) following. In such people the diet should ex- clude carbohydrates and include meats, fish, oils, as cod-liver or olive; also cream, milk, oysters, and even pork. Spinach is an excellent food for the neurotic, since it is laxative and contains a goodly proportion of iron. The white of an egg added to beef- tea, to which can be placed in addition some form of peptonoids. GENERAL THERAPEUTICS AND PREVENTION 81 is very nutritious. Besides the stale bread indicated, in which fer- mentation is complete and the individual elements better dis- persed, the nervous person can use the special fornif? of breads in which the starch has largely been removed. These give the gastric content a release from overtaxation in digestion of the carbo- hydrates. Practically, however, the patient cannot take these breads for any length of time, since they are unpalatable. If a rigid diet is desirable make it as follows: Milk, oysters, butter, eggs, raw or soft, cocoa, graham or gluten bread, beef, fowl, mutton, lamb, or fish. Among _ vegetables spinach, lettuce, string-beans, Brussels sprouts, or stewed fruits are the best. The neurotic person, from the subjective craving of nature (boulimia), is liable to eat too much. Hence this should be guarded against, since overloading the stomach in them may cause gastrectasia, an added mechanical cause for indigestion. Tea^, coffee, and alco- hol are baneful in effect upon the franhly nervous person. Over- use of the alkaline mineral waters should be avoided, since disturb- ance of the normal acid secretion of the stomach will be brought about and add to distress. Three to four pints of plain water should be drunk per diem. Dryness of or desiccated nervous systems cause instability of function. Exercise. — The value of exercise, if taken out of doors, as in rowing or horseback-riding, where the mind cannot run in special grooves, is a certain preventive of nervousness beyond calculation. The exercise should not be violent in brain-workers — i. e., they should not go into severe athletic training. Even the majority of youth or of adults cannot do well both physical training and men- tal work of the highest sort. Nervous persons need exercise asso- ciated with interest to the mind; hence the individuality of the pleasure of one person as compared to another must be borne in mind, and not too strict rules laid down by the physician. Gym- nastic exercises indoors, as a rule, do little good from the fact of the monotony of the procedure entailed. The mind must be properly exhilarated with it all. Walking is a valuable form of exercise, since it is moderate, and movements of the arms bring into play the muscles of the chest. Horseback-riding is the very best exercise the nervous patient can take, since it carries the pa- tient out into the fresh air, expands the chest, gives free use of the arms, and does not require the extremes of exertion as with other forms of exercise. Then the spinal cord is not drawn upon so 82 TREATISE ON NERVOUS DISEASES heavily in expending the little reserve of nervous energy the neu- rotic holds claim to as does walking^, bicycling, golfing, ,and the like. Exercise should be cut down much after the degenerative period of age has set in (i. e., after forty) if a person wishes to live a long life. HYDROTHERAPEUTICS IN NERVOUS DISEASES This important adjunct to neurological care of the many cases coming under our observation is important for the physician and nurse to know well. The proper external use of water aids much the general treatment of nervous disease. The effect of water be- sides the hygienic place, and often the favourable mental influence upon the patient, as in eases where neurasthenic and hypochondri- acal phobias exist, is mainly due to reflex action upon the nervous system. The " reflex " arcs so patent in the symptomatology of organic diseases of the central and peripheral nervous systems we are apt to let pass by when we are earing for the so-called func- tional diseases ; whereas in them can be found the reflex guide-posts to the treatment of the case that may be cured. In organic dis- ease, it must be re-enforced, we have the grosser expressions of what scientific clinical medicine behooves us to -search for in the very incipiency. And it is here in place to. say that the scientific physician will ever be the leader in progress, albeit medicine, for the very reason that we deal with life, can never be a true science. Much of the treatment at Carlsbad is scientific ; a great deal of the good results are from the engendered mental buoyancy which we must recognise. With, these well-balanced therapeutic ideas kept perfectly clear in mind, the physician of largest attainments will use bathing freely more and more conscientiously until he learns the true value of the bath in its physical effects on the body, sick or well. Turkish Bathing. — The origin of Turkish bathing, so peculiar- ly associated with the religious rites of the oriental people, is quite as much in nubibus as is the origin of language. The effects of dry heat are finally to stimulate hypergemia of the surface of the body, to cause hypercaloria and hyperhydrosis. As the heart is stimulated by increase of temperature, that organ must be very competent before a patient is relegated to this initiative step of the Turkish bath. Indeed the heart should be toned up by digi- talin, strychnine, or strophanthus when there is the suspicion of HYDEOTHEEAPEITTICS 83 cardiac weakness. A patient with pronounced valvular disease should be prohibited from Turkish bathing. Persons suffer- ing from obesity or interstitial nephritis may be greatly alleviated of distressing subjective phenomena of vertigo, headache, and de- pression by judicious use of Turkish baths. This beneficial effect must be due to elimination of toxines always retained in such cases. In anhydrosis, as in myxoedema, or in cases of atrophic dry skin I have so often seen in women at the climacteric suffering from general nervousness, Turkish bathing does a great good. In cases of neurasthenia terminalis I have seen much improvement through this form of bathing. Hystero-neurasthenia in persons of gouty diathesis, on the other hand, are not benefited at all by the Turkish or Eussian baths. Details of the Turkish Bath. — Like the massage we use in America, which is the resultant of selection from the best methods, the Turkish bath is modified as we use it for best therapeutic results. The patient should have at least two hours to give to the bath. This will allow amply for the one and three-quarter hours which should practically be the time consumed in the procedure. The patient is at first sent to the dry hot-air room, where he sits in a reclining chair, keeping perfectly quiet and relaxed. If he reacts favourably, beads of sweat will soon begin to come to the surface of the body, which is always a favourable aspect. Should the patient complain of sense of faintness, the application of cold cloths to the head by the attendant is directed; also the drinking of cool water will do much to relieve this symptom and to hasten hydrosis. As before stated, the patient should be allowed to re- main som.e fifteen or twenty minutes. The temperature of the room is kept up by means of hot water to the average of 153° F. In cases of obesity, the patient may next be taken to the hotter room adjacent, the temperature being as high as 175° F. The attendant must constantly observe the case taking an initial bath in order to avoid any ill effects of idiosyncrasy. The patient is next taken to the ruihing room in moderate temperature and placed upon a marble slab on his back, with his head and heels protected by cushions or sponges. He is then given a thorough surface massage by the attendant, the general movement being from periphery to the trunk. With 6 84 TREATISE OK" NERVOUS DISEASES this there is a series of slapping motions with the palms of the hands, Avhich greatly stimulates the circulation. The back is then treated in the same fashion after the patient is placed in the p^rone j)osition. The water from a hose at about the tempera- ture of 105° F. is frequently deluged upon the subject with some considerable force during the manipulations. He is finally " soajDed over '' thoroughly and again " washed down '' when he is prepared to enter the steam-bath. Then the " shower " is had, or he takes the "plunge."' in the bath, at the discretion of the physician. In the steam-hath lies the modification and Mending of the Turkish and Eussian baths used to-day. The patient enters the door and quickly proceeds to the opposite side of the room, where he sits on the marble slab quietly for about five minutes; this is likely to be the most discomforting part of the entire procedure, and the patient should be carefully watched by the attendant in the first entrance, for there occasionally comes a sense of suffocation, which is more a mental symptom than that it'is due to lack of oxy- genation of the blood. Otherwise at this stage there is a comfort- able feeling, the sweat seeming to pour from the individual, which, in reality, is not so, but is due to condensation of vapour upon the body. The temperature of the body is actually reduced by this part of the bath, and this is the only reason why the vapour part of the bath should be so short. The slioiver-hath should be substituted in all cases of first treat- ment in order to gain the confidence of the patient in the rather shocking changes. The shower-bath is administered by a series of sprays tempered to the patient pliysically, and it is essential that the water should pour in these fine streamlets upon the head as well as the rest of the body, else there may be a tendency to congestion of the brain and its membranes. Temperature should range from 65° to 85° F. If the plunge is taken, the patient should immediately immerse himself in the pool. A good way to do this is by diving, if he is familiar with the water. He should remain in the water three or four minutes, the aver- age temperature being 65° F. The patient is next dried and rubbed in the standing posture by the attendant. He is then wrapped in a sheet and blanket and placed upon a couch or bed, to lie quietly for at least half an hour, sleep usually followinff. HYDROTHEEAPEUTICS 85 HYDROTHERAPEVTICS-Gontimied Water may be used either a,s a tonic or as a sedative. As a tonic we employ cold plunges, shower-baths, varioiis forms of douches, as Charcot's and the Scottish cold sitz-bath, salt baths, either sea or artificial, and short cold packs. These all have a stimulating and tonic effect. In giving them, especially to weak people, it is best to begin with warm water and gradually lower the temperature. Showers and douches are the most stimulating. A reaction should always be obtained by vigorous rubbing afterward. For the cold plunge, the patient immerses himself in the bath of water at a temperature of 60 '^ to 70° F., and at once emerges. He should then be rubbed vigorously. The shower- or rain-hath consists in allowing water to fall on the body from a height for one or two minutes while the feet are in warm water. Friction of the body should be kept up during this process. A Charcot douche is given by directing a solid stream of water with force upon the back of the patient. By the Scottish douche we mean alternating a cold douche with a warm or hot one. Cold pacJcs are given by wringing a sheet out in cold water, wrapping about the patient for a few moments, when it is re- moved and the patient put to bed and rubbed. An artificial salt hath may be made by putting 25 pounds of salt (NaCl) in 30 gallons of water (2 per cent). It may be warm or cold. To obtain sedative effects we may use the lukewarm bath, wet pack, hot sitz-bath, hot compresses, and drip-sheet. The lukewarni hath is given at a temperature of 95° to 98° F. for ten to twenty minutes. To give a wet pack, spread a large, thick blanket upon the bed ; upon this is laid a sheet wrung out in water at a temperature of 40° to 60° F. The nude patient lies upon this and the sheet is wrapped smoothly about him, not including the head and feet. The sheet must be carried between the legs and brought evenly in contact with the body. The blanket is then folded over him, with others added if desired. Hot-water bottles may be placed at the feet and cold compresses to the head. The patient lies in this for half an hour, and is then thoroughly rubbed. 86 TREATISE OX XERVOUS DISEASES The Drip-Sheet. — Have a basin of water at 65° F. Put in tlie basin a sheet. The patient stands in comfortably hot water. Have ready a large soft towel and iced water. Wring out the towel in this and wrap it around tjie head and back of the neck. Standing in front of the patient, the sheet is seized by the two corners and thrown about the patient, who holds it at the neck. It is then smoothed out over the body; next loosened, dropped, and the pa- tient is instructed to lie down on a blanket, which is wrapped about him. Dry thoroughly with coarse towels, wrap in a dry blanket for a time, then put to bed. The water should be grad- ually cooled day by day until it is 55° F. The bath, pack, and drip-sheet are valuable remedies for in- somnia. A liot sitz-hath consists of water at a temperature of 100° to 125° P. In this the patient sits from twenty to thirty minutes. Hot compresses are often used for the relief of local pains and congestions. MASSAGE Massage has been used as a therapeutic agent in more or less crude fashion for centuries. The wrestling matches of the Greeks left many a lame back or joint which their rubbers dissipated by manipulations. We all know, too, the uses of rubbing in alleviating the sprains and bruises of our army of college athletes. By greater refinement in the modus opera?idi of massage, and by very careful analysis of the effects to be obtained by each indi- vidual movement, this useful adjunct has been in recent years placed on a much higher plane in the therapeutic arts; indeed, in some instances, in expert hands it has almost amounted to a sci- entific basis. Schools of massage have been established where lectures are given in the larger cities of this country, also thorough practical work is obtained during several months' course required to become experienced in rubbing. At the end of this time an examination is had, when a certificate is given entitling the holder to recogni- tion by the phj'sician. Then a course in electricity is added to complete the training of one who chooses the vocation of mas- seur or masseuse. The two (massage and electricity) go so completely hand in hand in the treatment of the nervous mal- MASSAGE 87 adies, where they are chiefly of value, that it is necessary to he able to administer either one or both under the direction of the medical man. Notably in American schools very good training is given, but also abroad, especially in Germany and Sweden, in which latter country the series of movements bearing the name of Swedish are perhaps best known in a general way. In America all these very intricate movements have been somewhat modified ; and while the general tendency is towards definite ends, yet the extremely rigid mechanical side of massage is largely done away with, and we have a more perfect system, much better suited to the delicate human organism. The Five Sets of Movements of Massage. — 1. Effleurage is the gentle surface stroking of the part which quietly starts the cir- culation before the more vigorous. 2. Friction is then begiin. This latter consists in a firmer and deeper pressure-rub than the preceding movement. 3. Petrissage, which is a very deep kneading of the part and completes what has been begun by 1 and 3. It is essential in petrissage to hold firmly to the skin and to make this rub the subcutaneous tissues, while the last in turn presses the muscles, and so on until the soft parts are so manipulated, squeezed against the bones of the patient, that a veritable pushing on all of the liquids (blood and lymph) takes place; also, indeed, of some of the semi-solids, which are urged to disintegration and their ulti- mate particles swept on in the hurried circulation, to be oxidized or converted into energy, or to be excreted, instead of remaining in the body as sources of irritation in the form of what we • call leucomaines. 4. After this thorough application a movement, not so very essential, is yet quite often used as a final stimulator of the circu- lation where it is extremely sluggish. It consists of tapotement or tapping in a rapid vibratory manner with the balls of the fingers of one or both hands held gently closed, similar to the position of holding a pen. 5. Next and last comes effleurage again, by which the harder rubbing now reached shades ofl' to less vigorous frictions. These are soothing to the part and to the patient generally, while they also equalize the blood circulating in the superficial tissues. Then the member is immediately covered with a light woollen garment, 88 TREATISE ON NERVOUS DISEASES and when the entire body is so manipulated the patient rests for an hour. Modified Swedish movements, passive then active {without and with muscular resistance of the patient), are often instituted after a course of general massage of some weeks' duration. We are now speaking of general rubbing or applying the art to the entire body, as in cases of neurasthenia, where partial or the complete " rest cure " is being systematically carried out. How to " Rub " a Patient. — First the subject is required to thoroughly relax all muscles; then he is placed on the right side, and the manipulations are begun on the left foot, toes, ankle, thigh, hip, and buttock in turn, using all the fi^e movements de- scribed over each part, varying the time and duration of each in proportion to the size, rigidity, and amount of muscle or other soft tissues present. The patient is then asked to turn towards the opposite side, and the right foot, leg, thigh, and buttock are rubbed in the same thorough fashion. Gradually one set of movements dovetail into the other, and the patient's extremity becomes almost a part of the rubber, as does the dough of the housewife; and yet you note that by the time the limb is finished every nook and cranny has been gone over, leaving a beautiful glow of the surface in evidence of the vigour set up in the circulation of the blood. Next the left fingers, forearm, arm, and shoulder are first given the long sweeping efileurage, followed again by the rest of the detailed movements described; but the eye has to follow quickly to appreciate the rapid changes, so much a part of the manipu- lator does the patient become. Four or five minutes will suffice, and then the right arm is taken up. After this we request the patient to lie on the abdomen with a pillow placed under for better resistance. The long series of strokings down the vertebral gutters made alternately with the fingers of each hand spread on either side of the spinous processes. Then comes a series of circular frictions down each recti group with one hand, then a spreading movement from the spines outward with the balls of both thumbs ; next a firmer petrissage with both hands, followed by that motion with the palms of both hands alternately run down either side of the spinal column, giving a delightful sensation, while the final efileurage finishes and the patient is requested to turn on the broad of the back, the pillow being removed. MASSAGE 89 The chest movements consist principally of two : a firm strok- ing, following the ribs from the sternum out and down, and of firmer petrissage, in which the balls of both thumbs play an im- portant role, and can be so dextrously done as to be not at all painful, which occasionally happens with the beginner. The abdomen is rubbed as follows (this is very important and difficult to acquire) : the thighs are flexed on the abdomen and legs on the thighs in order to relax the anterior abdominal walls. The effieurage is simple enough, but it requires tact to knead thor- oughly without tickling. Begin this over the small intestine and work with both hands in a " spanning "-like manner. Then start at the caput coli and work along the ascending transverse and descending coli, one hand following the other in rotary motions. Again effieurage follows, and, as pointed out above, if constipation is an indication to be met, that series of rapid vibrations described will aid much towards the cure. As a rule, the face, head, and neck are not rubbed in ordinary work. Where especially requested, it is given by a series of strokings and kneading movements in the direction of the venous circulation. It should be stated that in all movements the greater pressure should be from the periphery to the heart — i. e., centripetal in character. The patient is now allowed to have a quiet sleep. The salient points of massage are for the masseur to keep his hands soft, clean, dry, and warm. A general rub should last from one half to one hour, preferably about 10 A. M., or at bedtime. If electricity is used, give it at the opposite hour. The patient should rest at least three-quarters of an hour afterward. In orthopjedie work a maxim obtains — viz., " to tighten a loose joint rub easy, to loosen a firmly fixed joint rub hard and deep." The relation of gymnastics to massage we have only time to hint at; suffice it to say they are closely allied, and the former are perhaps of greatest value in lateral curvature of the spine and in aiding chest expansion in lung dis- ease. These regulated movements should also be under observation of the physician. It has been proved that the renewal of the epithelium of the alimentary tract is made more active under massage, and that it stimulates peristalsis. Blood-pressure rises after massage, and Dr. J. K. Mitchell's investigation ^ shows that the blood elements * American Journal of the Medical Sciences, May, 1893. 90 TREATISE OX XEEVOUS DISEASES are put into more vigorous circulation during and after this treat- ment. Massage is of great value for the surgeon in getting rid of exudates about old fractures. As to the matter of technique — of course some become more skilled than others, but any person using tact and practice will learn to rub well. The therapeutic results obtained from massage we have not time to consider further, except to mention the very frequent relief of neuralgia by its careful use. Contra-indication to Massage. — It .should not be administered for an hour after a meal. Fever is a contra-indication to massage. Enlarged and thrombosed veins should not be rubbed, else a great risk of setting up a local active inflammation ensues, or that par- ticles f emboli) may be carried on to some important organ, as the brain, causing paralysis or other serious results. Tumours, especially malignant ones, should not be manipulated for fear of exciting them to more rapid growth and metastasis. If massage is extremely irritating after a fair trial it should be discontinued. There will occasionally be found one in fifty who is made worse by rubbing. In these persons we must resort to g}^mnastics alone or to electricity. The pregnant woman should not be rubbed about the abdomen; and it is advisable to abstajn from abdominal mas- sage during menstruation, also in any case of acute pelvic disease. Bimanual pelvic massage may be of value in chronic ca.ses with fixation of the uterus from old adhesion.^ MUSCULAR MOVEMENTS Eegular muscular movemenis, according to a fixed schedule, as first used by Weir Mitchell, but since elaborated by Fraenkel, are of value in the treatment of muscular inco-ordination. The exer- cises should be performed with care and precision twice daily.' The following schedule, based upon that of Fraenkel - and Hirshberg. is recommended by Dana : Exercises for the Hands and Feet. — 1. Sit in front of a table; place the hand upon it, then elevate each finger as far as pos.sible. Then raising the hand slightly, extend and then flex each finger ' For more detailed and exhaustive stiiLly the works of William ]\riirrel, M. D., F. R. C. B., on Masso-therapeutics. 1890. and of Emil Kleen, M. D., Handljook of Massage, are recommended. 2 The Treatment of Tabetic Ataxia, etc., 1903. MUSCULAE MOVEMENTS . 91 and thumb as far as possible. Do this with the right, then with the left. Eepeat once. 2. With the hand extended on the table, abduct the thumb and then each finger separately as far as possible. Repeat three times. 3. Touch with the end of the thumb each finger-tip sepa- rately and exactly. Then touch the middle of each phalanx of each of the four fingers with the tip of the thumb. Eepeat three times. 4. Place the hand in the position of piano-playing and elevate the thumb and fingers in succession, bringing them down again, as in striking the keys of the piano. Do this twenty times with the right hand, and the same with the left. 5. Sit at a table with a large sheet of paper and pencil. Make four dots in the four corners of the paper and one in the centre. Draw lines from corner dots to centre dot with the right hand; same with the left. 6. Draw another set of lines parallel to the first with the right hand ; same with the left. 7. Throw ten pennies upon the paper. Pick them up and place them in a single pile with the right hand, then with the left. Ee- peat twice. 8. Spread the pennies about on the table. Touch each one slowly and exactly with the forefinger of the right hand, then with the forefinger of the left. - 9. Place an ordinary solitaire board on the table, with the marbles in the groove around the holes. Put the marbles in their places with the right hand ; same with the left hand. Patient may, with advantage, practise the game for the purpose of steadying his hands. 10. Take an ordinary fox-and-geese board with holes and pegs, and beginning at one corner place the pegs in the holes, one after the other, using first the right hand and then the left. Exercises for the Body and Lower Limbs. — 1. Sit in a chair. Else slowly to the erect position without help from .cane or arms of chair. Sit down slowly in the samie way. Eepeat once. 2. Stand with cane, feet together; advance the left foot and return it; same with the right. Eepeat three times. 3. Walk ten steps with cane, slowly. Walk backward five steps with cane, slowly. 93 TREATISE ON NERVOUS DISEASES 4. Stand without cane, feet a little spread out, hands on hips. In this position flex the knees, and stoop slowly down as far as possible ; rise slowlj^ Repeat twice. 5. Stand erect, carry left foot behind, and bring it back to its .place; the same with the right. Repeat three times. 6. Walk twenty steps, as in Exercise No. 3; then walk back- ward five steps. 7. Repeat No. 3 without cane. 8. Stand without cane, heels together, hands on hips. Stand in this way until you can count twenty. Increase the duration each day by five, until you can stand in this way while one hundred is being counted. 9. Stand without cane, feet spread apart; raise the arms up from the sides until they meet above the head. Repeat this three times. With the arms raised above the head, carry them forward and downward, bending with the body until the tips of the fingers come as near as they can be safely carried. 10. Stand without cane, feet spread apart, hands on hips ; flex the trunk forward, then to the left, then backward, then to the right, making a circle with the head. Repeat three times, 11. Do No. 9 with heels together. 13. Do No. 10 with heels together. 13. Walk along a fixed line, such as a seam on the carpet, with cane, placing the feet carefully on the line each time. Walk a distance of at least fifteen feet. Repeat twice. 14. Do the same without cane. 15. Stand erect with cane; describe a circle on the floor with the toe of the right foot; same with the left. Repeat twice. Be- tween the fifth and sixth exercise the patient should rest for a few moments. ELECTRICITY Physics. — The laws which govern the electrical current are similar to those governing the flow of water. If two vessels one above the other and connected by a tubing, and water is poured into the higher vessel, it will tend to run to the lower vessel ; the water will thus generate force or capacity for work which is called polenfial. The fluid in the lower vessel would also tend to reach a low level, but the force would not be so great as that of the higher vessel; at sea-level would be zero potential. The difference ELECTEICITY 93 in force exerted between these two bodies of water would be their difference in potential. By means of certain agencies (chemical change, friction) elec- tricity is separated into positive and negative electricit}^, the posi- tive being of higher potential than the negative, the positive tend- ing to flow towards the negative and thus cause an electric current. The zero point of an electrical current is the earth. Volt. — The force which starts the column of water flowing is gravity ; that force which causes an electric current to flow is called electro-motor force (E. M. F.). The unit of measurement of this is called the volt. Ohm. — Some substances are much more pervious to the passage of water than others. This is so with electricity. Conductors per- mit the electric current to flow easily. Metals, plumbago, dilute acids, saline solutions, water, and living animals are good conduc- tors in the order mentioned. iVow-conductors or insulators do not permit free passage of electricity — such as rubber, glass, silk, resins, and dry air. Just as water encounters resistance as it flows through a pipe, so does electricity meet resistance as it passes along a conductor; and this resistance will depend upon the length, composition, and area of cross-section of the conductor. Thus a current passing a short distance through a good conductor of large area of cross- section will meet with less resistance than a current when passing through a poor conductor with a small cross-section area, or a long distance. The unit of resistance is called an ohm. Ampere. — The current strength (C) is dependent upon Ohm's law, which is that the current strength is equal to the electro-motor -pi -vr Tji force divided by the resistance (C = '!,' ' ). The current strength is measured in amperes. In medicine we use yoVo" P^^^ of an ampere, called a milliampere. Wlien electricit}^ is confined, as by means of insulators, it is said to be static. Physiology. — Electricity acts in various ways upon living tis- sues. It possesses the power of cataphoresis — i. e., it may carry solutions through the tissues in the direction of the current. By this means cocaine for anaesthesia and various other drugs, as mer- cury, may be carried into the tissues. Electricity may also pos- sess the power of electrolysis or chemical decomposition of tissues at the electrodes. By this destruction of n^vi, or small tumours. 94 TREATISE ON NERVOUS DISEASES may be brought about. Electricity also causes a modification of nerve-excitability known as electrotonus. In the vicinity of the anode the excitability is lessened — anelectrotonus ; while at and in the vicinity of the cathode the excitability is increased — cath- electrotonus. When anelectrotonus is made to suddenly dis- apjDear by the breaking of the current at the anode, cathodal increase occurs, and the nerve is thrown into a condition of cath- electrotonus. Electric currents also cause muscular contraction, and this is produced by a sudden increase or decrease of electrical excitement in the muscle or the nerve supplying it. If this is done but grad- ually no contraction results. The most powerful contraction is therefore caused by the voltaic alterative. It is produced by sud- denly reversing the current direction, so that a nerve or muscle that was in a condition of anelectrotonus is thrown into a condi- tion of cathelectrotonus, or from a state of — excitability to one of 4" positive, and vice versa. By simple closure and open- ing of the circuit the increase is only from to -|- excitability and to — excitability, which, of course, is not so great a vari- ation. The galvanic current produces all of these properties in more marked degree than does the faradic or static. In the latter two forms the influence of the current, due to constant interruptions, is so brief in duration that they are practically only used to cause muscular contraction and relieve pain respectively. A degenerating muscle loses its power of response to static elec- tricity first, next to faradic, then to simple opening and closing of the galvanic current, and finally to the voltaic alterative. Diagnosis and Prognosis. — In many diseases of the nervous system, particularl)^ cord diseases, the muscles and nerves, when submitted to electrical stimulation, act differently to normal mus- cles and nerves. This electrical irritability may differ in two ways, quantitatively and qiialitatively. Change in quantity implies a diminution or decrease in irrita- bility, while change in quality that there is change in the character of the contraction. Quantitative Change. — Simple increased irritahility, or that in which the muscle or nerve responds to a weaker current than nor- mal, is met with most frequently in tetan3^ Decreased irritahiliiy, or that in which a stronger current than normal is required to pro- ELECTEICITY 95 duce contractions, occurs in mild cases of neuritis, and occasion- ally in long-standing central paralyses. And these conditions are generally the same for both currents. Quantitative Changes — Examination. — To ascertain these : if the paralysis is unilateral, the weakest current will cause con- traction on the normal side should be learned; then the strength of the current that will produce the same result on the diseased muscles is determined, and the two compared. If the disease is bilateral the reaction may be compared with the reaction of a normal person of similar physique, or judged by experience as to the strength of current usually re(juired in the particular muscles tested. Qualitative changes consist of reaction of degeneration (DeE,) and of the myotonic muscular reaction, the former being found in certain peripheral palsies, and therefore, when present, always in- dicates a lesion situated in the peripheral motor neurone — i. e., motor cell of medulla or cord — or in the axones forming the motor nerves that come from this motor neurone; while the latter (myo- tonic muscular reaction) is a symptom of the clinical disease myo- tonia congenita. (See Thomsen's disease.) Reaction of degeneration may be, according to the degree of disease of peripheral motor neurones, partial or complete. Com.plete reaction consists of (a) rapid loss of the power of the muscle and its supplying nerve to react to the f aradic current ; (&) a brief period of quantitative increase followed by a decrease when they are stimulated by the galvanic current; (c) the nodal change — i. e., instead of the short, jerky contraction caused by the stimulation of the healthy muscle or nerve by the galvanic current, the contraction is slow, wavy, and at times tetanic; and {d) the serial change when the muscle alone is subjected to gal- vanic stimulation. The partial or serial change depends upon a difference in the way the muscle reacts to different poles of the battery, normally the weakest current that will cause a muscular contraction is when the circuit is closed .with the cathode on the musfle (cathodal closing contraction CaCLC) ; a stronger current will cause an anodal closing contraction (AnCLC), etc. If we represent anodal opening contraction by AnOC and cathodal opening by CaOC, the normal formula will be CaClC>AnClC>AnOC>CaOO 96 TEEATISE OX XERYOUS DISEASES The serial change in complete reaction of degeneration (DeR) consists of an increase of the AnClC and AnOC over the CaClC ; so that one formnla wonlcl read AnClC = AnOC CaClC CaOC, or as follows: AnClO AnOC>CaClC>CaOC. Partial DeE is more usual than the complete as just given, and may consist of nothing but the loss of faradic irritability and the nodal change, the series remaining normal. The series may be so changed, however, that AnClC = CaClC. In partial reactions the nerve usually responds normally. Examination for the Presence of DeR. — Here we first use the faradic current as when testing for quantitative changes. Then use the large galvanic electrode over the sternum, and the other, a small one, over the muscle. This will show the minimum strength of current necessary to cause CaClC and AnClC. If a milliamperemeter is attached, we can note the number of milliamperes required ; or if not, by noting that the current which causes CaClC will not cause AnClC, or vice versa, or that they are equal. Anotlier method consists in making the electrode positive or negative alternately, using the same strength of current and noting the difference, if any, in the degree and intensity of contractions. In all of these tests there should be an interval of several seconds permitted between opening and closing the circuit. The myotonic reaction is due to a much increased irritability; mild faradic and galvanic currents produce contractions that are tetanic in character, hollows and ridges in the muscle being fre- quently produced. In the case of the galvanic current AnClC becomes equal to or greater than CaClC. When the galvanic cur- rent is allowed to pass without interruption through a muscle, rhythmical contractions, travelling from negative to positive pole occur. Electricity may at times help in giving a prognosis — e. g., complete DeR is only present when extensive damage has been done; the prognosis is more grave than when the reaction only shows partial DeR, particularly when in the clinical signs the anterior horns of the cord show involvement. Per contra it is better in nerve-trunk lesion per se. Prognosis is best in cases where no serial changes occur. In cases where only feeble AnClC can be elicited, it is usually hopeless. ELECTEICITY 97 GENERATION OF ELECTRICITY FOR PRACTICAL THERAPY Electricity is generated in a cell composed of two opposing elements, one being called positive, the other negative, both of these being placed in the same solution, a good conducting medium, as, for example, sulphuric acid. Then the current is given o£E from the battery at the softer metal— for instance, the zinc. A current thus set up passes from the negative to the positive pole within the " cell," so called, thence out a conducting wire to tlie electrode or pole, designated the positive pole, and from which the current passes when applied to the human body. The pole or electrode from which the current passes to the other conducting wire back to the " cell " is called the negative or active pole of the battery. This apparatus, simply described, is designated a galvanic or chemical instrument, and is most potent for action upon the tissues. A practical method of determining which pole is negative or not is perhaps best made by placing the electrodes in water ; the one from which bubbles escape is the negative, active, or electro- lytic pole. A good point also for remembering which pole is the more active is to be guided by the paradoxical fact that the " nega- tive pole " is the positive one for action, while the " positive pole " is the negative one in regard to its effect upon human tissues. Gal- vanic electricity produces profound action upon the human body, and is the one used where there are the so-called degenerations, if electricity has been prescribed for the case. SOME PRACTICAL INDICATIONS FOR GALVANISM In treating a case of Bell's palsy do not begin the application earlier than from ten days to two weeks following the attack. Ap- ply the positive pole to the nape of the neck, the negative being applied to the distribution of the peripheral nerve upon the face, .from 3 to 6 millimetres being used. So with other local palsies where " reaction of degeneration " has been found, such as in wasting of muscles from infantile palsy, or in brachial and sciatic neurites. In the tachycardia of Graves's disease, the application of from 4 to 6 millimetres of current for as many minutes will often act favourably in slowing cardiac action, through stimulation of the 98 TEEATISE ON XEETOUS DISEASES vagi. Place the negative pole over the apex and the positive over the carotids by an extension of the positive pole in Y-shape. The removal of superfluous hair can be accomplished through a galvanic current, as follows; by cathode application to the root of the hair within its follicle : For this purpose, a very fine flexible steel needle securely fastened in a plain insulated holder is passed down along the hair to be removed from its follicle. There should be neither resistance nor pain; if there be, the edge of the follicle has been struck and the attempt to introduce the needle must be repeated. The oifending hair is held by means of a small forceps, by which it is extracted later. The circuit is completed by the patient placing her hand upon the wetted sponge anode. The current must be imperceptible, and within twenty or thirty seconds of its passage froth appears about the needle, and a short while thereafter the hair pops out without traction on the forceps. The patient then removes the hand from the sponge, and another hair is selected for the same treatment. This subject is mentioned in detail since it is a valuable means of helping us in the therapeutics of melancholia in sensitive women due to excessive hirsute gTOwth. I have seen excellent results in the mental disorder where other therapeusis had failed. The galvanic is also the current used for the relief of pain, as in neuralgia; and the positive pole should be applied to the painful part in such cases, the negative pole to be applied to some indif- ferent distant part of the bod}^ It should not be administered longer than five minutes at one seance. When the current is pass- ing and both poles are applied, it is termed " closed," and when one pole is removed or the circuit broken by the spring attachment placed on the negative electrode, it is termed " open." There are certain definite relations in reaction of the muscles to the current. First, when the current is closed, the negative pole, being placed- over the biceps muscle — for example, the positive over the dorsal spine — there is contraction well seen at the moment of closing. When we reverse the pole, the positive being placed over the biceps muscle and the negative over the spine, you will see that at closing of the current by the attached spring or interrupter the contrac- tion of the normal muscle is much less marked at closing. " Eeaction of degeneration " is always made with a galvanic current; never determined in palsies the results of the cerebral disease — i. e., of central origin — but is found in lesions of the ELECTRICITY 99 peripheral neurone, as in disease of the anterior horns of gray matter of the cord, neuritis or other degenerative diseases of nerv- ous tissues, peripheral to and including the multipolar cells of the gray matter of cord or medulla, as indicated above. The order of lessening the contraction of muscles with begin- ning degeneration of nerves, finally represented in "reaction of degeneration," is as follows : CaClOAClC AC1C AOC. The formula AOC>CaOC always obtains, however. Ruddiness appears at the point of contact of the negative pole upon the skin, as over the biceps muscle, and if the current is made strong enough or allowed to pass a few moments, a peculiar " ting- ling " sensation will arise, and finally an actual " burning," which, indeed, can go on to excoriation where the current is al- lowed to pass of too great strength. You will find for use in the upper extremities an average of 5 to 10 milliamperes is quite enough, as shown by the attached milliamperes through its needle index. REGULATIONS OF THE GALVANIC CURRENT The rheostat governs the amount of electricity passing from the battery to the body. A convenient movable lever with IST. upon the index, when pushed far to the right or left, always points to the negative pole, and in larger machines the current is obtained from a series of galvanic " cells." Therefore we can take the cur- rent in different wards of a hospital by a transfer cabinet, or " con- verter." For use in private work, we generally • carry a galvanic battery of 20 to 30 cells. (See illustration.) AXIOMS A few axioms and terms used in electro-therapeutics it will be well to define. The force originating in a current is designated as the electro-motor force. The strength of current used upon the body is equal to the electro-motor force plus internal and external resistance. Ohm's law is that the strength of the current is equal to the electro-motor force divided by the external and internal re- sistance. Stabile application of a continuous current is where the 7 100 TEEATISE OX XEEYOUS DISEASES poles are first applied in one place, then the current turned grad- ually on. Labile is where the galvanic or interrupted currents are set up first, then the poles placed to the parts to be treated and constantly mo-\'ed from one nodal ^ point to another. Fig. 21. — Complete Gjllyassig Dry-Cell Battery (with milliamperemeter and rheostat). The current that produces the greatest contraction of the mus- cles with the least pain is always applied. A " dry " cell is one in which the conducting medium in the hatterT is not a liquid, and, while convenient, is not to he depended^ upon as is the "wet" ceU. The sinusoidal current is one that comes in therapeutics be- tween the galvanic and faradic currents. It is a current of greater intensity and less in quantity than the galvanic current, and is the result of insertion of a series of magnets in the galvanic cur- rent. It is used as a stimulating agent in cases of extreme atrophy of muscles, etc. ' Nodal points are points of constant potential in a muscle, more imtable than others. Motor points are points in a muscle ELECTEICITY 101 FARADIC ELECTRICITY The faradic current is the so-called induced or interrupted cur- rent, and is generated from a cell in a like manner to the galvanic current as described. It is, however, so modified by the interposi- tion -of a coil of fine iron wires as to change the character of the electricity by "induction" to great electro-motor force; but it has little chemical power compared to that of the continuous or. gal- vanic current, because the fact of breaking a current with the in- ductive coil changes the manner entirely in its action upon the human body. This current is simply used for the exercise or devel- opment of muscular tissue because it produces contraction of mus- cle. These contractions are either rapids, when the rapid inter- FiG. 22. — Combination Dry-Cell Galvanic and Faradic Battery. rupter is used, or sloiv^ as when the large lever is placed within the current and by magnetization is caused to swing to and fro slowly. In using this kind of electricity pain is not produced in the patient so easily as it can be produced by the galvanic current; at least, not of that burning or chemical character, as has been men- tioned. In fact, we do not think of using the word qualitative in relation to faradic electricity, since quantity of contraction and but little or no qualitative symbolism maintains; so little, indeed, 102 TREATISE OK NERVOUS DISEASES that it is not necessary to tax the memory with the very small amount of difference between contractions made when the positive faradic pole or the negative is placed over the muscle stimulated; since, too, the pole is changed through the fact that the direction of FiQ. 23. — Complete Electric Cabinet (with dj'namo alternator). the current is changed with each interruption caused by the act of induction itself. USES OF FARADIC ELECTRICITY The faradic current is used, as has been inferred, for the de- velopment of the muscles. The " rest treatment," consisting of massage, isolation and rest in bed, full feeding and electricity, is ELECTEICITY 103 aided by faradism very much in the efficiency of the fullest treat- ment and benefit to the large majority of cases. The application of faradism to the human body, as typified in this course of treat- ment, we shall now indicate. This consists of about forty-five minutes' application in the following fashion : The patient should be in repose and treated at about midway between the meals, prefer- ably in the morning or afternoon or early evening, all depending upon the time of giving massage, the two separated widely in the waking hours. The room should be at about 75° F. in the ma- jority of instances of neurasthenia, or varying with the idiosyn- crasy of the case ; the point being, of course, to prevent " catching cold." Having the patient placed on one side and thoroughly re- laxed, the rapid current is applied to the feet by metallic electrodes well covered with absorbent cotton. This will not take more than five minutes, and will produce an agreeable sensation of tingling to the patient, warming the extremities at the same time. Then the slow interrupter is placed, and the two poles are applied over the bellies of the extensor and flexor muscles of the leg alternately, producing in each separate group well-marked contractions at the breakings of the current. This will take five minutes more. The thigh is treated in the same wa}^, producing again as strong con- tractions of the muscle as possible without causing pain, the guid- ing principle being never to produce pain in administering any form of electricity. The other limb is treated in the same manner, the patient being turned on the opposite side and the treated limb being wrapped in a blanket for protection. This will have con- sumed about twenty-five minutes. The upper extremities are treated in like manner, and you will find the current much more easily perceived here by the patient. The agreeable sensation given to the hand by the rapid current is most soothing, while the con- tractions induced in the forearm muscles, then in the arm and shoulder girdle musculature will have caused a sense of warmth and stimulation to the whole of the members. Now apply the cur- rent for about twenty minutes upon the upper members — a shorter time than applied to the lower limbs, but quite as efficient, however, since the upper extremities and their muscles are much more easily manipulated. The blanket being folded across the chest protects this part of the anatomy, and while a cover also remains across the lower limbs (the patient lying supine), the broad flat muscles of the abdominal walls are next treated. Then the patient can be 104 TEEATISE ON XEEYOUS DISEASES turned over on the abdomen, the erector spinge group of muscles are given a few moments' contraction pr exercise, when the case will have been fully treated. The patient is now well covered, with the blanket kept next to the skin, and perfect quiet being insisted upon, he is apt to fall ofE into a delicious slumber. Pig. 24. — Static Machine and Complete Series of Electrodes. Thus the patient gets objective exercise without calling upon his subjective state — i. e., the central nervous system — to furnish force from his own vitality, which is needing the rest. It must be remembered we are describing the typical case, and as with mas- sage, exceptional instances occur which for some reason in an hysterical or excitable neurasthenic electricity will not be well borne. It should be stated also that the felicity and facility with which the faradic current is applied depend upon the amount of HYPXOTISM 105 practice and experience gained from persistent effort to do the thing well. With this ease of execution you will find the time of application can be cut down very much, and with the same efficacy to the patient. The faradic brush attached to the negative pole to produce irri- tation is another tonic method of applying the induced current, useful in such symptoms as hysterical anesthesia. The skin should be dry when this is employed. FRANKLIN OR STATIC ELECTRICITY This electricity is generated through friction, as of a revolving wheel upon leather or wool. It is a current of very low electro- motor force, but with great intensit}', and is used simply as a stimulant to arouse better circulation, such as in chronic rheuma- tism, old cases of hemiplegia, lumbago, and in chronic articular disease with joint pains. It is also a most active tonic, and a spark passed up and down the spinal column — the patient being placed on the insulating stool for three to five minutes — serves mightily to awaken nerve energy in one who is neurasthenic or in ephemeral nerve-tire from whatever cause. Before giving this current especially should the patient be warned else he might interpret the snap of the spark as something serious, whereas it is so rapid and of such a minimum c[uantity that there is no danger whatever, and, indeed, burning of the clothing or even of a piece of paper placed between the poles will never occur. You regulate the amount of current to the pleasant sensation produced in the patient. This is done by sliding resist- ance rods more closely together, thereby lessening the resistance which the body itself T\-ould otherwise have to perform, and, of course, with greater discomfiture. The static breeze is a milder form and can be used upon the scalp for neurasthenic, helmet-like headache. (See Fig. 24.) HYPNOTISM By hypnotism (from Gr. liypnos — sleep) we refer to the induced sleep or state of sleep produced in a subject by a second person.^ It is more easily induced in persons or individuals the subject of 1 Some authors claim that there is a self-induced hypnotism, but this will be found to be the result of suggestion immediate or remote from a second person in every instance. 106 . TREATISE OX XEEVOUS DISEASES highly nervous temperaments, or actually suffering from some func- tional nervous disease. Some psychologists contend that hypno- tism can be induced in the best minds as readily as in those persons referred to, but this is not my experience, although I have seen a very intelligent man hypnotized after a prolonged effort. In medicine, hypnotism should be used entirely as a curative agent. The school of Berhheim and Charcot have developed this form of therapeutics more than any other; and while there are a number of different stages given by certain authorities on this subject, it is sufficient to here define only three stages of the hypnotic state: (1) That of lethargy, in which the patient's mind is obtunded. He breathes easily and the circulation is quiet. In a few moments in the typical instance of hypnosis the patient will pass into (2) catalepsy, which latter consists of the lethargic state plus muscle rigidity, and from this the subject gradually passes into (3) som- nolence, when he breathes deeply and is apparently sleeping in a relaxed state. These three subdivisions are not accurately defined in the majority of subjects, one predominating over the other, depending upon the idiosyncrasy of the case. The methods of inducing hypnotism are many, but all depend upon the same phe- nomena — namely, absorbing the patient's interest entirely in one direction, having prepared him by the suggestion that he should think of nothing but sleep and at same time try to sleep. The holding of revolving mirrors before the eyes or any bright object for fixation will be the instrumentality used. The physician, of course, must have the bearing of confidence to impress the patient, and the subject should be told that nothing will be done save the desire to cure the given ailment. It is well to have the person in a Cjuiet room and to fix the eyes in a strained position so that they soon tire. Thus the conscious mind is held in abeyance and the subconscious mind alone predominates, the subject passing under the control of the manipulator. It is desirable to place the patient in the third stage, if possible, before attempting sugges- tion, although in difficult subjects suggestions for cure may be of avail even when the patient does not pass beyond the lethargic stage. The suggestion for cure should be made while the patient is hypnotized, and for practical success should not be too dogmat- ic, as, for example, in case of hysterical palsy. In this way the doctor has better control and the patient is not disappointed; moreover, the physician will more likely be able to succeed in the THE EEST TREATMENT 107 hyi^notism of the subject at another time if he fails in the first at- tempt. Indeed, in many patients or subjects tliat are really suscep- tible to hypnotism, it will be found that it must be resorted to at different times before suggestion for cure can be pressed upon them. The post-liypnotic suggestion, so called, which consists in the endeavour to induce in the subject hypnotized the doing of certain acts or the producing in them of certain sensations long after the hypnotic state — thus, a suggestion that tobacco will be unpleasant to the tobacco fiend — is a possibility. Hypnotism has a very limited range and should be used as a last resort in cases where the ordinary mental influence of the physician does not avail. It is especially of value in local hyster- ical palsies, either sensory or motor, and is distinctly of less value as the functional paralysis is more general. Cases of hysterical hemi-an^esthesia I have never seen benefited by its use. THE REST TREATMENT This method of treatment, devised by S. Weir Mitchell, is of especial value in neurasthenia and hysteria. Its essential features are isolation, absolute rest, diet, massage, electricity, and the personal influence of a good nurse. Isolation from the patient's family and former surroundings is essential. The diet^, if the digestion is bad, should be entirely of milk. Otherwise easily digested solid food may alternate with it. Rest must be absolute in severe cases; even sitting up in bed should not be allowed. The duration of the treatment should be from four to eight weeks. The following schedule, as given by Dr. J. K. Mitchell, will illustrate the method : 7 A. M. : Cocoa ; cool sponge-bath, with rough rub and toilet for the day. 8 A. M. : Milk. Breakfast. Eest for one hour. 10 A. M. : Eight ounces peptonized milk. ■ 11 A. M. : Massage. (See previous section.) 12 N. : Milk or soup. Eeading aloud by the nurse. 1.30 p. M. : Dinner. Rest one hour. 3.30 p. M. : Eight ounces peptonized milk. 4 P.M.: Electricity (general faradization). 6 p, M, : Supper, with milk. 108 TKEATISE ON NERVOUS DISEASES 8 p. M. : Eeading aloud b}^ nurse for one-half hour. 9 p. M. : Light rubbing by nurse with drip-sheet. Eight ounces malt extract with meals ; tonic after meals. Eight ounces peptonized milk with biscuit at bedtime, and a glass of milk during the night, if desired. This may be modified in various ways according to the symp- toms. If a mild case, the patient may be-allowed to sit up for a few hours, or even go out for a drive. Object of the " Rest Treatment." — Of which rest is the essen- tial factor, is (1) to secure repose and time for recuperation from exhausted nervous states, and this is assisted by ( 2 ) isolation from friends and other sources of cause for expenditure of nerve-energy; then comes (3) massage and electricity, both agents to mechan- ically exercise the muscles, to hurry the blood and lymph streams on, and to stimulate metabolism without using up the patient's little reserve force. To use Dr. S. Weir Mitchell's apt phrase, " massage and electricity deprive rest of its attendant evils." Im- agine any one in health lying abed for twelve weeks or more with- out this excellent energizing agent. He would more likely waste than gain in nerve or muscle tone, and even if his weight should possibly increase during the time, it would be in flabby tissues, the majority of which would be only deceptive evanescent fat. Fat in itself is a burden, not a gain, to the individual. Better be " lean " and hardened, as the athlete or thoroughbred, than to have excess of the so-called panniculvs adiposus. ON THE CARE AND TREATMENT IN CONVALES- CENCE FROM FUNCTIONAL NERVOUS DISEASE There is no department of neurology more neglected than the proper understanding, or at least if appreciated the neglect of sufficient advice to convalescents from serious disorder of the nervous system; and in this place we shall devote especial con- sideration to functional diseases, those so considered in the ab- sence of accurate scientific data to throw the light of a definite pathology upon many cases of them. Therefore those diseases to be discussed shall be" naturally enough neurasthenia, hys- teria, and chorea — the author admitting, however, that there are many cases secondary to some physiologic perversion or to an irri- tation ; still, as it is always difficult to determine the fo7is et origo TEEATMENT IN CONVALESCENCE 109 malij the majority of cases are usually set down in the text-books as functional. As it is not intended to be specially scientific as to aetiology, and as the resultant disease (whether functional or due to primal causes other than the ordinary overwork, mental strain^ etc.) is the same, the treatment of convalescents from either essen- tial or from secondary neurasthenia would be in large measure alike. Dismissing at once this subject of getiology — not because of its lack of importance, for we purpose insisting upon the keep- ing clear of all causes for the development of a secondary condition in the beginning or at any stage — we shall formulate certain prin- ciples to be obeyed in the management of cases where diagnosis of the diseases under discussion has been established; in other words, the care of the patient after the malady has fully developed and has been treated successfully towards the happy issue of cure, which latter can be maintained only by the principles that we shall attempt to lay down in this contribution. "We will include there- fore, in this practical treatise, suggestions for the betterment of the person who is called by the physician — for the want of a better name — " generally nervous," the result of previous functional nervous disease. Mental Care. — In the first place, these patients must be schooled or educated in self-control. This may seem to savour a bit of charlatanism; but when the profession learn to better appreciate that there is really a psychologic basis, a suggestion, in this form of therapeusis, there will be less chance for Christian Science and other fads, with more adherence to true medicine, so that the proper balance may some day be reached, and the modest medium of common sense more generally prevail. Nor will there exist, at that happy time, any basis for the rather trite slur at the social fabric which " Mr. Dooley " has recently- expressed, in effect, that Christian Science believes there is no disease, and physicians be- lieve that everything is disease. A certain amount of time will be required therefore, by the alienist and neurologist, in explaining away, to intelligent people, certain fads with which they have become infected; and while the task is a hard one, results of treatment will show a fair enough proportion of success, and the doctor will at least be given credit for making the endeavour to rid society of these baneful influences. Of course, if you are dealing with a crank, diplomacy will be shown by dropping the subject. As it 110 TEEATISE OX XERVOUS DISEASES has well been expressed by some one, " You can take a crank by the hand, but cannot lead him on." With these few words, we shall dismiss the somewhat mysterious side of medicine, so essential to success, however, and pass to more scientific truths — the care of the human body physically, the better understood and more easily ex- plained matter. Physical Care. — Most patients, after an attack of acute or pro- longed functional disease, feeling the burden lessened and cure set in, will, in their exhilaration, and from the fact that the nervous system does not feel the insult at first, go back to the usual method of life — of strain and overwork — ^with a zeal that will usually pre- cipitate disaster if persisted in; so that, as regards rest, the con- valescent vshould be taught responsibility in the care of himself. If he refuse to carry out our directions, the result cannot' be blamed upon his physician. These are they who pass from one reputable man to another, without any permanent good results. This is only within the bounds of reason, and does not necessarily require scientific demonstration, valuable as that may be. It is an axiom of nature that rest should follow after the central neu- rones have once been depleted, ph5^siologically or pathologically. Even in cases of hysteria with full muscular vigour, I doubt if overuse of the muscular system wiU but prevent fullest recovery. In the cases of hysterical palsies, it is necessar}^ however, to en- courage exercise to a limited degree in order to give confidence to the patient, as well as for development of the wasted muscles. Thus, the most desirable forms of exercise during the late, ultimate convalescence from neural maladies are in a general way to be made different from the exercise obtained by the patient in his usual routine of life ; and here again the psychologic element must enter prominently as the reason for this betterment. Exercises, therefore, that keep the patient away from his usual line of thought, or prevent him from thinking about self, are to be en- joined. And if the patient can be kept off his limbs, it will be more advantageous for rest of the central nervous s^'stem, and thus recreate that reserve force which has become wanting in them. vSo that rowing, canoeing, horseback-riding will be much more valu- able than golfing, tennis-playing, or bowling. Adjuncts and Medication. — It is important to treat symptomat- ically organs that are disturbed in function during convalescence from the diseases under discussion ; thus, in cases of gastralgia or TEEATMEi^T m CONVALESCENCE 111 of supersensitiveness of the gastrointestinal tract, it may be neces- sary to treat the mncous membrane. • In these cases, we have a neurosis of the vagi nerves and of the abdominal sympathetic system. In the case of Mrs. W., a woman of delicate constitution, aged thirty-six, under the writer's care, suffering from essential neuras- thenia, the result of society indulgence, one of the most annoying features in convalescence was subjective sensation of distress in -the abdomen. Three years previously, this had assumed a form of distinct gastralgia. The use of intestinal antiseptics, as small doses of salol, also the addition as a digestant of os-gall, gr. i, and extract of gentian, gr. ^, a half -hour after meals, acted effi- caciously, and the patient has gone on to complete cure after a prolonged treatment which had not entirely restored her equilib- rium when she left for the country. It was this little addition of a digestant that capped the climax towards cure. She gained fifteen pounds in four weeks. Another case of Miss P., aged twenty-five, a very intelligent young woman, was a most persistent case of neurasthenia, greatly benefited by intestinal antiseptic treatment in addition to a semi- rest cure. In this case large amounts of indican were found in the urine. Another adjuvant in the treatment was high flushings of the colon with a solution of lime-water, and it was interesting to see a facial acne disappear with the general improvement of the case, and especially after resort to' the measures mentioned. The reten- tion of toxines in the system is undoubtedly a factor in preventing many cases of neurasthenia from reaching fullest health; until this detail is carried out, the patient will never become well. The writer has seen good results in the treatment even of epilepsy by means of antiseptics and flushing the intestine with copiously pure water between meals. Apropos of this subject, the reader is also referred to an article by Morris de Fleury in the Bulletin General de Therapeutique, November 23, 1900, in which lie gives tables showing, in the Ex- cretion of Urine in Neurasthenia, the amounts of uric acid, urea, and phosphates; the earthy phosphates being greatly in excess of sodium and potassium. Indican or skatol was foimd 73 times out of 100. The coefficient of oxidation was decreased 65 times out of 100; the increased acidity of the urine and density 112 TREATISE OX XEPtVOUS DISEASES of the same^ 59 times out of 100 cases recorded. Such data as this goes to prove the wide-sjDread disturbance of metabolism in func- tional disease. An investigation ^ by the writer has been for deter- mining the same conditions. The treatment, therefore, will more and more depend upon the exact knowledge obtained through the physiologic and pathologic study of chemistry, it seems to us, for the permanent cure and prevention of these ubiquitous diseases; so that while the gastro- intestinal tract, the great laboratory of the body, may be second- arily affected in neurasthenia, it is essential to treat the symptom as well as the fundamejital condition of nerve-cell exhaustion. Frequently peptonization of the large quantities of milk taken will be of great value in aiding hypernutrition. The skilled use of massage is also a measure which will help metabolism in the muscle itself, as well as by mechanically forcing on waste products and giving vigour to the circulation; for frequently, in these cases, the cardio-vascular system is not doing the physiologic duty re- quired. Excitement of an unusual nature should be strictly prohibited in eases of neurasthenia, and this is especially more important in the convalescent from chorea. In the latter disease, even pleasur- able excitement may be sufficient to cause irritation, and relapse to follow. A very marked instance of this condition of things was shown in the case of a minister's daughter, aged fourteen, coming under my care on ISTovember 6, 1900. She had been continuously in choreic movements since January, 1900, having been somewhat improved in health by September, 1900, when she started to school and had a relapse. The slightest pleasures she enjoyed were suffi- cient to make her worse. The child was anaemic, complained of vague pains in the lower extremities, and was greatly emaciated. The use of Blaud's pill, 5 grs., three times a day, of salt sponge- baths at night and of arsenic in small doses, and the* insistence upon the use of woollen underclothing, by July 3, 1901, eight months after beginning treatment, brought her to a timely cure — to health she had not known for many years. This case is de- tailed to show that chorea is no slight disease to deal with, and that it should be studied in all of its aspects as to hygiene for the patient, if health is to be restored. It may have been that previous ^Uric Acid Excretion in Neurasthenia, Transactions of the College of Physicians of Philadelphia, vol. xxii, 1900. TREATME^^T m CONVALESCENCE 113 failures in this case were -due to a lack of hygienic precautions being insisted upon to the parents, Avho were perfectly willing and did carry them out when so forcibly directed, of which they are the greatest appreciators to-day. CLIMATOLOGY OF NERVOUS DISEASE -Under climatology come temperature, humidity, winds, purity of air, rarefaction of air, sunlight, electricity, soil, woodlands, and social surroundings. The therapeutic climate is one which im- proves functional activity or increases the resisting power of the organism. Climatology, the medical geography of climate, is to climatotherapy what materia medica is to therapeutics. The main use of climatotherapy is as an adjuvant to ordinary therapeutics. Dr. A. Manquat, of Nice, has given the best authoritative study of this important subject.^ Difficult though it be, certain fundamental facts must surely exist and are being gradually worked out. The writer has made some studies - upon the climatology of neurasthenia, finding that one of high winds or in an altitude above 2,000 feet, or in damp, low countries, is bad for this disease. Moderately high altitude, 2,000 feet, is, on the contrary, desirable in sclerotic cord diseases, since decreased atmospheric pressure favours better circulation. ' More elemental facts to be recalled are that air at sea and at high levels is purest. The temperature above sea-level diminishes about 1° F. for every 300 to 400 feet, and is less the drier the air. Temperature of air varies less near sea-level, and is less in the southern hemisphere. The higher the elevation and the colder the air the less moisture it contains. Ozone and electric influences of mountain countries are apt to irritate nervous people. AYeber speaks of marine, low-level inland and high-level inland as the great divisions of climate. Warm marine climates and sea voyages on calm water are best, perhaps, of all for -neurasthenics. High climates are best for anaemic cases. The Eiviera, low Colorado, Canada (in summer) are the most desirable climates for the nerv- ous invalid. Inland Maine is also of value. ' Bulletin medieale, November 27 and December 14, 18, 1901, and January 1 and 8, 1902. 2 Climatology of Neurasthenia, Medical News, January, 1901, and Nervous Cardiac Symptoms due to High Altitudes, February 14, 1903. CHAPTER V SYMPTOMATIC DISORDERS VERTIGO Synonyms: Dizzmess, Giddiness, etc. By vertigo we understand a disturbance of consciousness, char- acterized by a feeling of objects moving (objective vertigo) or of a sensation of the person moving, which is termed subjective ver- tigo. Causes. — The causes of vertigo may be classed somewhat like those of headache: (1) Htemic — anaemia, hypersemia, etc.; (2) toxic — tobacco, alcobol, lead, etc.; (3) arterial sclerosis; (4) acous- tic nerve irritation; (5)- neuroses — neurasthenia, epilepsy, etc.; (6) reflex — ocular, gastric, organic, as organic brain disease; (7) mechanical causes, as swinging, sea-sickness, car sickness. Symptoms. — They usually come on suddenly, and last but for a few moments. The patient may have the sensation of rising or sinking, or objects moving or whirling about (the objective form), or the patient himself may feel as though he was revolving or to rise and fall (subjective form). There is a sense of alarm and a feeling of faintness. Cerebration is disturbed and ideas are confused. There may be nausea or vomiting. The patient usually totters, and sometimes falls. It may be due to certain lesions of the cerebellum and its peduncles, or of the labyrinth of the inter- nal ear. It is then usually associated with forced movements. The characteristic of vertigo is that it is relieved when the patient lies supine. This is the opposite condition in a case of headache. (See section on Headache.) A large proportion of the vertigoes met with are due to dis- ease or irritation of the eighth nerve and its centres. The more common cause is a lesion of the labyrinth of the internal ear. Vertigo, therefore, is a symptomatic disease. If the blood is debil- itated, anaemia, or if the patient is plethoric, hyperaemia, the symp- toms of this affection will come hand in hand with the vertigo. 114 SYMPTOMATIC DISORDERS 115 If the disease be due to arterial sclerosis, which produces a local- ized anemia of the brain, the vertigo will then be associated with symptoms of cerebral arterial sclerosis. In some of these cases the kidneys are also affected in the process, and we have the symp- tomatology of the red-granular kidney, low specific gravity to the urine, decrease in the quantity of urea, etc. If associated with neuroses, we have the characteristic symptoms of these several affections, such as neurasthenia and hysteria, and the vertigo will be apt to present exacerbations commensurate with the paroxysms of the several diseases, or else the vertigo will be more exaggerated sequent to aggression of symptoms of the neuroses mentioned. The reflex vertigoes will be associated with the organ that is particu- larly involved, as the cause of the irritation. Thus a patient suf- fering with astigmatism would complain of the eyes, as a rule, but not always so, however. The patient with gastric vertigo would have gastric attacks or crises. This is more usual in persons about middle life. From organic brain disease the reflex vertigo would be associated with some pathologic process going on within the cranium. The mechanical causes giving rise to vertigo will be easily enough determined by the careful observation of the physi- cian. Toxic vertigoes are associated with sepsis in different parts of the body, or are from drug poisons, such as tea, lead, coffee, etc. Auto-intoxications will be associated frequently with the finding of indican in the urine; the gouty with secretion of urea, uric acid, and alloxuric bodies, and other end products. Diagnosis. — The differential diagnosis of vertigo would depend, as above indicated, by noting the symptoms of the several diseases associated with, preceding, or following the attack. Prognosis. — This depends entirely upon its duration and the ability to cure the cause. HEemic and toxic vertigoes will usually recover if treated early. Those cases due to arterial sclerosis 'are very bad as to the prognosis. Those due to neuroses are also difficult cases to manage. The mechanical vertigoes will subside with abatement of the cause. Treatment. — Quietude is an essential. This will depend en- tirely upon the cause. If there be anaemia, haematics should be administered, such as tincture of chloride of iron and Blaud's pill. If due to plethora, venesections, or better, wet cupping or the application of the natural leech, will often prove of great value. The use of potassium iodide as an alterative and sorbefa- 8 116 TEEATISE OX XEBVOUS DISEASES cient, continued in small doses, often produce marked ameliora- tion of the symptoms on any case. Xitrogiycerin y^ gr. t. i. d., or spt. of gionoin, 5-minim doses. If ear disease is present, the case should he referred to a competent aurist for the proper diag- nosis and treatment of the condition. The patient should lie supine during an attack. ■ INSOMNIA This is sometimes called sleeplessness, and is given to those conditions of insufficient or restless sleep or to the entire absence of sleep for a long time. Certain persons present idios}Ticrasies as to the amount of sleep required. Xapoleon required hut a few hours out of twenty-four. It is said that some people ca7i go with- out sleep for indefinite periods, as long as two or three weeks at a time, cases being on record of much longer times of the waking state, inflicted as a punishment. Eight hours in twenty-four is the average for an adult; children require more. - Causes. — The male sex suffers more than the female sex. no doubt due to employment being more of a mental nature in men than in the majority of women. Labouring classes are less liable to insomnia than those engaged in business or professional pur- suits. It is frequently hereditary, no other exciting cause existing that is known. It is also seen in certain diseases, such as gout and lithsemia, etc. Quite probably it is the result of auto-intoxication. the absorption of certain ptomaines or leucomaines, or other dia- thetic by-products. Diseases of the cardio-vascular system may lead to insomnia. Poisons may also cause insomnia, such as are seen as the result of syphilis, malaria, chronic nephritis, or other infectious diseases, lead-poisoning, etc. Those cases which are not due to definite lesions are designated functional : for instance, the insomnia of neurasthenia and vaso-motor disorders. The time of the sleeplessness varies. Some persons cannot sleep during the early hours of the night, and others will awaken at a certain time and cannot sleep thereafter. In children it is accompanied by much mental and physical disturbance, such as dreams, physical or mental excitement. The patient is also seen to be irritable from the loss of sleep, and this is much more exaggerated in children than in adults. Insomnia from neurasthenia usually presents a tumult of thoughts SYMPTOMATIC DISOEDEES 117 passing through the mind which seem to prevent sound sleep; or in them sleep is very superficial, the patient being aroused very easily and frequently imagining that he was partially awake during the sleeping period. In this form the patient wakes easily and afterward feels " draggy/' as though he had had no rest at all, and frequently describing the sensation as though he was weaker after his limited sleep than before the time when he went to rest. In the insomnia of adult insane,, there is a still greater degree of restlessness. A symptom described by Weir Mitchell fre- quently occurring just at the prcedormium is a sudden jerking of the body, which arouses he patient just when he was passing into a doze. PatJioIogy. — This seems to be as yet unknown. It is very likely, however, that there is a variation in the calibre of the cerebral vessels, causing congestion, due to a weakness of the sympathetic system. " Eetraction " of the cerebral neurones is also given as the " neurone theory of sleep." The pathology of s3^mptomatic in- somnia, due to organic disease, would be the pathology of the disease in cjuestion, as a chronic meningitis, cerebritis, gummata, etc. Treatment of essential insomnia, so called, lies often in the treatment of some, general disorder, such as hj^steria or neuras- thenia. If angemia, lithgemia, uremia, or other toxic influences exist, they must be removed by the proper remedies for these con- ditions. Measures for the relief of the symptoms themselves should be adopted, and the patient should get rid of worry as much as possible. The use of the constant cold douche to the spine from three to five minutes, followed by cold sponging of the body, usu- ally produces sufficient reaction to cause a dilatation of the su- perficial blood-vessels to induce sleep. The overuse of the hot bath is to be decried, since it is apt to weaken the patient, and by not producing proper reaction to the surface will allow stag- nation of the blood in the meninges. The methods of counting or other monotonous occupations will sometimes avail, but these are of doubtful efficacy, and should be substituted by other forms of occupation. The patient should live in the open air as much as possible, and particularly in those localities where dry winds prevail and at low altitudes. Drugs used with caution are bro- mides, 10 to 15 grains at bedtime or in combination with chloral hydrate, 5 to 10 grains, being cautious to guard the heart with 118 TREATISE 0^^ KERTOUS DISEASES the use of the latter drug. Trional or sulphonal in 15-grain closes in hot milk are the best hypnotics. Hyoscyamus in some instances is efficacious. Paraldehyde in drachm doses is a valuable hypnotic in insomnia due to alcoholism. Camphor, opium, and the evanes- cent drugs, as asafcetida, musk, valerian, etc., are all of value in hysterical or neurasthenic insomnia. The use of massage and Swedish movements at bedtime are measures that are of great value, and particularly the effleurage to the face, thus producing a quiet effect through reflex action upon the cerebral cortex. NEURALGIA This is a type of pain, shooting in character, occurring along the course of a sensory nerve, and functional or toxic in nature. There are different varieties of this disease, as follows : trigeminal, brachial, sciatic, cervical, intercostal, anterior crural, and visceral, etc. Reminiscent neuralgia is that which exists after the cause has disappeared. It is at times a monohysterical sign. Causes. — Common predisposing causes of this condition are early adult life, debility, and hereditary predisposition. The cliar- acter of the pain is sharp and shooting in nature, and frequently accompanied by tender spots or points over the exit of the nerve from a canal (points of Yalleix), although firm pressure over the site of the pain will generally give relief. Vaso-motor and secre- tory symptoms may occur. Facial Neuralgia.- — This is induced by cold exhausted condi- tions, and is more frequent in the female sex. It has a distinct hereditary tendency. The attacks come on at irregular intervals, and involve some one or all the three branches of the fifth nerve. The pain is sharp-shooting and paroxysmal. Treatment. — This consists principally in the protection of the surface and the building up of the system, and for the attack the use of analgesics, such as phenacetine and antipyrine. The appli- cation of warmth to this in the shape of hot water is sometimes a means of relief. The use of cod-liver oil, to build up the system, is a valuable adjunct. Aconitia in yi-^^ -grain doses is of value. Tic Douloureux. — This is a most severe form of facial neu- ralgia. Symptoms. — A sense of numbness, occurring at the site of the branch particularly affected, such as the superior maxillary branch, finally followed" by dull pain, which soon amounts to acute suffering SYMPTOMATIC DISOEDEES 119 and rather spasmodic in nature. In the height of the paroxysm the patient is in most exquisite suffering, all the branches of the fifth nerve being involved. There may-be an ephemeral blindness, occurring on the side affected. An attack may last from one to two hours to twelve hours or even longer. There may also be spasm of the facial muscles. The teeth may be very sensitive during or after an attack, and sometimes the pain is so localized in the teeth or maxillae that the physician or patient may think the tooth is the real seat of the disorder, and for this reason many teeth are extracted. The frequency of paroxysms varies from once a day to once in several weeks, although some cases may go much longer. The exciting causes are worry, overwork, exposure to draughts, and dampness. Diagnosis. — This lies between this disease and migraine, but the character of the pain in the two diseases is essentially different, and there is not the nausea and vomiting in the trifacial neuralgia as in sick headache. The type of pain which is induced by these paroxysms and may become chronic or hallucinatory is an exam- ple of reminiscent pain, and is a psychic phenomenon purely. Prognosis. — As a rule it is unfavourable. The patient seldom gets entirely well after the disease has once been established. Some few cases, however, have been cured when treated in their incipiency. Pathology. — This consists in subacute neuritis in the branches of the fifth nerve, also degeneration of the Gasserian ganglion in the worst cases. Treatment. — In the treatment, examination of the teeth should be a point in order to determine reflex points of irritation. Any other irritants about the face should be eradicated. For the par- oxysms of pain, the use of analgesics is indicated, as phenacetine combined with caffeine. Galvanism by placing the positive pole over the painful area is of service. At times a hypodermic injec- tion of morphine will have to be given in order to relieve, although this should be in a guarded measure in the treatment. Cannabis indica is of some value in these cases when given in prolonged small dosage. Cod-liver oil and tonics, with the use of iron in angemic cases, is very good treatment. Excision of the Gasserian ganglion is to be had as a dernier rcssort. Intercostal Neuralgia. — This is a form in which the pain is limited to the distribution of the intercostal nerves. This is some- 120 TEEATISE ON NERVOUS DISEASES times designated pleurodynia. The pain is worse on movement of the side or in the ordinary respiration of the patient, so that it is frequently called " a stitch in the side." Prognosis. — This is favourable. Treatment. — This is the same as for other forms of neuralgia, plus the strapping of the side of the chest; or the use of counter- irritation by means of the use of the actual cautery will sometimes give relief. The so-called lierpes zoster is the type in which we have a neuritis of the intercostal nerves and frequently an erup- tion, vesicular in character, along the course of the nerve. This disease seems to be in some cases infectious in nature, and is more frequently seen in childhood than in adult life, it also very fre- quently being bilateral. The treatment of herpes zoster does not differ from that of other forms of neuralgia except that protection to the eruption of the part should be insured. This can best be done by means of oiled silk or cotton batting. Sciatic Neuralgia. — This is neuralgia of the sciatic nerve. Some doubt the existence of pain in the sciatic nerve area with- out there being an active inflammatory lesion present. There are a certain number of cases in which the increased reactions and exquisite neuralgic pain, without tenderness on pressure, would lead one to suppose they were not inflammatory. Prognosis. — This is, as a rule, good. Treatment consists of splinting the lower extremity during the exacerbation of the disease. The use of the ordinary reme- dies mentioned above is indicated. The majority, of persistent cases that do not respond to the treatment outlined are really of an inflammatory nature — a neuritis. (See section on Neuritis.) Anterior Crural Neuralgia. — This is a neuralgia existing along the course of the anterior crural nerve, as its name would indicate. The pain shoots down through the outer upper aspect of the thigh towards the inner side of the knee. This sometimes is induced by lesions, as indeed is sciatic neuralgia in the pelvis, such as tumour, growths of bone. It is also designated parcestlietic neuralgia when the distress is of a burning sensation. Prognosis. — This is good if the original cause can be relieved or cured, as through removal of a tumour. Treatment. — This is the same as for the other forms of neu- ralgia, except that nerve stretching is singularly often curative. SYMPTOMATIC DISOEDERS 131 Visceral Neuralgia. — Gastralgia is one of the most important forms. This consists of pain localized to the epigastric region. It bears no relation to the ingestion of foods particularly, ex- cepting that it is at times relieved by taking of food. The dis- ease is due to the irritation of the gastric filaments of the pneumo- gastric nerve. Prognosis. — This depends upon the conditian of the system. If metabolism improves the patient usually recovers. Treatment consists in the application of heat to the epigas- trium, the use of Fowler's solution in gradually ascending doses, given after meals (gtt. iij to x t. cl.) and treatment of existent neu- rasthenia. The use of repeated blistering I have seen cure. Neuralgia of Heart. — This consists in painful paroxysms about the pra^cordia, and accompanied by a subjective feeling of pending death. There is a sense of constriction, as though the heart was grasped in a vice. The lips become pale, the pain is most in- tense in the praecordia, of a constricting character, and frequently shoots down the left upper extremity. The patient becomes cold and clammy, and lies, through both fear and inability to move on account of the pain, in a position of iixity of the entire muscu- lature until the passing of the spell, which may last from three to four minutes to an hour. The patient after the attack is greatly weakened, and it is some hours before the sense of fear and the pain subsides. Angina pectoris recurs without definite cause, although exercise may induce an attack. Pathology. — Sclerosis at the orifices of the coronary arteries with narrowing and fatty change has been found. Prognosis. — This is absolutely unfavourable. Treatment consists in the use of amyl nitrate inhalations dur- ing an attack, nitroglycerin over continuous periods, and the relief of arterial sclerosis, if present, by the use of potassium iodide. Such patients should live a quiet life, never indulging in over- eating or in stimulation. Mental strain should be avoided, since this is one of the patent causes. In the most serious attacks hypo- dermic injections of morphine may be necessary to relieve the pain. HEADACHE This is a condition of pain in the head. It is due to irritation of the fifth nerve branches. The characteristic of headache is that 122 TREATISE OX XERY0U8 DISEASES it is usually made worse when the patient lies down — i. e., when the head is lowered, with the exception of anamic headaches. Causes. — Overwork, malaria, and other infectious diseases," poisonings from witiiout, such as tea and various drugs; poisons from within, due to disturbance of metabqlism, such as in gout and rheumatism, anemia, and in diseases of the meninges. Final- ly, headaches are due to organic diseases of the brain, its mem- branes, or overlying structures. Some types of headache are : Boring, often described as though a nail were driven into the vertex, the so-called lavus of hysteria. Shooting or neuralgic headache, which is parox3^smal and ex- tremely painful. Constriction or helmet-like headache, characteristic of neuras- thenia, consists in the sensation of constriction about the scalp with vague pain through the top of the head. Finally, we have another type of headache, which is confined to one side of the head, and is called migraine or megrim or hemi- crania. J. C. Wilson gives as causes of headache : 1. Reflex Irritation — viz., ocular (e5^e-strain), nasal, pharyn- geal, auditory, decayed teeth, reproductive organs (especially fe- male), thoracic and abdominal viscera. 2. Toxsemic. — A. Infectioyis, as acute infectious diseases; ma- laria. B. Incornplete or perverted physiologic-chemical processes, or the defective elimination of waste, as uraemia, diabetes, gout, lithsemia, rheumatism, gastro-hepatic derangements, constipation. ■ C. Action of drugs and poisons, (a) Acute : nitrites, quinine, opium, alcohol, carbon dioxide, etc. (l) Chronic: lead, tobacco, alcohol, opium, tea, coffee. 3. Circulatory Disturbances. — A. Passive congestion, as by pos- ture ; tight clothing about the neck ; pressure on veins by tumours. B. Active hypercBmia, from excessive physical or mental strain ; early stage of acute meningitis. C. Ancemia, following loss of blood or the idiopathic ansemias, especially chlorosis. MIGRAINE (Sick headache, megrim) Migraine is a type of headache which is so distinctive in its phenomena as to warrant special discussion. There is a hereditary SYMPTOMATIC DISORDERS 123 predisposition very strongly manifest in this disease. First, direct hereditary predisposition to the disease itself is transmitted, sec- ond, where epilepsy or some other form of neurosis exists in the ancestry. The characteristic features are a periodic discharge of sensory impulse from the sensory nerves, producing pain. The attack itself is ushered in by hallucinations of sight, frequently accompanied by fortification lines, which are subjective phenom- ena of divergent lines appearing before the eye of the patient. Hemianopsia may develop. The pain is usually first manifest in the first division of the fifth nerve, and the pain is limited to one side of the head as a rule; hence the name of hemicrania. Soon after the onset of pain there is nausea and vomiting, the patient becoming very sick at the stomach and the pain reaching extreme intensity in from one to three hours, sometimes associated with a spasm of the muscles on the affected side of the head. The at- tack itself lasts from six to eight hours, when the pain gradually subsides, leaving the patient in a weakened condition, from which it takes him some days to recover full vigour. There is never loss of consciousness during the attack, but at times the exhaus- tion so closely simulates an abeyance of the mental state that epilepsy is with difficulty differentiated from migraine, some au- thors claiming that there is a direct relation between the two dis- eases. The attack of migraine comes on periodicall}^, and the pa- tient may have recurrences once a week or once a month, and in the female at the menstrual epoch, or less frequently. The attacks seem to be induced by overeating, auto-intoxication, and infectious diseases, such as malaria, etc. Prognosis. — This is very indefinite. A guardedly good prog- nosis can be made in cases where there is not a history of direct heredity and in those of good constitution. Pathology. — This has not as yet been definitely determined. So far as we know, it is a functional disorder, consisting of peri- odic discharge from the sensory cortical neurones, as already men- tioned. Treatment. — This consists of measures between the attacks and during the attacks. The emunctories should be kept in good con- dition, the liver and kidneys active. Any diathetic diseases should be treated, such as rheumatism, gout, etc. Carlsbad salts or Ro- chelle salts are of value to keep the bowels in a soluble condition and for the elimination of toxines. Salol, in 2-grain doses t. i. d.. 124 TREATISE 0¥ NERVOUS DISEASES is of value here. For the attack itself, phenacetine is a valuable remedy, given in 5-grain doses, repeated three to four times each da}'', and if not effective can be substituted by other analgesic drugs, such as antipyrine. The use of tincture of cannabis indica is of value in some cases, and should be given in small doses, 3 drops t. i. d., gradually increased to the physiological limit. In the worst attacks hypodermic injection of morphine may have to be resorted to, but this must be guarded, else the drug habit may be brought about. MENIERE'S DISEASE This is a persistent neurosis in which vertigo is one of the most important symptoms. There is also irritation or disease of the eighth nerve or its centres. The inner ear is usually affected in tlie labyrinth. Deafness is progressive from the first. Symptoms. — These are of the most exaggerated type of vertigo where other causes are excluded, excepting disease resident in the internal ear and where vertigo is associated with extreme nausea and attacks of syncope. In this form of vertigo, too, the pro- gressive deafness and tinnitus aurium accompanied by forced movements, staggering gait, or absolute inability to walk, due to the dizziness in the worst cases, each time the patient arises from the horizontal position, are all diagnostic. The course of the dis- ease is downward from the very first, the patient usually failing in general health on account of the extreme distress and inability to retain food. Deafness becomes profound as the disease progresses, and when complete deafness is present the vertigo ceases on ac- count of the destruction of the auditory centres of equilibrium which have been irritated. Diagnosis. — This is not difficult if the above points in symp- tomatology are carefully remembered. Prognosis is guarded even in cases where the deafness is only slight and the disease not too far advanced. TJsually the deaf- ness becomes absolute when vertigo ceases and the patient is much better in general health. Treatment. — The treatment indicated above for vertigo is em- ployed. A drug which is harmful in the ordinary cases of vertigo, but is of value in these cases, is quinine. This is given in small doses and then increased until cinchonism results, the drug then being withheld for a time and renewed at intervals in fairly large SYMPTOMATIC DISOEDERS 135 ph3'siological closes. Opium has been recommended in this disease, but this should be used guardedly on account of the danger of the drug habit. Hydrobromic acid in the form of a syrup, given 30 drops a day, or the usual bromide salts in moderate doses, or salicylate of soda, 5-grain doses, t. i. d., will be of great service in these cases. Sinkler recommends ergot. Hirt recommends hypodermics of 10 dropg of a 2-per-cent solution of pilocarpine. Bromides given in large doses (gr. xl, t. i. d.) have been recom- mended. CHAPTEE VI CRANIAL NERVES DISEASES OF THE CRANIAL NERVES Olfactory. — This nerve may be affected either by irritative or destructive lesions. If the former, such as a tumour pressing on a nerve, it may produce besides the symptoms of the growth hyper- osmia. Destructive lesions, as continued pressure of the tumour or a neuritis of the nerve filaments, would produce anosmia. Per- version of the sense of smell, or parosmia, may be a symptom in certain progressive diseases of the olfactory nerves or centres. A fracture at the base of the skull may be the cause of anosmia, as in a case of a woman seen under my care, where there were no other symptoms,' and in which an injury seems to have been the exciting cause. A case reported by S. Weir Mitchell in his Clin- ical Lessons on N"ervous Diseases, I have also had the pleasure of studying, but in addition to this the woman had hysterical stig- mata, including amblyopia and disturbance of the sense of taste. Diagnosis and Prognosis. — Disease of the olfactory nerve can- not be confused with other diseases, since the specificity of the condition is clear. The prognosis would depend largely upon the lesion discovered and the possibility of regeneration of the nerve in these cases. Treatment consists in treating the cause. Optic. — Affections of this nerve consist of functional amblyo- pias and organic diseases, such as choked disk, optic neuritis, etc. Optic neuritis occurs in 85 per cent of the brain tumours, so that diseases of this nerve can be expected in that proportion in cases of brain tumour, and when found would be suspicious of the presence of a neoplasm within the cranial cavity. Atrophy of the optic nerve is either primary or secondary. The sclerotic diseases frequently have as a symptom atrophy of the optic nerve, 126 CEANIAL NEEVES 127 such as in tabes ; and secondary atrophy of the nerve would be that sequent upon neuritis, usually preceded by choked disk. Hemianopsia is a neurologic symptom, and is more frequently due to lesions in the tracts, usually unilateral. When the lesion is well back of the chiasm (as far as the primary optic centres), the centre for contraction of the pupil when light is thrown upon the retina is wanting, hence Wernicke s pupillary inaction will be found. If the lesion causing hemianopsia is back of the thalamus, the centre not therefore destroyed, the Wernicke's sign will not be present. The test for this important sign is made as follows : Throw a ray of light in a darkened room upon the unsound side of the retina; it will not cause the normal contraction of the pupil for the reason given; whereas, as soon as the ray of light impinges on the sound side of the retina, contraction of the pupil takes place immediately. This is the most delicate test, and. has been by some writers thought impossible to make accurately, although admitting the scientific relation of the symptom to the disorder in question. Other forms of hemianopsia are hinasal, which condition is extremely rare, and is due to a double lesion, involving the outer fibres of the tracts as they pass to become a component of the optic nerves proper on their respective sides. Bitemporal hemianopsia is usually the result of a tumour of the pituitary body, which de- stroys the anterior fibres of the commissure, passing to the inner side of the retina. Hence in acromegaly where the pituitary is frequently found diseased that the symptom of bitemporal hemia- nopsia may exist. Hemianopsia may also be horizontal, as where a tumour or other lesion affects one-half of the nerve or tract above or below, destroying it or its function, and producing blindness in the upper or lower fields of vision. This, however, is a very rare affection (for illustration, see Fig. 19). Hemiopia should he explained here, since it refers to the side of the retina blinded. For instance, right lateral hemiopia implies disease of the retina on the right side, whereas it means in terms of hemianopsia blindness in the left field. Treatment. — Treatment of the diseases of the optic nerve con- sists in treating the underlying conditions when bearing upon nervous diseases. Optic atrophy seems sometimes to be benefitted by the use of electricity, passing 6 or 8 milliamperes of the gal- vanic current through the head, with the negative pole at the occi- put and positive placed over the eyelids. This done two or three 128 TREATISE OX XEEYOUS DISEASES times a week (a three to five minutes application) will often be of some benefit to the patient. Conditions of errors of refraction, muscular unbalance, etc., are entirely in the province of the oph- thalmologist, who should be consulted in all such cases. A dis- ease in one of the optic nerves and closely allied to diseases of the nervous system is cataract, since this insidious blinding of a person may lead to general nervousness and even melancholia, which should be looked after in all such cases with the idea for relief through extraction of the cataract. Oculomotor. — Paresis of the third nerve produces nystagmus, protrusion of the eyeball, and ptosis. There are two types of pa- ralysis of the third nerve — one in which the external muscles alone are involved in the palsy and to which the name external ophthal- moplegia is applied, and second, where the internal muscles of the eyeball are paralyzed, designated internal ophthalmoplegia. The causes are basilar men- ingitis, syphilis, and neuritis of the nerve and trauma as in some cases of fracture of the base of the skull. If the cause of the lesion is recent tertiary syphilis, the prog- nosis can be considered fairly good. If it is an evidence of parasyphi- litic intoxication, the treatment is not of much avail. Instances of basilar meningitis are guarded as to the prognosis, since no one can tell how much destruction will result in incipient paresis of the nerve from the jDressure that is produced. Diagnosis. — This could not be confounded with any other con- dition, if the movements of the eyeball in relation to the anatom- ical and physiological condition of the eye are carefully studied, external strabismus being the most prominent symptom besides the ophthalmoplegia already mentioned above. Treatment. — This consists in treating the original etiological factor. Potassium iodide in doses of 10 to 30 or 100 grains Fig. '25. — Congenital Nystagmus (mother also affected). CRANIAL NERVES 139 t. i. cl. is usually one of the most valuable treatments if persisted in early in all acute cases. Later, after the absorption of the exu- date has taken place, the use of strychnine, if generally indicated. If fracture of the skull occurred and the nerve was severed, there cannot be any hope for amelioration, since operation could not reach the site of the trouble without being the cause of death in itself. - Patheticus. — The palsy of this nerve is due to either neuritis, meningitis, or trauma. It causes paralysis of the superior oblique muscle; the eye is permitted to turn upward and inward. If the condition is dependent upon a neurological lesion, as indicated above, treatment would come under that of the neurologist, and would consist in the administration of iodides, and later strych- nine. The ophthalmologist, as in all diseases of special nerves of the eye, should be consulted in order to determine any special treatment of the eye affection itself. Isolated palsy of the fourth nerve is rare. Trifacial. — This is one of the most important nerves in the affections of same, from a neurological point of view ; since diseases of this particular nerve produce more suffering and occur more frequently in neurotic individuals than in any other nerve. The cortical centre of this nerve is in the anterior part of Broca's convolution, the lower centre being in the floor of the fourth ven- tricle. The lesions producing diseases of the fifth nerve are either central or peripheral; excepting in some few cases of cortical dis- eases where the lesion is supranuclear. There would not be the reaction of degeneration in any degree of destruction of this cen- tre, whereas, if peripheral parts of this nerve are involved, degen- eration of the branches would occur. This is a distinctive point in regard to all the cranial nerves, and must be carefully studied in making diagnosis of a given case. Neuralgia of the fifth nerve is the most common disease affecti'ng it. Tic douloureux has been mentioned under the head of separated diseases (see Neuralgia, p. 117). The simple neuralgia of the fifth nerve would be looked for in the different branches, acceording to the site of the disease, which has already been mentioned under the proper heading (see p. 117). It should be especially noticed in diseases of the inferior maxil- lary branch, it having a motor fibre as well as motor symptoms. Abducens. — Paralysis of the sixth nerve produces internal stra- bismus. This is frequently due to neuritis, not an unusual lesion. 130 TREATISE OX ^teryOUS DISEASES The treatment ^vollld be for the neuritis, and further, the case should be referred to the ophtlialmologist for an operation upon tlie muscles affected if degeneration has occurred. Facial.^ — This is affected from supranuclear or infranuclear disease. In disease of the cortical centre, which lies in the lower Rolandic region, there will be primar}' facial, spasm and secondary paralysis without degeneration. Here the lesion is generally unilateral, with the spasm or paralysis of the muscles opposite; the corrugator super- cilii muscle not being affected. Nuclear le- sions are generally bilateral, usually hemorrhage or gum- mata involving the floor of the fourth -^entricle. The symp- toms would be pri- marily spasm of the muscles, and, finally, paralysis with wast- ing and reaction of degeneration. The peripheral lesions of the seventh nerve, which j)roduce symp- toms of seventh-nerve disease, are, first, the intracranial ; second, intra-osseous ; and third, extra-osseous or extra-cranial. The lesions anywhere along the tract indicated in 90 per cent of cases are unilateral. They are all termed peripheral lesions, since they are not in the centre itself. And the paralysis is designated Bell's palsy. The extra-osseous form of peripheral disease is frequently excited by exposure to cold and draughts (neuritis), or, as in rare eases, due to trauma. Such a case the author has reported in a girl where a pipe stem entered immediately below the helix of the ear, where it lay buried. The onset of symptoms in the so-called idiopathic cases is, as Fig. 26. — Facial Palst, Left Side, Showing secondary spasm same side, and inability to dose left eye. CEANIAL NERVES 131 a rule, sudden, the patient perhaps waking in the morning and finding the face drawn to the well side. The wrinkles have disap- peared from the paralyzed side, the mouth is drawn towards the (Fig. 26) opposite side, and the patient is unable to wrinkle the brow as well on the affected side, saliva dribbles from the mouth; there will be inability to maintain the bolus of food between the teeth, and also some difficulty in deglutition. The patient may also complain of a sense of pargesthesia or numbness on the affected side, but there is rarely anesthesia, in AA'-hich case the neuritis has involved the fifth-nerve branches as well, No disturbance of the sense of taste exists. The duration of this type is, on the average, from six weeks to three months, and depending upon the amount of neuritis and destruction of the nerve-fibres will recovery take place completely, perhaps in 50 per cent of the cases fully. The intra-osseous portion of the nerve is involved in some of the so- called idiopathic cases of Bell's palsy, but is much more often affected when the patient gives a previous history of otitis media ; although this might be the predisposing cause to the extracranial form in rare cases. But with the history of ear disease the disturb- ance of the sense of taste should be looked for, and will also be fre- quently found. Taste will be absent or lessened on the anterior two-thirds of the tongue on the affected side in such cases, due to catching of the chorda-tympani nerve as it passes out through the hiatus Fallopii. The testing for deafness should also not be for- gotten, and this would be an important point in determining the site of the lesion, since if aerial induction of the tuning-fork is bet- ter through the external auditory meatus than when the fork is ap- plied to the temporal bone, the deafness is due to internal ear dis- ease; whereas if the conduction is better through the bone than by the external auditory meatus, the disease causing the deafness and the disturbance of taste is resident in the middle ear. Intra- cranial disease is associated with deafness or vertigo, the latter being a prominent symptom where the semicircular canals are in- volved, and deafness where the vestibular portion is the original seat of disease. In any case the degeneration of the seventh nerve will be found after the tenth day. Prognosis is uncertain. Treatment.— In any form of Bell's palsy the treatment of the underlying cause is of prime importance, while the prognosis will be good in proportion as this cause is determined and can be suc- cessfully eradicated; thus, if a meningitis can be controlled early, 132 TEEATISE ON NEEVOUS DISEASES very likely the patient will recover the full use of this cranial motor nerve. Cases clue to internal or to middle-ear disease are more serious, since the exciting or predisposing cause is the difJicuU condition to remedy. - Such a case should be referred early to an aurist for proper treatment. Idiopathic cases are best treated by applying a blister back of the ear, keeping the patient quiet, adminis- tering a purge and carefully searching for any other cause. The use of potassium iodide should be had early, and in fairly large dosage (from 10 to 15 grains t. i. d.), over a continuous period of two to four weeks, when the dose should be gradually lessened. A smaller dosage should then be continued for a fortnight, and finally the patient put under the tonic influence of strychnine, 3V of a grain t. i. d. The use of galvanism should be instituted by the tent:h day or second week after the onset of the disease. (See Electricity, p. 97.) This is the most valuable agent in the success- ful treatment of Bell's palsy. Auditory. — Disease of the eighth nerve proper consists of tin- nitus aurium, due to irritation of this nerve; and deafness, due to destruction of the nerve-trunk or its centre. Certain forms of paralysis of the seventh nerve, as shown in the preceding para- graphs, may complicate, but they need not be rehearsed here. Prognosis of eighth-nerve disease depends upon the nature of the disease within the temporal bone or whether the nerve or its centre is involved; in the latter treatment would be of little or no avail, whereas in peripheral trouble, as in middle and external ear disease probably much relief or cure by an experienced aurist may be brought about. A disease in which the eighth nerve is particularly involved is caled Meniere's disease. (See Symptom- atic Disorders). Glosso-pharyngeal. — The glosso-pharyngeal nerve supplies motor and sensory fibres to the pharynx, the larynx, back part of the tongue, and sends a branch (Jacobson's nerve) to the middle ear. It is also one of the special sense nerves of taste. (The chorda tympani supplies the anterior tAVO-thirds of the tongue.) Disease of this nerve would produce, if irritated, an increase of sensibility in the pharynx and hypergeusia, whereas the de- struction of the nerve would produce loss of sensibility, with ageusia, on the posterior third of the tongue. Disease of this nerve is usually of central origin, and the prognosis and treatment would depend upon the nature of the setiologieal factor of the CRANIAL NERVES 133 primary disease. Usually in disease of the ninth nerve ameliora- tion is doubtful. Diagnosis. — This cannot be confused with any other lesions of any of the other cranial nerves, when one remembers the anatom- ical distribution of same and its function. Treatment is of avail only as the cause can be got rid of. Pneumogastric. — This nerve has its origin behind the olivary body of the oblongata superficially, and has its deep origin in the floor of the fourth ventricle in close- conjunction with the centre of the glosso-pharyngeal nerve. It supplies the sensory and motor fibres ; through the auricular branch, passing to supply sensation to the external ear, and a pharyngeal branch supplying motion to the pharynx. There are also the laryngeal branches, of which the superior supplies sensation to the larynx and ^notion to the crico- thyreoid miuscles. The inferior or recurrent branch is entirely motor, and supplies the intrinsic muscles of the larynx, excepting the crico-thyreoid. Then there are also the cardiac fibres, the pulmonary and sensory, the oesophageal, and gastric motor fibres. Disease of this nerve, therefore, produces wide symptomatology, varying from the absence of sensation to the external ear to paral- ysis of the pharyngeal muscles, oesophageal, stomach, and laryngeal muscles, and even paralysis of the heart; so that in the majority of cases of disease of this centre or nerve itself death results from heart failure before any other special symptoms could come to the attention of the physician. Many vague symptoms in the thoracic cavity are due to a neuritis of the various branches of this nerve. As a rule, diagnosis is not made until the final symptoms develop and the patient is carried ofl' by heart failure. The treatment would consist in eliminating causes, such as intoxications or men- ingitis or polioencephalitis. Strychnine may be of service. Spinal-accessory. — This nerve has its superficial origin from behind the olivary body, and its deep origin below that of the tenth nerve, in the floor of the fourth ventricle, making its exit through the jugular foramen and supplying motion to the sterno- mastoid muscle, and it also gives motor branches to the tenth nerve. Disease of this nerve is usually of an irritative nature, due to func- tional disturbances of the centre, resulting in spasmodic wry-neck (Fig. 27) or torticollis. In this affection, which usually has its onset in early childhood, and is sometimes due to rheumatic taint or to catching cold, drawing of the head forward and towards the 134 TREATISE 0^ KEEYOUS DISEASES affected side occurs, the chin being pushed to the opposite side. It is paroxysmal, although there is a persistent tonic contraction of the muscles. If the tra- pezius is also affected, there will be elevation of the shoulder of the affected side. It is a very chronic disease, and may last for years. iSTo defi- nite pathology has as yet been discovered in the majority of cases. Some are distinctly hysterical, as proved by the fact that mental therapeutics often cure the condition. If it occurs in early childhood, it may deform the chest and neck of the patient so much that the deformity is a very important disability. Prognosis. — This is therefore very dubious. Treatment. — Both medical and surgical measures are to be re- ferred to; medical in the administration of antispasmodics, such as tincture of gelsemium or conium, gtt. v, t. i. d. Surgical, which consists in the excision of the nerve in whole or in part. Some surgeons, as Keen, of Philadelphia, recommend the excision of the cervical-spinal sensory roots. This I have seen cure one patient. Others have been operated on with the reappearance of the de- formity. The patient should have a change of environment, and he should live in quietude. Proper gymnastics and chest expan- sion exercises are especially necessary in young persons. Appa- ratus is occasionally of service in relieving contractures. Hypoglossal. — The cortical centres are in the lower part of the central convolutions. This nerve has its superficial origin in the front part of the oblongata and the deep origin in the floor of the fourth ventricle, and passes out through the anterior condyloid foramen. It is entirely motor, supplying the muscles of the Fig. 27. — Showing attitude in Spasmodic Tor- ticollis. CKANIAL NEEVES 135 tongue, excepting the palatoglossus, mylo-hyoid, and stylo-hyoid. The descendens noni branch communicates with the second and third cervical by the so-called communicans noni nerve. Disease of this nerve consists in paralysis in the majority of cases; irrita- tive lesions seldom, at least, giving symptoms. The cause of destruction of the nerve is eitlier cen- tral or peripheral — i. e., is either supranuclear, nuclear, or intranuclear. If central, it is unilateral. If nuclear, it miay occur as a symptom in bulbar pa- ralysis, as well as in local- ized minute apoplexies. Usually the cause of palsy is neuritis, specific in origin, in which case it is apt to be unilateral, the symptomatology being paralysis of one side of the tongue, fibrillary con- tractions, and atrophy. The base of the tongue is elevated and the tongue protrudes towards the palsied side (Fig. 28). Diagnosis of iso- lated lesion is made by excluding apoplexy or other paralyses due to a very extensive central lesion, and in excluding neuritis from other parts of the body. Atrophy occurs in nuclear or intranuclear lesions. Treatment. — This depends entirely upon the cause, central le- sions and chronic specific disease usually causing permanent dis- ability. Neuritis from traumatic causes would be more apt to be relieved by antirheumatics or by surgical interference. Elec- tricity does not prove of much avail in such a limited area. The use of strychnine is indicated, and tending towards regeneration of the nerve itself. Acute specific neuritis is hopeful if full anti- luetic mixed treatment is earlv administered. X Pig. 38. — Supeanuclear Palsy of the Right Hypoglossal Nerve, Showing tongue deviation to palsied side (Phila- delphia Hospital). CHAPTEE YII ' DISOBDEBS OF PERIPHERAL NERVES DISEASES OF THE PERIPHERAL NERVES The peripheral nervous system consists of twelve pairs of cra- nial and thirty-one pairs of spinal nerves,, together with their root ganglia and terminal sense and special sense organs; also of the sympathetic nervous system. The sympathetic system consists of the intervertebral and the cranial ganglia and the peripheral gan- glia. The latter arise during embryonal life from ganglionic cells of the same class as those of the spinal-root ganglia, then later migrate to their position in the sympathetic. According to Minot, therefore, the peripheral nervous system is composed of peripheral motor neurones, peripheral sensory neurones, and peripheral gan- glionic neurones. Origin of Nerves. — Modern studies have shown that the true nature of the nerve-fibre is but a prolongation of the nerve-cell — i. e., of the axis cylinder of the cell. Added to this axis cylinder are supportive structures, also those for insulation when the nerve is complete. Motor nerve-fibres, therefore, come from motor neu- rones and sensory nerve-fibres from sensory neurones or cells. All peripheral nerve-fibres of motor nerves have in the cord or brain certain motor cells of origin, and these are known as the nuclei of origm of these nerves. This is not exactly the same with the sensory nerves. All sensory nerve-fibres take their origin from nerve-cells in the posterior nerve-ganglia, or else in corresponding cranial ganglia, such as the Gasserian, lying upon the cranial nerves. The nerve-cells in these ganglia send off a single process, which divides in T-fashion, the peripheral branch going out to form the sensory fibre, the central branch passing into the cord or brain, and ending in a terminal arborization which surrounds groups of sensory nerve-cells. Hence, these latter sensory nerve- cells are not nuclei of origin, strictly speaking, but are terminal 136 DISOKDERS OF PERIPHERAL NERVES 137 nuclei. Therefore, there are no nuclei of origin for sensory nerves in the central nervous system, a matter of much importance when we come to consider the anatomy of the cranial nerves. PATHOLOGY OF THE NERVES Hypersemia and anaemia of nerves brings about types of nerve- irritation leading to various forms of neuralgia, of parsesthesia, and of motor irritation or paresis. These conditions are usually, however, secondary, and are but rarely recognized clinically, since it cannot always be determined whether an irritated nerve is anaem- ic or congested or, indeed, whether the central nervous system ma}'' not be mainly at fault. NEURITIS This is an inflammation of the nerves. It consists of inter- stitial and parenchymatous neuritis. The interstitial neuritis con- sists of inflammation of the connective-tissue elements of the nerve — the epineurium and endoneurium. The parenchymatous neu- ritis consists of an inflammatory process, being located in the parenchyma. It is further divided into local and multiple. In the local form of the disease it is frequently of the interstitial type, whereas in the multiple form it is apt to be of the proto- plasm of the nerve. It is also divided into acute, subacute, and chronic. Symptoms of acute neuritis are pain along the course of the nerve-trunk, tenderness, moderate fever, and lessening of the reflex in the parts involved, with perhaps hypsesthesia or angesthesias, de- pending upon the extent of the lesion. After the first few days the tenderness may largely subside, the sense of parsesthesia lessen, and the condition settle into a more regular course, somewhat below the severity of the onset — i. e., with lessened spontaneous pain and tenderness. If localized, an active case- may terminate within six weeks, or, if general neuritis, the acute may be designated to those cases- continuing a greater length of time. The reaction of degen- eration may be found as early as the seventh day of the disease. Causes. — Traumatism, poisons from within and without, in- fectious diseases, etc. Diagnosis would be only between myalgia and neuralgia, in which latter case there is no tenderness on pressure, but rather an 138 TEEATISE ON NERA^OUS DISEASES alleviatiori of the pain ; nor does elevation of temperature^ local or general^ exist in neuralgia. In myalgia the muscle pain would be relieved by firm pressure, while in myositis the belly of the muscle would be painful to the grasp, but no nerve-trunk tender- ness would exist. Prognosis is guarded and depends upon general state of health, as well as upon the severity and persistence of the cause. Subacute neuritis consists of the disease after it has run longer than the average duration of six weeks, or when the nature of the infection has been very slight from the beginning, and consequently the onset gradual. In the subacute type we have a modification of all the symptoms; pain and tenderness are much less severe, weakness of extremities and muscles less pronounced, both on ac- count of the fact that the nerve structure is not disabled function- ally and that there is less pain at the time of attempted muscular acts. Eeaction of degeneration may be pronounced. The fact that a case is subacute immediately makes the prognosis more guarded, since the name itself implies a chronicity of the condi- tion or a predisposition to the inflammation of the nerves in a particular case. Diagnosis. — It is likely to be mistaken for neuralgia, but may be confused with chronic rheumatism, the difference between the two being, of course, the lack of localized tenderness along nerve- trunks in rheumatic affections. If a rheumatic neuritis exists, there will also be found other evidences of the disease (rheuma- tism), such as fever, joint or cardiac involvement, with excess of urates in the urine. Chronic neuritis is that form which persists longer than three months, and is, as a rule, the sequel of the acute or subacute dis- ease. The symptoms are much more modified than either of the two preceding varieties, although localized atrophy of muscles may be much more in evidence; also, reaction of degeneration will be more distinctly shown, while the pain and tenderness and anaes- thetic areas along the course of the nerve-trunks will be very likely slight, but on the other hand, from the prolonged disability and muscular atrophy, palsy is much more pronounced, and the re- flexes may be entirely abolished, although in some of the chronic interstitial types of mild grade I have even seen increase of the deep reflexes, as the knee-jerks. When the latter occurs, it can be explained by the irritation of the nerve-fibres through inter- DISOEDEES OF PEEIPHERAL NEEVES 139 stitial connective-tissue overgrowth^ which re-enforces the reflex impulse. Diagnosis. — The ditBculty lies between it and chronic neuritis of rheumatic type. Tlie symptom pain may be confused with the pain of cord disease, as in tabes. In tabes we would have other evidence of spinal-cord lesion. There would be no tenderness at all, while anaesthesia or other sensory changes would not vary miich from week to week in cord lesions as it may in neuritis. As between rheumatism and neuritis, we have given points above which need not be repeated here. Prognosis. — This depends on the history of alcoholism or the use of other poisons, upon the vulnerability of the patient, upon the diathetic tendency of the individual towards rheumatism, etc., and upon the locality in which he resides, since a low, damp coun- try would be particularly bad for this malady. As a rule, patients will recover if proper treatment can be administered early. Treatment. — The treatment of acute neuritis, whether local or multiple, has certain fundamental principles to be observed. In the first place, rest of the part involved as nearly absolute as possi- ble, is a desideratum. The relief of pain is due largely to this measure as well as to cure of the inflammation itself, which is thus favoured by absolute immobility. A splint is often a useful meas- ure for producing this quietude. If the case is one of multiple neu- ritis, the patient should be placed in bed ; in the acute form, and in many cases of subacute and chronic types cure will be had much more quickly if this measure is adopted earlier than is at present the general practice. For relief of pain in the acute form, local ap- plications of lead water and laudanum (25 per cent) are also of value; the arm should be protected by means of cotton or heavy wool. Particularly if near a joint, the extremity should be splinted. Among drugs, the analgesics will do much to control pain, such as phenacetine, antipyrine, etc., in 5- to 10-grain doses, as re- quired. Finally, hypodermics of morphine may have to be given to control this symptom. The use of sodium salicylate is com- mended, particularly in those cases of rheumatic origin. Also the employment of potassium iodide as an alterative is of value. In chronic cases, with reaction of degeneration, the use of massage and galvanic electricity on alternate days are valuable adjuncts after the acute pain and tenderness have subsided. In acute cases the diet should be limited, but in chronic cases, where the patient haa 140 TEEATISE OX XEEVOUS DISEASES been run down, the use of nutrients is of par excellence, sucli as meats, regetables, milk, etc., and even cod-liver oil, although in cases of rheumatic origin the use of proteids should be guarded, according to the idiosyncrasy of the individual. The counter-irri- tation over the course of a nerve, by means of blistering, or the actual cautery after freezing is frequently 'of value. The use of strong tincture of iodine is another irritant I have seen do good service. Multiple neuritis as well as other forms may be idiopathic, or its getiology may be from sources already mentioned under the gen- eral head of neuritis. A better name for the idiopathic form would be essential, since this does not imply that there is not a cause, even though not discovered. The more frequent causes, however, are alcohol and lead and exposure or infectious diseases, as typhoid (Fig. 29). This type of the disease pathologically is usually of the parenchymatous variety. Special Forms of Multiple Neuritis. — In the alcoholic form of multiple neuritis there is early toe-drop, some pain along the course of the nerves of the legs and arms, loss of knee- jerks, which may indeed be absent before the patient complains of weakness or pain in the extremities. There is also consid- erable wasting of muscles, with reaction of degeneration coming on early in the palsy. The patient presents the gait which is styled the " steppage gait," due to the weakness of the anterior group of muscles and sequent toe-drop. There will also be found to be extreme gastric disorder, as a rule; a gastric catarrh, and pains in the abdominal viscera, due to the alcohol irritating the mucous membrane of the stomach, with subsequent inflammatory condition of. the entire gastro-enteric mucous membrane. There may or may not be marked wrist-drop in alcoholic neuritis. The heart may be affected, the patient suffering from palpitation and arhythmia, and in some cases death may result from involvement of the vagi nerves or centres. Palsy of the extra-ocular muscles may produce a strabismus, diplopia. In some cases atrophy of the optic nerve itself ; and blindness may follow due to the extension of the inflammation of the optic nerves. The nails often become brit- tle and transversely ridged, caused by Inck of growth at special epochs in the course of the malady. Frequently the patient be- comes the subject of a progressive muscular atrophy, the result of degeneration of the nerve protoplasm. In alcoholic neuritis pain DISOEDERS OF PEEIPHERAL NEEVES 141 is not a prominent symptom (but it is very pronounced in the so- called idiopathic cases ) . The duration of the disease may be from six months to several years, the patient recovering at the end of this time in the majority of cases under proper treatment. In lead multiple neuritis the symptoms are somewhat different from those due to alcohol, inasmuch as wrist-drop is a very distinc- tive and early symptom, toe-drop being rather a secondary or late phenomenon. In lead neuritis, the onset is more rapid, and fre- quently preceded by gastro-intestinal disturbances, such as tor- mina, vomiting, or other evidences of lead-poisoning. Another point is the fact of the blue lines being about the gums. This is due to reaction of the lead upon the saliva producing lead sulpho- cj^anide. The blue line is always at the junction of the teeth and gum, but is upon the latter. The blue line, however, does not exist when there are no teeth present, it must be remembered, since the Fig. 29. — Bed-ridden Case of Multiple Neuritis (post-typhoid infection). Showing toe- and wrist-drop. tartar is not then present to produce the characteristic chemical reaction. Diphtheritic Multiple Neuritis. — Another variety of multiple neuritis fortunate enough to be given a special place, and yet many times overlooked by the general practitioner, is the diphtheritic form, which may or may not be associated with the post-diph- theritic pharyngeal parahjsis. This I have recently seen in the case of a doctor who had been a most healthy specimen of man- hood, and who four weeks after the onset of severe toxic diphtheria developed neuritis. In him the palsy of the throat was 142 TEEATISE OX NERVOUS DISEASES ■very slight, but the universal involvement of nerves seemed to show the very profound intoxication of the nervous system. In diphtheritic neuritis, the history of diphtheria, or, if the case had not been closely observed, simply the story of a sore throat, will be the deciding factor, plus the inability early to swallow well or the incapacity to lift the soft palate as in saying " Ah ! " Arsenical neuritis is also a type of multiple neuritis, and is frequently caused by prolonged medication in the use of Fowler's solution or of arsenious acid, either due to the patient taking the drug for cosmetic effect, or perhaps in the treatment of chorea. Diagnosis of arsenical poisoning resulting in neuritis cannot be positively made without a previous history of poisoning, since there are not sufficient distinctive features to differentiate this. The physician should always look to the history of the patient sleeping in a room where arsenic has been deposited in wall paper prepared by the arsenical process, not a few cases having been reported through investigations by Shattuck, of Boston. BERI-BERI OR KAKKE This is a type of multiple neuritis, particularly endemic in the Philippine Islands. It is probably infectious. Some authors claim it is caused by CO2 poisoning, others that it is due to diet of fish and rice containing fungi. It is associated with oedema, effusion into the serous cavities, such as the pericardium, the peritonaeum, or into the ventricles of the brain. It is marked by paralytic and atrophic disorders, anaesthesia, and lightning-like pains. Death is the result of the effusions rather than of the neuritis proper, or else to early involvement of the phrenic or vagi nerves. Mental disturbances are frecjuent. Prognosis. — This is absolutely bad. Treatment of multiple neuritis does not differ in any chronic type except in so far as separate causes are determined — namely, alcohol, lead, diphtheria, or arsenic. Treatment of the resulting neuritis would, at least, be the same in any case. In the types mentioned there is the possibility for aid through early elimination of the poison. The use of potassium iodide is a valuable measure as an eliminant in all cases due to poisoning by drugs. The source of infection should he cut off. Besides, the patient should take large draughts of water. The persistent use of general massage daily, fresh air and sunshine, plus the use of DISOPtDERS OF PERIPHEEAL XEEYES 143 cod-liver oil and hypophosphites, living in a dry climate away, from prevailing high winds, will insure success if carried out over many months in cases where chronic invalidism has occurred from the lack of persistent endeavour in these directions by either the patient or physician. Strychnine should be given in large doses in cases of chronic neuritis — 3V to xo being administered thrice daily. The use of galvanism is also a valuable measure where there is degeneration of nerve tissue. In this case the nega- tive pole should be placed over the spine and the positive over the atrophied muscles, a constant current being applied to all the palsied muscles for several minutes three or four times a week. Massage is of great value when administered daily. Alcoholic cases must be rigidly guarded against indulgence in the drug, since a small amount of alcohol will precipitate inflammation. Auto- intoxication from intestinal fermentation should be prevented by restricted diet and the use of salol in moderate doses (3 grains t. i. d.). Erythromelalgia (see frontispiece) is a variety of multiple neuritis affecting the dorsal and plantar nerves of the foot. It was first described by "Weir Mitchell, who gave it the name of a vaso- motor neurosis. We have had the pleasure of studying two of Mitchell's cases. One was due to a crush injury caused by the fall- ing of a heavy stone upon the foot. The case cured through stretching of the plantar and by excision of the cutaneous nerves. The other case died of a complication of gangrene of the foot fol- lowing infection after the operation of excision and stretching of the internal saphenous and musculo-spinal nerves, and of stretch- ing of the posterior tibial nerve. Histological examination showed neuritis, thickening of the middle coat of the vessels of the amputated (affected) foot. This obtained in the smallest arteri- oles, while the larger vessels were also calcareous. This type of neuritis has particular characteristics. "When the affected foot is pendant it becomes intensely red ; a severe burning pain is set up, in which the local temperature rises to as much a&j-° C. higher than when the foot is held horizontally. This is the opposite of what occurs in a normal extremity, as Mitchell points out in his Clinical Lessons on Xervous Diseases, pp. 202, 203. Walking fre- quently is so painful as to be almost impossible. Excess of perspi- ration may occur when the foot is pendant or is paroxysmally pain- ful. Heat aggravates the pain also, while cold relieves it. Local 144 TEEATISE OX XERVOUS DISEASES ulceration from profound trophic disturbance follows in bad cases. Prognosis. — Usually chronic and persistent. Spontaneous cures have occurred. Treatment consists in rest in bed, local applications of cold, protection of the foot by cotton or splints loosely applied. Galvanic electricity, the positive pole being placed over the affected part, together with etfleurage, may afford relief. Stretching and excision of nerves are measures to be adopted where relief fails from other forms of treatment. The drug habit should be guarded against. Recurrent multiple neuritis is a type described by Sherwood, Ross, Osier, and others. Certain individuals are susceptible to re- current attacks from definite poisons, particularly from alcohol and lead. Since it is not necessary for the intoxicant to be again taken to produce recurrence of the neuritis, there must be induced in such patients a susceptibility. Each recurring attack is likely to be more severe than the former. Treatment is the same as for other forms of multiple neuritis. It is especially dangerous for these patients to be exposed to the poison originally causing the disease. Leprous Neuritis. — The leprous bacilli may cause neuritis. Proliferation of the nerve-trunks occurs, nodules are formed, and finally the bacilli may disappear. According to Martins and Sonza, the spinal cord may become invaded by the bacilli and cavities form, especially in the posterior horns and in the gray commissure. Sensory symptoms, particularly of angesthesia, occur, especially in large patches on the face, hands, forearms, feet, and legs. Through spreading, a very large area may thus become anaesthetic. The small muscles of the hand may be wasted, and even the bones may become atrophic. There may occur deformi- ties of the hands and feet due to atrophy of the parts, followed by contractures. The toes, fingers, hands, and feet may even be cast off, as in dry gangrene. The neuritis may last many years. Syringomyelia of the Morvan type may be simulated in some cases through existent dissociation of cutaneous sensation, very likely caused by the disease in the gray cord as noted above. After-treatment of Neuritis (continued). — In the toxsemic state following the acute infections, large doses of iron, as of the tincture of the chloride, are of great value. If malaria is present, quinine and arsenic are important remedies. The cachexias that DISORDERS OF PERIPHERAL NERA^ES 145 may yxist as predisposing causes should' be sought for and, if pos- sible, remedied. In cancer, tuberculosis, or in pernicious anaemia, the measures that cause general improvement will aid iii neuritis. In bad cases it may be necessary to pass food through the stomach- tube. If the heart is at all enfeebled, such cases should be watched most anxiously and quietude enjoined. At times a brachial neu- ritis will thus end in death suddenly by extension of the neuritis through some anomalous branch connected more directly with the vagi or phrenic nerves, or else it may be a reflex inhibition of the heart that occiirs. Contractures and posture deformities must be very carefully guarded against, especially in alcoholic cases. The weight even of the bed-clothing must be taken ofE the toes by means of " hoops " or other improvised apparatus. At times the use of splints, where there is not extreme sensitiveness, will aid much in preventing contractures; as about the ankles. Passive movements in full ex- tension, and especially in full flexion of the ankle, should be used several times a day in the alcoholic type. Heat applied will at times do good in relieving pain. We have seen cold occa- sionally do good, but for some unknown reason it invariably aggravates any form of neuritis of the upper extremities, though it may do good, as indicated in sciatic neuritis. Hot baths, Turkish and Russian baths, or needle douches, as advised by Charcot, may all be employed- late in the course of the disease. As with the coal-tar derivatives, the use of morphine or cocaine should be very guardedly emploj^ed. The bromides and chloral combined allay cerebral irritability and produce sleep more safely than any other drugs. Static electricity is of value to awaken the circulation and aid metabolism. This and the faradic brush will frequently greatly benefit the cutaneous anaesthesias. The pa- tient must be encouraged to walk as soon as possible, since the muscles gain power by exercise. Tenotomy may be required where contractions have occurred. The use of deep kneading about in- durated joints caused by disuse and the inflammatory exudate, is of great value, especially if associated with a hot bath (180° F.) in an alkaline solution (such as of soap), the Turkish bath, or Scotch douche. SCIATIC NEURITIS This has in the past been confused with neuralgia, or sciatica, but where tenderness is present neuritis must exist ; and as a rule. 146 TREATISE OX XEEVOUS DISEASES sciatic disease is neuritic in origin. Sciatic neuritis is a very important disease clinicall}^ Etiology. — The canses are like in other instances of neuritis — general and local. It is more frequent after twenty-one years of age. Gibron (London Lancet, 1893) says it is eight times as common in males as in females, and this is no doubt due to greater exposure of men. Hence, exposure to cold and dampness is one of the most frequent causes. It is common in puddlers, miners, stokers, and cabmen; neurotic, rheumatic, and gouty sub- jects are very liable to it. Lead-poisoning favours it. Diabetes, syphilis, typhoid fever, la grippe, and malaria predispose to its development. It may follow operations for lithotomy, childbirth, or from pelvic disease in women, or aneurysmal pressure. Bony thickening of the sciatic notch or gumma, in rare instances, are causes of sciatic neuritis. Lumbago may precede or complicate (extension by contiguity). Compression of the nerve may be a cause, as in sitting a long time on a hard bench, as in shoemakers; or it may be a direct con- tusion of the nerve, as from a blow. Excessive fatigue of the legs may precipitate an attack, as in prolonged use of the sewing- machine. The pressure of varicose veins may produce it. Spinal disease and new -growths in the spinal canal may cause sciatic neuritis by first affecting the nerve-roots, the vertebral canal, or at the cauda equina. Symptoms. — Pain and tenderness along the course of the nerve are the principal symptoms. While both of these signs may ex- tend throughout the sciatic distribution, they are more intense in the upper half of the thigh near the sciatic notch. The tender- ness is often extreme, and the patient may be able by this to trace the nerve down to the popliteal space. Below the knee the pain is likely to follow the external popliteal. The pain is more or less constant, and is very wearing upon the patient, especially since exacerbations occur mostly at night, keeping the patient awake, when physiological resistance of the nervous system is lessened. Flexing the thigh well down upon the abdomen, or walking, creates added pain very quickly. Partial flexion of thigh and knee, how- ever, with extension of ankle (a characteristic position when the patient lies abed), will relieve pain through relaxation. The char- acteristic gait of semiflexion and limp is due to the same semi- flexion. If it be a chronic case, lateral curvature of the spine may DISOEDERS OF PEEIPHEEAL XEEYES 147 develop, the convexity being towards the affected side. This sco- liosis, being muscular, disappears on recovery. A lumbar con- cave curve and dorsal convex curve of the spine may develop in those rarer cases, with spasm on the affected side due to neuritic extension to the anterior crural nerve, the sacral plexus, or lumbar cord. This is termed homologous sciatic scoliosis, and is likely to become permanent, as the sciatic association symptoms are chronic and contractures develop which fix the peculiar deformity. Particular points of exquisite tenderness in sciatic neuritis are designated tender points of Valleix, such as the gluteal point over the sciatic notch, the trochanteric point over the great trochanter, the popliteal point at the division of the nerve, and the fibular point, where the external popliteal winds around the head of the fibula. There may also be a tender point on the dorsum of the foot. In addition, in some cases there may be an iliac point about the middle of the crest of the ilium, lumbar points just above the sacrum, or a patellar point over the patella; points behind the malleoli, in the calf, or plantar points in the sole of the foot. It is at these points that the patient complains of paroxysms of pain occurring in the course of the disease. This pain may be boring, burning, tearing, or lancinating in character, which tortures the patient to distraction. Using the limb or " catching cold" will frequently at once precipitate an attack. At times the sudden attacks of pain are spontaneous and periodic, as in malaria. Cutaneous sensibility is often disturbed. This may be of hypersesthesia in the sciatic distribution followed by anaesthesia, or the sensitiveness may be confined to the areas of the painful points just given. Paresthesias, such as feelings of formication, fulness, pricking, or of heat or cold, may be present. Motor symptoms, as a rule, only appear in the grave cases. Cramps, violent tremor or spasm of calf muscles may be present and increase the pain. The Tcnee-jerh is rarely exaggerated; usu- ally it is much diminished, and the heel-jerJc may be absent. If there is atrophy of muscles fibrillary twitching is often found, and there is then palsy or paralysis. In the worst case a severe spasm involving the entire limb may be produced, at times creating the most profound distress. A slight draught of air or even the sud- den touch of clothing may bring on this spasm, so that the limb must be well protected from both. Vaso-motor disturbance may cause flushing or, in severer cases, lividity of the limb, or even 10 148 TREATISE ON ^terVOUS DISEASES oedema. Usually the sweat is reduced. It may be increased. Erythema^, acne, perforating ulcer of foot, herpetiform eruptions, or scaliness may all be found in some cases. Reaction of degen- eration may be elicited in the wasted muscles. In thin people the swollen nerve may sometimes be easily palpated. Excess of fat may mask the muscular wasting. Double sciatic neuritis is rare and is usually the result of pelvic or spinal disease, which makes the diagnosis easy. Pathology. — Perineuritis and inflammation of the adventitia are present. The nerve parenchyma suffers secondarily. The nerve is red and tumefied (cedematous). It is therefore distinctly interstitial neuritis primarily. Diugnosis. — This must be made from neuralgia or muscular rheumatism. In the former the pain is fleeting, and there is no nerve-trunk tenderness. In muscular rheumatism the pain is dif- fuse, and the muscles about are sore to touch. Hip disease is de- termined by the joint tenderness and fixation and pain in the region of the obturator nerve. Hysteria may be simulated, but is distin- guished by the fleeting character of the pain and the emotionalism or other stigmata. The pelvic organs and spine should always be looked to as a possible source of the inflammation of the nerve. If the disease is bilateral it has pretty positively come from within the pelvis, as from a growth, or as indicated above. History of syphilis, malaria, or of exposure, often tells all. Injection of a local anaesthetic may stop pain for a time when it has begun or is entirely located in the nerve, not above the notch. Prognosis. — In uncomplicated sciatic neuritis the ultimate re- sult is good. If due to spinal disease, the prognosis is to be guarded, since cure of the original trouble is doubtful. The aver- age case will last several months, but if the part is used the neu- ritis may last for months or even years. Relapses are common. If the limb is wasted it may take a year to recover full use of the extremity after the pain has subsided. Treatment of Sciatic Neuritis. — This is allied to that of treat- ment of any local neuritis. Special measures consist of absolute rest of the limb, the patient being put to bed. Or a long, well- padded splint can be applied from axilla to external malleolus, and the heel should be protected by raising it from the bed by a pad over the tendo-Achillis, The limb should be thus held in a partially flexed position, first having applied a flannel bandage from foot to DISOEDERS OF PERIPHERAL XERA^ES 149 hip for protection and warmth. Diathetic states, as of rheumatism or gout, must be treated if present. Examination of the urine is very important as to determination of this. Counter-irritation by means of strong tincture of iodine thrice repeated, or the use of a blister, or of the actual cautery of Paquelin, are all of great serv- ice. Extremes of heat or cold may do good in individual cases. Thus, ice-bags or hot poultices "kept applied along the course of the nerve may give great relief to suffering. I have seen sodium sal- icylate, gr. X, every three hours in peppermint water, do good in acute cases. Potassium iodide in chronic cases or injection of co- caine or atropine down near the nerve may be of much service. But other fluids injected into the tissues the writer has not seen of any service whatsoever, nor has puncturing the nerve-trunk been productive of any relief, and there is some danger of re-exci- ting more active inflammation. Pressure upon the nerve, as recom- mended by Negro, repeating the bloodless procedure some six times every third day, may aid resolution in chronic cases with sheath thickening. Massage likewise is only valuable in chronic cases. Electricity is of most value when used twice or thrice weekly, the positive pole being applied over nerve-trunk and calf (10 to 15 milliamperes). Faradization may be of service late in the case to develop atrophied muscles. Nerve-stretching by the blood- less measure of thigh flexion, the knee being extended, or by open incision and lifting the limb from the table by a dull hook applied around the nerve-trunk, are required in stubborn cases. Tumours near or on an inflamed nerve should be excised. Mor- phine hypodermically may be required in bad cases for the pain. It seems to produce a good effect upon inflammatory tissue. Alka- line mineral waters, as the Buffalo lithia or Londonderry lithia, or a course of alkaline baths, as at Virginia Hot Springs or at Baden abroad, may be of great value. TUMOURS OF NERVES A. Hyperplasia. B. True neuroma; single henign. C. False neuroma; multiple henign, or malignant. A. Hyperplasia or hypertrophy of nerve-trunks is rare. It is usually due, therefore, to increase of the interstitial connective tissue. At times there is an increase of fibres and thickening of the myelin sheath. 150 TEEATISE OX NERVOUS DISEASES B. True neuromata are also very rare, and occur most exclu- sively on spinal nerves. In some instances there is an increase in medullary fibres, in others only an increase of non-medullated fibres — i. e., only the axis cylinders and neurolemma increase. These tumours may occur single or multiple. Multiple neurom- ata are generally, however, neurofibromata. ISTerve-fibres massed in hyperplastic connective tissue form plexiform neurofibromata. True neuromata are usually quite small, measuring several centimetres in diameter only, but they may be much smaller or larger. They are usually few in number, though there may be a local multiplicity of these true neuromata. Gowers has shown that in one case 1,000 were present, and this number may be exceeded in rare instances. C. False Neuromata. — This term is applied to nerve tumours intermixed with fibroma, myxoma, glioma, sarcoma, carcinoma, or syphiloma, although the first is the most common variety. Gumma has only been found in the false neuroma on the intracranial or intraspinal nerves. Scirrhous or medullary (rarely the colloid type) carcinoma are the varieties found in combination. Leprous neuritis sometimes forms neuro-fibromatous swellings. Malignant Neuromata. — Some 30 cases of very malignant neu- romata have been recorded in the literature. Hereditary influ- ence and trauma are the setiologic factors. The great nerve-trunks are most frequently affected, such as the medium or sciatic. The tumours start from the perineurium, and are at first spindle- shaped ; they may grow very large. Sarcomatous cells are the most frequent, but myxomatous cells may be found in them, or fibroma- tous tissue, or the tumours may be mixed. Tuhercula dolorosa are simply false neuromata situated super- ficially at the ends of sensory nerves. .Etiology. — A. Heredity generally tends to cause the true mul- tiple or plexiform neuromata. B. Diathetic — e. g., tuberculous — influences which produce various forms of tumour formations — sarcoma, carcinoma, etc. C. Injuries or surgical operations, which cause especially the fibroneuromata, as the amputation neuroma, forming often the so-called irritable stump. Neuromata may be congenital, and are then usually of the plexiform type. Multiple neuromata may develop in early life. Men are more liable to neuromata than women. Symptoms. — Neuromata may not produce symptoms, but the DISORDEES OF PEEIPHEEAL XEEYES 151 most frequent evidences of their presence, besides physical exam- ination, are pain and tenderness. Pressure above the tumour over the affected nerve may at times relieve- the exacerbations of pain probably by obtunding sensation or cutting off the blood supply temporarily. Paresthesia, anaesthesia, paralysis, and reflex spasm may be found. I had a case recently of false neuroma upon the median nerve where spasm of the biceps muscle was most annoy- ing! Some forms of persistent headache are due to multiple neu- romata of the sensory fifth. Single neuromata cause symptoms more frequently than multiple or plexiform because they are points of irritation, as a rule, near the periphery of the nerve; and connective tissue contracting in them also aggravates pain, the multiple type being purely nerve tissue. Keuroma of the splanchnic or vagi nerve may cause most serious symptoms (sudden unaccountable deaths are at times due to neuroma of the vagus). Multiple (true) neuromata may last for years and cause no serious symptoms or inconvenience. Malignant neuromata cause such symptoms as always result from irritation or compression of a nerve. Diagnosis. — The diagnosis is only positively made when palpa- tion reveals the tumour. In other cases diagnosis is made by ex- clusion. Lipoma over the site of a nerve is the most easily con- founded with neuroma. (The liability of lipoma to appear on any part of the body should always make this innocent tumour thought of in diagnosis of any growth.) True neuromata are often multi- ple; the false are usually single. . Idiocy, lieredity, neuropatliic constitution would always favour the disease being true neuroma. Treatment is essentially surgical. Internal medication and applications are valueless save as the former is towards general building up of the constitution to the invasion of disease. Strong galvanic currents (descending), mercury, and the iodides in large doses may assist in the resorption of exudate about such a growth. Excision is the proper treatment if pain or paralysis are prom- inent symptoms. The growth may return. CHAPTEE VIII DISEASES OF OTHER SPINAL NERVES A SINGLE spinal nerve may be injured by disease or trauma, or several nerves may be injured by the same local conditions. The principal disturbances resulting are those of sensations, or of motor or trophic disorders which manifest themselves within the distribution of the nerves involved. (See Fig. 8.) The most usual lesions are new growths, division, degenera- tion, neuritis (see Chapter YII). When the lesion is irritative, the symptoms are of hypersesthesia, pain, spasms, tremor, spas- ticity, and rarely of hypertrophy. When the lesion is destructive from the first or has passed on to the destructive stage, the symp- toms produced are such as anaesthesia, palsy or paralysis, of dys- trophy, atrophy, or wasting. The above two groups of symptoms are not infrequently blended, the result of partial involvement of a special nerve or of the sensory-motor fibres being affected to a different degree in a raixed nerve. Cervical Plexus. — The phrenic nerve arising from the third, fourth, and fifth cervical nerves may be impaired in function by penetrating wounds of the neck, as by a pistol shot, or by new growths, or aneurysm causing pressure upon it. Disease of the cervical vertebrae, or disease of the spinal meninges, may finally affect the nerve-roots or spinal nuclei. Inflammation, primary or secondary, from contiguity with seats 'of inflammation, may be a cause. Sensory disturbance in disease of the phrenic nerves may- simu- late the pain of intercostal neuralgia or of rheumatism; but its association with the motor symptom.s will clear this up. The latter will consist of inactivity of the diaphragm, unilateral or bilateral, as shown by failure of the abdominal walls to advance with deep inspiration. If the lesion is of both phrenic nerves the breathing is distinctly of feminine or costal type; the dyspnoea is extreme. The suprascapular nerve, which arises from the fourth, fifth, and sixth cervical nerves, may be affected singly in dislocations of 153 DISEASES OF OTHER SPINAL NERVES 153 the shoulder. If so, the supraspinati and infraspinati muscles be- come atrophied, the scapula being prominent. Also, the external rotation of the arm is impeded, with general weakness of the mem- ber due to lack of balance at its fulcrum, the shoulder- joint. Wri- ting is very difficult for the reason given. There may be an ances- thetic area over the outer aspect of the scapula and posterior por- tion of the deltoid region. The long or posterior thoracic nerve, branching from the fifth and sixth cervical nerves and supplying the serratus muscle, is quite frequently exposed to mechanical pressure, as from heavy weights carried upon the shoulder by expressmen, etc. ; or it may be com- pressed by muscular efforts exerted by overhead workers, as plas- terers, etc.; or by swinging the arm constantly, as in chopping, mowing, or tailoring. For all these reasons men in active early life are more frequently affected, and usually on the right side, because the majority are " right-handed." The nerve may also be affected along with others in the course of spinal disease. Symptoms are mostly motor, since it is almost a pure motor nerve. These consist of impairment of expansion of the chest on the side affected, and of diminished movement of the upper ex- tremity, as a result of the non-fixation of the scapula. The in- trinsic muscles of the arm itself are not weakened. The deformity from paralysis of the serratus produces a peculiarly characteristic disfigurement. Placing the arm forward causes the posterior bor- der of the scapula to widely wing out from the chest, so that a deep recess is formed behind the shoulder-blade. The upper por- tion of the scapula also moves outward, and the lower angle ap- proaches the spine. Sensory phenomena are but slight, and con- sist of pain in the neck and shoulder in 'case neuritis coexists. Prognosis is less favourable than in injury to other spinal nerves, even though the disease affecting it is a simple pressure neuritis. This may be due to the fact that pressure is usually made along a much greater extent than in the case of any other nerves that may be so injured. The treatment of palsy of the phrenic nerve will be entirely confined to treating the cause, since the nerve is inaccessible to mechanical stimulation, and this is largely so with palsy of the suprascapular or the long thoracic; but galvanism can be em- ployed to advantage in some cases by placing the negative pole over the digastric region and the positive down the border of the scap- 154 TEEATISE OX XERVOUS DISEASES ula on the affected side. Strj-chnine;, gr. gV to yV three times a day, may prove of value. Massage is of most service. CERVICO-OCCIPITAL NEURALGIA The symptoms of neuralgia of the first four cervical nerves, especially of the occipital branch, are caused by exposure to draughts, catching cold, rheumatism, etc. Pain here may also be due to caries of the cervical vertebrae. It may be associated with neuralgia of the fifth nerve and with torticollis. The pain is usually located in the occipital and at times in the posterior pari- etal region. It may be bilateral. There may exist tenderness of the scalp. Tender spots are found (a) in the triangle between the trapezius and sterno-cleido-mastoid muscles; (&) at the angle of the great occipital between the mastoid process and the spine; (c) above the, parietal eminence. Prognosis is usually good excepting where the disease comes on late in life. Treatment consists in counter-irritation to the neck and occi- put by means of strong tincture of iodine, the fly-blister, or the actual cautery. Galvanism with the positive pole of a galvanic current placed over the three tender points indicated above is of value. A hypodermic injection of morphine, gr. ^ to gr. -J, guarded by atropine, gr. i^q, may be required during an exacerba- tion of pain. Quinine in full doses or sodium salicylate pushed to the physiological limit are of value. Arsenious acid is a de- sirable alterative in these cases, especially where aneemia compli- cates, when Blaud's pill, gr. v, t. i. d., should be added. The Circumflex Nerve. — This nerve arises from the fifth, sixth, and seventh cervical nerves, and descends in the posterior cord of the brachial plexus. It then branches off, to pass outward under the deltoid muscle, and winding around the neck of the humerus is distributed to the teres minor and deltoid muscles, also supplying the shoulder-joint with trophic influence. It also supplies sensa- tion to a chevran-shaped area over the lower two thirds of the deltoid. From its exposed position it is often injured in shoulder dislocations, in arthritis, or by falls or blows upon the shoulder; or by crutch pressure. Symptoms of paralysis of the circumflex nerve consist of in- ability to abduct the arm from the body due to deltoid paralysis. DISEASES OF OTHEK SPIXAL NEEYES 155 while the palsy of the teres minor is insignificant. Soon the del- toid wastes and the shoulder becomes pointed and prominent, with the shonlder-joint relaxed from sequent dragging upon its liga- ments. The head of the humerus can be felt very readily. Nutri- tion of the joint failing, it becomes the seat of neuro-arthritis and partial ankylosis. This is ascertained by noting synchronous movement of the scapula with arm motion. An initial arthritis may likewise spread by continuity to the circumflex nerve and injure the deltoid. AnjBsthesia over the skin distribution of the deltoid, already described, is usually present in circumflex paral- ysis. Prognosis is guardedly favourable in cases not due to frac- ture. Treatment consists of blistering, sodium salicylate in rheumatic cases, and after the tenth day galvanism, massage, and move- ments, kept up for months. Paralysis of the infrascapular nerve, which arises from the fifth and sixth cervical roots, consists of palsy of the supraspina- tus and infraspinatus muscles, which it supplies; but isolated paralysis of these muscles is rare, palsy of this nerve usually being associated with deltoid palsy from circumflex-nerve disease due to dislocation of shoulder-joint, etc. Paralysis of these two muscles alone, however, causes loss of power of outward rotation of the humerus, shown in loss of power of carrying the hand from left to right, as in writing. Prognosis is also guarded, since it is difficult to determine the extent of injury. Treatment is exactly similar to that of circumflex palsy, save that massage and electricity are applied directly over the muscles involved; so that treatment is more available at least. The musculo-spiral nerve arises from the posterior brachial cord, and winds around the humerus in the musculo-spiral groove between the two heads of the triceps muscle, where it can be sub- jected to muscular pressure, external violence, or pressure. It is the most frequently diseased nerve in the body, and at the same time is the one in which disease is best in its prognosis. This nerve supplies all the extensors of the elbow, wrist, and fingers; also both supinators, and through its radial branch the skin on the dorsal surface of the thumb and two radial fingers, and the posterior radial border of the hand. It furnishes as well 156 TREATISE OX XEEVOUS DISEASES trophic- joint filaments to the carpus and hand. High up it also supplies cutaneous branches to the skin in an area extending from the wrist in a narrow but widening strip up the forearm, and over the outer aspect of the arm as high as the insertion of the deltoid muscle. These latter branches are but seldom involved in palsy of the circumflex. Causes of disease of the circumflex nerve are legion. It may be due to lead-poisoning, when the posterior interosseous branch ( " nerve of lead palsy " ) is most affected, wrist-drop being the only prominent symptom in such cases. In pals)' of the circum- flex from drug-poisoning, it is also interesting to note that the supinator longus is not affected. From its exposed position in the axilla crutch pressure frequently causes pressure palsy; or it may here be due to dislocation of the head of the humerus. Lower down the nerve is liable to suffer from blows upon it, by being caught in callus or fractures, or by a cord being tied about the arm, or even by direct action of the triceps catching the nerve in its grasp, as in extreme muscular exertion. By far the most common cause is from pressure by the patient lying on his arm, or when it hangs over a chair, he being asleep, in alcoholic poisoning. The reason for this is that the alcohol benumbs sensibility and the pa- tient is not awakened by the parEesthesia that would occur under normal circumstances. Of course, such pressure may occur under any form of narcotism. The surgeon must be careful not to have 'pressure upon this nerve, in operations, while the patient is anaes- thetized. Hanging pendant when under an ansesthetic may also produce pressure palsy from the ijuU made on the nerve. Finally, " catching cold " may be the cause of neuritis and palsy of the circumflex. Symptoms. — Sensory symptoms are slight and at times not present when the motor fibres, of the nerve are almost completely functionless. If present, it would be in the course of the radial and cutaneous branches of the musculo-spiral. (See Fig. 32.) Motor symptoms are widespread and characteristic. There is wrist-drop and inability of all the long extensors of the hand to react if the lesion is high up. There is also inability to extend the elbow. If the nerve is affected in the musculo-spiral groove, the most usual location as stated, the branches to the triceps escape and extension of the elbow is not lost. Lesions below the lower one third of the humerus do not catch the branch to the DISEASES OF OTHEE SPIRAL NERVES 157 supinator longus. The position of the hand (Fig. 30) is char- acteristic. The fingers can only be extended by the interossei muscles, after the first phalanges are extended, which latter are supplied by the ulnar nerve. The thumb cannot be extended and the fingers can be but a very little better, being progressively dimin- ished from the index to the little finger. Occasionally, on the back of the wrist there develops a synovial tumour due to extreme carpal flexion, and in part due to insufficient support of the ex- tensor tendons, also to involvement of the articular branches of the nerve. This tumour is painless and much exaggerates the wrist deformity. The " grasp " is greatly reduced, due to the ex- tensor loss and unbalancing of the muscle movements. Muscular wasting shows on the dorsal surface of the forearm, and where the supinator longus is involved a peculiar flattening of the fore- arm is noticed. The triceps may be somewhat wasted. Prognosis is good in the vast majority of cases, cure resulting. Fig. 30.— Wrist-Drop from Musculo-spiral Alcoholic Pressure Palsy. Treatment consists in getting rid of the cause, as of alcohol, callus, crutch pressure, etc., or of suturing of the nerve if it has been severed. Ordinarily the use of a blister over the supposed site of lesion is indicated. The arm can be placed in a well-padded anterior splint where there is marked wrist-drop. -This will tend to prevent joint deformity in chronic cases. Massage and fara- dism after the fifth day are indicated in compression cases with separation of the nerve elements. Strychnine in full doses is the drug indicated par excellence. In eases of active neuritis the case is to be treated more conservatively as one of local inflammation. The ulnar nerve, originating from the lowest cervical and first dorsal nerves, and supplying the forearm and ulnar flexor of the wrist, the two inner divisions of the deep flexor of the fingers and all the small muscles of the hand except those innervated by 158 TEEATISE OX XEEVOUS DISEASES the median, the abductor of the thumb, and one half of the short flexor of the thumb, also supplying sensation to the ulnar border of the hand, including the little finger and half the ring finger, is when palsied likel}' to give a wide distribution of symptoms. Causes. — Neuritis, idiopathic or from trauma, tumours, pres- sure or separation as by a knife or crockery cut. It may be in- jured (a) above the elbow, (&) at the elbow, or (c) at the wrist. Symptoms. — Sensory symptoms consist of loss of sensation in one half of ring and all of little finger, running up the palm and back of hand to wrist, where it tapers off. Motor symptoms are marked. The wrist cannot be actively flexed to the ulnar side, and the thumb is rotated towards the palm by the abductor, and cannot be adducted. The fingers lose lateral motion. There is overextension of the metacarpophalangeal joints, while the unopposed flexors of the second and third are offset by strong contraction of these digits towards the palm, making the so-called " claw hand.'^ This flexion is least marked in the index and middle fingers, which do not lose their lumbrical muscles. The interosseous spaces are hollowed and the fifth metacarpal bone is entirely subcutaneous. The hypothenar eminence disappears, but part of the thenar eminence stands out prominently. Prognosis is good if the palsy is due to separation as by a knife- cut and nerve-suturing is done at once. In cases of fracture of the ulna, with compression, good results will only follow early eradica- tion of the offending bone or callus. Idiopathic cases of neuritis are less promising of cure. Treatment consists first in getting rid of the cause if surgery will do it, as indicated under prognosis. Acute neuritis should be combated along ordinary lines. Massage and galvanism are the most valuable adjuncts to the medical treatment, consisting of strychnine, the iodides, and general tonic measures. (It is of interest here to note the sudden restoration of function, especially of sensation, in case of suturing of the nerve after section, thus giving a clue to the possibility of nerve force being through some such agent as electricity.) Median Nerve. — This nerve arises from the inner and outer cords of the brachial plexus, and follows the brachial artery to the bend of the elbow. It supplies all the flexors except the ulnaris, and the ulnar portioii of the deep flexor. It also supplies both pronators. In the hand it supplies the opponens, abductor, the 160 TREATISE ON NERVOUS DISEASES short flexor of the thumb, and the first and second lumbricals. These latter, like the interossei, are accessory to flexors of the fingers (first joints), and are aids to common extensors for ex- tension of the second and third phalanges. The sensory distri- bution of the nerve supplies the radial half of the hand on the palmar side, and the tips of the index and middle fingers on the dorsal aspect. (See Figs. 31 and 32.) Cause of Paralysis. — Injury in common with the ulnar and musculo-spiral near the axilla may be the cause of paralysis. Stab wounds near the wrist are not uncommon sources of palsy, also sprains about the wrist, or fractures, as Colles's. Symptoms, Sensory. — These are usually slight, due to the ex- tensive distribution of the ulnar and radial nerves about the same areas, but would, in complete loss of function, be in the distribu- tion already given. Motor: Pronation is destroyed. The thumb cannot be rolled into the hand or opposed to the fingers. None of the fingers can be fiexed except the ring and little fingers, which still act through the ulnar portion of the flexor profundus and interossei. The wrist is flexed slightly to the ulnar side through the flexor ulnaris. The first joints of the fingers are still able to be slightly flexed through the interossei. The hand becomes flat- tened because the thenar eminence is atrophied and the thumb lies in adduction parallel to the other fingers ("ape hand"). It is the same deformity seen in progressive muscular atrophy of spinal origin. Prognosis is guardedly favourable if the disease has not gone more than six weeks without proper treatment. Treatment consists in thorough massage, the use of the ascend- ing galvanic current, 10 milliamperes daily five minutes; strych- nine, gr. -gV t. i. d., and local protection (splinting) and alter- atives, as sodium iodide and arsenic. Nerve suture even late as six months after nerve severance has been attended with good results. COMBINED PALSIES OF NERVES OF THE ARM The proximity of the brachial plexus to bony prominences of clavicle, scapula, and humerus makes it liable to injury as a whole ; hence, palsy of its various nerve branches may result. The mus- culo-cutaneous, suprascapular, and circumflex may also be af- fected secondarily to disease of the fifth and sixth cervical nerves. DISEASES OF OTHER SPINAL NERVES 161 from which they arise. Peterson quotes from the Revue Neurolo- gie, December 15, 1900, that forcible dragging of the arm up or down may lacerate the anterior nerve-roots. Or a neoplasm or injury opposite the sixth cervical vertebra may affect both nerves. At this point (between the scaleni mus- cles) Erb has found that the circumflex and suprascapular nerves can be stimulated by electricity. The muscles involved in such a palsy are the spinati, deltoid biceps, and brachialis anticus, while the sensory disturbance corresponds to the cutaneous distribution of the nerves affected. Injuries to the brachial plexus are usually severe. I have never seen a crush involving the branches recover. As a rule, injuries involve all its branches. But single nerves — e. g., the ulnar — may be affected ; or the ulnar in association with the nerve of Wrisberg, etc., in which- case anaesthesia along the entire inner aspect of the arm will also accompany the motor palsy. The so-called " birth palsies " are due to traction on the arm, or to the use of a hook in the axilla or to head forceps during delivery; and usually involve all the branches — viz., the median, ulnar, and musculo-spiral. A fracture of the humerus may injure the musculo-spiral and ulnar nerves. The radial and ulnar nerves may be simultaneously in- jured in fractures in the forearm or disease at the wrist. In- fected wounds of the hand may produce ascending neuritis, which may ultimately affect the entire brachial plexus (neuritis mi- grans). Pott's or other disease of the vertebrae may affect the brachial nerves secondarily, as also may meningitis, particularly the hyper- trophic form: or even disease of the cord, as syringomyelia, may do the same thing. Prognosis has been indicated. Treatment will consist of getting rid of the cause at once if degeneration and an ill result shall not follow. The other measures to be adopted will be described below. Brachial Neuritis. — Gowers compares this with sciatic neuritis. The symptoms consist of pain and tenderness in the distribution of the branches, particularly when the shoulder is moved, since the circumflex is then much disturbed as well as the other nerves, though to a less degree. The pain is often mistaken for neuralgia, for rheumatism of the shoulder or arm; careful examination will eliminate these. Women suffer more frequently than men. The 162 TREATISE OX NERYOrS DISEASES disease occurs oftener after middle life, especially in gouty or rheumatic people. Lumbago or sciatica may also be existent in the case. I have seen a needle prick in the finger in two cases External Cutaneous Genito-Crural Anterior Crura] External.Popliteal ■ Uio-Inguinal - Long Saphenous Fig. -34. — Showing the Distribution of the Sensory Nerves of the Skih, Anterior Aspect of Trunk and Leg. produce most profound brachial neuritis. The entire arm becomes wasted and the hand flattened. The muscles as well as the nerves are tender, and the slightest movement gives severe shooting pain in the arm and neck. Reaction of degeneration is found. The DISEASES OF OTHER SPIXAL XERVES 163 reflexes are iisiuilly diminished^ but as in chronic sciatica may rarely be exaggerated. The prognosis is most serious as to cure, relapses being com- mon in the most favourable cases. Treatment consists in rest of mind and body as fundamental principles. The lithsemic state must be looked to. Counter- irritation along the course of the plexns and nerves by the actual cautery affords great relief. Dry heat will often do good. Cold usually aggravates. Protection of the arm by a splint or cotton wool is a valuable remedial measure. Ascending galvanism is of value. Amputation of the arm below the insertion of the del- toid is the only treatment for severe laceration of the brachial plexus. In this way the incumbrance of a totally palsied arm is done away with, to the comfort of the patient. NERVES OF THE TRUNK These nerves supplied by the thoracic and two upper pairs of lumbar nerves are rarely singly involved. Pott's disease may affect them, but the loss is slight unless several nerves are affected simultaneously. The girdle sense of tabes or neuritic pain of vertebral disease are diagnosticated by observing other signs of the respective diseases. Herpes zoster may encircle the body, and in such cases the symptomatic disorder is significant of serious root mischief either due to extension from spond5ditis or to sclerotic involvement, as in tabes ; or it may be from direct metastasis from a neoplasm. Unilateral herpes is rather characteristic of gastro- intestinal disorder only. Wide-spread trunkal herpes is, as a rule, due to final disease of the gray matter rather than of the nerves themselves. (See Figs. 34: and 35 for cutaneous nerves of trunk.) NERVES OF THE LOWER EXTREMITY These are not so frequently involved as those of the arm, but are subject to special disease through pressure in pelvic growths, and in females by pressure upon the sacral plexus during labour. In- flammation of pelvic viscera or psoas abscess may affect the plexus. (See Figs. 33 and 3i for cutaneous nerves of lower extremities.) The external cutaneous branch of the anterior crural nerve supplying the outer side of the thigh is very liable to disease. A queer condition termed parcBsthetic meralgia, consisting of a sense 11 164 TREATISE ON NERVOUS DISEASES of burning (causalgia) in the outer upper aspect of the thigh, is found in neurasthenic women, especially when secondary to ovarian disease ; probably caused by a reflex reference through irritation of this sensory branch. In other cases a neuritis has been set up. Fio. 35. — Showing the Distribution of the Sensory Nerves of the Skin. Posterior Aspect of Trunk (Butler). Gout, rheumatism, excesses in tea-drinking, in alcohol or to- bacco may cause it, or as a resultant of multiple neuritis this peculiar hypersesthesia may continue for months or years. Treatment consists in treating the neurasthenia and in nerve- stretching, which usually is successful. Anterior Crural. — This nerve may be affected (a) within the abdomen, when flexion of the thigh on the abdomen is weakened because the iliacus muscle is included, and (&) below Poupart's ligament. DISEASES OP OTHEE SPINAL NERVES 165 Symptoms due to cutting off of entire function, are wasting of the quadriceps and abolition of the knee-jerk. Anwstliesia will be found to extend from the groin to the inner side of the foot. There is but a narrow strip of normal sensation remaining, which runs down the back of the thigh below the knee, spreads oiit over the external portion of the calf, embracing the foot except on the inner aspect. (See Pigs. 33, 34, and 36.) 'Prognosis is good if the cause can be eradicated. When due to pelvic tumour, it is hopeless; but disease of the internal geni- talia, if causative, being eradicated will relieve the secondary neu- ritis. Idiopathic cases must be treated as neuritis elsewhere. Ap- plying a long external splint is of great service. Galvanism and massage are valuable after acute symptoms have abated. Obturator Nerve. — This nerve comes from the same source as the anterior crural nerve. It supplies the adductors of the thigh, also the knee and hip-joints. Hence it is that " referred " pain may be to the knee in cases of coxalgia or disease of the knee may be referred to the hip of same side. Causes. — Prolonged horseback-riding may cause the neuritis, or tearing of the muscles by athletes; or a direct trauma may pro- duce neuritis of the obturator. Symptoms of paralysis of this nerve. Proper adduction of the thighs is prevented; there is impaired external rotation of the thigh through palsy of the external obturator and pectineus mus- cles. Wasting occurs on the inner aspect of the thigh above. Sen- sory symptoms consist of knee or hip pain, depending upon whether one or both branches are involved. Treatment consists of rest, massage, galvanism, and relief of pain by anodynes or by hot applications of lead water and laudanum, twenty-five per cent. Disease of knee or hip should be treated. The superior gluteal nerve may be inflamed, and this causes palsy of the gluteus minimus and medius and the tensor vagina femoris muscles. The symptoms consist of weakness of abduc- tion, outward rotation, and circumduction of the thigh. The Great Sciatic Nerve. — The size and exposure of this nerve and its branches make it more liable to disease than any other single nerve of the lower extremity. It supplies the knee flexors, which are also partial extensors of the thigh upon the body. It also applies all muscles below the knee. (See Pigs. 33, 34, and 35.) 166 TREATISE OX XEEYOUS DISEASES Symptoms.- — From the peculiar mechanical position of the mus- cles palsied in disease of this nerve, the disability to the patient is less than that resulting from disease of the anterior crural nerve above recited. The paresis of muscles supplying onlv ahoiit the large joints of the hip and knee is the explanation of this. The leg is carried forward iti progression as a " pegleg " similar to that of the hemiplegic gait. Wasting is marked. Perforating ulcer of foot may follow. Sensory phenomena consist of anaes- thesia occupying the narrow strip of the thigh posteriorly and the outer aspect of leg and foot described in the last section. Disease of the external popliteal or peroneal nerve may be lo- cated (a) in the ham or (&) below the knee on the outside of neck of the femur. This branch nerve supplies the long extensors of the toes, also the peronei muscles. Symptoms, Motor. — Foot-drop with toe-drop follow; and equinovarus may result from contraction of the ttnopposed flex- ors. There is much wasting about the fibula and in the anterior group of leg muscles. (See also Sciatic Xeuritis.) The internal popliteal nerve supplies the calf muscles, the long flexors of the toes, all the small mtiscles of the foot save the short extensors of the toes. If its branch, the internal plantar, is di- vided, there results a paralj^sis of the short flexor muscles of the toes, the plantar muscles of the great toe, except the adductor, and the two inner lumbricales. " Hammer-toe " results from ex- tension of first joint and flexion of second joint. Sensory symp- toms consist of auEesthesia in the outer plantar surface of half the sole, one half of the fourth, and all of the fifth toe. (Fig. 36.) If the external plantar branch is alone involved, the symptoms are loss of power of the muscles of the little toes, the two outer lumbricales, all the interossei, and the adductor of the great toe. The hammer-toe deformity is found in all the toes. Sensory symp- toms then consist of anaesthesia in the outer plantar surface of half the sole, one half of the fourth, and all of the fifth toe. If the internal popliteal is divided in the popliteal space in addition to above symptoms, there is inability to rotate the flexed leg, due to palsy of the popliteus muscle ; and also a loss of power of extending the foot. Talipes calcaneus may therefore result with, in addition, the arch of the foot becoming exaggerated. Morton's Disease, or Metatarsalgia. — I have seen a number of cases under the discoverer's care. Dr. Morton considered it due Long saphenous Anterior tibial Internal External plantar plantar External plantar (Br. post, tibial) Internal plantar (Br. post, tibial) Anterior tibial Long, saphenous Internal plantar External saphenous External plantar Long saphenous Muscu lo-euta neoue (Br. ext. popliteal) Posterior tibial Anterior tibial Internal plantar Fia 36.— Showing the Distkibution of the Sensory Nerves of the Skin of THE Foot (Butler). 167 168 TEEATISE 0^ NEEVOUS DISEASES to pressure neuritis of a filament of a digital branch of the exter- nal plantar nerve lying between the heads of the metatarsal bones. Narrow shoes may favour its development, as may gout. The symptoms consist of sudden excruciating pain in or near dorsum of foot opposite the fourth toe. This pain shoots up the leg, and may be relieved by firm pressure, as of a lace shoe; or by placing in the boot a " sole plate " as manufactured by Gefvert. Prognosis in gouty cases is, however, bad. Excision of the head of the fourth metacarpal bone is the radical measure that we have seen effect a cure in several cases. Treatment of palsies of the various branches of the sciatic nerve outlined above consists in nerve suture for division; of getting rid of adjacent local disease, as tumours, fracture, or callus; and in the treating of any diathetic tendencies. Other treatment useful is described under Sciatic ISTeuritis. RHIZOMELIQUE SPONDYLITIS This disease consists of an osteo-arthritis of the spine of un- known origin ; hence it can be set down as probably dependent u]3on trophic disturbance through the nervous system. Deformity ma3^ result, depending upon whether the interarticular vertebral fibro-cartilages are absorbed or not before the proliferation and ossification occurs about the respective joints. When the disks are absorbed quickly, kyphosis, scoliosis, and other deformities of the spine follow. The large joints near the body are next attacked, such as the hip, knees, and shoulders. The Eoentgen rays show bony exuclate and the absorption of cartilages as described. etiology is not definite. Heredity, cold, wet, and trauma or gonorrhceal infection are all supposed to be factors in individual cases. But the above causes may be but exciting elements, the dis- turbed metabolism from lowered nutrition being the predisposing cause. Symptoms. — These are entirely dependent as to the nervous system upon trophic disturbance noted (also atrophy of muscles may occur as in two cases that are under the writer's care at the Philadelphia Hospital at the present time) or upon whether spinal nerves or spinal cord are encroached upon by pressure, etc. Pain and limitation of motion are usually prominent symptoms. The pain may be severe and be " referred," or occur at the site of the spine disease, usually then at anterior aspect in the back of abdo- Fig. 37.— Rhizomblique Spondylitis (Doksal, Spine). (Medico-Chixurgical Hospital.) 169 170 TREATISE OX NERVOUS DISEASES men. It is worse after sleeping, f)robably due to sluggish circula- tion during sleep producing stagnation of circulation about a dis- eased area; also to metabolites irritating the sensory nerve roots. " Girdle pains " are one-sided usually, because one side of the vertebral column is first attacked. There is impairment of mo- tion in the legs; or, indeed, complete paraplegia may result. Close study may reveal areas of hypereesthesia, hypsesthesia, or anaes- thesia depending on the lesion being at the time an irritative or destructive one. Coughing or movement of the head or trunk will bring on severe pain. According as the erosion of cartilage and osseous deposit predominates or muscular spasm is productive of the rigidity or deformity, will they be of more or less permanent nature. Prognosis. — Ultimately the patient may become entirely bed- ridden and helpless save for the use of the smaller joints. Occa- sionally the disease is stayed from advance by timely hygiene and treatment. Treatment consists of constitutional and hygienic measures. Sirup hypophos. comp., oi t. i. d., or cod-liver oil in cold weather are valuable nutritional drugs. Sod. salicylat., gr. s t. i. d., or potassium iodide, gr. x t. i. d., or syr. ferri, iodidi, a half drachm after meals, are respectively the best antirheumatics, alternatives, and hsematics that can be employed. Look to the kidneys and the eliminative functions generally. A toxic process in the intestine may aggravate, hence the use of salol, gr. ii, in elix. lactopeptine, a drachm, thrice daily, may be desirable. The digestive tract must also be conserved in these patients and full simple diet given, including abundance of eggs and milk. The orthopedic surgeon may aid by bloodless operation of extension or through applying apparatus, or by use of a wheel crutch to get the patient about on his feet. I have had one case thus bettered, so that from being bedridden he could walk about. His general health was much improved. CHAPTER IX INFLAMMATION OF MENINGES DISEASES OF THE MEMBRANES OF THE BRAIN We shall consider here anemia, hyperfemia, inflammation of the dura mater (pachymeningitis), and inflammation of the pia mater (leptomeningitis). Ancemia of the membranes of the brain cannot be well sepa- rated from anfemia of the encephalon itself, and must therefore be studied with ansemia of the brain. Eypercemm must likewise be considered with hypersemia of the brain so far as that of the pia is considered. Dural congestion or hyperasmia may occur as the result of injuries, of sunstroke, of poisons such as uric acid, or of infectious diseases, such as mea- sles, scarlet fever, and syphilis; the symptoms bein^ like those of pachymeningitis of the congestive stage, which will be described under that heading. The principal symptoms, are, however, ver- tiginous attacks and peculiar sensations of fulness in the head. The treatment is the same as for the onset of meningitis. INFLAMMATION OF THE DURA OR PACHYMEN- INGITIS EXTERNA Since the so-called pachymeningitis interna is probably a hgem- orrhagic disease (or hsematoma of the dura mater), it will be de- scribed under the head of dural haemorrhage. It is extremely rare to have a true" simple internal meningitis of the dura. (See p. 175.) Pachymeningitis externa first involves the outer surface of the dura. There are less pressure symptoms than in hsematoma. MENINGITIS This implies inflammation of the membranes of the cord and brain, being divided iiito jjachymeningitis (dura) and leptomen- ingitis (pia), each in turn being divided into acute and chronic 171 172 TEEATISE ON NERVOUS DISEASES simple meningitis; and secondarily into acute and chronic infec- tions meningitis, the latter including infectious cerebro-spinal meningitiS;, tubercular, leptotlirix infection, and tlie various strep- tococci infectious forms. Various other organisms produce in- flammation of the membranes, the principal ones, however, being included in the above list. Usually when we speak of meningitis we refer to meningitis of the dura, so that specifications should be made of these inflammations for the sake of exactness. ACUTE CEREBRAL PACHYMENINGITIS Inflammations of the Membranes of the Brain. — This may be primary or secondary, the former being caused by the so-called " catching cold," or exposure to cold, or exposure to extreme heat. The causes of the latter form are infectious diseases, such as pneumonia, typhoid fever, infectious cerebro-spinal meningitis, injuries, carious bone as from mastoid disease, syphilis, erysip- elas, etc. Symptoms. — This disease is usually ushered in by a marked chill, followed by, as a rule, hyperpyrexia, the temperature run- ning up to 104° or 106° F. The patient may suddenly pass into convulsions of tonic and clonic nature, with retraction of the head, delirium, mania, and hyperemesis, frequently of the projec- tile type. The convulsions may be localized or at least begin in one member, due to irritation of a jDarticular centre over the motor cortex. Paralysis may follow. The pupils usually are irregularly dilated. There may be amblyopia, due to optic neuritis, which is soon set up in severe eases and accompanied by marked swelling of the disks. Various other palsies may occur, producing internal strabismus or external strabismus, frequently accompanied by diplopia. It is very rare that hemianopsia follows. Hearing may be affected in the beginning, it being acute as is the case with the other special senses. Late in the disease deafness or dul- ness of hearing may occur. Localized facial palsies may also follow ^spasm of these muscles,, due to the involvement of the nuclei of the facial nerves. If the basilar membranes are involved bulbar symptoms may supervene; or a deafness, or blindness in the most serious cases. The duration of acute pachymeningitis will depend upon the degree of infection or the resisting power of the patient. Death may follow early severe convulsions. The acute INFLAMMATION OF MENINGES 173 symptoms may last a week or ten days, when termination by crisis may occiir.^ Or, as is the rule, a gradual defervescence of the fever and recovery with more or less sequelae, depending upon the severity of the disease. Prognosis. — In children it is worse than in adults, owing to the lack of resistance through immature development of the nervous system in them. Occasionally a case will recover with apparently absolute integrity of the nervous system and no sequelge whatever, but in the vast majority of cases some defect is left behind, either blindness, due to progressive atrophy of the optic nerves, or deaf- ness from involvement of the acoustic nerves, etc. These two spe- cial senses are the most frequently involved, although the others, but very rarely, may also be affected. Sequelae, as hemiplegia, paraplegia, or monoplegia of spastic type, depending upon the de- gree of involvement of the motor cortex, are frequent. Treatment. — This will depend entirely upon the nature of the cause. If primary disease or any septic foci exist in the body, these should be dealt with at once. (The treatment of infectious cere- brospinal meningitis will be considered in its proper place.) The patient should be, as a rule, placed in a dark room, in quiet surroundings, and well protected from atmospheric exposure. Such measures are necessitated by the extreme hyperexcitability in the beginning of the disease. Hyperpyrexia should be treated by antipyretics guardedly administered, by the sponge-bath or ice- pack, and in some cases of plethoric individuals venesection should be tried. The application of leeches to the temple or wet cups to the nape of the neck are valuable methods of depleting the con- gested meninges; to-day not enough used. For the control of con- vulsions, the antipyretic measures detailed may be sufficient in the milder cases, but in the more serious ones the use of large doses of bromides and chloral may be necessary. If these cannot be retained by the stomach they should be given per rectum, and in twice the dosage as given by the mouth. If heart failure occurs later in the course of the disease, cardiac stimulants may be necessary, such as digitalis, or in acute syncope hypodermics of ether or strychnine may be necessary, continued until the crisis is past. In case of injury or abscess, surgical help must be sought. * Kernig's sign may be present in meningitis — viz., the inability to extend the legs while sitting, but ability to do so wben recumbent. It is ?iot pathog- nomonic of the disease. 174 TEEATISE OX XERVOUS DISEASES Potassium or sodium iodide are valuable remedies for the absorp- tion of the exudate. If betterment of ocular troubles does not occur with this, the destruction of the cranial nerves passing out at the base of the brain may be inferred and a basilar type confirmed. The treatment of sequelse, as optic atrophy, etc., will be the province of specialists in this department of medicine, to whom the case should be early referred. Epilepsy may be a sequel, and should be treated symptomatically if the original source of irritation cannot be removed. Causes of Clironic Meningitis. — This is generally the result of the acute form. Some cases are so insidious that they are desig- nated subacute or chronic from the first discovery of symptoms. Sunstroke is quite frequently a cause of this type, as may be lues or trauma. Symptoms. — Persistent headache of a dull character, worse when the patient is exposed to heat or when he stoops forward or lies down. He also complains of pain in the neck, frequently radiating towards the shoulders, and may suffer from general paresis of the extremities, usually of a spastic nature. Or he may be the subject of deafness, vertigo, or optic atrophy. Such pa- tients, too, may be subjects of secondary epilepsy. Diagnosis. — This is to be made from chronic cerebritis, tumour of the brain, hydrocephalus. In cerebritis there is usually more mental failure or even dementia with less spasticity of any existent palsy. In tumour of the brain the special predominance of optic neuritis (95 per cent), together with localizing symptoms, will difi!er"entiate, while in hydrocephalus, the enlargement of the head of the peculiar metallic sound on percussion, or the exophthalmos, are points for differential diagnosis. Prognosis. — This is usually bad as to permanent recovery, the patient being liable to exacerbations at any time, due to catching cold or exposure to heat. In adults the chronic form of menin- gitis may exist for many years. In children, since interference of development of the brain follows, life is materially curtailed even in the milder cases, such patients usually succumbing early to intercurrent disease. Blindness and deafness occur in the. chronic form as the result of the acute type, and as a rule such cases are practically incurable. Imbecility is not unusual. Treatment. — This will simply consist of additional measures to those already referred to — namely, the treatment of the convul- INFLAMMATION OF MENINGES 175 sions or of contractures and of palsies, which latter may require the services of the orthopsedic surgeon. Massage and Swedish move- ments should be given a fair trial in these cases. If a large exu- date, especially of the hgemorrhagic type, or a localized blood tumour of the dura exists, the surgeon may by prompt operation save the patient's life, as I have known in one case. Extensive counter- irritation over the scalp is of value. CEREBRAL PACHYMENINGITIS INTERNA HJEMOR- RHAGICA OR HyEMATOMA DURA This is a type of local inflammation involving the internal layer of the dura. It is more frequent in male adults and in those subject to chronic alcoholism or prolonged intoxication. Symptoms are insidious, the patient complaining of pain in the head, following an alcoholic debauch. There are manifest symp- toms of dementia, such as loss of memory, incoherent speech, with periods of excitement. Frequently the patient will pass into an urgemic state, which is due no doubt to kidney insufficiency at the time, even though the kidneys may not be permanently disabled. The case may recover from the ursemic attack rather suddenly. Usually within a few days or a week recurrence of symptoms oc- curs, such as added weakness of the extremities, more pronounced upon one side of the body. Fifty per cent of the haemorrhages are on one side of the dura. The mental obtundity 'deepens, the pa- tient passes into delirium. There is also noticed general tremu- lousness. It will be found, too, that the paralysis is much more spastic than the rapidity of onset and the extent of motor weak- ness would warrant. This is a point of value in making the diag- nosis of this serious malady. A distinct point in the symptomatol- ogy is, therefore, exacerbations and remissions without profound coma at any time until late in the disease. Diagnosis. — This disease is so difficult to diagnose that it seems useless to set down differential points. Ingravescent htemorrhage into the cerebrum may be mistaken for it, as well as uraemia, indi- cated above. From the former it may be distinguished by the more exact symptomatology of true apoplexy in the latter. From uraemia, the urinary examination would be of great value, since the lesser bulk of albumin, if any, would be found in a meningitis. Progfiosis. — This is absolutely bad. The patient is usually car- 176 TEEATISE OX XEEVOUS DISEASES ried off "within ten days after the onset of symptoms. Death gen- erally occurs not alone perhaps from the haemorrhage, which is usually massive and spread over the entire cortex of one side, but very likely it is completed by the general alcoholic toxaemia existent in these patients. Treatment. — This consists, therefore, in the same form as the acute meningitis given above. Surgical ireatmejit is not as yet Pig. .38.— H.emorkhagic Pachtmenixgitis Ixterxa (Alcoholic). Specimen from a case in the Philadelphia Hospital. (Dura is reversed in the photograph.) fully developed, and has not been resorted to in many cases, but would seem to be the onlv possible chance of saving the patient's life. If it were not for the extreme asthenia, a diagnosis could be made and the surgeon's skill in trephining and removing the clot might save some cases. Yenesection arid transfusion of nor- mal salt solution is a treatment that should be resorted to in IXFLAMMATIOX OF MENINGES 177 cases of marked toxgemia. Supportive measures should, of course, be insisted upon in all these cases. CEREBRAL LEPTOMENINGITIS This is usually an acute infection. It is^ as a rule, secondary to some septic foci, as abscess of the lung, liver, etc. . Symptoms. — These are fulminating in character, accompanied by high temperature, great mental anxiety, and a hectic type of temperature curve, which remains, at about 104° or 106° F. Con- vulsions are not so common, nor -spactic rigidity of muscles so frequent as in the acute form of pachymeningitis, nor is intense head pain of so great importance as in the former disease. Local- ized palsies of sudden development are rather frequent, depending upon exudation over a motor centre. Duration of the disease is from a few days to ten days, the patient usually succumbing with the hyperpyrexia or from the general infection. Termination by crisis may occur, or a chronic septic inflammation of the brain may result. Prognosis. — This is bad in the majority of cases. Death of the patient usually takes place within seventy-two hours. In many cases a remote abscess in the brain may be the result of the above disease. Treatment. — This would not be different from that for pachy- meningitis excepting that it is more incumbent to seek for septic foci both in the brain and in other organs, to which it is so fre- quently secondary. HYDROCEPHALUS This is a condition, congenital or acquired, in which there is an accumulation of the fluid within the ventricles of the brain. There are two types of hydrocephalus, external and internal. It is again divided into acute and cJironic, although the chronic form is the more common variety. The internal type implies an excess- ive collection of fluid within the ventricles, whereas the external type refers to cases in which the fluid is mainlv in the subdural space. Usually the two are coexistent, but internal hydrocephalus always predominates. Symptoms of acute liydroceplialus may follow acute inflam- mation of the epend}Tna. It is more usual in babyhood and in 178 TEEATISE OX XERVOUS DISEASES children suffering with marasmus, in which subjects there seems to be a special tendency to local inflammation of this serous lining of the brain. Symptoms are those of subacute meningitis, excepting that convulsions are not so frequent and the temperature is never so high as in the former disease. The child is usually in a condi- tion of muscular rigidity, however, the attack itself generally being induced by autointoxication. In addition to the muscular rigidity with tetanic spasmus, at times there is evident an enlargement of the head, bulging of the fontanelles, and depression of the eyeballs within the socket, together with exophthalmos. The vault of the cranium projects out in proportion to the rest of the skull,^so that there seems to be enormous enlargement above the ears. In some cases the sutures are seen to be separated and the Wormian bones palpable. The " hydrocephalic cry," consisting of a long, deep re- spiratory sound, is a very usual symptom. Percussion over the skull will frequently produce a pseudo-tympanitic note, and on aus- cultation over the skull a distinct bruit can be detected synchro- nous with the pulse-beat. The patient may finally pass into a con- dition of tetany and die from exhaustion. Pathology consists of subacute ependymitis with excess of serum within the ventricles, which may, as indicated, also extend to the arachnoid. Prognosis. — This is bad, as a rule. In the acutest forms life becomes extinct within a few months. Occasionally the symptoms abate, and the patient is left with the chronic enlargement of the head which, if not too extensive, will not produce paralysis of the extremities nor any considerable degree of mental impairment, the rule, however, being that cases will result in imbecility with the general symptoms of spastic paralysis of childhood. It should be remembered that this is frequently a congenital condition, which is lit up soon after birth. It is astounding to what degree the convolutions may be pressed upon, and life and fair mentality be preserved in a small number of cases. Treatment is hygienic, medicinal, and operative. Prophylac- tic measures should be part of the treatment — nourishment of the child predisposed or born with the condition is most essential. Inunctions of cod-liver oil, with the idea of gaining weight and greater resistance to diseases, is of value. Spasms should be con- trolled by chloral and bromides. Sodium iodide is especially of service in infants, being less liable to disturb the stomach. It INFLAMMATION OF MENINGES 179 should be given in two-drop or three-drop doses of a saturated solu- tion, gradually increased to the physiological limit. Some advise compression of the skull by proper bandaging with the idea that this may tend favourably against the formation of exudation. Should symptoms of compression develop, however, the bandage should be removed immediately. Surgical aid through craniec- tomy, or tapping the ventricles, under antiseptic precautions, may be of value as a dernier ressort. Chronic Hydrocephalus. — This is usually the result of the acute form of hydrocephalus, and from the evidence found at birth in same cases, it is apparently chronic from the very first — i. e., it has existed some time in the prenatal life of the child. The signs here may first be noted during labour, an enlarged head being the cause of dystocia. More frequently, however, the hydrocephalus becomes apparent some time after birth. Causes of this condition are not definitely known. The pathol- ogy offers no direct clue to the nature of the trouble. The lateral ventricles are greatly distended, but the ependyma is usually clear, occasionally granular and thickened. The chorioid plexuses are extremely vascular. The third ventricle is dilated, as is also the aqueduct of Sjdvius and the fourth ventricle. The quantity of fluid may be several litres. It contains salts, albumin, etc. The cerebral cortex is greatly stretched, and over the middle region it may measure but a couple of millimetres. The basal gan- glia are flattened. The bones are extremely thin, and the Worm- ian bones themselves may gradually extend, due to the effect on the part of nature to fill in the ga-p of the widely separated edges of the bones. Symptoms are similar to those of the acute type, although not so severe. Convulsions may occur, reflexes are increased, the child may learn to walk late, but ultimately usually becomes feeble and very spastic. The mental condition is widely variable, from that of the ordinary imbecile to that of average intellect. Diagnosis. — The rhachitic head should be told from that of acute hydrocephalus, and is known, too, by the other evidences of the enlargement of the epiphyses of the long bones. The head in rickets is usually square, and not round or globular. The sepa- ration of the bones of the skull is not usual, nor is there the tympanitic note produced on percussion over the skull nor the bruit heard on auscultation, as in hvdrocephalus. 12 180 TEEATISE OX NEEYOUS DISEASES The acquired form of clironic hydrocephalus is simply the re- sult of acute hydrocephalus, but is said by some writers to be primary, essential, or idiopathic; that is to say, it comes on spon- i X, i 'V 'y i J I I i i ' ' ^ ' ' ' > ^ -t Fig. 39.— Braix. Case of Hydrocephalus in a Child of Five Years. Size indicated in inches (reduced). — (Howard Hospital.) taneously in the adult without observable lesion. Osier quotes the statement of Mr. Whiteway that Dean Swift was a subject of this variety, but doubts the possibility, and assumed that his ease was INTLAMMATION OF MENINGES 181 probably one of a spurious form of hydrocephalus, ex vacuo ; that is, within the arachnoid alone. , The symptoms of the acquired form would vary with the time in life of its development. If developing early, the symptoms already rehearsed will be present; if late in life, the patient will suffer from headaches, the gait becoming gradually irregular and ataxic; with a spasticity, how- FiG. 40.— Spastic Diplegia from Chronic Htdrocephalus (Adult Male). (Philadelphia Hospital.) ever, which distinguishes it from other forms of gait. In some cases there will be prolonged attacks of coma with slow pulse, due to irritation of the vagi nuclei by the pressure. One case on record is reported to have been unconscious for three months. Optic neuritis soon supervenes, and in the worst cases rapidly progresses after once begun. Chronic purulent ependymitis may precede death in some cases. 182 TREATISE OX NEEVOUS DISEASES Meningitis serosa is a type distinguished by Quincke, and con- sists of serous meningitis as distinguished from ordinary lepto- meningitis and from hydrocephalus. Quincke describes the affection as coming on suddenly in children with intense pain in head, signs of intracranial pressure, slow pulse, and choked disks. Retraction of the head exists, without fever, however. Some cases are much more insidious and are frequently mistaken for brain tumour. Treatment consists in the relief of pain and in making an effort to cause absorption of the collected fluid. This will be best done by giving depletive remedies, such as gamboge in stlienic individ- uals, or podophyllin or even calomel in repeated dosage. For the more usual asthenic cases such harsh treatment cannot be carried out, and we must depend upon free diuresis, producing in- creased action of the skin through such drugs as pilocarpine. Potassium iodide is a valuable remedy as a sorbefacient. Bichlo- ride of mercury, added to the above iodide, may favour resorp- tion of the exudate within the brain. As a prophylactic measure the patient should be carefully guarded against inclement weather and given nutritious diet; and mental strain should be avoided. Skilled massage may be of value in these cases. CHAPTEE X DIFFUSE AND LOCAL DISEASE OF THE BRAIN Cerebral Localization (Epitomized). — It must be remembered that cerebral localization is not an exact science, because symptoms may also be produced by compression, causing irritation, paresis, or paralysis of adjacent centres ; also, that circulatory disturbances occurring in the course of disease of the membranes of, or of the encephalon itself, may cause wide-spread functional disturbance that disobey all scientific rules.^ Still, in the majority of instances, close day-to-day study of the case will be rewarded by brilliant diagnoses, and help, therefore, for the patient. The accompany- ing illustrations (Figs. 41 and 42) give the respective locations of the definitely know centres in the cerebrum. Beginning from the posterior aspect, we will enumerate the function of each centre and lobe (for fuller description, see Chapter I, on Anatomy, etc.). Occipital Lobe. — Here lie the centres of vision, destruction of which causes cortical blindness (in the absence of lesion of the eye or optic nerve). Hemianopsia may also result as indicated under diseases of the optic nerves. Sensory centres are also present in the occipital lobe. (Cortical centres concerned in speech are de- scribed under Aphasia.) Temporal Lobe. — Here lies the centre of audition — i. e., for word hearing — in the posterior part of the firsst and second convo- lutions — and the centre for naming in the third convolution. The central convolutions of the parietal and frontal lobes of the cerebrum are principally centres for voluntary motor func- tion. The upper portion of the first and second frontal govern movements of eyes and head. These centres overlap one another. These convolutions probably also receive sensory impressions from the skin, muscle, and very likely from the viscera, and thus ^ See Some Points on Intracranial Neoplasms considered from the Neu- ronic Standpoint, by the author. Read before the Section on Medicine, New York Academy of Medicine; Philadelphia Medical Journal, November 16, 1901. 12* 183 184 TREATISE 0^ NEEVOUS DISEASES are the cortical sensory centres for muscle and tactile sense, the superior parietal lobule being probably the location where sensa- tions from the muscles are received. Irritative lesions in the motor cortex cause local spasms ( Jack- sonian epilepsy), or general convulsions. There may also be par- aesthesia of the parts convulsed, due to vaso-motor paresis. Superior frontal sulcus. Fissure of Rolando. Interparietal sulcus. Ascending ramus of the fissure of Sylvius. Fissure of Sylvius. Posterior ramus of the fissure of Sylvius. Superior temporal sulcus. Fig. 41.— Schematic Representation of the Cerebral Cortex and ITS Centres. (After Tillmanns.) 1. First. 2. Second. 3. Third. 4. Anterior. 5. Posterior. 6. Upper. 7. Middle. 8. Lower. 9. Upper. 10. Lower. > Frontal convolution. Central convolution. )- Temporal convolution. Parietal convolution. 11. Gyrus angularis. 12. Upper. ) 13. Middle. r Occipital convolution, 14. Lower. ) -^ In 4 and 5 on both sides of the fissure of O Eolando, motor area for the upper extremity. Motor area partly for the upper and partly for the lower extremity ^gTeat toe). Motor area for the lower extremity. ^ Cortical area for the hypoglossal nerve. ® Cortical area for the facial nerve. e Q (3) Motor aphasia. X(6) Sensory (auditory) aphasia with word- deafness. I (11) Aphasia with word-blindness. (12) Region of the visual area (see also * Fig. 10;. Destructive Zesions. involving these same central motor convo- lutions cause paralysis of the muscles of the opposite side of body, DIFFUSE AND LOCAL DISEASE OF THE BRAIX 185 which soon become spastic. The paralysis is not always complete, since only a few centres may be involved. Muscles acting together (as of respiration) or those which express emotion (as the facial), Fig. 43. — View of the Right Cerebral Hemisphere from the Median Side. B, corpus caUosum divided longitudinally ; G./., gyrus fornicatus ; H, gyrus hippocampi ; S.h., sulcus hippocampi ; G. m., gyrus uncinatus; .§. c. m., sulcus calloso-margiuaUs ; F. 1, first frontal convolution; .S'. c, termination of the fissure of Kolando; in front the anterior central convolution with the motor area partly for the upper and partly for the lower extremity, and behind the posterior central convolution with the motor area for the lower extremity ; P, prsecuneus ; C, cuneus ; F. po., pari eto- occipital sulcus ; p, polus ; F. c, calcarine fissure ; in the posterior part of this the visual area is shown by a red dotted hue. (After Tillmanns.) being represented on both sides of the cerebrum, are not com- pletely palsied. Asteriognosis, or disturbance of sensation, may be found if the lesion extends to the posterior part of the parietal lobe. The cells of the ascending frontal or precentral convolution, the ascending parietal or post-central convolution, the superior parietal lohule, the upper portions of the first and second frontal convolutions, part of the cuneus, the paracentral lohule, all con- trol or originate voluntary motor impulses. These same centres also receive sensory impressions; hence this region of the brain is designated the sensorio-motor region. The trunk muscles and 186 TREATISE 0^ NeeVOUS DISEASES Ipg muscles are largely represen-ted in the upper portions of the precentral and post-central convolutions. The muscles ,of the arm have their centres in the middle third of the precentral and post-central convolutions; the face, tongue, larynx, and pharynx being represented in the lower part of these same gyri. The Prefrontal Region. — This consists of the part of the fron- tal lobes in the anterior part of the third and ascending frontal convolutions. The centres that have to do with higher mental faculties (higher psychical centres) lie here — viz., those of judg- ment, reason, memory, attention, and comparison. It is the great association centre (Bianchi). It also is supposed to be a centre for the trunk muscles, according to Munk. Centrum Ovale. — Lesions here may involve association, sensory, or motor fibres. A subcortical lesion may simulate a cortical palsy, but there is not likely to be spasm at any time except after inva- sion of the cortex. Hence, spasm always foUoivs paralysis, just the opposite to that in cortical lesions. When the lesion is near the internal capsule the palsy resembles that due to lesion of it. There may be hemianopsia, hemiansesthesia, and if lesion is on the left side, aphasia in disease of the centrum ovale. Corpus Callosum. — ^Symptoms are of partial or complete palsy, a hemiplegia gradually extending to the opposite side, with later development of dysphagia, dysarthria, and an insidious dementia. A double cortical lesion may, however, closely simulate symptoms of disease of the corpus callosum, but the greater asymmetry in the degree of muscle weakness would be in favour of cortical disease. Corpus Striatum. — The function of this ganglia is not defi- nitely known. It is very likely that, as excision experiments on dogs lead to suspicion of (and in a case under the care of Dr. John M. Swan and the writer, one of Friedreich's disease with tem- perature, which seemed to point to its degeneration as a cause of the pyrexia) the existence of a centre for heat, regulation is in the striatum. ' Optic Thalamus. — This important ganglia is joined with the cortex of the frontal, temporal, parietal, and occipital lobes. It is the site of the ultimate ending of the optic tracts as well as of some sensory fibre neurones, which latter extend through their axons to the cortex. Very likely the main centre of regulation of body heat is in the thalamus. With the external geniculate DIFFUSE AND LOCAL DISEASE OF THE BRAIN" 187 hoclij and corpora quadrigemina the posterior part of the thalamus forms the primary optic centre. The corpora quadrigemina^ with the other two bodies just enu- merated, form the primary visual centres. The remaining part of these centres control the reflex movements of the iris and ciliary- muscles. The posterior bodies also, together with the internal geniculate bodies, are joined with the cerebellum and auditory centres, hence control in part sen- sations of space and audition. Internal Capsule. — The motor and sensory projection fibres (or peduncular fibres) pass within very narrow compass through the internal capsule. In the region of the " knee " are fibres which pass from the cortex to the motor nerves of the eye, to facial and hypoglossal nerves, also those fibres which pass to the nuclei of the nerves that govern the other muscles that have function in speech, which are supplied by the vagus. The pyramidal tract fibres lie next posteriori}^, those of the leg being also posterior to the arm. Posterior to all of these are the fibres that transmit common sensation and special sense im- pulses (hearing, vision, taste, smell). As the pyramidal tract fibres are in a very compact mass in the capsule, a lesion here produces hemiplegia on the opposite side of the body, monoplegia being never produced by such a located lesion. If the lesion is in the posterior part of the capsule hemiansesthesia will result, associated or not with homonymous hemianopsia, and with muscular paresis. Cms Cerebri. — A lesion of the crus will cause spastic palsy or paralysis upon the opposite side of the body, with palsy of muscles supplied by the motor oculi, since this nerve makes its superficial exit from the crus. The optic tract, as it crosses the Fig. 43. — Diagram of Motor and Sensory Representation in the Internal Capsule. NL., Lenticular nucleus. NC, Caudate nucleus. THO., Optic thalamus. The motor paths ai'e red and black, the sen- sory are blue. (From Osier's Practice of Medicine.) 188 TREATISE OX NERVOUS DISExVSES crus, may also be affected, producing homonymous hemianopsia. The tegmentum may, however, be involved without disease of the fibres of the crus, in which instance disturbance of common and muscular sensibility may occur associated with ataxia of the oppo- site side of the body. The Pons Varolii or Bulb. — The gray matter here consists of cells which form nuclei of the peripheral neurones of the motor division of the fifth; also the sixth and seventh nerves. The pons is the centre for the ascending or sensory nucleus of the fifth nerve ; also for the sensory and motor tracts on their way to and from the cortex. There are also neurones in the pons which connect with the cerebral and cerebellar cortices. Cerebellum. — Here the gray ganglionic masses are in the cen- tre, but the gray matter proper is upon the cortex. The vermis or middle lobe is alone known positively as to function, and is joined with sensory and motor paths of both brain and cord, the auditory nerve, some of the nuclei in the pons, and with the infe- rior olivary bodies of the medulla. The functions of the cere- bellum are not definitely ascertained in detail. It is known to take part in maintaining the equilibrium of the body, in muscular movements, and in maintaining our relations to surrounding ob- jects. Hughlings-Jackson claims that disease of the cerebellum causes palsy of the trunkal muscles also, and that the cerebellum maintains muscle tone. Medulla Oblongata. — The lower motor neurones or nuclei of the eighth to twelfth cranial nerves lie here, except the spinal root's centre of the eleventh, which is in the cord. The oblongata is of course only the expanded portion of the cord, and the cells lying here have the same sort of function as do those in the gray matter of the cord. In the medulla are also found reflex and automatic centres controlling the respiratory and circulatory functions, secretion, and the visual movements. The olivary bodies (.superior and in- ferior) are small masses of gray matter in the medulla, and are joined with the basal ganglia, cerebellum, and cord, having to do in part with co-ordination and equilibrium. A lesion high up in the oblongata may damage the pyramidal tract above its decussation and the liypoglossal nerve upon the same side as the lesion, producing an alternate paralysis. Affection of the nuclei "gives rise to the so-called bulbar symp- DIFFUSE AND LOCAL DISEASE OF THE BRAIN 189 toms — those of glosso-lal)io-pharyngeal paralysis. Death may fol- low suddenly from involvement of the respiratory or cardiac cen- tres. Polyuria or glycosuria may also result from chronic lesions of the medulla. The functions of the occipital lobe have been mentioned under diseases of the optic tract. Cortical centres concerned in speech are to he described next under Aphasia. APHASIA By this we mean disturbance of the power of communication by the ordinary signs of language. The word aphasia, which signifies loss of speech, is the general designation applied to all forms of defects of the elements of speech due to disease of the cerebral hemispheres. This is usually a lesion involving the cor- tical centres of the speech mechanism.. Aphasia is to be distin- guished from disturbance of speech that follows mechanical trou- ble with articulation due to lesion of peripheral organs or nerves, and also from speech defects due to the lesion of the cranial nuclei or of the association and co-ordination tracts of speech in the ob- longata, pons, and cerebellum. Aphasia is, therefore, limited to a partial or complete loss of the power of comprehension or expres- sion of language. It is divided into two* classes — motor and sen- sory aphasia. The former may be designated emissive, and the lat- ter a receptive type. Of the motor form we have subdivisions con- sidered as elementary^ — namely, (1) aphasia, or complete motor aphasia, (2) agraphia, or inability to write. Of the sensory form we have (1) word-deafness, or auditory aphasia, and (2) word- blindness, or visual aphasia. Mills desig- nates another form of elementary aphasia — namely, verbal, or that variety which is due to the lesions of the naming centre. Apraxia is the form where the patient is not able to understand the uses of objects. Motor Aphasia. — Aphemia, as Brocker, Ross, and others have designated motor aphasia, is divided by some into two or three forms, the first being strictly limited to that produced by lesion of the foot of the left third frontal convolution, the so-called Broca convolution. Broadbent names another variety, in which the lesion is at the foot of the second central convolution back of the Broca centre. Total destruction of Broca's convolution in right-handed 190 TREATISE OX XERVOUS DISEASES peojjle makes spoken speech impossible for a time at least. Later, the hitherto untrained centres in the right third frontal convolu- tion develop. Tlie patient may thus accjuire or regain partially the faculty of speech. Usually, however, recovery in part is due tq the fact that the centre was not entirely destroyed. The reason for the speech centre being on the left side is, theoretically, assumed to be that this side is much more highly developed than the other, in obedience to the ^Drinciple of the economizing energy, most peo- ple being also right-handed. Articiilative ataxia is nothing more than the old ataxic aphasia, so-called, or the asynergia verbalis of Lordat — i. e., the existence of incomplete motor aphasia, which is Fig. 44. — Zones and Centres. External Aspect. Cerebrum. (After Mills.) generally the sequel of the complete form. Most cases of motor aphasia also suffer from agraphia. This loss or defect may be due to lesions of the centre for word-seeing, which centre is placed at the caudal extremit}^ at the second or medio-frontal convolution, and in close relationship with the upper or mesial boundary of the true speech centre. True agraphia is an almost invariable result of destruction of Broca's centre, however. It is probable, as Wiley concludes, that motor agraphia, as far as writing with the right hand is concerned, may result from a lesion in the graphic centre in the posterior portion of the second frontal convolution. Pantomime study is only second in importance to that of spoken speech in the consideration of aphasia. It is in general a part of speech, and so closely associated that disturbance of DIFFUSE AND LOCAL DISEASE OF THE BRAIN 191 speech is always accompanied by disturbance more or less of pan- tomime. Amemia is loss or impairment of power of expression by signs, when due to cerebral disease. Paromemia is confusion of the signs in efforts at expression through them. Sensory or Receptive Aphasia. — This is considered usually as having three special forms: (1) auditory aphasia, or word-deaf- ness; (2) visual aphasia, or word-blindness; (3) and apraxia, also called mind-blindness, soul-blindness, and object-blindness. Physi- ological investigations, including those of Ferrier, prove (1) word- deafness is due to lesion in the posterior third or first and second temporal convolutions, as verified by Mills, who contends " that it is not complete unless the corresponding region on the right hemi- sphere is also impaired or destroyed." Other symptoms present in this form are inability to read aloud correctly. The patient is un- able to verify what he reads by hearing. In the complete form he cannot echo spoken words. Paraphasia and paragraphia may also be present in these cases, as may also verbal amnesia, and as may articulative amnesia. But it is probable that in some of these cases the amnesic phenomena are due to the involvement of the centre, or of tracts leading from the centre of word-hearing to the conceptional or motor centres. Music-deafness may be associated with word-deafness. But from the fact that it is sometimes pres- ent when auditory aphasia is absent, it is assumed that in some people the faculty for music belongs in both hemispheres of the brain to a greater degree than does the faculty of hearing. Be- tween the auditory centres at the base of the brain and the cortical auditory centres in the left temporal lobe are also entering tracts for hearing. A lesion of these tracts, which probably go from both sides of the brain, will give rise to a form of word-deafness. Lichtheim has placed the entering auditory tracts chiefly in the left temporal lobe. A lesion of this tract will cause outer word- deafness. A case of lesion restricted to this entering tract alone has been reported by Lichtheim. We must have entire comprehen- sion of cortical anatomy aphasia and complete understanding of the auditory path before this matter becomes clear. (2) Visual localization, like auditory localization, has also cer- tain tracts to be considered from an anatomical and physiological point of view before we can understand ambl5^opia, hemianopsia, 13 192 TEEATISE ON KEEYOUS DISEASES etc. Henschen believes that the centre for the macuhir fiekl lies in the calcarine cortex. There is also doubtless stored near the visual centre images of words, letters, and probably of objects. Fig. 45. — Zones and Centres. Mesal Aspect. Cerebrum. (After Mills.) This is likely in the angiilo-occipital region or on the lateral surface of the hemisphere, as located by Ferrier. Partial destruc- tion will produce word- or letter-blindness. Alexia, or the inability to read, will, of course, be produced by such a lesion as will cause agraphia so far as this is dependent upon sight. Patients who have been rendered alexic or word-Mind (lesion of centre for word-seeing) can sometimes write their names or simple words; apparently doing so through touch or by recog- nition of psycho-motor im.ages. Between the primary optic cen- tres at the base of the brain and the cortical centres recited are certain entering tracts for vision (optic radiations of Grateolet). It must be remembered that the primary cortical visual centres are connected with half of the retina on each side — the same half on which the centre lies — the fibres passing to the angular region in each hemisphere. This is the centre of eye functions. A lesion which severs the tracts coming from both occipital lobes to higher centres will cause word-blindness, but not agraphia. Commonly such a lesion will also produce hemianopsia, since the radiations of Grateolet are usually involved. ( 3 ) Not infrequently associated Avith word-blindness is another disorder, wbich has been variously called mind-Mindness, soul- blindness, and object-blindness. In examining for this, the physi- DIFFUSED AND LOCAL DISEASE OF THE BRAIN 193 cian tries to determine if the patient shows signs of recognition of various objects. He may not comprehend the use of the simplest things and he may not recognise intimate friends, excepting by touch or by hearing their voices. (Occasionally there is added to this form a psychic deafness in which the patient cannot recognise a friend by the sound of the voice.) The centre for mind-blind- ness., may or may not be separate from the centre for visual images of words (visual aphasia). Both hemispheres of the cerebrum doubtless take part in the storing of images in equal degrees. The mental percepts of objects and of names are the results of defi- nite processes of cerebration (Mills). Ideation is particularly dis- turbed through lesion of the radiating fibres, whereas the determi- nation of names is disturbed through lesion of the centres for per- cepts only. Mills, with Broadbent, holds the view that a naming centre exists in the cortex of the brain. Destruction of this centre will produce verbal amnesia. A form of verbal amnesia, called articu- lative amnesia, would be due to partial destruction of this centre. Conducting aphasias are those forms of speech disturbance Fig. 46. — Plechsig's Association Areas — Lateral Aspect. which are due to defects or destruction of the tracts associating various regions concerned in the mechanism of speech. Some of these are parapliasia ; paragraphia, the misuse of words in writing ; paramemia, the misuse of signs; paralexia, misuse in reading of 194 TEEATISE ON NERVOUS DISEASES syllables or words; and dyslexia, which is difficulty or fatigue shown in reading. Examination for Aphasia. — First: determine associated phe- nomena of aphasia, as gesture language, already detailed. Test for these carefully. Second: extra-graphic symbols should be sought Qut, such as the methods of implying numbers, algebraic signs, etc. Third : the determination of mind-blindness. Fourth : emotional and intellectual faculties, which include determination of emotion, mentality, etc. Fifth : motor and sensory functions should be studied. These should all be critically observed. Fig. 47. — Flechsig's Association Akeas — Mesial Aspect. The definite subheadings, as given by Mills, are as follows : The methods of (A) spoJcen speech should be determined — 1. Inquiry as to how the patient receives and interprets. 2. (a) How is it produced? making a record of words, etc (&) Evidence of amnesia and its companionable symptoms — artic- ulative amnesia and paraphasia. 3. How is it repeated or echoed? (B) Written Speech — 1. How is it received and interpreted? 2. Is sight good, is hemianopsia present ? etc. 3. How is it produced? 4. Ask the patient to write his name. 5. How does the patient write to dictation or from copy? Try him in both ways, and if he is able to do either or both, try to ascertain if he understands the meaning of what he writes. CHAPTER XI OTHER DISEASES OF THE BRAIN AND MEMBRANES GENERAL SYMPTOMATOLOGY Theee are certain general signs and symptoms that are found more or less constant in almost all organic diseases of the en- cephalon. These symptoms may be placed in five classes: (1) general symptoms of brain irritation; (2) general symptoms of brain pressure; (3) symptoms of focal irritation or destruction; (4) symptoms due to local pressure; and (5) those due to the pathologic process itself. The symptoms of brain irritation are headache, vomiting, ver- tigo, photophobia, mental irritability, insomnia, a sense of pres- sure and fulness about the head, noises in the ears (tinnitus) or in the head, tenderness of the scalp, and in bad cases convulsions, paralysis, or delirium and stupor. Brain compression has as symptoms headache, vomiting, men- tal hebetude or dulness; or it may be some form of. paralysis, contraction of pupils, and finally coma. Retraction of abdomen (scaphoid) accompanied by constipation is often present. Symptoms of brain compression may be associated with anae- mia, oedema, or increased blood pressure; or, indeed, in states of malnutrition, when the brain mass is impoverished, symptoms of compression may prevail. Irritation and pressure symptoms may inter digitate, so that at times it is impossible to differentiate one from the other. Encephalic irritation symptoms are usually asso- ciated with hypersemia. Focal or local symptoms depend almost absolutely upon the location of the lesion causing them. If the motor area is af- fected, twitching, spasm, or convulsion would be likely to follow early; while when destruction at the same site occurs, the symp- toms will be of paralysis. If in a sensory centre or tract, the first symptom would be of paresthesia or hyperesthesia; the later one being of anaesthesia of the part supplied by the centre involved. 195 196 TEEATISE OX XEEA^OUS DISEASES Symptoms due directly to the pathologic lesion itself may he meagre; just as in tumour of the spinal cord^ for example, the symptoms of irritation, pressure, or even destruction or local dis- turhance of circulation may be dwarfed by septic infection. Gen- eral symptoms, the result of septicaemia, such as chill, fever, sweat- ing, etc., may become paramount. Hemiplegia and aphasia are symptoms that may be caused by so many different kinds of lesions that they demand some special study here. Both groups of symptoms pertain in general to motor or sensori-motor disturbance. Hemiplegia, is paralysis of one half of the body, as a rule in- volving the side opposite the lesion. The arm is usually the most palsied, the leg next, and the face least. Hemiplegia may be acute or of slow onset, the former being due to hsemorrhages, cerebral softening, or more rarely to injuries or to inflammations. The latter is usually very insidious, and is generally caused by tumours or slowly developing areas of sclerosis ; but this may be only a part of diffuse sclerosis. The particulars of hemiplegia will be given under Special Diseases of the Brain. MALFORMATIONS OF THE BRAIN AND ITS MEMBRANES There is little practical importance to this subject as regards congenital malformations, since in most cases the monsters die — a most fortunate result. The following are some of the types : Brain. — Anencephaly; micrencephaly and microcephaly; por- encephaly; malformations or absences (cyclopia). Brain and Membranes. — Acrania; meningocele; encephalocele ; hydrencephalocele. With acrania, anencephaly is always present. In anencephaly, the cerebellum and part of the basal ganglia existing may permit the child to live for a -hort time after birth. In micrencephaly the brain is but partly developed; and if in addition the cranium is also abnormally small, as is generally so, the name microcephaly is given. This is due to lack of growth of the brain, and probably not at all to premature growing together of the cranial bones, as once contended by Virchow. If the circumference of an adult cranium is less than 42 centimetres it will contain a micrencephalic brain. iSTormallv the weight of an adult man's brain is 960 DISEASES OF THE BEAIX AXD MEMBEAXES 197 grammes, while 880 grammes is the weight of an adult woman's brain. It is 14 per cent of body weight at birth and 2.4 per cent at adult life. Porencephaly is often the result of hsemor- rhage. In cyclopia there is an undivided anterior cerebral vesicle, and the orbits form a continuous cavity with a single rudimentary eye. Meningocele is a hernia of the brain membranes. In en- cephalocele the brain also protrudes through the cleft in the skull. Fig. i8.— Lack of Development. Left Half Cerebrum. (Specimen from woman at the Philadelphia Hospital.) These forms usually occur in the occipital region and in the me- dian line. In hydrencephalocele there is a sac with fluid contents. MENINGOCELE This may be either of the membranes of the brain or of the cord. It consists in the protrusion of the meninges out of the natural position within the skull or spinal cord. In the case of the brain, where there is also an existent internal hydrocephalus, the distended ventricle may form a part of the tumour, in which case 198 TEEATISE OX NEEVOUS DISEASES it is then designated a hj^drencephalocele. Usually such tumours are covered with the skin of the scalp. At other times they are devoid of the cutaneous covering. The most frequent position for the appearance of these tumours is in the anterior portion of the skull^ very seldom occurring at the base of the brain. This is largely on account of the thinness of bone and the position of the fontanelle openings. The hernia is caused by increased cere- bral pressure from within, due to excessive fluid, and frequently to teratological defects as the primary cause. Adhesion of the amnion to the cephalic end of the embryo is probably an impor- tant factor in the production of the congenital condition type. Disease of the meninges in early life may be the cause of some acquired cases. Sex has no influence in their production. Ma- ternal impressions and fright are said to be exciting causes of these malformations. . Usually the length of life in infants affected with this deformity does not extend beyond one year. Cases have been reported, however, where they reached adult life. Symptoms. — Membranes protrude. Drowsiness and mental enfeeblement, also paresis and convulsions, are the most impor- tant symptoms. Pathology. — ^Usually the condition is an embryological defect. If disease of the membranes has been the primary cause, the path- ological condition or cause will be that of the primary disease, such as meningitis, acquired hydrocephalus, etc. Treatment. — This is most uncertain. If the protruding mass is small it may either be excised by the surgeon or com- pressed into the cranial vault. Some authorities have advised the withdrawal of the fluid in the sac; and where the membrane ex- truded is quite isolated from that within the skull, injection of carbolic acid, with the hope of setting up subacute inflammation, which may shrivel the mass in question, can be tried. APOPLEXY (CEREBRAL HiCMORRHAGE) By this term is generally understood hsemorrhage into some part of the brain, and in the majority of instances the bleeding is from the lentieulo-striate arteries. These supply nutriment to the motor cortex and important ganglia at the base of the brain, from which projectile fibres extend' to the spinal cord and transfer nerve energy to the lower neurons and extremities. DISEASES OF THE BKAIX AKD MEMBRANES 199 Apoplexy is sometimes called a " stroke," or " paralysis " ; and while paralysis is the usual result of a hsemorrhage into the central nervous system, it is more exact to speak of apoplexy than any of the other terms commonly used by the laity. The physician under- stands a broader definition of apoplexy even than that above given — i. e., thrombosis of cerebral blood-vessels, or embolism, either, though more limited, practically produces similiar signs and symptoms ; ,the former insidious, the latter sudden. As the treat- ment of these three conditions would not much vary, it will be Anterior cerebral Middle cerebral Sylvian Posterior cere- bral Lenticulo optic Lenticulo striate set of arteries Internal carotid Basilar Vertebral Fig. 49. — Showing Arteries at the Base of the Brain. One, the lenticulo- striate, is called the artery of cerebral hemorrhage. (Slightly modified from Dercum.) unnecessary to more than mention them. The predisposing causes of true apoplexy are in the following order of occurrence : first, chronic alcoholism; secojid, syphilis; tliird, other infectious dis- eases. The predisposition to cerebral hsemorrhage with what might be called normal sclerosing or hardening of the vessel walls due to advancing years, must be considered ; and here it is espe- cially that heredity plays an important role in etiology. In pro- portion, then, as persons past middle life develop arteriosclerosis, will the tendency to this serious malady occur. Induced plethora from overeating is a predisposing cause. Physical and mental strain are exciting causes. Night or early morning hours are the 200 TEEATISE ON NEEVOUS DISEASES most favourable times for cerebral hasmorrhage, and especially for embolism and thrombosis. Singularly, it often happens when the patient has been feeling particularly " well," although it will be found there have been some days or months of sense of vertigo with fleeting attacks of congestion of the brain. The attack may appear in such a predisposed individual following exertion, strain- ing at stool, or after partaking of a hearty meal. Signs of Attack. — Eather sudden loss of consciousness pre- ceded by thickness of speech, or motor aphasia, accompanied with flushing of the face, extreme objective vertigo, followed by falling Fig. 50 — Showing the Portions of the Cekebral Hemispheres Supplied by THE Anterior, Middle, and Posterior Cerebral Arteries. (Redrawn from Dana. ) in unconsciousness if the patient is standing or sitting. With this there is more or less stertorous breathing, and perhaps clonic convulsions will precede the ultimate paralysis, which is usually of one side of the body, owing to the location of the hsemorrhage on the opposite side of the cerebrum. It will be found within a half hour that the temperature of the patient has risen slightly, the coma becomes more profound, following the marked restlessness which is seen just after the stroke. There is slight hypersesthesia of the paralyzed side, as shown in a few cases where the coma is not too profound. The increase of temperature is more pronounced on the affected side, and averages half a degree by the axillary record DISEASES OF THE BKAIN AND MEMBRANES 201 or less by surface thermometers. Hyperpyrexia may rarely occur, and is always an unfavourable, usually a fatal sign (Fig. 53). i « The paralyzed extremities when raised from the couch will drop flail-like; the patient occasionally, on partial recovery, will, how- ever, be able to move the other side of the body. There may also 202 TREATISE OX XEEVOUS DISEASES be retention of urine, wMch must be guarded against by the nurse. The deep reflexes on the paralyzed side are always diminished or absent in this stage. Conjugate deviation of the eyes, or a turn- ing of the eyes away from the paralyzed side in cerebral lesions, may exist; or the eyes may remain "fixed." If convulsions occur the " deviation " of head and eyes may be towards the palsied side. At the end of three or four hours, if the case does not go to a fatal issue, the patient begins to improve. The coma now becomes less profound, the reflexes appear again in the paralyzed side, the patient may recover power in muscles, perhaps an extremity, and he may turn from the supine position in which he lay to one or the other side. Here the nurse should be instructed as to care to prevent pressure paralysis, which may be caused by lying upon the enfeebled arm. The chronic stage now sets in. Gradual restora- tion of speech takes place in the majority of cases, although there may remain some form of dysarthria, as " thickness " of speech, for some months in even the most promising cases for large recovery of power. There remains difficulty in swallowing, and the saliva may dribble from the mouth for some months. As a rule, the tongue is protruded towards the paralyzed side and the face drawn towards the sound side, although there is no disturbance of taste. The muscles of the paralyzed side do not degenerate in the sense of showing " reaction of degeneration " by the galvanic current, and there is rarely true trophic wasting,-only that due to disuse of the affected members. In the average case, at the end of a few weeks, the patient Avill be able to move about with the assist- ance of crutches or cane. The manner of progression will be typ- ically characteristic of the so-called hemiplegic gait. The affected limb is thrown out and forward, describing the arc of a circle, and then the foot is dropped down flail-like upon the ground. This peculiarity in walking is caused by the patient throwing his trunk forward and to the sound side, due to the fact that the extremity being paralyzed, compensatory movements and muscular effort must be made by the other limb. Substituting this flaccid hemi- plegic gait, in the course of a few weeks there develops in the patient spasticity of the muscles of the affected side ; and then the paralyzed member will be, with the partially regained power, pushed along in a spastic fashion, the toe being " dug " into the ground. > i -0 2o DETAILS OF TREATMENT §„ g, 8„ 2 1 i CLINICAL MEMORANDA 1^ iS 20 21 «; ■ 14 1 1 1 -t- MI-4--LL II _LL 1 30 114 1 1 1 III i II II --Jda a!m. 1 •;ii dn cM' ' ' 1 , 11 ___^__!_ Js'^ - . 30 88 !►=;■ — ' ! 1 1 -- »R 96 1 h t .1. ^---08 j. ,.[ •-. 1 1 1- ^ i 26 G8 ll>.eP.M. ..^ :■■■-■■- f' -■■ '" ■ - ■ 38 108 S 1 1 : 1 . 1 ~~ ~^ Mi '~ ^^^ . p.\. 32 108 i ,S,P.M.( l^!"^ ,, "T*^ ~~ ~~ 1 11. - ; ■■ ■ ' ~ .; .■ s ■ j 1 .' E - C - 1 1-^^ 1 ^~ ■•-■■-:(- 1 _ „ .^ ■..:;■■ 1 1 7~ "7~ !•■ - t - - !3S3i&iinL 1 i 1 - 1 ^^.^ ? » ,^ . 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TREATISE OJT NERVOUS DISEASES The affected arm, which has thus far himg flail-like, improves more slowly as to power than does the lower limh; hut with the return of power^ flexion of the elhows and fingers takes place. This is due to secondary contraction of the flexor muscles, which are disproportionately increased in power over the extensor group of muscles. In the course of the affection there will be found secondary degeneration, and this may extend to the opposite side of the spinal cord, causing great increase of the deep reflexes on both sides of the body. As, the case progresses, joint symptoms are not unusual ; the disuse of the- joint and lowered trophic con- dition sets up a low grade arthritis, the affected joint becomes painful and semi-ankylosed. Subacute neuritis in the affected extremity may also be set up. Great wasting of the extremity is the exception. There is never reaction of degeneration in the paralyzed muscles in cerebral lesions, as already referred to in a previous paragraph. Sweating upon the paretic side of the body is not a usual symptom, but when present shows vaso-motor weakness. The following hygroscopic observation has been made for me by Dr. H. E. Wetherill : Case of M. K., aged thirty years, female: Right palm, 82.5 per cent; left palm, 96.0 per cent; abdomen, 2 inches above umbili- cus, 84 per cent ; mid-scapular region, Wurtzer's uncovered instru- ment, 70 per cent; temperature by the mouth, 98.3° F. ; tempera- ture of the ward, corrected, 72° F. ; relative humidity of air of ward, 84 per cent ; barometric pressure, corrected, 30.045 inches. Result in this one case : " It would appear that the skin moist- ure is increased in the diagnosed condition of left hemiplegia, not- withstanding it was a damp day." PafJiology. — The haemorrhage is generally due to disease of the blood-vessels, which is usually a degenerative arteritis : First, attacking the media. Miliary aneurysms form. The aneurysms occur most frequently upon the cortical vessels, and may also extend to the smallest arterioles. On section of the brain- substance they appear as localized, dark bodies about the size of a pin's head. Second: Endarteritis and perim-teritis may lead to apoplexy, either by producing miliary aneurysms or coarse ones of the larger vessels, as of the circle of Willis. Third: Fatty degeneration of the small vessels occurring in purpura, scurvy, leucocythsemia, marasmic conditions, and acute DISEASES OF THE BRAIK AND MEMBRANES 205 infectious diseases. Atheroma is usually found in the larger vessels. The parts affected in haemorrhage, in the order of frequency, are the caudate and lenticular nuclei, meninges and cortex, cen- trum ovale, optic thalamus, pons, cerebellum, and medulla. Ven- tricular haemorrhages are usually secondary to hemorrhage into the neighbourhood of the basal ganglia. After a haemorrhage there is first coagulation of the blood, which soon begins to soften and be absorbed. The inflammation occurring about the clot usually causes the formation of a fibrinous wall around it, which forms a cyst with fluid contents. In other cases, instead of the formation of a cyst, there is proliferation of connective tissue and the formation of a pigmented scar. Secondary degenerations follow, due to the cutting off of nerve- fibres from their parent cells, which in most cases, as hemorrhage in the region of the internal capsule is very common, would in- volve the pyramidal tract and be the cause of late rigidity and in- creased reflexes (the inhibitory influence of the cortical cells being cut off). Diagnosis. — The history of an apoplectic stroke with conse- quent hemiplegia is the important point. Embolic apoplexy is to be diagnosed largely by history of cardiac disease and in the finding of a well-marked organic heart disease, as shown by murmur over the prfficordia. In embolic apoplexy, too, there is not so constantly disturbance of consciousness, and the sequent paralysis is very apt to be more permanent and localized. Following the embolic form also, careful examination may reveal alteration in the phys- ical signs of the existent heart disease; for instance, the murmur may partially disappear, or at least change in quality very mate- rially. In tliromhosis there is no positive way of telling, except by noting previous history of thrombosis in other parts of the body and by extensive arterial degeneration : also of a slow onset. Prognosis. — About 50 per cent of cases of apoplexy recover from the attack; 75 per cent of these are very apt to have re- currence; the remainder go on through life with motor paralysis of the parts involved, life being perhaps curtailed, on an average, by a decade. The expectancy of life in these cases, therefore, is relatively proportionate to the heredity of longevity. Treatment and Nursing. — In the apoplectic attack the patient should be guarded very carefully, placed in the supine position, 206 TEEATISE ON NEEVOUS DISEASES with the head partially elevated; ice-caps should be placed to the head and hot-water bottles to the feet, being careful not to burn the patient, since obtunded sensation by the unconsciousness would prevent the appreciation of heat. Friction to the lower extremities will aid in restoring circulation here, and thus favour the relief of congestion in the brain; or a mustard bath may be of value. A denture or other foreign body should be carefully sought for, since there would likely be strangulation from this source. It may be necessary in some cases to produce traction on the tongue, by means of a handkerchief or an artery forceps " clipped " on to the tip of the organ. Eespiration can also be aided by gentle, firm ele- vation of the larynx with the tips of the thumb and index-finger. The inhalation of oxygen is a method I have nowhere seen used, but it is scientifically ideal for oxidation, and should be tried in serious cases when other methods have failed. The revulsant ac- tion through the intestinal tract should be brought about by a hydragogue cathartic. For this purpose croton oil is employed by the physician, 2 to 4 drops being placed upon the tongue directly or in solution upon sugar. The reason for this therapeutic meas- ure is that the congestion of the mucous membrane causes great exudation of serum from the blood, and in consequence of such local and general depletion, the marked relief of the congestion in the brain. Venesection or bleeding by leeches are important adjuncts in sthenic cases. At the end of forty-eight hours small quantities of milk may be administered, although for some days there should never be excess of nutriment placed in the stomach. The patient should be kept warm, with especial attention given, however, to ventilation. Stimulants should be eschewed save in the use of strychnine, which may be prescribed for heart failure only. In the " getting up " of the patient, as indicated "before, exer- cise should be. sparingly indulged. The time of sitting up (not before a fortnight) should be very gradually increased from day to day until there is a proper adjustment of the altered and ham- pered circulation. A patient generally has to employ crutches in his first endeavour at walking, and this should be encouraged until sufficient power has been regained, when the crutches can be substi- tuted by a cane. When contractures occur in the paral^^zed ex- tremities, and even before this to prevent such deformities, it is wise to employ massage and stretching in the affected members. DISEASES OF THE BEAIN AND MEMBEANES 307 The use of iodide of potash is the most valuable remedy at our command for the absorption of the exudate in the brain. We have seen some excellent results accomplished with this drug, espe- cially in the specific cases where the remedy can be gradually pushed up to several hundred grains a day. Extra exertion, as in lifting, should be guarded against, the bowels must be kept regu- lar, and the patient should live a life much less active than usual. With this outline, subjects of apoplexy may live many years in fairly comfortable health, although hampered considerably as to motion and mental capacity. Cases of cardiac disease are always more serious, since life is menaced by the fact that a vegetation may be carried into the brain at any time. ENCEPHALITIS By this is meant an inflammation of the encephalon or brain mass. Causes. — The causes of this disease are injuries, infectious dis- eases and local, infections; or an arterial sclerosis, by cutting off nutrition to the cortex of the brain. Varieties. — These are acute, as the hemorrhagic; and second- ary or chronic, which is divided into the septic (or brain abscess) and the simple chronic encephalitis, which is divided into enceph- alitis superior, where the third nuclei are affected, and enceplialitis inferior, where the cranial nerves below the third are involved. Symptoms of Acute Enceplialitis. — The symptoms of acute hsemorrhagic encephalitis are mental confusion, slight rise of tem- perature, palsy of the extremities without actual paralysis, and but seldom convulsions. There may be palsy of the third nerves. The disease is very rapid in onset, and may be accompanied by paraly- sis of one side of the body (hemiplegia). Prognosis. — This is bad, the disease lasting from a few days to a week or even ten days, the patient dying of pressure upon the brain or from involvement of the respiratory or cardiac centres. Pathology.— This consists in an inflammation of the cortical cells of the brain with minute haemorrhages scattered here and there throughout, and in some cases a distinct hemorrhagic effu- sion may exist. There may be optic neuritis, but seldom choking of the disk. 208 TREATISE OX XEEYOUS DISEASES Symptoms of Chronic Encephalitis. — S3^mptoms of chronic septic encephalitis are all the above symptoms in less severity, plus the addition of chills in some cases, and in few a rise of tempera- ture, although depression of temperature is frequent even in cases of abscess of the brain. There is usually a history of ear disease or chronic nasal disease preceding the attack, and -with this history the case (giving symptoms of inflammation of the brain) will be found to be of septic nature. In 90 per cent of all cases sepsis will be found. There is very frequently localization of the inflammation in septic encephalitis, although there may be multiple foci scattered throughout the encephalon; if local, such symptoms as convul- sions or paralysis may be set up by the irritation or destruction through the abscess. Choked disk is not the rule, although optic neuritis is likely to occur; and especially is this the case if the abscess is cerebellar in origin, which is the most frequent site of abscesses, because chronic middle-ear disease is the most frequent cause of brain abscess, and the cerebellum being adjacent to the ear would explain the prevalence in this locality. If the abscess is in the cerebellum, the cerebellar gait will be a feature in the diagno- sis; if in the motor area, convulsions and paralysis would be looked for; if in the spheno-temporal lobe, deafness should be looked for; or if in the posterior parietal lobe, asteriognosis and mind-blindness may be a part of the symptomatology; whereas if located in the frontal lobe there are no special symptoms, the men- tal stupor, however, being profound. Diagnosis. — Differentiation should be made from brain tu- mour. This is done by the history of the case and the development of irregular temperature in encephalitis and its more rapid progress. Prognosis. — The growth of brain abscess is usually rapid, the patient dying within a few months after its development. It may, however, last for years, and become incarcerated and form a " cold " abscess, which may at any time, from trauma especially, develop sj'mptoms of acute septic encephalitis and result in death. Treatment. — This is surgical alone. If a case is diagnosed, the surgeon should be called into consultation immediately for decision as to operation. The best results are obtained in those that are cerebral rather than cerebellar, on account of the anatom- ical difficulties in the latter. DISEASES OF THE BRAIN AXD MEMBRANES 209 The symptoms of chronic polio-encephalitis superior are those of simple encephalitis of mild type. There is no pain connected with the disease, and the third nerve being involved, we have in addition ptosis, exophthalmos, and iridoplegia. The eyes are also held in external strabismus if the sixth nerve is still intact. The symptoms of polio-encephalitic inferior are those of ordi- nary encephalitis, plus those of the involvement of the nuclei of the fourth and the cranial nerves below this. If the pathetic alone is involved there would be, in addition to the above symptoms, rotation of the eyes up and in. There is an absence of tempera- ture in cases of chronic nature. According to the nerves involved below the fourth nerve, will we have symptoms of paresis of those nerves. Prognosis is very unfavourable. Some amelioration may be ex- pected under thorough treatment. Diagnosis. — It should not be confused or confounded with any other form of disease, the particular point being preservation of consciousness with the incomplete palsies suggested above. Treatment. — This is palliative; quiet is essential; apply cold to the head, and use supportive measures, such as strychnine and belladonna in small doses, or of nitroglycerine, to support the heart. Iodides should be used, as also sorbefacients where there are any symptoms indicating exudates about the inflammatory area. Individual galvanization of muscles of paralyzed parts, such as of the eye muscles, may be of some value. These patients may live for a long time — years; however, they are very likely to be carried off by an intercurrent affection, as pneumonia. BRAIN TUMOUR OR CEREBRAL NEOPLASM This occurs in the majority of instances in early adult life, depending somewhat on the nature of the growth, which are in the order given: tuberculoma, fibroma, sarcoma, glioma, carcino- ma, and gumma, the first and last being really deposits of the spe- cific granulomata. The tubercular tumour is more frequent in childhood, the gumma occurring between twenty and forty, and sarcoma at about thirty years of age, whereas carcinoma is apt to develop after forty years of age. Brain tumours are in many eases distinctly hereditary, perhaps in 50 per cent of the cases. This fact has helped the writer in 14 210 TREATISE OX XERVOUS DISEASES the diagnoses of obscure cases, Avhich, put with the weight of other evidence, will alwa3's be of service. Symptoms. — These are of two kinds: (1) general, and (2) spe- cial, local, or focal symptoms. The general symptoms consist in mental excitement, vomiting, so-called reflex or cerebral vomiting, vertigo, choked disk and headache, the latter being of a dull character. The choked disk is present in between 90 to 95 per cent of cases, and is usually more intense in cerebellar lesion. It is much more frequent in neoplasm than in other organic affections within the cranium. The vomit- ing mentioned comes on without cause, being not accompanied by nausea, nor is it particularly related to the ingestion of food. It is designated reflex or cerebral or central vomiting. Special local or focal symptoms are of importance in deter- mining the location of the growth. If it be located in the frontal lobe, there will very likely be undue mental apathy, unless the tu- mour itself produces much irritation or protrudes into the orbital cavities, where, of course, ordinary methods of diagnosis will de- termine. The peculiar incoherency of mind in frontal-lobe disease is a symptom, if taken in conjunction with other signs of tumour, that is of great value. Keen has laid great stress upon tenderness over the site of the tumour. This is of value only in cortical growths, where it may be a distinct help. If the tumour be localized in the motor cortex of the brain, there will be convulsions, focal in character, due to the location of the tumour, and later in its growth paralysis of the same parts will follow. If the tumour be located in the parietal region, sensory changes may be found associated probably with mind-blindness or asteriognosis, depending upon the location of the growth. A tumour in the temporo-sphenoidal lo"be would produce word- deafness. A tumour in Broca's region would produce motor aphasia. A tumour located in the corpus striatum would produce a pare- sis of the opposite side without convulsions, and likely disturb- ances of temperature, due to the involvement of the centre for heat regulation within the striatum. A tnmour in the optic thalamus would produce hemianopsia, and within the anterior part the Wernicke pupillary inaction symp- tom; whereas, if posterior to the thalamus, the centre for pupil DISEASES OF THE BEAIX AND MEMBEAXES 211 contraction not being involved, we would not have the symptom present accompanying the lateral homonymous hemianopsia.. A tumour in the corpus callosum will produce symptoms simi- lar to subcortical tumours from which they cannot be distin- guished. A tumour in the cerebellum produces a most marked choking of the disk, is typical, and in addition there is titubating gait, with other evidences of ataxia, frequently manifested in the hands, as athetosis. Knee-jerk would be vacillating and early increased. Later it may disappear, mostly in cases involving the middle lobe. Gyrus Uncinatus. — Tumour here will produce perversion of sense of smell — anosmia, hyperosmia if involving the olfactory bulb or nerve. Gyrus Fornicatus. — Tumour in this region will be evidenced by a loss of sense of smell. Cuneus. — Tumour will produce, when located in this region, mind-blindness and hemianopsia without the Wernicke sign. Sensation of taste may be disturbed when the tumour reaches the centre of the glosso-pharyngeal and facial nerves (chorda tympani). Tumours of the meninges will cause a greater amount of pain than if the growths develop in the brain structure, since the sen- sory nerves are in the dura, and are therefore irritated. Pathology of Brain Tumours. — This will entirely depend upon the nature of the growth, whatever that may be. There is always found about the neoplasm a subacute inflammatory process with round-cell infiltration and more or less serous exudate. The brain is apt to become oedematous from interference with the circula- tion. These points should be particularly remembered, since they give rise to symptoms which are necessary in the diagnosis of the case. In a case of Weir Mitchell's, the localization of the tumour was confirmed by autopsy, although the localizing symptoms were entirely masked in the later course of the affection by the circula- tory disturbances already referred to. Diagnosis. — This is a difficult matter indeed. The principal disease to be confused with it is abscess, where the history of septic process about the cranium will be an important point to be taken into consideration. The excursion of temperature above or below normal will also assist in the diagnosis. Chronic men- ingitis and sinusitis from the pain alone are likely to be confused ^13 TEEATISE 01^ :N^ERV0ITS DISEASES with tumour, but are wanting in localizing symptoms, and in the intensity of the choked disk seen in tumour. Prognosis. — This is bad, biit 7 per cent of the cases are oper- able, and just this per cent has a chance of recovery. Treatment.- — Beyond surgical there is little to be done; med- ical treatment is simply palliative, such as in the use of iodides, mercury, or other alteratives. Hygienic guarding of the patient is essential above that of all other brain affections. Pain must be controlled by morphia. A pill of camphor monobromate, gr. iij, often affords relief. CHAPTER XII INFLAMMATIONS OF THE MEMBRANES OF THE CORD AND UNCLASSIFIED DISEASES External pachymeningitis involving the dura mater ; internal meningitis in- volving the dura mater ; leptomeningitis involving the pia mater ; hyper- trophic pachymeningitis involving both dura and pia. Inflammations of the Dura (Pachymeningitis). — a. Pachymen- ingitis externa is a secondary inflammation, but is occasionally met in the acute form following caries, tumours, aneurysms, or syphilitic affections of bones. An abscess may penetrate the spi- nal cord, or the inflammation may be set up in the peridural tissue in long-standing cases of decubitus, pachymeningitis re- sulting. Symptoms. — These are usually those of compression myelitis. The chronic form of external pachymeningitis is most commonly secondary to tuberculous disease of the spine (see Myelitis in Pott's Disease, Chapter XJ ; hence the vertebral disease is impor- tant in the production of symptoms. This form is apt to be local- ized to the site of Pott's disease. The internal surface of the dura may be perfectly smooth and in some cases but slightly ad- herent to the arachnoid. The external surface is rough and cov- ered with a cheesy substance. In some cases this material is chiefly anterior to, and in other cases it completely surrounds the cord. h. Pachymeningitis interna is usually found located in the cer- vical region. The space between the cord and the dura is occu- pied by a form of concentrically arranged fibres, developing within the dura, and not on the outside at all. The condition is similar to ha?morrhagic paeliymeningitis interna of the brain. The cord is usually compressed, the central canal dilated (hydromyelus), and there are secondary degenerations. The nerve-roots are in- 213 214 TREATISE OX XervOUS DISEASES volved in the growths and are damaged and compressed. The disease is chronic and may he limited to one segment, or in the greater number of cases it actually involves a con- siderable portion of the cervical enlargement. Symptoms. — Intense pains along the nerves whose roots are involved are present. There may be hypersesthesia or anaes- thesia with numbness and atrophy of the interossei, hypothenar and thenar groups. The arms be- come weak;, the extensors may remain intact while the flexors are affected, producing the so-called " claw-hand " — main en grijfe. At times the sec- ond stage also, of the French,- consisting of in- volvement of the lower ex- tremities and introduction of spastic paralysis, may >upervene several months later, due to secondary de- generation in the cord. The disease runs a chronic course, lasting two or more 5'ears. In a few instances in which symptoms point- ed definitely to this condi- tion recovery took place, and I have no doubt that not a few cases of amyotrophic lateral sclerosis that have been reported much improved by several observ- ers are cases of pachymeningitis interna with complete absorption of exudate. Diagnosis. — (a) The external form is diagnosed by the con- FiG. 5:3.— Chronic Cervical Tubercular External Pachymeningitis. (Specimen from case of complete diplegia in the Phila- delphia Hospital.) (o) Site of tubercular deposit at site of kyphosis ; (0) Cauda. IXFLAMMATIOX OF MEMBRANES OF COED 215 currence of Pott's disease, the absence of atrophy of muscles, and the usual seat being in the dorso-lumbar region of the cord. (&) The internal type is diagnosed first from amyotrophic lat- eral sclerosis by the fact that severe pain does not occur in the latter ; from syringomyelia by the absence of sensory changes char- acteristic of gliosis ; and from tumours by the more localized symp- toms in neoplasm. Prognosis. — This is to be guarded, since some of the most marked cases have been greatly improved to the surprise of the neurologist. Given a case in which the disease has been stayed with physical health of the patient maintained, and vs^here great contractures or atrophy of the part has not occurred, the prog- nosis may be guardedly given as favourable to partial restoration of the health, at least. Acute fulminating cases from the begin- ning usually end in the death of the patient. Even in cases that have apparently recovered any undue exertion or exposure to heat is apt to cause recrudescence. Treatment of either form is the same as for that of other types of meningeal inflammation. LEPTOMENINGITIS This is a condition closely allied to pachymeningitis physio- logically, although pathologically pachymeningitis consists of in- flammation of the pia. Practically these inflammations are asso- ciated more or less in every case. Leptomeningitis is more likely to be acute or fulminating, due to the fact that it is, as a rule, a septic type of inflammation, and also is resident in the larger blood-vessels of the pia associated more intimately with the nerv- ous system. For this reason, even although the inflammation be not so severe, serious symptoms would result. The difference in the symptomatology between leptomeningitis and pachymenin- gitis would consist largely in the fulminating character of the for- mer, accompanied by much less pain in the back or over the site of inflammation, for the reason that the sensory roots are less im- pinged upon; but there is greater parah'sis in the parts below site of lesion, and also the greater liability to decubitus. Lepto- meningitis is seldom a chronic disease, hence there are no special symptoms described for the latter, since that would be clinically the same in all respects as pachymeningitis chronica. Prognosis. — This is uncertain. It will depend largely upon the 216 TKEATISE OK NERVOUS DISEASES degree of infection and the extent of involvement of the cord. Where there is early involvement of the multipolar nerve-cells there is usually decubitus^ accompanied by great palsy and disturb- ance of the bladder as well as of the rectum, the patient usually succumbing within a few days. Such cases rarely recover without chronic myelitis and paraplegia being the result of the leptomen- ingitis. Fig .54. — Atrophy of Interossei, Thenar and Hypothenar Muscles of Both Hands; (also of Shoulder Girdle and Pectoral Muscles) in a case of Infectious Pachymeningitis Cervicalis Hypertrophica. (Medico-Chirur- gical Hospital.) Hypertrophic packymeiimgitis involves both pia and dura. It is usually septic in origin. The gonococcus may be the organ- ism acting as exciting cause, as in the case under our care shown in the illustration (iFig. 54). Treatment of Pachymeningitis and Leptomeningitis. — This consists of absolute rest in bed in a quiet, darkened room, the appli- cation of ice to the spine, and the use of counter-irritants, such as UNCLASSIFIED DISEASES 217 strong tincture of iodine over the site of the inflammation, of blis- ters, or the actual cautery, repeatedly applied, in chronic cases. In the acute form general antiphlogistic measures may be necessary, such as cold sponging or the cold pack ; or by antipyretic drugs cau- tiously used, such as phenacetine and antipyrine. It may be neces- sary to give small doses of morphine to control the pain. If there are convulsions, the use of bromides and chloral, mixed, in fairly large doses, will be indicated. A 15-per-cent ointment of soluble metallic silver used by inunction in dram doses is a valuable rem- edy in septic cases. In chronic cases, if convulsions persist, admin- ister ether for their control. If contractures follow, orthopaedic treatment may be necessary, such as tenotomy, or extension of tire contracted limbs. This, of course, should be resorted to after it is evident that massage and Swedish movements prove of no avail. The use of potassium iodide is valuable as a remedy in chronic cases for the absorption of the exudate. This drug should be pushed to its physiological limit and continued for many weeks. In cases of paraplegia, resulting from pressure of exudate or actual inflammation through extension from the pia to the cord, the treatment will be that of the existent sequent myelitis. CAISSON DISEASE Synonym: Diver's disease This is a disease with marked nervous manifestations, induced by the long submergence of the body in air at high pressure. It is doubtful if the affection would develop, until very late at least, were the body kept in a gradually increased atmospheric pressure. Etiology. — As indicated above, the affection is caused by the sudden change from increased to decreased pressure of the atmos- phere. It is probably due to the enfeebled vaso-motor nervous sys- tem. Divers are particularly subject to this, hence the name of diver's paralysis. The pressure that will induce diver's paralysis must be more than three atmospheres. Symptoms. — It is characterized by a paraplegia, less frequently general palsy, appearing on returning from the compressed to the surface atmospheric pressure. These symptoms are more likely to develop on rapid change from the high to the ordinary atmos- pheric pressure. They may supervene shortly after leaving the 218 TREATISE ON NERVOUS DISEASES caisson or may be several hours in their development. In the mildest forms there are pains about the knees, which are often of great severity. Abdominal pain and vomiting are not uncommon. The muscles may be tender to the touch and the patient walk in a spastic fashion. Accompanying the other neurologic symptoms there is dizziness and intense headache, which later may, however, occur without vertigo. In the severer forms we may find com- plete motor and sensory paraplegia, a monoplegia or hemiplegia being rare. The most extreme attacks resemble apoplexy; pro- found coma, and death, rapidly supervenes within a few hours. Prognosis. — In cases of paraplegia the outlook is usually good. The palsy may pass off within a day or may continue for several months. Pathology. — This is indefinite, although it is probably a vaso-motor disturbance in the simple cases that recover. In the severer cases there have been found, as in the case of Ley den, foci of haemorrhages and evidence of acute myelitis. Fissuring of the cord sometimes occurs, some authorities believing it to be a constant phenomenon. It has been suggested that this condition is due to the freeing of nitrogen within the cord, the element having been absorbed by the blood under high pressure. Treatment. — The patient should be kept quiet. Pain must be controlled by analgesics, such as morphine, etc. Inhalations of oxygen and the use of compressed air has been advised. Paral- ysis should be treated as any other form of palsy of similar type. As a prophylactic measure divers should pass gradually into the compressed-air chamber. According to A. H. Smith, at least five minutes should be allowed for each additional atmospheric pres- sure. Another prophylactic measure consists in bringing the patient very slowly into the normal atmosphere; as we have indi- cated should be the case in entering the compressed-air chamber. Ergot is a remedy which may control the vaso-motor nerves in cases where there is paralysis of vaso-constrictors. It should be given hypodermically in half-dram doses. Bandaging of the limbs has also been advised. UNCLASSIFIED DISEASES 219 LANDRY'S DISEASE (ACUTE ASCENDING PARALYSIS) This is a disease probably of toxic nature, more frequent in males, and coming on in cool weather in the greater number of cases, as though the temperature had something to do with its pro- duction. It is in all probability due to an autocthonous poison. Symptoms. — A case of Landry's disease, or ascending palsy, if it be typical, consists of a fulminating onset of paralysis, begin- ning in the lower extremities, and ascending rapidly to the trunk and upper extremities, the head muscles escaping. It usually occurs between twenty and thirty years of age. The symptoms are frequently preceded by moderately high temperature. Nausea occurs, but gastro-intestinal disturbance is not a particularly nota- ble feature of the disease. There is a sense of parsesthesia, to a slight degree only, in the extremities, but no other distinct sen- sory disturbances. While the reflexes are absent there is no ten- derness of nerve-trunks and no involvement of the sphincters of the bladder or of the rectum. The patient is almost completely paralyzed, as above described, within seventy-two hours after the onset of the disease, and may not be able to move a muscle below the head; the chest expansion being very little, cardiac rhythm irregular, sometimes very rapid (tachycardia) ; the respiration being carried on entirely by the diaphragm through the phrenic nerves. The external respiratory nerve coming off lower down from the cord being affected, leaves the motor function of respira- tion alone to the phrenic nerve. Involvement of the pneumogas- tric nerve frequently occurs, which is another serious cause of em- barrassed respiration, heart action, and cord function. This is often the cause of the sudden death which usually supervenes at the end of a week or ten days. There have been no cases recorded, such as those described, that recovered without leaving some dis- turbance or serious alteration of the nervous system as a sequelae. A case under the writer's care may be referred to, where the man is to-day the subject of chronic muscular atrophy with main en griffe or claw-hand. So that cases that do recover are generally those where the symptoms will have been proved to be the result of some definite lesion, and not those in which the pathology has not as yet been understood or discovered. In some instances the paralysis may be descending in its initiation and sequent course. 220 TREATISE OX NERVOUS DISEASES Diagnosis is therefore as between this disease and multiple neuritis, if any difference at all exists, the only point being that the cases that have recovered present signs of multiple neuritis or involvement of the cord. The fatal cas6s, through the rapidity of their courses, do not develop pathologic changes that are demon- strable by modern microscopic technique. Prognosis. — This should be put down as absolutely fatal. Pathology. — In some cases diffuse nwelitis or neuritis has been found. In others, the majority, no lesion has been detected. In one reported by the writer (Journal of Nervous and Mental Diseases, January, 1893), a multiple neuritis is the real cause of the clinical picture. Of course, these cases are taken out of the realm of Landry's palsy per se, but the clinical picture may be identical. A typical ease of Landry's palsy consists of no definite lesion; nor does the patient develop trophic changes, such as bed- sores. Treatment. — This consists in supporting the patient by means of strvchnine hypodermically, or by transfusion of blood by hypo- dermoclvsis of normal salt solution, in order to counteract the con- dition of the blood, which is undoubtedly toxic. The use of galvanism to encourage respiration and cardiac tone would be of importance in the cases where these fimctions are particularly hampered. Rectal nourishment is a procedure which will be of value, since any attempt to give food per or em might excite dan- gerous symptoms of respiratory or cardiac failure. If the case should survive, the after-treatment would be as indicated in chronic neuritis or m3^elitis— i. e., massage, galvanism, alterative drugs, as iodide of potassium or the so-called Donovan's solution, the liquor arsenii et hydrargyri iodidi (a 1-per-cent solution), given in 3- to 5-minim doses thrice daily. We know of no better alterative remedy in chronic non-specific inflammatory states than this drug. The use of crutches may be necessary to get the patient about. In all chronic palsies we wish to again urge getting the patient into action soon, since use stimulates function ; otherwise hysteria may soon become a part of the clinical picture. CHAPTEE XIII DISEASES OF TEE SPINAL CORD MALFORMATIONS OF THE SPINAL CORD— SYSTEM DISEASES {General considerations) Theee are some thirty diseases of the spinal cord. The ma- jority are organic and come under the head of inflammations and of degenerations or system diseases. Organic diseases the result of injury and inflammations are most common. Functional dis- eases of the cord alone are rare, such as the so-called " irritable spine/' which latter, too, is associated with general functional dis- eases, as hysteria. Etiology. — Most causes come under injur}', auto-intoxications, poisons from without, exposure, infectious diseases, and excess of functionation. Middle-aged persons are more liable to these affections. Heredity may play a part in the predisposition due to vulnerable nerve-tissue. Symptoms. — These all come under the head of irritation, de- pression, and of perversion. Irritative symptoms consist of pains, paraesthesias, hyperassthesias, and feelings of constriction around the waist, rigidity, spasms, exaggerated reflexes, and irritability of the visceral and vascular functions. The symptoms of de- pression are those of anaesthesia, ataxia, palsies, wasting, and loss of control of viscera, as of the bladder. In cord disease para- plegia is the common form of palsy. S}Tnptoms of irritability and depression often accompany each other. The more super- ficial, the more irritative signs exist; the more central, the more paralysis and visceral weakness prevail. In meningitis and men- ingeal affections there is much pain, and vice versa, as to cord diseases j^er se. Pathology. — Inflammation of the cord membranes is not un- common; ])ut primary inflammation of the cord itself is unusual, > 221 32a TREATISE ON NERVOUS DISEASES since most of the diseases that used to be called myelitis are sec- ondary to injuries and softenings. Tabes and progressive muscu- lar atrophy are given as " system diseases " by most writers, be- cause they affect certain long-fibre tracts or groups of cells; but this name implies too many restrictions, hence it is retained only as a matter of convenience. Secondary degenerations alone are sys- temic. The cord is not infrequently the seat of abscesses, haemor- rhages, or tumours. Diagnosis. — In making a diagnosis of cord diseases help comes through a thorough knowledge of cord functions. Physiology land anatomy point out the signs and symptoms more clearly than in any other part of the body. (See Chapter I.) Prognosis. — Spinal-cord tissue once destroyed can never be renewed to more than a very limited extent. This regeneration applies to the nerve-fibres, jiot the cells. The diseased cord fre- quently adjusts itself to the pathological damage; but again, in- jury is very likely to extend by the process of secondary degen- eration so rapidly that compensatory function cannot take place. The special diseases of the cord are as follows: (1) Malformations: Myocele, meningo-myelocele (spina bifida), meningocele, heteropia, amyelia, micromyelia, macromy- elia, double cord. (2) Vascular disorders: Ansemia, hypersemia, haemorrhage, endarteritis with aneurysm, embolism, thrombosis, oedema. Sec- ondary to these conditions are softenings, myelomalacia, and scle- rosis. (3) Inftmnmations : Meningitis, myelitis, abscess. Also sec- ondary softening and sclerosis. (4) Degenerations: Primary: Locomotor ataxia, combined scleroses, hereditary scleroses, progressive muscular atrophy, and similar affections. (5) Syphilis: Meningo-myelitis, gumma, single or multiple, and specific endarteritis. (6) Tuberculosis: Miliary and solitary. (7) Tumours. (8) Functional and toxic disorders. DISEASES OF THE SPINAL COED 223 MALFORMATIONS Spitia Bifida {Rhachischisis Posterior) This is a congenital hernia of the spinal membranes^ sometimes of the cord, through a cleft in the vertebra caused by absence of the vertebral arches. It is therefore more of a malformation of the vertebral canal rather than of the cord, although this is not always so, for the cord and its membranes may be found in a con- dition of agenesis at the site of canal malformation. Etiology. — About 1 in 1,200 children are thus affected (French statistics). It may be associated " with hydrocephalus or with some other defect of development, such as imperforate anus or pharynx, or of ventral hernia. Heredity may be a factor in its causation. It is not due to dropsy of the cord, but is a true malformation. It is more common in males. Varieties. — There are three forms described: (1) Spinal meningocele is a condition in which the spinal membranes alone protrude into the sac. (2) Spinal meningo-myelocele is a form in which the mem- branes and cord both pass into the sac. (3) S3'ringo-myelocele (hydrorhachis- interna) is a form in which the fluid is in the central spinal canal and the inner lining of the sac is formed by the meninges and thinned-out spinal cord. Anatomy. — The most common are the first two types, wliich are called hydrorhachis externa. The fluid lies in the subarach- noid space, hence the wall of the protruding cyst is lined with the dura and arachnoid. The nerves and cord protrude into the sac in two thirds of the cases, forming a meningo-myelocele, but in some only a few nerves are found. When protruding into the sac they lie on the posterior and median surface, being attached and forming part of the wall; hence the spinal nerves start from the wall of the sac and go back into the vertebral canal. Be- sides the above-noted contents the tumour contains fat and con- nective tissue. The external surface is often red, flattened out, and smooth, and there is sometimes a depression on its median surface where the cord is attached. Symptoms. — Spina bifida generally occurs in the lumbar and sacral regions, since the laminas here are the last to solidify. But two or three vertebrge are usually involved. The tumour varies from 1 inch to 6 or 7 inches in diameter. It may be sessile or 224 TEEATISE ON NEEVOUS DISEASES be pedunculated. The outer skin is often glossy, or tough, thick- ened, or ulcerated. Children with spina bifida are usually very poorly nourished or inherently feeble, and as a rule poorly developed mentally. In over 50 per cent of the cases paraplegia is found associated more or less with ansesthesia or involvement of the sphincter muscles. Contractions and contractures may occur, causing various phases of acquired talipes. Prognosis is grave, being best for meningocele. The patient may live in such cases to early adult life, but injury or infection may occur, and the patient be carried off by secondary myelitis. Diagnosis is fairly certain. Usually it is only necessary to exclude congenital tumours which happen to be located in the lumbo-sacral region. • The most important question to decide is w^hether the cord and nerves are present in the sac, which is very probable if there is much paralysis, ansesthesia, or sphinc- ter trouble, or if there is a depression on the median external surface. The passing of an aseptic insulated needle connected with a galvanic battery may be tried in a difficult case. Treatment is entirely surgical, and of • avail only in menin- gocele. At present injections of Morton's fluid (iodine, gr. x; potas. iodid., gr. xxx; gh^cerin, §j), in dram doses, seem to be the most successful. These injections should be made on the outer portion of the sac, the child being kept on the back. Com- pression is dangerous if the fluid has been previously withdrawn. Opening the sac, excising, or ligaturing are most dangerous, especially if part of the cord should happen to be in the sac. In skilled hands surgical results have recently been more favour- able. Operation should not be done within the first four months of life. MENINGOCELE OF THE CORD Meningocele of the cord is protrusion of some or a portion of the membranes of the cord from the canal. It usually occurs in the infant, being a congenital defect of closure of the neural canal, the bones and membranes themselves being involved. In some cases the cord itself protrudes. Symptoms. — 'No symptoms exist except the physical signs of protrusion of the tumour (which is usually in the lower lumbar, or in the sacral region of the cord) until at some later period in DISEASES OF THE SPINAL COED 335 life injury to tiiis mass sets up an inflammation, when the symp- toms of spinal meningitis and paraplegia will follow. The worst cases, due to the defect of the nervous system as well, will pre- sent typical signs and symptoms of paraplegia, with contractures, loss of sensation, involvement of the sphincters, bedsores, etc. Prognosis. — This will depend upon the degree of defect and the condition of the patient. More cases may pass through life undisturbed, but the existence of a tumour about the sacral re- FiG. 55.— Agenesis and Micromtelia. of Spinal Cord in a Male aged Forty Years ; also Lack of Development of the Acoustic Nervous Centres. (Philadelphia Hospital. ) gion is always a menace to life. Cases with paraplegia at birth will be very apt to succumb within a few months to a year. Treatment. — As in cases of spinal meningocele, treatment would be mainly surgical, if at all. This consists in compression and protection of the part. Removing the protruding mass, or the injection of carbolic acid or some other irritant into the tumour mass, with the hope of causing its disappearance, should of course only be done in selected cases. Heteropia is a rare malformation wherein masses oi gray mat- ter are found in abnormal positions. Van Gieson describes a false heteropia that may be caused by manipulation of the cord after death, in which case the displaced masses consist of nerve-cells or neuroglia. Amyelia, or absence of the spinal cord, can exist only when 15 22G TREATISE OX XEETOUS DISEASES the brain is absent^ although absence of the brain may occur without absence of the cord. In amyelia Ihe spinal nerves are usu- ally present. Amyelic monsters cannot live. Double cord is very rare, and involves only a part of the cord except in cases where there is a double vertebral canal. Double central canal is not rare. It usually is found in only a part of the cord, and the two canals lie parallel. Asymmetry of the cord, usually due to abnormality in the course of the pyramidal tracts, is not so rare. Splitting of the cord and defects in development at special levels are found occasionally. Agenesis implies lack of proper development of the cord. (Eig. 55.) Micromyelia is a condition in which the cord is abnormally short or is small in size. The normal cord varies in diameter from 6 to 9 millimetres (dorsal), 8 to 11 millimetres (upper cervical). 15 millimetres (cervical), and 12 millimetres (lumbar). SYSTEM DISEASES By reference to the chapter on i\.natomy will be found the division of the spinal cord into certain tracts or systems. A degenerative disease of these tracts is frequently confined to one or may extend to two tracts. The first is designated a simple sys- tem disease, and the second is stjded combined system disease. Both the peripheral and central motor neurons may be involved, singly or together. LOCOMOTOR ATAXIA {Tabes dorsalis ; posterior spinal sclerosis) Locomotor ataxia is a system disease, affecting the afferent or sensory tracts of the cord. It is divided into the following stages: 1. Preataxic. 2. Ataxic. 3. Paralytic. The prominent symptoms, as its name indicates, are ataxia, inco-ordination of gait, sensory disturbances, loss of reflexes; also accompanied by atrophic disturbances and impairment of the spe- cial senses. In tabes the bones are brittle. The symptoms confined to the preataxic stage are of shoot- DISEASES OF THE SPIXAL CORD 237 ing pains, coming on at irregular intervals, and usually in the legs, and principally in the calves. The patient may complain of a sense of numbness in the extremities, and may or may not have a sensation of constriction about the body, which is called the girdle- sense, or, if painful, it is called the " girdle-pain." The patient even now may develop the perversion of sensation, as of some- thing soft, when really walking on a hard surface like a pave- ment. At times there may be violent paroxysms of pain referred to certain internal viscera, the so-called " gastric crisis " being the most important and frequent one. This pain is located in the epi- gastric region, and is accompanied by vomiting and excessive secre- tion of the gastric Juice. The attack may last from a few moments to an hour or so. In severe attacks the prolonged weakness follow- ing may exist from one to several days. The sexual power is gener- ally decreased in this stage, although the appetite is frequently in- creased. There may be difficulty in urination. Upon examination of the eye, the so-called Argyll-Robertson pupil may be determined — this consisting of a lack of response of the iris to light stimulus, although accommodation reaction is preserved. In some rare cases there may even begin optic atrophy in this stage of the disease. Ataxic Stage. — This is the stage when the patient usually is seen by the physician, from the fact that he does not report for treatment until inco-ordination of gait actually sets in; or fre- quently from lack of diagnostic acumen of the physician the disor- der is not made out until this stage is reached. It is characterized by the ataxic gait, which consists in throwing the limbs forward, outward, and downward in an irregular and lax fashion, the heel descending first. The gait is more ataxic when the patient's eyes are closed or when he is walking in the dark. Since the cause of this symptom is the perversion or diminution of the muscular sense, the explanation of a better locomotion in the light or with the eyes open lies in the fact that the eyesight makes up for the im- paired muscular sense. Another symptom present and dependent upon the same disorder of co-ordination is the Romberg's sign, which consists of marked swaying of the individual, the feet being in the position of attention. The sway is more pronounced so soon as the eyes are closed. Other evidences of inco-ordination are shown in muscular movements generally, and particularly in these finer movements, as of the fingers, the patient being unable to write properly, the letters being slowly and irregularly outlined. 228 TEEATISE ON NEEVOUS DISEASES If the index-fingers of opposite hands are brought together there will be found to be great inco-brdination as they approach each other, or if brought to the nose the same phenomenon will be observed; this sign being also exaggerated by the patient clos- ing his eyes. A variety ^ of ataxia called static ataxia, frequently exist- ing, is detected by hav- ing the patient lie on his back, then elevating the legs from the bed in a fixed position. If in- co-ordination exists the patient is said to have static ataxia. Or it is tested for by the patient standing erect, eyes closed. If he sways badly, he also has static ataxia. The latter is the Eomberg sign, as indicated above. In this stage there generally is an aggression of all the other symptoms mentioned, though in the minority of cases the painful sensations become abated, and pargesthesia will become lessened or disappear in them. The patient loses his vigour, and there is usually muscular wasting and weakness, in spite of preservation of the digestive function. It will be found in 50 per cent of the cases that the optic nerves degenerate, this being a primary optic atrophy and not accom- panied by the choked disk of optic neuritis. The ataxic stage may last for many years, and during that time periods of exacerbation and remission of the symptoms occur, out of proportion appar- ently to the extent of lesion. This irregularity in such cases must be due to loss of nutrition for the time being, rather than to organic change in the cord. Fig. 56. — Standing Posture, Static Ataxia IN Tabes Dorsalis. (Philadelphia Hospital.) DISEASES OF THE SPIXAL CORD 229 Paralytic Stage. — This comes on very late in the course of the disease, and signifies muscular paralysis, associated with signs of paresis. In this stage the patient becomes bedridden; develops more or less atypical paresis or progressive paralysis of the insane, A very small per cent of cases reach this stage, since they are usually carried off by some intercurrent malady. The absence of the deep reflexes determined so early in the preataxic stage re- main persistently absent during the entire course of the disease. In some cases optic atrophy is an early symptom, and is so rapid in its onset and progress that this class of cases is given a dis- tinctive name, the so-called amblyopic form of tabes. In these cases it is frequent to find the ataxia held in some subjection or actually bettered with the onset of blindness. This is marked in a coloured man in my Avards at the Philadelphia Hospital, where on becoming totally blind the ataxia is much lessened ; so with the crises from which he suffered up to that time. Other cases of tabes may develop unusual symptoms, such as perforating ulcer of the foot, which is a very rare condition, occurring in not more than two per cent of the cases. There is a typical case of this complication in ataxia, a man, aged forty, now in the paralytic stage of the disease, at the Philadelphia Hospital, a description of which ulcer will be typical of the condition.- The ulcer extends from the base of the great toe on the sole of the foot, over the ball, is much indurated, but signs of inflammation are very slight; the nutrition of the surrounding tissue being at a low stage. The ulcer is sharply cut, -| by f of an inch in diameter, and extends down to the depth of f of an inch by a central sinus which leads down to the metatarsal bone. There is also a foul odour emanating from the sore, with considerable sanious discharge therefrom. It is not at all painful. Another unusual development in tabes is the arthropathy, which consists in enlargement of the joint, generally a large one, as the knee, due to a subacute trophic inflammation. The bones become porous, the synovial membrane lustreless or entirely dis- appears, the ligaments of the joints becoming so relaxed as. to permit of easy dislocation. Synovial fluid occurs in excess early, ])ut may later be absorbed, leaving a much relaxed joint. These joints are not painful, and only give disturbances by the enlarge- ment and weakness entailed. The hypotonia of the muscles about the affected joint exaggerates the deformity. (Eig. 57.) FiQ. 57.— Charcot Joints (Right Knee and Both Ankles) in Tabes. (Medico-Chirurgical Hospital.) DISEASES OF THE SPINAL COED 231 The characteristic feature of all cases of tabes is the dispro- portionate increase of inco-ordination to the small amount of muscular weakness per se and wasting; so that in some cases the patient will show very good strength of muscle when the ataxia is pronounced. Absence of the Argyll-Eobertson pupil, the other symptoms being present usually, but rarely occurs. Other unusual symptoms are the areas of anaesthesia, which are generally irregular in outline, and are situated upon the chest, over the shoulder girdle, or upon the upper arm, and disobey the anatomical rules in that they do not follow the nerve-trunks, nor apparently the segments of the cord in all cases. The duration of tabes will be on an average from three to thirty years. The disease is much more frequent in males, occur- ring at about thirty years in an average case. Etiology. — It is a parasyphilitic infection in over 90 per cent of cases, usually occurring from eight to fifteen years after the initial lesion; other causes being overwork, auto-intoxications, or chronic poisonings, such as of malaria, of which I have seen one case in a young man eighteen years of age. Patliology. — The pathology of tabes consists in sclerosis of the posterior columns of the spinal cord and the nerve-roots. The columns of Clarke and Bu'rdach are particularly involved. The spinal ganglia and roots are frequently affected. The peripheral nerves are occasionally diseased. The pia mater between the pos- terior roots is thickened and opaque, the posterior roots being enlarged, while in advanced cases they become thinner and more translucent. The spinal cord is reduced in size, and the poste- rior columns appear to be shrunken and present a grayish ap- pearance. The first sclerotic areas, as a rule, are found in the posterior roots, usually in the lumbar region and in the tract of Lissauer; next the columns of Burdach are affected, beginning along the median side of the posterior horns, spreading out towards the posterior median seeptum, finally involving, as in- ferred, the column of Goll ; and may ascend to the upper thoracic and cervical regions, the usual seat of lesion being confined to the lumbar cord. The fine fibers running from the posterior roots to the column of Clarke are also sclerosed, but the cells then are not usually destroyed, and consequently the direct cerebellar tract is rarely degenerated. Diagnosis, — Tabes should not be confused with any other dis- 232 TREATISE ON NERVOUS DISEASES ease, save possibly syringomyelia, where the dissociation of sensa- tion in the latter and muscular atrophies would be distinguishing points. Chronic multiple neuritis, with ataxia, would be deter- mined by the muscular atrophy again; also by tenderness over the inflamed nerves, so that in studying a given case the presence of shooting pains, absence of knee-jerks, the presence of Argyll-Rob- ertson pupil with or without optic atrophy, and history of syphilis, there would be very little doubt as to tabes being present. There is increase of knee-jerks in ataxic paraplegia. Prognosis. — While complete recovery rarely occurs, much can be done, however, to ameliorate the symptoms and to lengthen the period before the paralytic stage should occur. Ten years is an average duration. Treatment. — In an early case usually antisyphilitic measures are indicated, since it is possible that some remnants of the patho- logical exudate of the third stage of syphilis should exist, which the use of the iodides and mercury by the sorbefacient and altera- tive action may tend to dissipate. Prolonged active antisyphilitic treatment should not be carried on after it is noted that distinct improvement has not occurred. In debilitated cases a combination of cod-liver oil with the alterative drugs, as arsenic, should be em- plo3'ed. In anaemic persons the use of iron is indicated. If after a thorough trial benefit is not had, some of the following drugs may be used until the one is determined that particularly benefits the case. Arsenic given in the form of Donovan's solution, 4 drops t. i. d. ; or the chloride of gold and sodium, ^i_ gr. t. i. d. ; and the glycero-phosphate of lime or soda. Long-continued doses of sil- ver nitrate, | gr. t. i. d., have been found efficacious by some ob- servers. Strychnine may be resorted to in cases where there is much weakness, although, as a rule, strychnine is not an ideal drug, often making the patient irritable and exaggerating his ataxia on account of muscle stimulation. In addition to , drugs the patient should be instructed to abstain from alcohol, tobacco, and sexual indulgence, and he should have plenty of nutritious proteid food, fresh air, and sunshine. The overuse of the lower ex- tremities, as in a half-hour's walk, is baneful. Exercises shouldbe rather of a passive nature ; hence the ideal treatment for a case of tabes is the "rest cure," plus the use of massage and SM^ertish movements by an experienced manipulator. In mild cases, where, the patient is going about, the method first introduced by Weir DISEASES OF THE SPINAL COED 233 Mitchell and later amplified by Frankel is important. This con- sists in a series of educational movements, the patient lying on his back and approximating his toes and his fingers together, etc. ; finally walking along a crack in the floor and stepping over bricks placed upon the floor, with the eyes opened, then closed. As the patient improves he is instructed to do more difficult exer- cises, such as walking backward under the same conditions. • Warm sponge baths given at night are valuable in the relief of pain, and by the stimulation of secretion to the carrying off tox- ines from the system. The warm bath (temperature of 150° F.) must not last longer than fifteen minutes, and should be followed by a cold spray down the spine for two or three minutes, the tem- perature of the water being about 60° F. The entire procedure thus far should be folloAved by a brisk rub with a Turkish towel, in order to stimulate the superficial circulation, and thereby to relieve congestion about the posterior roots of the spinal cord. Another measure not used sufficiently for the relief of tabes, and especially the painful cases, is to resort to high altitudes, above- 5,000 feet, in a dry climate. Such cases I have seen benefited in Colorado and Kew Mexico. Suspension treatment is a valuable measure also in some cases to relieve pain. It consists in suspension of the patient by lift- ing the body to the tip-toes by means of a head-piece about the chin and occiput and under the elbows. The seance should last three to five minutes once or tv/ice a week. It relieves pain by stretch- ing the spinal ligaments and aiding circulation about the nerve- roots. Drugs to relieve pain should be only used with great precaution for fear that the patient may form the drug habit. Antipyrine can be given in 5-grain doses; a combination of the analgesics with codeine, ^ to | grain, is frequently very valuable ; a hypoder- mic injection of morphine, i to | grain, guarded by atropine, -s|-o of a grain, must be given to control crises. To relieve the tingling and numbness of the legs static electricity administered thrice weekly is good treatment; but more particularly is the use of the Faradie '^ dry brush " an excellent procedure in these cases. Coun- ter-irritation by blister or cautery over the lumbar spine at times acts remarkably well in alleviation of painful paroxysms. Of great importance is the nutritive state of the patient, which should be carefully watched at all times even to the holding 234 TKEATISE ON NEEVOUS DISEASES in abeyance all other treatment, since if nutrition is not pre- served improvement will not take place. Eed meats, eggs, oysters, cereals, good bread and butter and milk, in as large quantities as the patient is able to digest, are the ideal foodstuffs that should be employed. DISEASES OF THE MOTOR NEURONS OF THE SPINAL CORD Primary Lateral Sclerosis This is a disease characterized by a paralysis of the muscles, beginning usually in the lower extremities, and attended with in- creased reflexes, but unattended by muscular atrophy or sensory disturbances. This disease occurs most frequently between the ages of twenty and forty. It may appear earlier, as reported in a case by H. IST. Moyer in a child of five years. I have seen for some years a case with Sinkler, reported by that gentleman and myself in a paper on family diseases, already referred to. In this case — a woman about thirtj^-eight years of age — the disease began about twenty years ago, and has been very slow in progress. Some cases have been supposed to follow syphilitic infection, or to be caused again by hereditary syphilis or alcoholism transmitted from the parents. Others have appeared to be due to traumatism to the back, or to exposure to cold and wet, and to certain infectious dis- eases; or to excesses, predisposing to general physical debility through excessive drain on the nervous system. Symptoms.— "The patient first complains of rigidity with weakness of the muscles of the lower extremities, which may be associated with a sense of fatigue or dull pains, but never of an active character. The symptoms may first commence in one leg before the other is at all affected, or one may be affected more than the other. The loss of power is very gradual and not at all in proportion (as in ataxia) to the impairment of progression, which in this instance is due to spasticity. The extremity soon becomes rigid, so that on flexing the joint a sensation as of bend- ing a piece of lead pipe is transmitted to the examiner. If the movement is continued the rigidity lessens. The gait in the very beginning is slightly spastic, as shown by the patient wearing the shoes out at the toes or complaining of tripping over slight impedi- DISEASES OF THE SPINAL CORD 235 ments. Later the characteristic spastic gait prevails, and the feet appear glued to the ground and are pushed forward with effort. The toes are raised over obstacles with great difficulty. Voluntary effort increases the clonic and tonic spasms of the mus- cles, and owing to spasm of the adductor and stronger muscles the knees are kept close together, and in aggravated cases there is often cross-legged progression. The knee-jerks are markedly in- creased and ankle clonus well developed, although not so large as in cases of insular (or disseminated) sclerosis. The superficial re- flexes are slightly increased. Muscles are not wasted, excepting that resulting from disuse. They feel firm to the touch. The sphincters are not involved until very late in the course of the dis- ease. Sensory disturbances are absent, other than paresthesia, the result of circulatory disturbances from vaso-motor weakness. The upper extremities do not become involved until late in the course of the disease. Seldom do trophic ulcerations occur, but the affect- ed extremities are very easily frost-bitten. The patient may live many years in comparative comfort, other than the physical dis- tress of being thus disabled from active life. Pathology. — This consists in a degeneration in the pyramidal tracts. That this may occur primarily is not definitely settled, and many observers believe that degeneration of the pyramidal tracts alone cannot occur, except as a secondary degeneration due to lesion higher up. A few cases have been reported, however, in which no such primary lesion could be found. Diagnosis. — In transverse myelitis sensory symptoms are more pronounced, the disease is more acute, anaesthesia frequent, and the sphincters are early affected. In ataxic paraplegia the spasticity of the muscles is not so marked and evidence of lack of co-ordina- tion is present; involvement of the sphincter is also common. In amyotrophic lateral sclerosis there is muscular atrophy, not noted in the disease under consideration. Secondary degeneration fol- lowing cerebral apoplexy may rarely be mistaken for cases of pri- mary lateral sclerosis, in which one side is more affected than the other. The history of a previous apoplexy would, of course, settle the question. Hysterical paraplegia may quite often be difficult to distinguish. In lateral sclerosis rigidity of limbs is more pro- nounced when they are extended, and vice versa, a condition that does not occur in hysteria. Also the deep reflexes, while they may be increased, are not so much so in hysteria. True ankle clonus 236 TREATISE ON NERVOUS DISEASES is exceedingly rare in the disease under consideration. Other evidences will also be found, such as "stigmata'' or hysterical paroxysms, which are more frequent, too, in females. Prognosis. — The prognosis of the disease is steadily slowly onM^ard and downward until the power of progression is lost. The patient may live for twenty or thirty years, and die as the result of an intercurrent disease, although involvement of the bulb may through inhibition of the vagus cause death from heart fail- ure. Treatment. — This is not very satisfactory. Nitrate of silver, chloride of gold and sodium, iodide of potassium, etc., may be of service. Massage is a valuable agent in arresting muscular wasting. The electric brush is also of use in stimulating the cir- culation. The patient should be well fed, given the hypophosphites from time to time, and must be well protected with woollen cloth- ing. Strychnine is contra-indicated, as it excites the muscular spasms in already irritable muscle fibres. SPASTIC SPINAL PARALYSIS Spastic Paralysis This term applies to a form of paraplegia caused by (a) chronic myelitis, as well as to a (h) congenital disorder in which there is sclerosis of the lateral columns of the cord. There has been much controversy as to the latter, some giving the name of Lit- tle's disease to the diplegic or paraplegic forms of the cerebral pal- sies of childhood, though, properly speaking, this should be ap- plied to lateral sclerosis. Little first described the condition in 1846 and in 1877. In 1873 and in 1879 Dr. E. C. Seguin, of New York, described a condition of similar type which he called "tetanoid paraplegia." Erb and Charcot in France independ- ently in 1875 published articles on "spasmodic spinal paralysis" and "spasmodic dorsal tabes" respectively. After this there was much confusion. Finally, the spastic paralysis has been shown to be due to spinal, associated probably with cerebral defect. Etiology. — It is congenital and due to lack of development of the pyramidal tracts, which leads to a sclerosis of the lateral col- umns and to symptoms of spasticity of legs and arms, exaggerated reflexes, with some weakness, and at times slight atrophy. Pre- natal or natal in its origin, it is primarily an agenesis in the first DISEASES OF THE SPINAL COED 237 instance; or if caused at birth, as Little supposed, may be due to premature or forced deliveries. It may be a family disease. Symptoms appear shortly after birth, usually within a year, but may appear after the fifth year in family types, or even after maturity. There is a type of this disease I have seen where the spasticity remains entirely in the lower extremities, coming on at about fifteen years of age, and not affecting the upper extremi- ties at all. In the ordinary type it is, as inferred, difficult to dis- tinguish spastic spinal paralysis from the cerebral palsies (or ''birth palsies," so called). The lack of marked mental impair- ment is a point in differentiation, the brain seeming to be spared except for its motor areas being damaged. At times, too, lateral sclerosis cases occasionally gain in development, and some in- crease in the use of the limbs follows more than in cerebral palsies. The so-called " scissor-legs " frequently are found in these pa- tients, the crossing of the limbs being exaggerated in the efforts of walking.. The arms are much less affected than the legs. The throat and facial muscles may be slightly involved. In some cases the disability increases quite rapidly. There is no pain, however. The arms may later be contractured. Finally the patient becomes helpless. Epilepsy or mental deterioration may develop at the time of puberty or adolescence. Prognosis. — The mild cases that learn how to walk should be kept carefully at the practice of their muscles, when they may slowly improve and reach average health and adult age. Severe cases rarely reach adolescence, and generally die of some inter- current disease before the twenty-first year of age. Diagnosis. — It is distinguished from the cerebral (or birth) palsies by the absence of any material initial mental defect, micro- cephalus, or of epilepsy. From compression myelitis spastic paral- ysis is distinguished by the affection of the arms, the absence of pain, and of disturbance of the sphincters. Hereditary spastic palsy, which is also found to occur in families, begins later (at about the fifth year, see p. 238), and involves the legs chiefly. Treatment consists in orthopgedics, massage, and Swedish move- ments to prevent contractures and deformities. General nutri- tion must be carefully maintained; also the protection of the body from cold or extremes of temperature. Employment of tenotomy may be necessitated where mechanical treatment fails, in which case 238 TREATISE OS XERVOrS DISEASES braces should be applied to retain the normal position of the limbs, and the child then encouraged to walk about by means of the wheel crutch or other form of apparatus. Many cases have been improved so as to walk with some facility by persistence in this ■regard, and a hopeless life of invalidism stayed. HEREDITARY SPASTIC SPINAL PARALYSIS ^ This disease is of the family type, affecting different members of succeeding generations. It begins about the age of five, affects mainly the legs, runs a very slow course, is not accompanied by pain, ataxia, or visceral symptoms, and may continue for thirty years or more. The writer has two cases of this rare affection under observation where there seems to be a remission of all symptoms within the last six months. FRIEDREICH'S DISEASE, OR HEREDITARY ATAXIA This is a developmental disease, occurring in early youth, is more frequently met with in males than in females, and the symp- toms very frequently begin at about the tenth year, the patient having been in apparent good health up to that time, although undoubtedly of vulnerable nerve protoplasm. There may be found a history of heredity, although the affection is never congenital ; or there will be a history of syphilis or alcoholism in the progenitors, usually in the parents. Symptoms. — These cousist first in ataxia, very much like that of tabes, but accompanied by irregular choreiform movements, perhaps athetosis, as in a case reported by Swan and myself (Philadelphia Medical Journal, January, 1896). The speech is frequently affected in this disease, staccato-like and drawling, accompanied by dribbling of saliva from the mouth, inability to masticate food properly, and by dysphagia. The mental condition remains fairly good, although one is apt, from the mechanical de- fects, to appear feeble-minded, a condition similar to the pseudo- imbecility in some cases of spastic paralysis of childhood, where mental failure is exaggerated by the fact that the vocal muscles are 1 In all these so-called spinal spastic paralyses occurring in early life there must be some cerebral defect or agenesis, though the degeneration is largely associated with the lateral tracts of the spinal cord. DISEASES OF THE SPINAL COED 239 spastic. The Arg-yll-Kobertson pupil is not so constant as in tabes dorsalis, but there is often present nystagmus, usually bilat- eral. The knee-jerks are not constantly absent, though usually so, and may change from year to year in accordance with the in- volvement of the posterior columns, lateral columns, or anterior horns of the cord in varying degrees, and thus disturbing the physiological reaction of these parts as the disease picture changes. The patient may also develop club-feet — the equino- varus position being particularly common — due to contraction of the posterior leg muscles. Localized muscle atrophy is in evi- dence, and where this occurs fibrillary twitchings will also be found. Curvature of the spine is another symptom that may exist, dependent upon muscular weakness of the erector spinas group. Trophic joints are very rare indeed. Pargesthesia may exist. In Marie's cerebral type cerebellar gait exists. Pathology. — This consists in an overgrowth of neuroglia cells within the central nervous system, particularly involving the posterior roots and posterior columns of the spinal cord. In addition round-cell infiltration may be present in other parts of the cord about the anterior horns and in areas diffused through- "out the brain. It is undoubtedly the remnant of an embryological defect in the child, which by the developmental period first gives expression to symptoms, just as syringomyelia gives rise to symp-^ toms due to a gliosis commencing in prenatal life from defect in the embryo itself. Diagnosis. — This disease should not be confounded with any other. Diagnosis may lie between it and spastic paralysis of child- hood, which latter presenting increase of reflexes in the spastic condition with more marked athetosis and lack of atrophies, would be sufficient signs for the proper diagnosis of this disease. Insular sclerosis is told by the more pronounced nystagmus, increase of reflexes and its later development. From tabes, the earlier devel- opment of Friedreich's disease, the lack of crises, and the type of. movements (choreic) will make it clear. Prognosis. — The patient may live for many years, but usually does not reach maturity. Treatment. — This is solely palliative, and consists in proper nutrition ; hygiene, as to clothing and exercise, which latter should be limited, though systematic, and particularly in the form of 240 TEEATISE OX XervOUS DISEASES calisthenics towards preventing contractions; for which massage and SAvedish movements are also valuable agents. Drugs, sucli as potassium iodide, in small continuous dosage, also the chloride of gold and soda, -^-^ gr. t. i. d., and in atonic cases the use of strych- nine will be of great service. For the prevention of deformities, or where they exist already, the use of a " brace " may be necessary to the spinal column or to the lower extremities, and in some cases the use of crutches will be of value in permitting the patient to move about. These subjects are very liable to become bedridden, so that educational movements should be faithfully .tried. CEREBELLAR ATAXIA This is also an hereditary disease, and begins later in life than Friedreich's disease — from fifteen to eighteen years of age. Symptoms. — It is particularly characterized by the cerebellar or titubating gait added to the other sj^mptoms of ataxia. The knee-jerks are increased, diminished, or precocious in this dis- ease, but there is seldom found ankle clonus. The duration of the affection may be for many years (eight or ten), the patient generally dying of some intercurrent affection. Club- feet are very apt to develop, due to contractions, the gait being somewhat similar to that of ataxic paraplegia. The patient pre- sents no sensory symptoms. Pathology. — This consists in degeneration of cells of Purkinje in the cerebellum and the posterior columns of the spinal cord. Atrophy of the optic nerve may exist and nystagmus may be present. Treatment. — This is symptomatic. The use of the hypophos- phites and nutritional measures with calisthenics and Swedish movements as described under the previous disease. For the pre- vention of deformities of the legs braces should be applied by the orthopaedic surgeon. FUNCTIONAL DISORDERS OF THE SPINAL CORD Functional disorders of the spinal cord include those of irrita- tion or of depression coming under the head of spinal neurasthenia, or spinal irritation, or spinal exhaustion. These symptoms are described under the head of Neurasthenia (see Chapter XVI). DISEASES OF THE SPIXAL COED 241 CAUDA EQUINA The Cauda equina is made up of five lumbar, from five sacral and one coccygeal (Muller), nerve-roots. They lie within the dura, extending beyond the spinal cord some 15 centimetres. These distinct motor and sensory roots do not quite [ -. — ....■ TV unite until they pass out of the dura. The cauda begins at the lower edge of the second lumbar ver- tebra. The term conus is applied to the part of the cord below the second sacral segment. In this part (conus) the anterior root-fibres are smaller and fewer in number than the posterior or sensory root- fibres. Muller gives the arrangement of the vis- ceral centres as follows : Second sacral, erection centre; third sacral, ejac- ulation centre ; fourth sacral, bladder (detrusor) centre ; fifth sacral, sphinc- ter ani centre. Symptoms and Diag- nosis. — The diagnosis of cauda lesions involves a study of: 1. Lesions of the lower end of the cord. 2. Cauda compression, irritation, or destruction. 3. Lesions of the peripheral nerves. 1. Lesions of the loiver end of the cord generally come on rap- idly, in a few days, following myelitis, etc. There is little pain, and dissociation of sensation comes on late. 16 Fig. 58.— Tumour (Psammoma) springing FROM Dura, Lower Dorsal Cord. (Specimen from Philadelphia Hospital.) 242 TREATISE OX XERVOUS DISEASES Fibrillary contractions and involuntary twitcliings of the leg muscles occur. * Paralysis rapidly appears, involving the lower limbs in accordance with the segmental distribution of the nerves. It is a flaccid palsy and is followed by atrophy. The visceral cen- tres are involved. If the conus is not implicated the paralysis does not seriously involve these centres nor the muscles of the pelvic girdle. The motor symptoms are far more prominent than sensory symptoms. The cord being small is easily destroyed, and very little improvement ever occurs. 2. In disease of the cauda, since it is usually a neoplasm, the symptoms generally come on slowly. In injury the symptoms appear rapidly after the trauma. There is often severe pain in the bladder, in the sciatic distribution, and it is bilateral. Anass- thesia in the area of the sciatic nerves follows later. The paraly- sis is slow in development. The sensory symptoms are far more prominent than the motor at all times. The sexual bladder and rectal centres are later paralyzed. Sometimes prompt operation, as in tumour, will give quick relief. This should always be done where tumour is suspected, otherwise the case is hopeless as to cure. The symptoms in compression of the cauda without de- struction are like compression of the cord, but there is less motor disturbance, and there may be no involvement of the sphincters. 3. Lesions of the peripheral nerves (neuritis or injury) is rapid in onset. There are sciatic pains — tender spots along the nerve-trunks. ■ The lesion may be only unilateral, the pain being not so severe, and there is no m.arked antesthesia. There is little or no paralysis of the visceral centres, the sensory slightly pre- dominating. There is often a history of sciatica or alcoholism^ or injury. Examination may disclose the presence of a tumour or of some disease affecting directly the sciatic plexus; and the prog- nosis is favourable. CHAPTEE -XIY DIFFUSE AND FOCAL DISEASES OF THE SPINAL CORD SPINAL HYPERyEMIA, ACUTE AND CHRONIC 2Etiology. — Violent physical exertion, sexual excesses, amenor- rhoea, and certain poisons, as strychnine, are causes of spinal hyperaemia. It is also the first stage of acute inflammatory dis- eases. Chronic spinal liypercemia is rare. It may occur in the membranes as the result of meningitis or injury. There is no absolute knowledge of separate chronic hypersemia of the cord. Symptoms are of a sense of weight aroundthe loins, of heavi- ness, twitching of the muscles, a numbness, formications, and actual pain of a neuralgic nature, accompanied by numbness of the lower extremities. The sphincters may be involved. The symptoms are as inferred, usually confined to the lower extremi- ties. The position of the patient, as mentioned by some authors, can have but little influence upon symptoms due to spinal hyper- aemia. The signs and symptoms of chronic spinal hyperemia are much like those of spinal irritation. They will be described under that head. Pathology. — The circulation of the blood in the spinal cord, as has been shown in the chapter on Anatomy, is one which is diffi- cult to disturb ; but if so, if is slow in being brought back to nor- mal. The violent activity of the heart and great increase in arte- rial pressure, and then the weakened state of the heart muscle and lowered tension, appear to modify but little the spinal functions. Hence it is unlikely that the large number of clinical symptoms that have been attributed to the circulatory failure are so caused. Treatment. — This consists in the application of cups to the back, rest in the horizontal position, better upon the side or face, counter-irritation to the spine, or the use of cold, as in the form of ice-bags. Among drugs the employment of bromides and mor- phine is good treatment. The sorbefacient and alterative effect of 243 244 TREATISE ON HERYOUS DISEASES chloride of ammonium and the iodides is recommended ; or the use of galvanic electricity, the negative pole being placed over the- spine and the positive at some indifferent point (5 minutes). SPINAL ANEMIA Spinal anaemia is less known in its cause, symptomatolog)^, and course than is hypergemia. It is more apt to affect the posterior columns than the ventral aspect of the cord, for the reason that the dorsal nutritive arteries are smaller than the an- terior ones. Severe hsemorrhages or extreme diarrhoeas may be predisposing factors by causing general anaemia. Or aortic obstruc- tion, as in aneurysm, may be the cause (through cutting off blood supply to the cord) of almost total abolition of cord function. It is not common for serious disturbance of the cord to persist from anemia excepting where there is disease of the arteries, and in that event the sclerosis of the posterior columns may follow in the wake of an added pernicious anaemia, in which latter the general symp- toms overshadow those of the spinal cord. The test of the patient's improvement when lying on his back is perhaps incorrect. Some writers associate with sjoinal anemia a class of symptoms such as pain in the back and weakness of the legs,- which may amount to paraplegia, a group of symptoms that has been given the name of spinal concussion, but it is impossible to scientifically state whether spinal anaemia is the underlying condition in such cases. SPINAL HAEMORRHAGE Spinal Apoplexy This general name may be given to (1) hsematorrhachis or spinal meningeal haemorrhage, and (2) hsematomyelia or hsem- orrhage into the cord substance. (1) Spinal meningeal haemorrhage is the most usual form, and may be extradural or intradural. Extradural haemorrhage is the more usual disease. Etiology. — It is more common in men than in women. It also oc^-urs in newly born children. Falls, injuries, and fractures of the spine are the most usual causes. Convulsive seizures due to epilepsy, tetanus, chorea, eclampsia, or strychnine may cause it, the same as in severe muscular strain. The various dyserasiae fol- DISEASES OF THE _ SPINAL CORD 245 lowing infectious diseases, such as purpura, may cause it ; or it may be due to the bursting of an adjacent aneurysm, such as of the aorta or vertebral artery, and in very rare instances cerebro-spinal meningitis. - Symptoms. — There may be no ascertainable symptoms in minute hsemorrhages. In large hsemorrhage there is sudden se- vere pain in the back, shooting down the limbs, associated witlr- numbness, hypersesthesia, muscular spasm, generally of the back muscles; later, paresis, paralysis, and ansesthesia may follow, with disorder of the visceral centres. The disease is fulminating, reaching its acme in the course of a few hours. Remission may then occur, accompanied by slow recovery or followed by chronic meningitis. Death may occur very early from exhaustion. Diagnosis. — Injury, or childbirth followed by the sudden onset of attack, with irritative symptoms, as pain, which suddenly sub- side, point to extradural haemorrhage. In hgematomyelia there is less pain and irritation, but more marked paralysis and anaes- thesia. This is also true of crush of the cord from fracture or dislocation. In tetanus the symptoms are more gradual in onset and trismus is present. Prognosis. — If the patient survives beyond the fifth day there is a chance for partial or complete recovery. Usually the prog- nosis is most grave, the patient succumbing within a few days. Treatment consists of absolute . rest in bed, administration of sedatives and drugs to move the bowels and relieve pain. Local de- pletion may be tried, as by means of wet cups over the supposed site of lesion. The use of styptics, as suprarenal extract or min- eral acids, may be of service in the purpuric cases. The sorbe- facient effect of the iodides may be tried later; also the use of mercury. In chronic cases counter-irritation over the spine on alternate days for a fortnight may prove of value- by its alterative action. (2) Hsematomyelia. — Heemorrhage into the substance of the cord. Etiology. — This is not unusual. It may be due to vascular diseases or purpura hsemorrhagica, or may be secondary to tumours or to myelitis. Primary haemorrhage occasionally occurs in in- fancy, but it is usually found in males in early adult life. Accord- ing to Gowers, excessive coitus is a potent cause, as are injuries, ex- posure, overexertion, syphilitic endarteritis, or convulsive seizures, 246 TEEATISE OX XERYOUS DISEASES which latter may also be the cause of hasmorrhage into the skin and intermuscular connective tissue. Hsematomyelia may occur in old people with arteriosclerosis^ spinal apoplexy being produced, in- stead of cerebral haemorrhage. Symptoms develop rapidly, with numbness or weakness for a few hours. Then sudden paraplegia, or ataxia, or both. Often "the anaesthesia is dissociated — there being a loss of pain or ther- mic sense, with the retention of touch sense. The urine may have to be drawn on account of paralysis of the sphincters. The reflexes may at first be absent, but soon return and become exag- gerated. There is much pain in the back, and if the lesion is high up the anus and thorax are involved. The acute symptoms will have subsided within a fortnight, when the case becomes practically one of chronic myelitis. If improvement has not oc- curred, the symptoms will instead take on the character of acute myelitis, and death will soon follow. Pathology. — The blood-vessels diseased are those of the gray matter, which are in the ventral cord and under considerable ten- sion. The rupture of these vessels is due to fatty degeneration or to specific endarteritis. ]\Iiliary aneurysms are rare in the cord, such as not infrequently develop in the brain. Hsemorrhage may be the cause or the result of a myelitis. In the former case the clot may be absorbed, leaving a cavity as in the cord; or broken- down tissue may become the central foci of a myelitis. The hsemor- rhage is usually single ; it may be multiple. It is likely that cases of disseminated myelitis following infectious fevers are due to multiple ecchymoses. The bleeding at times is the result of new growth, as in syringom3'elia. Diagnosis. — Sudden onset without any long premonitory symptoms and the absence of fever followed by gradual improve- ment are characteristic of spinal hcemorrJiage. There is much less pain than in meningeal licemorrliage, while the dissociation of cutaneous sensation is very characteristic. In acute softening there is less of the dissociation of sensation, but a more extensive paralysis. The latter may be mistaken for acute primary myelitis, which does often follow. Meningeal haemorrhage is usually more painful, and there is less paralysis, more spasm, and a more com- plete recovery afterward. Prognosis. — This is often serious as regards life, and it is dubious as to recovery of power. Both much de]:iend on the DISEASES OF THE SPIRAL CORD 247 extent and seat of the haemorrhages. Dorsal hsemorrhages are more favourable, cervical the least. Treatment. — Cold to the spine, such as through ice-bags, asso- ciated with absolute rest, together with small doses of cardiac de- pressants, as aconite, can be tried. Treatment must be prompt if any good is at all to be done. The after-treatment is entirely symptomatic, and later it is for the myelitis that may follow as a seciuela (see Myelitis). SYRINGOMYELIA Is an affection of the spinal cord, which, while not more rare than disseminated sclerosis, has only been in recent years brought to full light. The disease was first accurately described by Sehultze in 1886 ; since that time there have been some hundred cases reported in the literature, and in the light of the pathological findings undoubtedly many obscure cases of cord disease reported in the past have been of this nature. There are two varieties of dilatation of the spinal cord: First, hydromyelia, which is a dilatation of the central canal, this being lined by the normal columnar epithelium. This condition may give rise to the symptoms of syringomyelia proper, similar to the second type, where the cavity occurs within the gray matter of the cord, but, as a rule, is separated from the central canal. A cavity or cavities in this instance are the result of softening areas in glio- matosis in the gray cord. The latter condition is probably hered- itary, being an unnatural excess in development and continuance of the formation of this embryological tissue. The cavities may be single, multiple, or consist of numerous dilatations connected by irregular and deviating sinuses; so that one opening may be in this manner connected with another at a distance longitudinally from the first one. One-half the cord may be involved alone, or be at least more diseased than the other half. The cervico-dorsal cord is the most frequent site of the disease ; although the medulla and pons, or lumbar and sacral cord, may be involved. That the disease has occurred following the infectious fevers does not particularly sliow them to be causative of the malady; so that the hereditary feature is the principal point in astiology, as alroadv indicated. 248 TREATISE ON NEEVOUS DISEASES Symptomatology. — Four distinctive types of symptoms exist in certain groups of cases of syringomyelia, viz. : 1. The ordinary type described above. 2. Motor type, resembling amyotrophic lateral sclerosis. 3. Sensory type, in which disturbances of sensation, particu- larly loss of thermic sense due to disease in Glower's tract, are prominent features. It may be hemiplegic in distribution, or in irregular areas. 4. Those cases with pronounced tro]3hic changes, painful whit- lows, etc., as described, by Schlesinger in 1895. The disease may re- semble a number of chronic cord diseases in its clinical aspect, de- pending upon the im- pingement of the de- structive lesion in vari- ous anatomico-physio- logical centres and tracts. Thus syringo- myelia may resemble tabes of an irregular type when the posterior columns of the white matter are invaded, or it may present particularly .he picture of progressive muscular atrophy of spinal origin if the dilatation occurs towards the anterior horns of the gray matter. In rare cases the disease may simulate spastic paralysis due to irritation of the lateral col- umns of the spinal cord; or in the rarest cases it may simulate in- sular sclerosis. So that given a case of chronic spinal cord disease of atypical or irregular manifestations, syringomyelia must be thought of. The particular symptom of diagnostic import is the dissociation of sensory phenomena — for example, there is usually loss of pain and temperature sense in irregular areas (analgesia and thermo-ansesthesia), with preservation of the sense of touch and muscle sense. If the cavity is on one side of the cord alone, and is of considerable size, we may have symptoms of Brown- Sequard paralysis, to be told from the usual type of "crossed Pig. 59. — Atrophy of Intrinsic Muscles of THE Hand and Thermo-An^sthesia in A Case of Syringomyelia. (Philadelphia Hospital.) DISEASES OF THE SPINAL COED 249 paralysis " of this sort by the absence of pain and temperature sense rather than the touch and muscular sense, as indicated; or as in spinal tumour or unilateral sclerosis, ansesthesia would be the sen- sory manifestation more particularly, or all forms of sensation would be absent. In cases where the cervical cord is affected high up the ascending branch of the fifth nerve may be affected, produ- cing anaesthesia of the face. From involvement of the cervical sym- pathetic, the pupil on the affected side may be contracted, and there may be an absence of sweating on the same side of the face. Lordo- sis or scoliosis may occur in cases where the spinal centres govern- ing the muscles of the spinal column are destroyed, this permitting muscular atrophies and consequent spinal curvature. In some cases motor cells of the spinal column are destroyed, permitting mus- cular atrophies and consequent spinal curvature. In many cases there is absence of the deep reflexes in the upper extremities; or if the disease descends low enough the knee-jerk may be absent — all depending upon destruction of the posterior roots of the spinal cord. The atrophy may extend to the lower extremities, and there may be reaction of degeneration found in the affected muscles. The course of the disease is slow, and may at any time come to a standstill. There may be remissions in the clinical course, no doubt due to extension of the process being abated. The patient may die from involvement of the cardio-respiratory centres in the medulla. Treatment of this affection is of little value, although gen- eral hygienic measures to control the circulation by means of proper woollen clothing and the protection of the individual against inclement weather is to be instituted. Such patients should live an inactive life in the open air and sunshine. Contin- uous doses of iodide of potash may do good in the minority of cases through the alterative and sorbefacient effects of the drug. Ee-education by exercises will prove of value where ataxia exists. Massage and static electricity may aid nutrition, better the cir- culation, and assist in staying the muscular wasting and sensory changes. 350 TEEATISE ON NEEVOUS DISEASES MUSCULAR DYSTROPHIES These are classed under diseases of the nervous system, although no constant pathological finding has been found in the nervous sj^stem. Palsy is, however, a constant neurological symp- tom of all of them. There are three forms of muscular dystrophies, so called : 1. Pseudo-hypertrophic paralysis (Duchenne). 2. Idiopathic muscular atrophy. 3. ISTeuritic form of muscular atrophy (Charcot-Marie-Tooth). (1) Pseudo-hypertrophic Paralysis. — The first, a disease begin- ning in early childhood, is a family type of disorder, although not known to be directly hereditary. The progenitors of the patient will be found to be alcoholics, subjects of syphilis, or some other form of degenerative disease. This has been satisfactorily proved to us in investigations made by Wharton Sinkler and the writer in a statistical study made in the Infirmary of Nervous Diseases of Philadelphia in 1899. ^ Males are more frequently affected, and several in the family may be picked out, others escaping. The age limit of five to ten is the most usual time of onset. The patient first complains of feebleness in progression, and it will be noted that there is slight toe-drop, that the calves of the legs are enlarged, which greatly increase, causing a sense of firmness to palpation. Other points of pseudo-hypertrophy may exist in the pectoral muscles, the del- toids, and about the shoulder-girdle. With the enlargement comes on an increasing weakness of the muscles involved (Fig. 60). An early and characteristic feature is difficulty in arising from a supine position. The patient contorts the trunk in the endeavour to aid the specially weakened extremities, beginning by pushing the body up with the hands upon the thighs, then forcing the trunk to the vertical, thus extending the trunk upon the thighs, then draw- ing the lower extremities into the erect posture. The characteristic attitude is the hand-over-hand method in pushing up the trunk with the arms, in bringing the body to the erect position. This characteristic sign of the paresis may last for many months. There is no true ataxia, however. The patient is seen to have difficulty in mounting steps, and will frequently trip over slight ' -Tournal of American Medical Association, November, 1899, Family Dis- eases. DISEASES OF THE SPINAL COED 251 elevations on the surface. Finally the patient cannot rise from the sitting position, and it will then be found that the^ muscles, which were apparently enlarged, have atrophied down to the nor- mal size perhaps, or beyond this, and are board-like to the sense of touch. Other muscles may pass directly into atrophy without any pre-existent enlargement. Reflexes. — The deep reflexes will be found lessened or absent 2 3 Pig. 60. — Pseudohypertrophic Paralysis showing Atrophy of Shoulder, Girdle, and Thighs ; also Manner of Rising in the Order 1, 2, 3. (Medico-Chirurgical Hospital. ) and the superficial reflexes diminished. The end picture in this malady is of extreme muscular atrophy and absolute helplessness. Coldness of the extremities, cyanosis, enfeebled heart action, and general lessening of the functionation of the special senses with mental deterioration, occurs later in the affection, with dribbling of saliva from mouth, difficulty in swallowing, etc. The average 252, TBEATISE ON NEEVOUS DISEASES duration of the disease is from one to twenty years, yet depending much upon the preserved nutrition and vegetative function of the patient; also upon his immunity or the absence of any of the complicating infectious diseases, which are particularly fatal in them. If not carried off by intercurrent disease, the patient may die of heart failure, from involvement of that organ. Pathology. — This consists of excessive deposit of fat cells within the sarcolemma, and fatty change and swelling, loss of striation of the muscle cells. Overgrowth of connective tissue also takes place between the muscle cells. As the disease progresses the disappearance of the fat cells takes place, connective-tissue growth predominates, and the muscle substance is degenerated, leaving debris and connective tissue instead. Diagnosis.^This should not be confounded with any other disease. In neuritis there is pain and tenderness of nerve trunks. Pro gliosis. — An incurable malady. There may be prolonged remissions. Treatment. — Much can be done to stay the progress of the dys- trophy. This consists in persistent, scientific use of massage to favour better circulation, as well as of the elimination of the products of catabolism, and to prevent retrograde change in the muscle cells. Nutritious diet, consisting of eggs, red meats, or any other nutritious proteids, is indicated. Vegetables containing iron are valuable in this disease, in which metabolism is so per- verted. In spinach iron can be introduced into the blood Avith least gastric disturbance. The overdistention of the stomach with carbohydrates is most certain to do harm. Predigested foods, as beef, is only called for when the stomach absolutely refuses to digest the more ordinary foodstuffs suggested. Electricity does not aid us much, although the static breeze may be of value in stimulating the circulation at the periphery, and to the carrying off of the waste products. The hypophosphites, phosphorus, and strychnine as a nerve tonic are all of value in this chronic disorder. Such patients should be carefully protected from cold and dampness, and given plenty of fresh air and sunlight, in a stimulating climate, at low altitudes. Sea air is particularly bracing. (2) Idiopathic muscidar atrophy is of two types: (a) the fascio-scapulo-humeral t^^pe (Landouzy-Dejerine), and (h) the juvenile form of Erb. (a) In the former the atrophy begins in the orbicularis oris and Fig. 61.— Progressive Muscular Atrophy of Spinal Origin (Anterior Pol- iomyelitis Chronica) showing Wrist-Drop, Atrophy of Hand Muscles, AND of Shoulder Girdle, and the Pectoral Muscles. (Medico-Chirur- gical Hospital.) 254 - TREATISE ON NERVOUS DISEASES the face, producing the hollow-cheek appearance, the so-called " tapir month," and accompanied by fibrillar}^ twitching of the mnscles involved. This atrophy progresses in the trapezius and deltoid muscles, upper part of the arms, until within six months or a year there is a very marked physical change in the appearance of the upper portion of the body. The patient is unable to adduct or abduct the extremities, and particularly to raise the arms on a level with shoulder. Finally, the atrophy extends to the lower part of the arm and interosseous muscles, the lower extremities becoming involved last, if at all, in proportion with the duration of the case. (&) The juvenile form begins in the interosseous muscles of the upper extremities, the thenar and hypothenar eminences, ex- tending to the upper arm, finally to the lower extremities — thighs and legs — the patient's progression being with feebleness and evident toe-drop. This occurs most frequently between the ages of twelve and sixteen. It is very slow in progression, the pa- tient living for many years. The vaso-motor weakness is shown by coldness and clamminess of the extremities, the indurated condition of the skin, brittle nails, etc. The deep reflexes are abolished early, but there is no reaction of degeneration, except in rare in- stances, very late in the course of the disease and where particu- larly large bundles of fibres are affected in the muscle atrophy. The sub-type known as progressive muscular atrophy of spinal origin has a similar symptomatology, but begins in early adult life. This is the so-called poliomyelitis chronica. At times there is pain, the marked feature being fibrillary contractions, also that it occurs later in life than the muscular dystrophies proper, and that in the pathology of the disease, in addition to atrophy of the muscle cells and overgrowth of connective tissue, there is a degen- eration of the multipolar cells in the anterior cornu of the gray matter of the cord. (3) The so-called neuritic type is that which begins in the perineal muscles, producing peculiar guttering in the perineal region of the legs, with infrequently a toe-drop, and the process gradually extending up the thighs, and finally affecting the gen- eral musculature. Pathology.— T\ie pathology of this affection is not known fur- ther than the involvement of the muscles in atrophy and over- growth of connective tissue. DISEASES OF THE SPINAL CORD 255 Treatment. — In all these difEerent forms of muscular atrophy it is largely symptomatic. Mechanical stimulation of the muscles directly by means of massage, Swedish .movements, or galvanism are to be assiduously applied. Static electricity is a valuable agent to promote nutrition and bettered circulation in the tissues. The orthopaedist should be consulted in many of these cases in order to prevent deformities as well as to strengthen joints en- feebled by the muscular disease, thus making life more useful in these patients, who might otherwise be prematurely crippled. The hypophosphites and cod-liver oil, plus a nutritious diet, con- sisting largely of proteids, with the use of eliminants, as copious draughts of water, the various mineral waters being particularly adaptable, are all agents of vital importance. Much can be done for these patients in the way of alleviation by persistent endeavour, even though cure is not established. Strychnine is of value in fairly large dosage — gr. j\ to j\ t. i. d. ANTERIOR POLIOMYELITIS ACUTA OR INFANTILE PARALYSIS This is a disease of sudden onset, more frequently seen in child- hood, and is probably of microbic nature. The disease is fulminat- ing, and is, as a rule, ushered in by a chill, followed by hyperpy- rexia (104° F. or more), accompanied by nausea and vomiting and general restlessness. With these there may be hypersesthesia and sensitiveness of one or more extremities. The fever lasts from several to forty-eight hours, as the case may be, when it will abate and the patient be left in a generally weakened condition, with palsy of one lower extremity, as a rule. Rapid wasting will super- vene in the paralyzed part, and at the end of ten da5rs or two weeks reaction of degeneration will be found in the paralyzed mus- cles. One lower extremity is generally involved, and the anterior tibial group more than other muscles, the next in frequency being the calf, the extensor femori, and the adductor muscles. Rarely an upper extremity is alone affected. There will be found an absence of the deep reflexes; as a rule the knee-jerk is wanting where the lower extremity is involved. The limb becomes cold, clammy, cyanosed, and wasted. If thg member is not totally para- lyzed, the patient will be able to limp about, and contractures, de- formities of the limb, such as acquired clubfoot, occur later. The 256 TEEATISE OK KERVOUS DISEASES disease A^ery seldom extends to other parts of the cord after the original attack; the patient generally recovers full and usual health. The paralyzed extremity does not grow in length as do the others^ and in consequence of the shortened limb there may be a spinal curvature as a remote consequence. The sphincters are never involved in the acute attack of infantile paralysis. Decubitus seldom results. The symptom of " palsy " is at first rather rapid in its partial recovery, then promptly progressive. In some cases the deep reflexes are retained or increased. It may occur in epi- demic form in spring and summer. Pathologij. — This consists of acute inflammation of the multi- polar cells in the anterior horns of the gray matter of the cord;, usually in the dorso-lumbar region. Following the inflammation there is found a degeneration of the multipolar cells, overgrowth of connective tissue, and molecular debris ; also degeneration of the nerves coming from this particular segment of the cord, with atrophy and fatty degeneration of the muscles supplied by them. Diagnosis. — In neuritis there is tenderness of the nerve-trunks, and as a rule it is less sudden in onset, with less severe palsy, though a more general and constantly progressive or regressive paralysis. Some cases of hip-joint disease may simulate infantile palsy only in inability to move the extremity. The hip-joint would be partially ankylosed in eoxalgia. The pseudo-palsy of rickets is always associated with that disease and there is little wasting and no history of an '''attack.'^ The knee-jerk is capricious. Pseudo-muscular atrophy or other local forms of dystrophies need but to be mentioned; as well as the cerebral palsies of child- hood, which latter are associated with spasticity; while the former are gradual in onset and widespread. Prognosis. — This depends entirely upon the degree and extent of involvement of the gray matter of the cord. An attack very seldom kills. If a few muscle-bands are affected, it is possible that almost complete recovery may occur with time and proper treat- ment. Where one member is markedly paralyzed usually consider- able power will be restored within a few months' time, when fur- ther recovery of the individual muscles will seldom take place. Treatment. — This consists in the management of the attack, which would be as of an ordinary acute infection, treating the hyperpyrexia, giving a calomel purge, and protecting the affected limb by carefully bandaging in cotton. After the acute stage has DISEASES OF THE SPIXAL CORD 257 subsided, the general nutrition of the patient should be looked after. The use of the hypophosphites and a careful dietary are important, the remainder of the treatment being entirely local. This consists in massage and galvanism to the paralyzed muscles, continued for months or years, depending upon the severity of the ease. If the child is able and there is no tendency to deformity, it can walk about; or if there be a tendency to deformity, the orthopgedist should be consulted with the hope of " bracing " the weakened limb to prevent deformity that may occur in such cases. A high shoe may be necessary for the paralyzed limb where there is marked slowness of growth in it. The use of strychnine is of value, and should be given in doses according to the age, over prolonged periods of time. In inclement weather these patients should always be well clothed. They should be especially well protected against cold of winter and sequent frost-bite. In eases where there is very little power remaining in an ex- tremit}^, a method of assisting the exercise of the muscles is by daily immersing the child in a warm bath and permitting him to " float " the affected limb about in the water. The weight of the water displaced by the member will be just that amount of relief of dead weight in attempted exercising. I have seen great good from this method of treatment in one case. GLOSSO-LABIO-PHARYNGEAL PALSY, OR BULBAR PARALYSIS Bulbar paralysis applies to a number of systematized symp- toms, due to diseases or lack of functionation in the centres in the bulb or oblongata (fifth, seventh, ninth, tenth, eleventh, and twelfth cranial nerves), and is divided into several varieties: (1) acute, (2) chronic, (3) asthenic, and (4) pseudo. Symptoms. — These may accompany other diseases, such as amyotrophic lateral sclerosis, etc. (1) The symptoms of acute hulhar paralysis are a sudden onset, dribbling of saliva, with the motor difficulty (dysarthria) of speech, and atrophy of the tongue. This acute form may be ushered in by an apoplectiform attack. It is also known as polio- encephalitis inferior. The symptoms are rapidly progressive, the patient losing the power to swallow. With the dysphagia there is loss of flesh. The patient is the subject of choking spells on attempting to swallow either solids or, in bad cases, liquids. In 17 258 TREATISE ON NERVOUS DISEASES. this affection the patient is perfectly conscious, bnt at times it is a cTifficnlt matter to determine whether the mind is affected or not, owing to the motor difficulty of speech. The latter is of a drawling nature^ the words being prolonged, the consonants first being affected ; finally the inability to pronounce words of more than, one syllable with any degree of distinctness. The patient, however, is able to write perfectly well. With this added fact, bulbar paral- ysis is easily diagnosed from any form of aphasia. The course of the disease is very rapid, and within three or four months' time the patient is in a very serious condition. Death is frequently caused by an inspiration pneumonia, or a sudden attack of choking; or from respiratory or heart failure, due to the involvement of the vagi centres. (2) The chronic type of bulbar paralysis is much slower in its progress. The symptoms — stuttering, dysphagia, regurgitation of liquids from the nose- on attempting to swallow — being more gradual in progress. The patient otherwise keeps in fairly good health, since the slowness of the process does not deprive him from getting ample nourishment until late in the course of the disease. The main difference between this and the acute form of the dis- ease lies in the rapid progress of the latter, accompanied by general wasting, and the slower progress of the former. The pathology of these forms is different in that in the acute types there is inflammation, a softening process, or minute haem- orrhages into the bulbo pons and cord, while the symptoms are apt to be consistently bilateral from the first; whereas in the chronic form, which is due to atrophy of the motor neurones, there is simply an aggression of the symptoms of one side out of propor- tion to the other, although both are involved. The duration of the chronic type is from eighteen months to three years. The patient may suffer from irregular cardiac action and attacks of tachycardia. It is somewhat singular that heart failure does not occur more frequently at the very onset of the disease, because of the involvement of the vagus centre. The prognosis of both of the above forms is unpromising. Results of treatment may but ameliorate. The treatment is more palliative than anything else, but con- siderable can be done in chronic cases to alleviate suffering by a careful attention to the manner of food administration, the use of the stomach-tube being a valuable method of feeding the DISEASES OF THE SPINAL CORD 259 patient. This should be done at regular intervals during the course of the disease, even when the patient can swallow only a small amount, since in this there is liability to "inspiration" pneumonia. The use of strychnine in fairly large doses ( -gV to ^-^ of a grain, t. i. d.) is of great value. The patient should live a very quiet life. Galvanism to the throat muscles is of value. Treat- ment of complications, such as pneumonia, is medical detail that need not be given here. (3) The astliefiic form of bulbar paralysis occurs later in life than the organic forms, and is more frequent in women than in men, occurring about the age of forty. It is designated asthenic because no definite lesion has as yet been determined, there being asthenia of the throat muscles. The pathology is very like an auto-intoxication due to deficiency of metabolism, weakening the bulbar centres. The muscles sup- plied by the motor cranial nerves are involved ; the centres are not able to generate or transmute nervous energy. Besides the symp- toms already rehearsed other characteristic features of this form of disease are the remissions which recur in it regularly from time to time. Thus a patient may be unable to speak save in a whisper or in very indistinct monosyllables for a week or ten days, bodily weakness being present at the same time, and within a fortnight the voice may have returned, the patient having become much brighter mentally, and physically stronger. Prognosis. — This is not good as to recovery, but the patient may live for many years in comparative comfort between the attacks, although harassed at frequent intervals by aggression of the symptoms. I have had the pleasure of observing a case of this sort with Dr. Wharton Sinkler at the OrthopEedic Hospital for some three or four years. (4) Pseudo-huTbar palsy is a type of progressive failure of the glosso-lahio-pharyngeal muscles unassociated by atrophy of muscles or general weakness. The lesion is very likely cerebral, affecting the upper motor neu- rones of the motor cranial nerves, particularly the ninth and tenth. Treatment of pseudo and asthenic bulbar palsies does not differ from that of the chronic type. Good food, out-of-door life, arsenic, strychnine, the hypophosphites and glycerophosphates being of importance; also the use of gavage. 260 TEEATISE ON NERVOUS DISEASES THE COMBINED SCLEROSES By the combined scleroses is meant those forms of degeneration in which both the lateral and the posterior columns are ajffected. Westphal first described the condition in 1867. There are several types : (1) Hereditary spinal ataxia (Friedreich's disease and hered- itary ataxic paraplegia). (2) Combined sclerosis in anaemic and toxic states (Putnam and Dana type). (3) Combined sclerosis complicating general paresis. (4) Accidental forms, as Gowers's ataxic paraplegia. The clinical pictures of the many reported cases of combined scleroses vary greatly. Such cases must be of chronic ascending myelitis or meningomyelitis followed by degeneration. Accord- ing to Marie and others, the vascular supply of the spinal cord is such as to favour sclerosis in the lateral and posterior columns, hence chronic leptomeningitis, many instances of which are due to syphilitic infection. The ataxic paraplegia described by Gowers, in which he believed the sclerosis lay in the lateral and posterior columns of the cord, is still observed as a clinical entity ; but many similar cases can best be classed with tabes, with insular sclerosis, or with a form of limited chronic myelitis. We shall describe, there- fore, only the hereditary form of ataxia with paraplegia, which is congenital and a family disease closely related to Friedreich's ataxia ; also the type of combined sclerosis in which ataxia, some sensory and motor symptoms, are found associated with pernicious anaemia. There is no particular clinical picture attached to the cases of combined scleroses described by Striimpell and others with autopsies ; hence the two above-indicated types at the present stage of our scientific knowledge, that are proper subjects for accu- rate description, clinically and pathologically, are (1) hereditary ataxia (see Friedreich's ataxia, p. 238) and (2) the combined scle- roses of ance.mia, etc., as described by Lichthein. Putnam, and Dana. (2) COMBINED SCLEROSIS OF THE TYPE OF PUTNAM-LICHTHEIN-DANA This affection occurs past middle life, and is usually associated with cachexia, a pernicious anaemia, or some toxic states, as in influenza, lead poisoning, malaria, or chronic diarrhoea. Fre- DISEASES OF THE SPIN^AL CORD 261 quently there is a history of heredity. This disease was de- scribed as develop- ing in the course of anaemia byLichthein in 1877; those pro- duced by other causes by Putnam, and in 1891 again by Dana. Symptoms. — The earliest symp- toms are persistent paresthesia, accom- panied by slight weakness, most com- monly in the feet, and somewhat later followed by ataxia. Pain in the limbs and back may exist. At first there is some spasticity of the muscles, in- creased knee-jerks, and ankle clonus. Later in the disease the rigidity may dis- appear and reflexes be lost in the lower extremities. After some months the arms become affect- ed and symptoms develop similar to those in the legs. Occasionally the dis- ease begins in the upper extremities. FxG. 63. — Combined Sci.ekosis of the Type Put- nam -Lichtuein -Dana FOLLOWED BY LeFT Hemiparesis. (Medico-Chiiurgical Hospital.) 262 TREATISE OX XEEYOUS DISEASES Lessening or absence of pain, tactile and thermic senses may occur, or there may be dissociated sensation, as in case of syringo- myelia. In the course of the disease dementia may develop. Pathology. — The posterior columns are first and mostly in- volved. In some cases of pernicious angemia these were the only columns that were found to be sclerosed. In the majority of cases the lateral columns (crossed pyramidal tracts) are affected as well, and late in the course of the disease the anterior columns may be attacked. Softening of the cord with the production of cavities may appear. The condition is essentially a primary degen- eration of the nerve-fibres. Diagtiosis. — This is to be distinguished from tabes. It is rapid in onset and there is some motor weakness, but absence of ocular symptoms is characteristic, while the early increase of knee-jerks with the angemia should be taken into consideration. From ataxic paraplegia or posterior lateral sclerosis it is also told by its rapid development, the greater degree of weakness, and the 'constitu- tional symptoms. Those cases with dissociation of sensation are also distinguished from, syringomyelia by the absence of severe pain and tenderness or of marked muscular wasting. Prognosis. — This is unfavourable. In the majority of cases the patient will not survive longer than six months to several years, although cases of great improvement have been reported. Treatment. — Hypernutrition. rest, massage, and Swedish movements. Measures tending strictly towards eradicating the diathetic or specific conditions underlying should be employed. The anasmia or any form of intoxication should be treated. The drugs of value in the disease are arsenic, quinine, iron, and other tonics, together with nutrients. Ee-education of the ataxic extremities can be had where im- provement may happily occur if asthenia is not too great. INFLAMMATIONS OF THE SPINAL CORD-MYELITIS Myelitis, an inflammatory lesion of the spinal cord, is a dis- ease rather insidious in onset, sometimes very abrupt, and running a course of several degrees; the first, or mildest, which fre- quently recovers, leaving little damage to the organic constitu- ents of the cord ; the second, running a serious course, and after subsiding the individual is a paraplegic ; while the third type DISEASES OF THE SPINAL COED 263 is malignant;, rapid destruction of tlie cord and death of the patient follows. Causes. — These are exposure to cold and dampness; injury, such as a trauma to the hack; or it may be of a septic nature, due to metastasis from other seats of infection, including tubercular. Myelitis is much more frequently met with in the male, on account of the liability to exposure in men. Pathology. — This condition consists of a low grade of in- flammation with infiltration of round cells within the gray and white matter, more particularly of the gray matter. Granular debris is the result, plus fatty degeneration of the nerve-cells, and their replacement by connective-tissue elements. Where the proc- ess has been insidious and mild the neurones throughout the transverse section of the cord will be found but partially degen- erated. In malignant cases there is a complete destruction of the parenchyma of the cord (see Infantile Palsy). Depending upon the extent of lesion, we have iransverse, as- cending, and descending myelitis. The lesion of poliomyelitis need not be mentioned here. Symptoms. — There is a rather sudden onset, a slight rise in temperature, parsesthesia and feebleness of the lower extremities. This continues more or less rapidly until the patient within a few days becomes bedridden, incontinence of urine follows, and per- haps of the rectal sphincter. The upper extremities may be in- volved, depending upon the site of inflammation, but usually not, since the process is generally confined to the lumbar cord. In the beginning the reflexes are heightened, ankle clonus even may develop, .and the patient have a spastic gait and become more or less ataxic, depending upon the degree of involvement of the posterior white columns. Usually the gray matter is more involved, and if the multipolar cells are affected distinct atrophy and wasting of the muscles will follow. In a rapidly progressive myelitis, parsesthesia and hypergesthesia (irritative symptoms) will within a few days to a week be replaced by a hypEesthesia or anaesthesia, involving both lower extremities very likely in their extent, or the trunk may be thus affected as high up as the umbili- cus. At this stage bladder distress from incontinence and paresis of the detrusor muscle will permit of retention of urine as well, and resulting cystitis. At this time, too, bedsores may occur, par- ticularly liable over the buttocks and sacral region, due to the low- 264 TKEATISE ON NEEVOUS DISEASES ered trophic condition and pressure upon these dependent parts. At this last stage the reflexes will be abolished. The patient is rest- less, loses flesh, and becomes hectic, and may go into a septicsemia, which may cause death ; or after a number of weeks the inflamma- tion may subside and the paresis partly recover, permitting the patient to get about on crutches within a few months to a year. In other cases the destruction of the cord may be so absolute that even partial recovery of function seldom occurs, although held in abeyance, and the patient may go on living a vegetative life for some months or years. This is especially apt to result in those cases of traumatic origin, such as in " broken back " of the coal miner. In some few cases I have seen almost entire recovery after a most severe attack, and in these cases it is very likely that the meninges have been particularly involved, and while the function of the cord for the time is greatly interfered with, the absolute destruction of the neurones has not occurred. The extremities in- volved in m3^elitis become cold, clammy, cyanosed, etc. On begin- ning recovery of a case the patient moves about with a spastic gait, which he will retain in some measure, although he may pretty completely recover from the palsy. Diagnosis. — This is to be made from neuritis, Avhere pain and tenderness along nerve-trunks would differentiate ; from subacute rheumatism of the limbs, which would be distinguished by the nature and distribution (to the joints) of the pain with other symp- toms of the rheumatic disorder ; and finally from syphilis of the spinal cord, where the course of the disease is much slower, and spasticit}^ is out of proportion to palsy. In syphilis too seldom are the signs equally bilateral ; paresis is less marked and muscle tone not increasing in proportion to the heightened reflexes existing, as indicated. Prognosis. — This is a very difficult matter to determine. It should be held in abeyance until the first few weeks of the dis- ease have passed, and will depend in some measure upon the phys- ical stamina of the patient, although distinctly plethoric persons are apt to suffer the greatest. Infectious cases particularly will often recover more completely than the so-called idiopathic class. The tubercular cases are the most promising for restoration of the function of the cord. Here, again, the inflammation is liable to be localized in the membranes. DISEASES OF THE SPINAL COED 265 Treatment. — This consists in absolute "rest in bed, preferably a water-bed; the use of mild antipyretics, if the case is fulminating in type, and there is much constitutional involvement. Protection should be had to the extremities by means of " hoops " to sustain the bed-clothing, and the dependent part should be amply guarded against prolonged pressure by frequent changes of the position of the patient. The use of analgesics may be necessary ( phenacetine, 5 grains) where there is considerable distress. The bladder should be guarded, especially for retention of urine, by a careful use of the catheter, both to prevent injury of the mucous membrane and from the aseptic point of view. If marked cystitis develops it may be necessary to flush the bladder with some antiseptic solution, as boracic acid or a minimum solution of potassium permanganate (1 grain to a quart of water). The decubitus developing should be antiseptically cleansed, and a soap plaster placed around the adjacent tissues to prevent pressure on the sore, the latter being antiseptically treated. The so-called " ring," when used, I have not seen of practical value, since it disturbs the patient, and will slip and only do more damage in the already inflamed area. Among drugs, the solution of potassium iodide, directed to be taken in 5- to lO-grain doses, t. i. d., is of great value from its sorbefacient effect upon the exudate about and in the cord substance. This should not be pushed to a high dosage, as in cases of specific dis- ease, which shall be mentioned in the next chapter. Prolonged rest is essential for the hastening of good results. The necessity for care of the skin in any case is to be insisted upon by the proper bathing and stimulation with alcohol, etc. Thorough massage is a valuable aid in restoration of tone of the muscles in convalescing cases, and should be continued for months. When the patient gets about he should be cautioned to use crutches or a cane and to avoid activit}^, lest he increase the inflammatory process. The treatment for myelitis following Pott's disease differs in one particular — i. e., in the use of extension and counter-extension to the patient by means of the jury-mast, which is weighted from the head of the bed, the counter-extension being made by elevation of the head of the bed. This extension may be increased to from 10 to 30 pounds, and should be practically continuously applied to the patient until the inflammation of the vertebrge subsides and the palsy has partially recovered. This class of cases comes under the neurologist's care when the paraplegia is marked, and may 206 TKEATISE OX XERVOrS DISEASES reach the orthopaedist when the vertebral sjrmptoms predominate. Another method of extension is by suspension of the patient while sitting in a chair by means of an inverted " L "-shaped rod at- tached to the back of the chair, to the short end of which a pulley, scales, and the head-extension apparatus is attached. This can be nicely adjusted to the weight desired for the extension. I have seen patients with complete motor and sensory palsy of three months' duration recover entirely from palsy, by combination of the bed-and-chair extension described, within seven months of per- sistent treatment. The tendency in these cases to relapse is to be noted, and a brace should always be worn afterward to support the spinal column. Cases of Pott's disease with suppuration are least apt to develop paralysis, very likely because extension is out- ward rather than inward in pus cases; also due to the apparent immunity of nervous tissue to sepsis. CHAPTER XY DIFFUSE DISEASES OF BRAIN AND CORD Multiple sclerosis, or insular sclerosis, or disseminated sclerosis, or sclerose en plaques, is a chronic affection characterized by focal areas of sclerosis scattered throughout the brain and cord; occa- sionally the sclerosis is limited to the brain or to the cord. ^Etiology. — Multiple sclerosis may be the result of trauma, as of the spine, to the influence of exposure to cold and wet when various metabolites and toxins are developed in the blood as sources of irritation. Overwork may in the same way act as an exciting cause, as will emotional states, which may also much per- vert all bodily secretions and excretions. Infectious diseases or the metallic poisons, such as of lead or mercury, may also act as causes. Symptoms. — The symptoms will vary in accordance with the distribution of the sclerosis as well as its extent. Still there are certain signs and symptoms of sufficient importance to be char- acteristic. These consist of weakness of one or more extremities, such as of the legs. The limbs become spastic, the deep reflexes being increased. A coarse tremor develops in the affected parts, and this is of the intention type — i. e., it is awakened or exagger- ated by volition or a voluntary act. These irregular tremors may involve the arms, legs, and finally the head. The tremor usually subsides when the parts are at rest, and absolutely so when the patient sleeps. Occasionally the tremor is so coarse that it is diffi- cult to differentiate it from ataxic movements. Nystagmus is a common symptom. This may be persistent, and is usually lateral nystagmus. It may, however, only be brought out by having the patient strain the eye muscles, as in looking far to one side in attempting to produce conjugate deviation. Ophthalmoplegia may finally occur. Optic atrophy is frequently found, but the Argyll-Eobertson pupil seldom occurs. The lower cranial nerves, such as the fifth, seventh, and twelfth, may be also involved. Speech is apt to be affected; when it is slow and sing-song with 267 268 TEEATISE OX XEEA'OUS DISEASES elision of letters and words. The patient articulates as in scanning poetry, the so-called staccato utterance or scanning speech. Some- times atypical forms of dysarthria, resembling the speech in bulbar palsy, or Friedreich's ataxia, or even paretic dementia, may be seen. At times patients affected with insular sclerosis may be sub- ject to attacks of vertigo, apoplectiform or epileptiform seizures. In unusual cases anEesthesia may be existent, when it occurs in the form of small irregular patches, although if a sensory tract is involved and destroyed high up hemianesthesia may result. Of course various forms of pargesthesia may be found, since irritation of sensory tracts without destruction of them is the more fre- quent condition present in the brain or cord in this disease. Diagnosis. — Most of the cardinal symptoms just enumerated will at once serve to differentiate this malady from any form of system disease, which latter would only be simulated where there is a large plaque involving a special tract, as the sensory, for ex- ample, as mentioned above. The symptoms may remain entirely cerebral or spinal. Eemissions are frequent. Intention tremor, scanning speech, and nystagmus are rare in cerehro-spinal syphilis; while in syphilis, too, there may be irido- plegia in one or both eyes, or the pupils may be irregular in con- tour from previous synechise, which latter would never occur in insular sclerosis (Sachs). The tremor of paralysis agitans is more marked when the part is at rest, and it is inhibited by volition or voluntary movements — a dynamic or continuous tremor. Parkin- son's disease is also one of old age, and true scanning speech or nystagmus are neither present in it. Paraplegic forms of infantile cerehral palsies are told by their appearance in very early life, occurrence of convulsions, associated with a more pronounced fail- ure of mental development. The diplegic type is more difficult to distinguish, since scanning speech, nystagmus, and ataxic move- ments may be present. The syndrome of all three of these last- mentioned symptoms is, however, seldom found in cerebral palsy; also paralysis and contractures are apt to be marked in cerebral palsy. In the hereditary ataxia of Friedreich, optic atrophy, less- ened or absent reflexes and ataxia of lower limbs are points in diagnosis. From the cerelellar type of hereditary ataxia it is more difficult to distinguish. Eomberg's sign, which is present in cere- bellar ataxia, is, however, very rare in multiple sclerosis. Prognosis. — Insular sclerosis is slow in progress, but is incur- DIFFUSE DISEASES OF BRAIX AND CORD 269 able. Remissions ma}^ occur spontaneous!}^ or may be clue to treat- ment in those patients with good physiques. Treatment. — Alterative remedies, such as arsenic or Donovan's solution, or even the iodides, may be of much service. oSTitrate of silver has been commended, but I have never seen benefit from its use. Re-education by teaching the patient to co- ordinate is of value in the symptomatic management of the case. Massage is im- portant. General nutrition of the patient (such as through the administra- tion of syr. ferri iodidi, gtt. XV, t. i. d., or cod-liver oil §ss. after meals) is the most important part of treatment. PARALYSIS AGITANS (SHAKING PALSY) Paralysis agitans is a disease occurring more fre- quently about the fifth dec- ade of life, and in which tremor and palsy are fea- tures. The name ParJan- S07i^s disease is also applied. Causes'. — Heredity, overwork, or trauma to spine. Symptoms. — The cardi- nal features are paresis, ac- companied by fine constant tremor, beginning as a rule in the hands, face, and lips, gradually spreading until the entire musculature is involved. The tremor is a continuous one in the majority of cases when the disease has become well established, although there is the unusually rare case that does not manifest tremor except periodically. The Pig. 63. — Expkession, "Pill-rolling'" Hands, and Attitude in Pakalysis Agi- tans (Adult Male ; but little Tkem- Ok). (Philadelphia Hospital.) 270 TREATISE ON NERVOUS DISEASES tremor is never what we designate an intention tremor — i. e., one brought out by voluntary movement of the parts; in this we have a diagnostic symptom, as between it and insular sclerosis, in which there is generally marked intention tremor. Other signs of paral- ysis agitans are a masked expression, the so-called " wooden face," due to rigidity and immobility of the muscles of expression ; and increased reflexes. With these there is slowness of cerebration, and still more of articulation due to mechanical interference with speech from lingual and pharjmgeal involvement in the muscular rigidity and paresis. Later, as the disease slowly advances, drib- bling of saliva, very marked stooping of the body with rigidity of the neck, an assumption of the pill-rolling position of the hands and fingers are characteristic, and finally. the festinating gait, or running gait as it is sometimes called. This gait is really an exag- geration of that of old age, and in which the patient is said to be running after his centre of gravity (not an inapt term). If the subject feels himself falling forward, the term propulsion is implied; if he has the sense of falling backward, we designate it retro pulsion. The circulation is generally feeble in these patients, cardiac palpitation is not uncommon upon slight exertion, there is usually marked arteriosclerosis, and frequently iridoplegia in myosis. The tremor in its incipiency is also more marked when the patient is relaxed, though it is exaggerated with the relaxation following extraordinary exertion for him; and finally tremor may become so large and persistent that sleep is prevented from the mere mechanical effects upon the body, but when the patient does sleep the tremor disappears for the time being. Save for pares- thesia no sensory symptoms are found, excepting in rare cases, where there are rheumatic or articular changes of a trophic nature in the joints, when fleeting arthritic pains may occur. The patient is eventually compelled to give up the use of the hands, as in writing first, then of larger movements; although it is singular, the ability to write is preserved to extreme advance of the disease in some cases. Local flushing of the face and neck and body with evanescent sweating of the parts is always a notable symp- tom in this disease, due to vaso-motor irritability. The sphincter muscles are almost never incontinent. The duration of paralysis agitans is indefinite. As the disease is incurable in itself and occurs at the degenerative period of life, the demise of the patient will depend upon the complication of DIFFUSE DISEASES OF BRAIN" AND CORD 271 other maladies, or upon the degree of degenerative tendency in the individual. The latter should he sought for in some measure by noting the heredity of the family. Pathology. — While no lesion has been found in the majority of cases coming to necropsy, in a fair proportion of them changes in the cord have been noted, largely consisting of congestion and dilatation of blood-vessels of the gray matter, atrophy and pig- mentation of nerve cells, and increase of the interstitial tissue. Dana considers, however, that the central motor neurone is most at fault. Prognosis. — As inferred from the above, recovery never occurs ; but taken early, the malady can be controlled very materially in 25 per cent of the cases. Remissions and exacerbations are nota- ble. I have in mind a patient, who will be referred to under treat- ment, in whom there has been very marked amelioration of the sym.ptoms, especially in the restoration of general tone to the sys- tem, although the tremor has never been greatly improved. An- other advanced case at the Philadelphia Hospital under my care has been greatly improved as to the tremor itself by therapeutic measures. Where it is clearly shown that there is no family tend- ency to the disease we can hope for better results than in cases with neurotic taint in a preceding generation. Just when the stage of paresis will develop cannot be accurately foretold, although generally speaking, the greater extent and range- of tremor the earlier will palsy result. Treatment. — The essentials in treating paralysis agitans are rest and hypernutrition. In an incipient case, therefore, ideal treatment lies in change of scene, the leading of a quiet life, with abundance of fresh air and sunlight. Light gymnastics and pas- sive movements are of value in preventing rigidity of the limbs. Tonics, as quinine, arsenic, and mineral acids, are helpful. Warm baths daily and the constant galvanic current are of value. Hyoscine hydrobromate, gr. ^^-^ t. i. d., will frequently relieve the symptom tremor, or a com.bination of tincture of conium and tinc- ture of hyoscyamus, equal parts, given in 5- to 10- drop doses, is of service. Gowers recommends cannabis indica and arsenic. I have seen the Brown-Sequard ^ injections do good. Elimination through skin, kidneys, and intestinal tract must be regulated. * Testicles of healthy bulls are ligated and excised immediately after kill- ing the animal. Under antiseptic precantions the tunics are completely 272 TREATISE 0^ NERVOUS DISEASES SYPHILIS OF THE NERVOUS SYSTEM General Considerations and Distmctio'ns Scientifically speaking, " syphilis of the nervous system " applies to the tertiary lesion located in the membranes of the brain or cord, or both; although parasyphilitic disease or the toxin stage (or quarternary stage of some authors) is also a sequela of syph- ilis. In the latter, however (as in tabes and paresis), there are no characteristic lesions of syphilis. In it, too, the specific poison may expend itself upon the progeny, affect the general health, lessening resistance, and may create morbid tendencies or even sclerosis, as inferred above, in descendants of parasyphilitics. The acquired syphilitic diseases of this parasyphilitic stage may therefore be paresis, ataxia, neurasthenia, hysteria, epilepsy, and mental diseases. The congenital syphilitic diseases of this same stage may be arrest of development (as in Little's disease), hydrocephalus, paresis, juvenile tabes, the hereditary form of cere- bral palsies in children, etc. We have described all these various parasyphilitic diseases in other chapters. NERVOUS SYPHILIS General Considerations. — In the so-styled specific form of S3'ph- ilitic disease of the central nervous system there may be the hered- itary or acquired forms. In the former, symptoms are present at birth or may appear early in childhood. Very rarely this form may even appear late in life, affecting all parts of the nervous system singly or collectively. The acqmred and usual form may appear at various times after the primary lesion. Usually symp- toms present between eighteen months and six 3^ears. Some acute fulminating cases may even occur during the secondary period. Others may, exceptionally, occur even after thirty years of the luetic infection. Pathology. — There are various forms of tertiary lesion found. (1) Disease of Blood-Vessels. — Endarteritis ohliterans is fre- quently found in which there is proliferation of endothelial and removed down to and including the albuginea. The gland is then macerated in pure glycerin and allowed to dissolve for forty-eight hours. The whole is then filtered and a small extra amount of the liquid part of the residue is added to make a supersaturated solution. The mixture is then sealed in anti- septic phials. By this method one testicle is equal to one ounce of solution. DIFFUSE DISEASES OF BRAIN AND COED 273 subendothelial cells. This much thickens the walls of the blood- vessels, and narrows and sometimes obliterates them completely. The other coats may also be destroyed. Periarteritis in which nodular gummata may develop in the adventitia of the vessels may produce globular or ovoid swellings. The interna may or may not become diseased. Secondary thrombosis, softening, or rupture or the development of aneurysms may occur from any of these blood- vessel lesions. Cases where the secondary symptoms have , been mild are particularly apt to develop syphilis of the nervous system. This is probably due to insufficiently treated specific disease or to a vulnerable nervous system, or both. (2) Gummata. — These may be single or multiple, and usually involve the pia mater, affecting the brain or cord secondarily, fre- quently only by compression. They spring from the walls of the blood-vessels, and are composed of round cells derived from them and from proliferated connective-tissue cells. Hence the walls of the blood-vessels becom.e thickened. A gummatous meningitis also is usually found. The gummata may be attached to the dura, and rarely to a vessel of the brain or cord substance proper. Gummata are not as commonly found in the cord as in the brain. In the brain they are usually seen upon the cortex or in the pons (hence the symptoms of palsy will depend on location of growths). (S) Gummatous Meningitis. — This is a condition in which the membranes are infiltrated with cells, and are much thickened in consequence. This is found always about gummatous masses, but may exist separately. It is more common at the base of the brain, and generally involves the dura. Gummatous growth themselves are much less frequent at the base than is specific meningitis. Symptoms of Cerebral Syphilis. — The onset of symptoms is generally from three to six years after the initial specific lesion or chancre. The patient will complain of drowsiness in the daytime and wakefulness at night, with persistent headache, due to menin- geal irritation and inflammation. According to H. C. Wood, he becomes a restless nocturnal automaton. The mental conditions of obtundity, with failure of memor}^, but without delusions, are other distinctly psychic phenomena. Ocular palsies are very likely to develop early, perhaps the first svmptom being that the patient will complain of seeing double (diplopia) ; or it may be noted that he has a strabismus, or on testing the ocular balance that the move- ments are restricted, due to neuritis of the ocular motor nerves, 18 274 TEEATISE ON KEEVOUS DISEASES because basilar exudate is common. The patient is physically weak;, the reflexes are heightened, due to the chronic irritation of the motor tracts and centres; and localized palsies may supervene in other places, such as in an arm or a lower extremity, due to destruction or pressure upon the motor centres. Acute optic neu- ritis and optic atrophy may develop, but is uncommon, while " choked disk " is but seldom seen, thus differing from eye symp- toms of brain tumour. The patient may develop convulsions from time to time in proportion as the process is chronic. Various parsesthesige of the extremities may occur in cerebral syphilis. A palsy is almost never complete in this disease, and the vacillation from month to month is a point in favour of this diagnosis. One of the principal points in the symptomatology of cerebral syphilis, we wish to insist, is early palsy of the ocular or other cranial nerves. Such palsy also varies much in extent from week to week, according as active specific treatment is pursued or not. Symptoms of Spinal Syphilis. — ^^\^hile the symptoms are usu- ally conjoined with those of cerebral syphilis, still the predomi- nance of the spinal disease occurs in a sufficient number of cases to warrant the title given, and which has frequently been called, since Erb first well described it, Eri's paralysis. The time of onset of spinal syphilis is the same as that of cerebral syphilis (usually two to four years after infection). An early complaint is of pargesthesia of the lower extremities, accompanied by feebleness and a sense of rigidity of the muscles, with at the same time incontinence of urine or difficiilty of urination, clue to weakness of the vesical sphincter. Indeed bladder sym.ptoms are the earliest symptoms of the disease. The reflexes are heightened, the knee-jerks being greatly increased, and marked sustained ankle clonus occurs. Sel- dom is there ansesthesia, but' hypersesthesia or hypgesthesia fre- quently exists of irregular distribution, depending upon the seg- ment of the cord and roots involved. Some disturbance of co-ordi- nation and Eomberg's symptom may be present. A clinical point of partfcular note is the heightened reflexes out of proportion to palsy and the associated proportionate diminution of muscular tone; so that seldom do contractures occur, even though the knee- jerk is wildly spastic. The muscle development remains good; there is seldom wasting or fibrillary contractions, but cyanosis and coldness of extremities among vaso-motor phenomena are fre- quently seen. Bedsores or other severe trophic changes are rare. DIFFUSE DISEASES OF BRAIN AND CORD 375 because all nerve-paths are seldom entirely destroyed. The non- symmetrical distribution of symptoms is also a special clinical fea- ture in syphilis of the spinal cord, as is also the remission of the symptoms. The duration is indefinite, and tends towards degeneration or sclerosis if not properly treated. The patient is liable to sud- den death, though usually the course is slow. Diagnosis. — Careful observation should not confound this dis- ease with any other malady. Confusion may be had with myelitis, where the symptoms are symmetrical in distribution, seldom with remission, while the onset is acute in character and accompanied by bed-sores. There are also distinct sensory symptoms, such as girdle sense and ansesthesiae, throughout the course of myelitis. Prognosis of Cerehro-Spinal Syphilis. — It is most hopeful of all organic affections of the central nervous system, excepting in the fulminating cases, where the profound intoxication destroys the nerve-cells before relief can be had through timely treatment. These latter cases are the rarest and do not present the typical features described above. Treatment. — This consists in vigorous and thorough appli- cation of antisyphilitic remedies. The use of potassium iodide, increased to 100 or 200 grains a day (taken in solution), will prove of greatest value. It is astonishing to see the good results obtained in the cases that have received prompt and early treat- ment. Where the iodide cannot ,be borne, or in case there be no response to the drug, the use of bichloride of mercury in ^^- grain doses, rapidly increased, is a therapeutic procedure of great value. Inunctions of mercurial ointment into the axilla and groins, on alternate days, will also be efficacious. During the administration of antisyphilitic measures the efficacy of the drug action may be bettered by the use of hot steam (Russian) baths given once or twice weekly. The stomach must be conserved in all cases, and if gastric symptoms occur the syphilitic treatment should be held in abeyance for a time and gastric sedatives and tonics administered, after which the specific treatment may again be resorted to. Reconstructives are essential, such as cod-liver oil, phosphorus, and hvpophosphites. Copious draughts of water should be given, and the bowels should be kept freely open and the contents soluble by means of salines. The diet should be of a sim- ple, wholesome nature, such as eggs, milk, and other proteid food 276 TliEATISE 0^ XERVOUS DISEASES in limited measure. Careful treatment of syphilis of the nervous system, as outlined above, persisted in for six months' time at least, will often produce excellent results ; and some cases seem to be re- stored to normal health. If improvement does not occur within six months degeneration of the nerve-cells has most likely set in, and a favourable issue cannot then be expected, although treat- ment should be continued with the idea of ameliorating the dire effects of the syphilitic poison or toxin itself. CHAPTER XVI , GENERAL AND FUNCTIONAL NERVOUS DISEASES In functional nervous diseases no definite known anatomical change underlies the morbid alteration of function. We there- fore classify such affections clinically. There may be made, how- ever, pathogenic and etiological classifications. Thus we may have primary or degenerative and secondary or acquired neuroses. This classification is helpful, though not perfectly correct, because several factors often enter into the cause of the same disease. Classification should not be made a fetich. Dana gives the following classification, which serves well in the majority of diseases of this nature : Primary degenerative neuroses . . . ^ Exhaustion and shock neuroses. Primary neurasthenia, hypochondriasis. Epilepsy. Hysteria major. Hereditary chorea. I General spasmodic tics. L Myotonia. ''Neurasthenia. Hysteria. Exophthalmic goitre. Occupation neuroses. f Tic douloureux. 'Acquired degenerative neuroses. ■{ Local spasmodic tics. 1^ Paralysis agitans. ' Chorea, Tetanus. Tetany. Rabies. Tremor and neuralgia. Vaso-m'otor, trophic, and sleep disorders. (See appendix.) We shall give the most important of the general and functional diseases of the nervous system, classifying them clinically, but 977 Acquired neuroses. « From infectious, autochtho- nous, and mineral poisons. Miscellaneous. 278 TREATISE ON NERVOUS DISEASES with the understanding that the cause of the disease is always borne in mind to be of first importance in considering its treatment. CHOREA MINOR, SYDENHAM'S CHOREA OR ST. VITUS'S DANCE Chorea is a general disease, at present designated functional, since its aetiology is not definitely decided. An autochthonous poi- son, as in rheumatism or other diathetic disease, may be the excit- ing cause ; or it may possibly be infectious in origin. Usual excit- ing causes are mental, moral, or physical trauma (fright, blow upon the head, etc.). Anaemia and general ill health and heredity are predisposing factors. Definition. — Chorea is a functional nervous disease associated with irregular inco-ordinate movements of the voluntary muscles, and accompanied by mental obtundity, anaemia, and at times car- diac and rheumatic symptoms. Paralytic chorea is the name applied to that form of St. Yitus's dance where muscle palsy from exhaustion is markedly present. There is more or less paresis in all cases. Symptoms. — Sex bears important relation to the disease, it being found much more frequently in the female; perhaps the proportion is about two to one. Onset occurs most frequently between the seventh and fourteenth years. The adolescent period has something to do with the development of the cases occurring latest in this susceptible epoch. The first symptom is generally peevishness of the child, ac- companied by general restlessness, which the mother will describe as " fidgets." The child will drop an object without any apparent cause — e. g., a fork at the table, or the pencil if working at school. Within a week the movements will have begun in the arms, face, tongue, and lower extremities in the typical case. The move- ments are very irregular, in some cases tending to vermicular mo- tion, but never in any degree consistently of one type. The pecul- iar contortions of the face give the child a grotesque appearance, which with the difficulty of speech and dribbling of the saliva present the aspect of a case of dementia (facies choreica). This is at once unwarranted by the mental condition of the case to be described later. The gyrations become larger and increased until the range of FUNCTIONAL NEEVOUS DISEASES 279 movement may extend to extreme abduction of the extremities, the throwing about of which will prevent the child from walking or even sitting erect from mere mechanical disturbance. In other cases the palsy is so much greater than the movements that they are designated the " paretic type/' In these the patient is at times absolutely disabled, with a few movements remaining. In other cases the irregular movements appear well marked and yet are asso- ciated with palsy out of proportion to the motor weakness. The movements of chorea cease during sleep. They are much bettered when the child is quiet, and are exaggerated on physical or mental endeavour. At times chorea is confined to one side almost exclusively, which type is termed JiemicJiorea, or one side of the body may be affected more than the other. Occasionally one upper extremity and the opposite lower will be most involved. The child's mental condition is below par, and while sensitive, the function of the mind is singularly obtunded, memory being poor, with inability to concentrate. In some cases there is mild ephemeral dementia; in other cases the dementia may go on to permanent mental impairment or death. In rare instances an excitable condition of insanity without high temperature will occur. S. Weir Mitchell divides chorea into five types, as follows: (1) Those with absence of movements during rest, during some stage of the disease. (2) Cases in which continued movements are increased by effort. (3) Cases in which movements disappear during intentional muscular acts. (4) Cases unaltered during muscular acts. (5) Those in which the various types alternate. In violent cases the child may injure himself by tossing about, so that restraint is necessary. The only somatic symptom of im- portance is feeble and irregular cardiac action. In 75 per cent of cases a systolic mitral murmur occurs, either hgemic or due to a mild grade of endocarditis. The duration of a case of chorea is from four to six weeks. Severer cases may last many weeks. Eecurrences are quite fre- quent, many cases having relapse in the spring months (March and April), or in the early fall (September). This is probably due to the effect of the changing weather as well as to overwork at those periods of the year. The subsequent attacks are generallv not as long afe the primary ones, and may recur from two to fourteen times in as many years. 280 TEEATISE ON" NEEVOUS DISEASES As the patient convalesces from the attack the movements grad- ually cease. Frequently when the paresis is very prominent the child complains of greater weakness and apathy than when in the attack. The movements cease last in the face and tongue, physio-- logically the most sensitive parts of the body. Extreme ansemia will at times develop, a cardiac murmur at the base be very pro- nounced, and even fatty degeneration of the heart muscle be shown by the feeble contraction of the myocardia. In some cases oedema of the lower extremities will be noted. The urine is generally de- ficient in chlorides, with excess of sulphates and phosphates, show- ing the waste in the nervous system; while indicanuria is a fre- quent finding in those cases where gastro-intestinal fermentation exists, as a complicating factor in symptomatology through auto- intoxication. In rheumatic cases the mitral cardiac murmur may be very persistent, due to organic disease of the heart, which symp- tom may dominate in the case, and be the sequel of an apparently mild attack of chorea. The co-relation of rheumatism, chorea, and heart disease is therefore to be .borne in mind ; while a patient suf- fering from rheumatic pains with cardiac disease before or in the attack of chorea is a more gravely ill person than one not having this trio of signs. The knee-jerk is capricious in chorea, fre- quently lessened, and always easily exhausted. Diagnosis. — Chorea minor is not likely to be mistaken for other diseases. Hysteria may simulate this disorder, but the ex- plosive nature of hysterical chorea, the larger movements, and less palsy will distinguish it. HaMt chorea is told by the spas- modic and localized character of the movements. The choreiform movements of the cerehral palsies are to be differentiated by noting the other signs in the disease in question, such as palsies, increased reflexes, etc. Huntingdon s chorea is differentiated by its occur- rence in adult life and its association with mental diseases; also the hereditary nature of Huntingdon's disease. Prognosis. — The prognosis of chorea is good in the vast ma- jority of cases. A usual duration is six or eight weeks. The eases with cardiac affection are more apt to be prolonged, as shown by murmur, even if the heart disease is functional; also the ansemic cases are graver, due to the condition of malnutrition of the cen- tral nervous system in these patients. The prognosis in cases of organic heart disease is decidedly bad, both as to recurrence of the chorea and as to the life of the patient, since with each succeeding FUNCTIONAL NEEVOUS DISEASES 281 attack of chorea of a severe nature the systemic failure is great. Such patients usually die of organic heart disease (endocarditis) within two to five years after the original attack of chorea. The distinctly atrophied condition of the mucous membranes in these cases is shown by the fact that portions of the mucous membrane of the nose will be discharged en masse. In the milder cases that recover even after a series of attacks, the patient usually grows into vigorous health, no condition of previous cardiac trouble re- maining in after-life. Treatment. — This depends upon the severity of the disease. The average case can be given ambulatory treatment. Physical and mental rest for a few hours each day is essential, as is qui- etude at all times, and fresh air and sunlight. The child should be kept away from exciting influences of all sorts, particularly school ; even agreeable excitement is harmful. The emunctories should be carefully guarded. Copious draughts of water between meals are indicated, especially in cases giving evidences of auto-intoxication. The diet should be simple, consist- ing largely of milk, given at stated intervals (3 to 6 ounces every three hours during the day) ; the patient can also be given whey, buttermilk, largely to act as a diuretic, junket, soft-boiled eggs, bread a day old, and the lighter meats, avoiding carbohydrates and hydrocarbons, which disturb digestion in these cases. In bad cases the patient should be put to bed absolutely, and where the movements are violent, padding about the bed should be judiciously done to prevent injury to the patient. Restraint will sometimes have to be resorted to in these severe cases. Salt- water sponging either with sea-water, or that artificially made by placing half an ounce of common salt to a quart of water, at a tem- perature of 100° F., will be a soothing measure, when applied by sponging for five minutes twice daily. Light effieurage is a meas- ure assisting in soothing the nervous system, as well as aiding the circulation and bettering the nutrition. Among drugs, iron is indicated. It should be employed espe- cially in the ansemic cases of chorea. In children the tincture of chloride of iron, from 10 to 30 minims, given in water, three times a day, is of great value. This acts as a stomachic as well as an hematic. The teeth should be carefully guarded from the acid, rinsing the mouth with a solution of hicarhonate of soda. The French pill of Blaud, consisting of equal parts of sulphate of iron 282 TREATISE ON NERVOUS. DISEASES and potassium carbonate^ is a valuable remedy. In my experience this pill acts better in the older cases. The treatment of the disease per se is principally alterative, and no remedy acts quite so well as arsenic, which in the form of Eowler's solution is pleasant to take; also the dose can be nicely graduated to the necessity of the case. The usual method of administration is by giving 3 drops in water after meals, gradually increasing each dose by one drop, as shown in the accompanying table : 1st day 2d " BREAKFAST. 8 drops 3 " DINNER. 3 drops 4 " SUPPEK. 3 drops 8 " 3d " 4 ... 4 " 3 4th " 4 4 " 4 5th " .. 4 5 " 4 6th " 5 5 " 4 7th " 5 6 " 5 8th " 6 " 5 9th " 6 6 " 5 0th " 6 6 " 6 etc. etc. etc. This can be increased to 15 or 25 drops. When the physio- logical limit is reached the dose should be reduced one half, and kept at this dosage during the active course of the disease, unless recurrence of the arsenical symptoms are noted. In some persist- ent excitable cases the use of the bromides is indicated; particu- larly the ammonium bromide should be used, since it is less depressing to the heart. This salt will be found of special benefit in chorea with gastric irritability. Quinine, antipyrine, cimicif- uga, and sodium salicylate are of value in rheumatic cases. The cardiac symptoms should be very carefully guarded in a given case. Tincture of strophanthus is an excellent remedy for deficient compensation, and should be given in 10- to 15-drop doses three times a day until circulation is restored to the normal. Where serious organic heart disease complicates, digitalis should be employed. Long rest should be enjoined after the chorea has been recovered from. Cod-liver oil is a valuable reconstructive agent to be employed after the acute attack of chorea has waned. It is often desirable to change the scene in mild cases of chorea. Sea air, where high winds do not prevail, is desirable. High alti- tudes — above 2,000 feet — are never good for the patient. FUNCTIONAL NEEVOUS DISEASES 283 HABIT CHOREA OR HABIT SPASM This is a disease of childhood, having its origin in a previous attack of simple chorea or developing primarily. Heredity plays an important part in the (Etiology, as does simulation of another case. Children of robust physique, who have developed a simple chorea of very active type, or, indeed, in whom the chorea has been of mild form, are very apt to be those who will have a habit spasm remaining after the simple chorea is apparently cured. Other ex- citing causes of the development of primary habit chorea are reflex causes of many sources, such as e^^e-strain, nasal disease, binding or irritation of some part of the body by clothing, a phimosis, seat worms, deformities of speech mechanism, such as tongue-tie or enlarged tonsils, or anything interfering with the functionation of the unstable nervous system. Thus, a boy, with the predisposition, upon donning his first pair of " suspenders " may develop shoulder twitching; or the child with tongue-tie may begin a contortion of the neck, induced by the endeavour to speak properly ; or blinking of the eyes may result from an uncorrected astigmatism. Symptoms. — The parts most frequently affected in habit chorea are the eyelids, facial muscles, neck muscles, and shoulder-girdle muscles — parts particularly sensitive in their nerve supply. The nature of the movement is that of a spasmodic rather than true choreiform motion,- usually excited by mental or physical endeav- our, although the patient can frequently control the movements in part by the will. They are absent during sleep, but, unlike simple chorea, are worse when the attention is not drawn to the condition at all. Inhibition of the movements exists more decidedly than in simple chorea, in the latter of which any form of mental action exaggerates them. As inferred, the patient's physical vigour is generally excellent in cases of habit spasm. In some cases where it is markedly localized, as in the posterior cervical muscles, they may become actually hypertrophied from overuse in these violent twitchings. There may be speech defects, such as echolalia, where sounds heard are reproduced; coprolalia, or the sudden utterance of profanity, etc. Prognosis. — The duration of the disease is indefinite, but a favourable prognosis can be given in proportion to the move- ments and the cases resulting from previous simple chorea. Where it develops from some other exciting cause, as peripheral ;i84 TREATISE ON" NEEVOUS DISEASES irritations^ in my experience, the disorder is sometimes seen last- ing for years or becoming incurable. Pathology. — This is not known. Irritability of the upper motor neuron probably exists from some unknown poison. Diagnosis. — It may be confused with Sydenham's chorea. Per- sistency of habit spasm distinct from typical choreiform move- ments, also the absence of rheumatic history, are important points. Habit spasm from hysterical chorea is distinguished mainly by stigmata existing in the latter disease. Treatment. — This consists in getting rid of every source of irritation, such as by correcting eyes, by circumcision, extraction of misplaced tooth, removal of enlarged tonsils, or operation for tongue-tie, etc. If the case is the resultant of simple chorea, rest cure and tonics are principally indicated. Moral influence is of vital importance in the therapeusis. Hypnotism is a means, which, if it can be induced in the subject, is a quick agent towards cure. A valuable measure is to have the child stand before the looking- glass for three to five minutes, making an effort to control him- self, and in this way educate the nerve-centres to proper inhi- bition. Among drugs, the use of bromides, sparingly, or hyoscya- mus may be of value until the nerve-centres become less irritable. Proper resort to bathing is a valuable measure, and should be used. The cold shower-bath at a temperature of 60°, given every morning, will do much towards restoring nervous control in these cases, largely through establishing better equalized circulation within the central nervous system. HEREDITARY CHOREA Synonyms: Huntingdon's Disease or Chorea This is a disease beginning at about thirty years of age, more frequent in the male sex, and characterized by its chronicity and tendency to mental affection. The hereditary taint of this mal- ady is not always directly in the ancestry, but there is always some neural vulnerability or cause for degeneration, such as chronic alcoholism, syphilis, etc., in the immediate progenitors. The patient in the onset will scarcely have been seen by the physician, but it will be reported to him that the disposition has been chang- ing for some months, the patient having become nervous and irrita- ble, forgetful and perverse, and at times showing violent temper. FUNCTIONAL NEEVOUS DISEASES ' 385 The movements generally begin in the upper extremity, are larger in the gyrations than in Sydenham's chorea, the head and neck becoming soon affected, and with the movements of the lower ex- tremities the gait is particularly characteristic. The patient in his endeavour to walk slides and pushes one limb forward, then at- tempts to draw the other in its wake; then the other limb will be advanced in the same fashion, thus making with all its irregu- larity a more or less rhythmical alternation by the hampered vol- untary effort. The movements of the trunk become marked within two or three months. These may cause compression of the abdo- men and thorax. Occasionally involvement of the diaphragm produces sudden explosive sounds, similar to echolalia of habit chorea. The mental deterioration will have been well manifest by the time the choreiform movements, etc., as described, begin. This now consists of periods of mental depression, alternating with maniacal tendency, with forgetfulness, and the mental status tend- ing towards dementia, the patient using finally a sort of jargon in speaking, entirely distinct from the mechanical disturbances of speech which also exist, due to the involvement of the pharyngeal muscles. So that careful observation has to be indulged to deter- mine in foretelling the rapidity of downward progress of the case. The tendency to suicide is a characteristic symptom of the mental derangement. The patient's movements finally become so exag- gerated that he cannot walk about, the irregular choreiform move- ments continued during the waking state, which, however, entirely cease when the patient is asleep. The movements also obey those of simple chorea in regard to the effect of mental excitement, physical endeavour, etc. The movements lessen only as mental deterioration progresses. This in time amounts to an active pare- sis, the patient becoming bedridden and dying of some intercurrent malady. Duration. — The patient may be a sufferer for six or eight years before death supervenes, although the majority of cases are carried away within four or five years after its active development. Diagnosis. — The diagnosis of Huntingdon's chorea must be made between it and simple chorea, or liahit chorea, or hysterical chorea. The age of the patient, the recovery and relapses, and history of rheumatism and milder grade of movements would dis- tinguish the simple chorea. The localized spasmodic disorder also occurring in children without any mental disturbances would dis- 286 TEEATISE OX XEEVOUS DISEASES tinguish the habit eases. H3'sterieal chorea would be known by other evidences of hj^steria, the vacillation of symptoms, the ab- sence of dementia and suicidal intent, and the hysterical chorea being more frequent in females. Prognosis.— This is absolutely bad, no cases having been in any way permanently benefited. Pathology. — This consists of congestion of blood-vessels in the cortex of the brain and final resultant irritability and degenera- tion of the central motor neurones, with areas of softening in those cases where the symptoms and signs of paresis develop. Treatment. — The treatment of the disease is, as far as known, therefore, entirely of symptomatic nature. Supportive measures is the first desideratum. A simple nutritious diet, consisting of proteids in part, such as red meats, oysters, milk and eggs. Excess of carbohydrates should be avoided in all instances, and particu- larly in those where there is a diathetic tendency, such as to rheu- matism or rickets. The system should be kept well flushed with water to prevent the retention of autochthonous and other forms of poisons, particularly absorption of ptomaines from the intes- tinal tract. The use of iodide of potassium or salicylate of soda, in small doses, is indicated where uric-acid retention is suspected. Such nutrients as cod-liver oil and hypophosphites and the lime- salts are valuable adjuvants. A pill of phosphorus, y]j -g- of a grain, or extract of chirata, 1 grain, thrice daily, are of service. Tincture of hyoscyamus or tincture of conium are antispasmodic medica- ments that are sometimes of value in controlling the movements. The careful use of bromides to overcome the restlessness and gen- eral irritability is desirable. Hypodermic injections of hyoscine hydrobromate, yftr of a grain, increased to --Vj acts markedly well in cases with maniacal disposition. Patients should be constantly guMTded as to the possibility of committing suicide, and if paresis becomes a prominent and permanent symptom, it will become essential to commit the patient to a hospital for the insane. CONVULSIVE TIC Synonyms: Tremor, or Oiles cle la Tourette's Disease This is an afPection characterized by large irregular choreiform movements, involving the face and neck, at times affecting other parts of the body, and which may become general. It is also char- FUXCTIOXAL XEKTOUS DISEASES 28t acterized by large movements, and further by peculiar mental dis- order. Heredity is a strong predisposing factor in this disease. Fright or shock is the most frequent exciting cause. By some au- thorities it is designated a psychosis, similar to hysteria. It usu- ally begins in early childhood, and is accompanied by three promi- nent sets of manifestations. First, the involuntary movements, given in the definition — these being extreme contortions of the part rather than any typical form of movement. The face is thrown into a most grotesque physiognomy. The head is rotated and moved about irregularly upon the shoulders. In semiclonic spasm the movements extend first to the shoulders, causing a spas- modic shrugging, depression, and throwing back of the same. The trunk is finally involved in the spasm, and at length the extremities may be the seat of the wildest movements. All of these are exag- gerated by excitement or voluntary muscular effort. At times the spasm is so great that the patient may be thrown to the ground. Peculiar involuntary sounds are emitted, due to the spasm of the glottis and pharyngeal muscles. These echolalia or coprolalia may be manifested in sudden exclamations. The mental disturb- ance consists of morbid fears, of doubt (misophobia), of disease (pathophobia), etc. Morbid impulses such as erotomania exist. Imperative movements may be attempted, but are usually frus- trated by the involuntary retraction of muscles. The patient may finally become extremely delusional and pass into chronic terminal dementia, accompanied by wasting of all the muscles. Death from exhaustion will then supervene. Diagnosis should be made from hysterical affections without difficulty, and would be clarified upon noting the persistent down- ward course of convulsive tic without the remissions of hysteria. Prognosis is absolutely bad, there being no instances of bet- terment through any forms of treatment. The malady is an acute form of degeneration of the nervous system, a diffuse lesion being found in the central neurones, although of no definite dis- tribution in any particular part. SALTATORY SPASM Synoxym: Jumper s Disease This is a neurosis allied to hysteria, occurring in early adult life in endemic form, often due to the simulation of other cases of the disease, and characterized by sudden violent spasms of the 288 TEEATISE ON XervOUS DISEASES flexor muscles of the thighs and calves in particular, which, in contraction, produce the typical symptoms of the disorder — a series of skips or jumps, keeping up for a few moments, and finally ending in enfeeblement or collapse of the patient, again to he renewed upon recovery. These remissions may occur many times during the twenty-four hours, the patient after each seance becom- ing utterly exhausted. Then a disturbed sleep will follow the at- tack. Biit the " jumping " begins on waking. The duration of the attack or of the affection is indefinite. Both are pretty much in proportion to proper treatment instituted. Such cases quite fre- quently develop during religious revivals, and will disappear after the excitement is over. Some may die of exhaustion. Pathology. — There is nothing known of the pathology. G-iven an emotional subject, such irritability of the motor neurones may be set up by excitement ; the only clue we have to pathogenesis. Diagnosis. — This is made clear by observing the endemic form of the disease, the peculiar paroxysms, and the hysterical mental aspect. Prognosis. — This is good. Most cases should recover. Treatment. — Cure depends upon the ability to gain control of the patient and to impress his moral and mental nature. Hyp- notism is a valuable therapeutic measure in this disorder, for, if the patient's mind can be concentrated enough to subject him to hypnosis, the ease can generally be turned towards a rapid cure. The separation of the patient from the predisposing cause, or from others affected with the same malad}^, is, of course, to be insisted upon. Such conditions are allied to the hysteria observed in the northern coal regions of Pennsylvania four or five years ago, as investigated by Professor Newbold, of the Univer- sity of Pennsylvania. THOMSEN'S DISEASE Synonyms: Paramyoclomis multiplex; Ilyotonia congenita; Myospasm or Convulsive tremor. It is a congenital and inherited disease of the muscles, which is manifested by irregular bilateral spasmodic contractions of the muscles, 5 to 120 a minute, either in groups of muscles in the extremities, or involving all the muscles of the body. The disease appears earlier in life than the preceding, starting in early child- FUNCTIONAL NEEVOUS DISEASES 289 hood, is much more frequent in the male sex, and is of hereditary nature. Tlie patient while sitting will suddenly develop violent spasms . of a part which may be sufficient to dislodge him from the sitting posture, or, if in progression, may cause him to tumble about or fall. The muscular contractions are accompanied by slight pain, but there is no tenderness over the muscles, and dur- ing the time of contraction they stand out in great prominence. The movements are generally quieted by rest, and are altogether absent during sleep, although the spasms themselves prevent som- nolence in many cases. There is not the m^ental deterioration that is seen in convulsive tic. Exercise or catching cold aggravates the spasm. Pathology. — Little is understood of pathogenesis, and save for the hypertrophy of the muscle fibres and the constant prolifera- tion of the muscle nuclei, nothing is definitely known of the pathology. The duration may be ten or -fifteen years, the patient finally succumbing to intercurrent disease. Diagnosis. — It cannot be mistaken for other maladies on care- ful study of the above outlined semeiology. Treatment. — Massage, Swedish movements, and hot-water bath- ing are methods of relaxing the muscles. Nutritive measures, the hypophosphites among drugs being of value in keeping up the tone of the nervous system. Protonuclein may be of service through supplying nuclein to the degenerating muscle cell (gr. V, t.i.d.). EPILEPSY Definition and JEtiology. — Epilepsy is a neuro-psychosis in which unconscious attacks and a tendency to convulsive seizures are permanent features of the disorder. The disease is well known to be hereditary as to the degenerative predisposition; and it will frequently be found that where epilepsy has not existed in the previous generation there will at least be a history of alcoholism or specific disease in the ancestry. The disease may occur at any period of life. In those more truly hereditary eases (75 per cent) it begins quite early, before the tenth year. The sexes are about equally affected. It can be pretty positively stated, the more ad- vanced the age at the development of the disease in the so-called idiopathic case, the less likelihood of heredity being an setiological factor ; but up to the degenerative period of life, when inhibition 19 290 TEEATISE ON NERVOUS DISEASES is less stable, epilepsy may appear as real stigmata of a degenera- tive tendency. Other causes of epilepsy are mental shock, injury to the head, such as fractures, concussion or compression of the brain, meningitis, brain tumour, gunshot wounds, toxsemias (alco- hol, lead, diabetes, uraemia), reflex irritation (eye-strain, phimo- sis, nasal or intestinal disease), and circulatory disturbances. Cor- tical apoplexy or meningeal haemorrhage is not infrequently the fundamental cause of the epilepsy coming on, due to insuperable obstacles at birth; and in such cases the epileptic disease is but a symptom of the cerebral palsy of childhood. This is well marked in the case of a boy under the writer's care who is spastic, has a dolichocephalic head, has had convulsions since babyhood, and has from three to ten attacks of grand mal daily. He frequently suffers from post-epileptic palsy. Hydrocephalus is a cause of epilepsy. Diagnosis and Symptoms. — Epilepsy is divided into major {grand mal) and minor attacks (petit mal). Major epilepsy is divided into focal or Jacksonian, where the spasm is limited to a part or member of the body, or where the convulsive seizure begins locally. There are also general epileptic convulsions. AVhere the disease is well established there is present a peculiar physiognomy, one of mental depression and instability of purpose; also acne on the face, as a rule, the result of prolonged use of bromides — the so-called epileptic fades when associated with the features of mental instability mentioned. Premonitory symptoms frequently precede the attack. These consist of headache, giddiness, jerkings, mental depression or ab- erration, etc., and may occur for some hours before the attack. The attach may be ushered in by a peculiar subjective sensation called an aura; usually a globus or a feeling of depression, as of a cloud coming over the patient, the vision becoming dull, and in a moment passing into the convulsion. There are many aurse. Senso7-y Aurce. — The aura may also be a pain in the epigas- trium — gastric aura; or rarely, it may be of paresthesia in an extremity; or less frequently, an hallucination of smell or taste or hearing or sight. I have known a ease where the odour of violets preceded the attack; another in which the sound of the disr charge of a gun was the hallucination; while irregular scotoma or the seeing of some grotesque object may be the visual disturb- ance preceding the seizure. Motor aura as a marked tremor may occur. Following this there may or may not be irregular auto- FUNCTIONAL NERA^OUS DISEASES 291 matic movements in different parts of the bod}^, the patient quickly becoming pale, then cyanotic and unconscious. In the light attack (petit mal) the patient may, with or without this precedent phenomena, pass into unconsciousness, accompanied by dilatation of pupils, and if at table, dropping the fork or some other object — the spell lasting but a few seconds, when the patient may resume his usual condition. The attack may be succeeded by somno- lence or sound sleep lasting a half hour or more. In case the attack is one of grand mal succeeding the premonitory signs already mentioned, or with the initial cry in most cases, due to the firm rigidity of muscles of the chest, the patient falls over unconscious and goes into a general convulsive seizure, consisting of tonic rigidity followed by clonic spasms accompanied by froth- ing at the mouth and conjugate deviation of the eyes up and out towards the side of most violent movements; also dilated pupils. Blood may also be seen coming from the mouth, due to biting the tongue in the attack. The convulsion finally ends by rigidity of the flat trunkal muscles, and within a minute or so the entire attack is completed, there being rather sudden restoration of con- sciousness and of power in the extremities, although the intellect remains especially dulled for some moments, and there may be transient aphasia. The patient here again is apt to go into som- nolence, which may last half an hour, or several hours in rare cases; but exceptionally post-epileptic paralysis may occur or automatic acts, the patient going about without mental control or apprecia- tion of his surroundings. In an attack the patient usually suffers vesical or rectal incontinence, or both. Occasionally " masked epilepsy " or substitution phenomena take place of the attack per se, the patient passing through auto- matic acts instead of a convulsion; or a condition of double con- sciousness may exist in which the patient may wander off for some hours or days, " coming to himself " in a remote locality. This is termed ambulatory epilepsy. Rarely, too, some marked ps3^chosis may be the substitution, as a mania or delusional insanity with homicidal or suicidal tendencies. If the attacks follow one upon the other in rapid succession, M^e have what is termed status epilepticus, and in such condition the patient may actually die of exhaustion. The epileptic complains of soreness and pain in the limbs after a seizure, and the body mav be bruised or dislocations oc'cur from the movements or in the falling at the beginning of the attack. 292 TREATISE OX XEEYOUS DISEASES Convulsions occur more frequently in the early morning hours when the patient is asleep; this is probably due to the lowered physiological ebb of the nervous system at this time. In chronic cases this rule will not be maintained; the patient will have the attack at any part of the day {diurnal) or hour of the night. If it be nocturnal epilepsy^ frecjuently the patient is not aware of the atiack except for the soreness in the muscle. Intercurrent diseases or pregnancy may stay attacks for the time being. Gowers mentions the following as the chief characteristics of Ijetit mal, arranged in the order of frequency : 1. Sudden momentary unconsciousness, or " fainting/' or " sleepiness/' without warning. 2. Giddiness. 3. Jerks or starts of the limbs, trunk, or head. 4. Visual sensations or loss. 5. Mental state: Sudden sense of fear, etc. 6. Unilateral peripheral sensation or spasm. 7. Epigastric sensation. 8. Sudden tremor. 9. Sensations in both hands. 10. Pain or other sensation in the head. 11. Choking sensation in the throat, 12. Sudden scream. 13. Olfactory sensation. 14. Cardiac sensation. 15. Sensation in nose or eyeball. 16. Sudden dyspnoea. 17. General '^ indescribable '' sensations. After these attacks patients may perform automatic actions, as after attacks of grand mal. Eating at times induces attacks re- flexly. Convulsions usually sooner or later develop, and the two forms often coexist and interchange in the nature of attacks. In either form of epilepsy there is excess of leucocytes and poikilocj^tes. Diagnosis. — Epilepsy may be confused with the hysterical paroxysm in rare cases. In hysteria there are stigmata of the /"'disease, such as reversed colour fields, hystogenic zones, etc. ; and the attack itself is prolonged a half hour or more, the spasms being more irregular and tonic in character. The patient bites the lips rather than his tongue. The eyelids are kept closed. FUNCTIONAL NEEVOUS DISEASES 293 The pupils are not dilated. Syncopal attacks may resemble petit mal. Careful study of 'the circulation will differentiate. Puerperal convulsions are told by the history of the case, the finding of albumin in the urine, and the more prolonged series of convulsions. Other symptomatic epilepsies are easily diagnos- ticated. Myoclonic epilepsy is told by the preceding myoclonic state of the muscles. Pathology. — This is most likely a subtle anatomic or physio- logical affection of the cerebral cortex in all cases, though careful search in the majority of so-called idiopathic cases fails to reveal any changes by our present methods of research, which only goes to show our profound ignorance of this enigmatic disease. If a patient. dies in convulsion, venous engorgement and minute haem- orrhages may be found in the cortex. Diffuse sclerosis of the cortex has been found (tuberculous or otherwise), meningo- encephalitis. Fere has frequently found neuroglear prolifera- tion, while Marenesco and Block have described vascular and peri- vascular changes in the cortex. Hypertrophy of neuroglear bun- dles between pia and cortex is very frequent. .Organic epilepsy will have as its pathology the pathology of the causative disease. Prognosis. — An axiom in prognosis of epilepsy is, that the younger the case the worse it is for help or cure; the older the person, per contra, the greater hope for amelioration or recov- ery. Among the latter class we have subdivisions: first, cases in which mental degeneration takes place rapidly; and secondly, those where the attacks do not seem to produce any great mental depreciation. Napoleon's case was an example of this class. Focal epilepsies are pretty positively due to some definite organic lesion. In proportion as the cerebral cortex itself is involved will surgical aid fail of relief. But where such lesion is operable, as, for example, a localized meningeal lesion or depressed fracture, operation at the earliest moment will be fraught Avith relief or cure in 15 per cent of cases, x^f ter five years surgery cannot help epilepsy, since the habit has been too deeply established. In pass- ing, it should be stated that extradural haemorrhage in the newly born ought to be treated surgically, if sequent epilepsy from a' secondary irritation is to be avoided in later life. Such surgical procedure has as yet never been done, but has been suggested by Dr. S. Weir Mitchell and Dr. W. W. Keen. As refinements of diagnosis become more and more accurate in the new-born will the 294 TEEATISE OF NERVOUS DISEASES possibility of such help from the surgeon be determined. Spon- taneous cures rarely occur. If attacks have lasted two years, there is little hope of cure in " idiopathic " cases. Treatment. — The above-indicated surgical treatment we most earnestly commend in early cases of the disease where there is any evidence of dural hgemorrhage, or other foreign body causing irri- tation of the cortex. A child with epilepsy should be subject to most rigid scrutiny for evidences of reflex irritations. Gastro- intestinal disord,ers, including those due to parasites, as the nema- todes or trematodes, should be eradicated by first expelling the offending parasite. The use of depresso-motors is indicated in epilepsy, since there is excitation of the motor cortex; such symp- tomatic treatment is, of course, to be desired in itself, and these drugs do much good in this disease. Ten to 15 grains of the bromide of potassium should be given three to four times a day, according to the age of the patient and the physiological idiosyn- crasy. In giving the bromides, they should be continued for a month or two, when, even if the attacks are stayed, it is wise to withhold the drug for a week, then to continue with small doses, gradually getting up to the maximum, as mentioned. The opium treatment of epilepsy, which consists in the gradual increase of the drug up to producing stupor in the patient, has been commended by Collins in this country and by Flechsig and others abroad. The tendency to disturb the stomach of the patient or to produce the morphine habit seems to me a strong contra-indication against the use of the drug ; although I have seen a hypodermic injection of morphine sulphate given during an epileptic status quiet the patient and prevent further seizures for the time being. The use of cannabis indica will be found of value in cases of petit mal. The berries of the horse-nettle or Solanum carolinense, especially in the form of the fluid extract, I have found beneficial in a num- ber of cases of idiopathic epilepsy where there is no hereditary taint. A fluid extract of the drug is particularly serviceable if made from fresh berries, the drug being pushed to the full physio- logical limit. At present in a case under this form of treatment, after all other methods have failed, a fluid extract of the berries, pushed to a dram four times a day, has prevented an attack for three months, whereas the girl had been havinsr them previously on an average of one attack every ninth day. Belladonna is occasion- ally a useful remedy, especially where the circulation seems to FUNCTIOITAL NERVOUS DISEASES 295 have failed through vaso-contraction ; this in conjunction with nitroglycerin, given in continued dosage, will sometimes act favourably in allaying the spells. The use of digitalis in combina- tion with the bromides has controlled attacks in many cases with feeble heart circulation, where the bromides alone had failed. The reason of this lies perhaps in the better circulation produced in the brain, as well as in the more active circulation carrying off waste products. In all cases of epilepsy the gastro-intestinal tract should be particularly guarded. If indican be found in excess in the urine, especially is it important to use intestinal antiseptics, such as salol, grains 2 to 4, in twenty-four hours ; also high flushings of the colon with lime-water solution, an ounce to a quart of tepid water. If there be gastric dilatation, lavage of the stomach will frequently, by preventing absorption of undigested food products into the blood, produce happy results. Regulated exercise is essential. The mind should be lightly employed. Special care should be given to massage and the hygienic condition of the skin ; salt bath- ing is particularly desirable to stimulate cutaneous circulation, and to the full extent relieve any congestion of the meninges. Tou- louse speaks of the value of withdrawing common salt from epi- leptics, thereby permitting free absorption of the bromides. Dis- turbed metabolism, especially the uric-acid diathesis, calls for careful attention ; and in the latter class of cases the use of alkaline waters is to be commended. Milk diet, or at least the withhold- ing of meats and indigestible foodstuffs, is important. The worst cases are better treated in the colony farms, as at Sonyea, N. Y. NEURASTHENIA Synonyms: Nervous exhaustion; Nerve tire; Nervous prostration ; Beard's disease. Definition. — This is a functional disease in which there is a condition of irritability with weakness of the central nervous sys- tem. It was first described by Beard, of New York, in 1869. The age of onset is usually between eighteen and thirty years. It is more frequent in women (75 per cent of the cases), more persistent when occurring in the male. The disease is hereditary or acquired. Causes. — Overwork, worry, hereditary predisposition, poisons, autoinfections, and fright. Other predisposing causes are ane- mia and sedentary habits, lack of exercise, unhygienic surround- 296 TREATISE OX XEEVOUS DISEASES ings, absence of sunlight, improper food, and genital disease, par- ticularly in women. (See Fig. 64.) The communications of the nervous system to the genital organs may be better understood by the following diagram: Spinal eord. Plexus luchiadicus Plex.padendaliS Plexu.i coccygeus Plexus deo-inguinal. . plexus genito crural. y.n. Iieii iXerves of lower extremities) \ I .V. spennUnt. N. lumbo-inguinalis Branches to uterus \ \ \ y.,perinealis I -Y. dorsal clit. \ I \ ' Fleu:iis aavernoaus {cHtoria) \ \ # Plexus vesico-vaglnalis (Bladder and vagina) Plexus utero-vaginalia '( Uterus and vagina) Plexus spermat (ovaries, tubes and fund, uteri) \^ Plexus renalis iovaries) Plexus Ccdiacus Tig. 64. — Communications of the Neryocs System to the Genital Organs. Dotted lines indicate combinations. (Pearce-Beyea.)' From this description it is definitely shown that there is an anatomical relation between the female genitals and the nervous system, and it would seem that there must be, at least in some measure, a communication between certain physiological functions and diseases of the female genitals and the nervous system; and also, therefore, to some diseases of the nervous system. Symptoms — Psychic. — Generally an irritability of the mind, lack of power of concentration, f orgetfulness and inability to carry on a continuous line of thought; peevishness, and supersensitive- The Memphis Lancet, September, 1898. FUKCTIOXAL XEETOUS DISEASES 297 ness,' with insomiiia. The patient complains of vertigo. Photo- phobia or other special sense irritability may be manifest. The bladder may be " irritable "' and an early symptom. Sensory. — Peculiar sensations exist as of heat and cold, parses- thesia of the extremities, or actual hypersesthesia. There are usually tender spots on pressure over the spinal column, princi- pally over the cervical, dorsal, and lumbar enlargements of the cord. The patient complains of a sense of constriction about the head, a vague feeling' of distress, often described as a "helmet- like" headache. The pain may be localized particularly in the frontal and occipital regions. It is made worse by use of the eyes and by mental or physical work. Backache is constant. Motor. — These consist of a fine tremor of the extremities, and tongue, and lips. The tremor is brought out by intention. It is apt to subside when the patient is quiet in the milder cases. The muscular tone is lessened, fibrillary contractions of the mus- cles may occur, especially if tapped with the percussion hammer, that may bring this phenomenon out enough to simulate the fibril- lary contraction of degenerative states, as in chronic poliomyelitis. There is widespread enfeeblement of the musculature. The patient tires on the slightest exertion, but there is- never palsy or convul- sion. The reflexes are heightened. Weakness is worse before noon. Yaso-moior palsy and leakiness of the skin with cold extrem- ities is frequent. Palpitation of the heart is not uncommon. The urinary secretion is usually increased and of low specific gravity, with excess of phosphates. Indicanuria is very general in cases of gastro-intestinal origin. Colliquative diarrhoea is a common symptom, although it may alternate with persistent constipation. The patient often complains of tympanites, borborygmus, and tenesmus. Hyperchlorhydria is not uncommon, and is especially marked after a meal. In some cases there is distinct gastrectasia. Displacements of the abdominal organs will be found in a few cases of neurasthenia; thus floating kidney is not a rare occur- rence; displacement downward of the liver we have seen, due entirely to the relaxation of its ligaments. The occurrence of abdominal pain in the right lower quadrant of the abdomen is undoubtedly due to a fermentation in the csecum, and while some cases have been mistakenly diagnosed appendicitis, it is possible that neurasthenia may .be responsible in this way for that disease in a few instances. Patlwlogy. —Thei-e has been found by Hodge granular change 298 TKEATISE ON NEEVOUS DISEASES of the c3'toplasm of the neurone, following induced exhaustion, in bees. This is accompanied by a diminution in size of the cell, but without actual degeneration; the incipient pathologic state being recovered upon the restoration of the bodily function. In the human body it is likely that this same change occurs, which has, however, not been actually demonstrated as yet. Adjunct pathogeneses of neurasthenia are circulation of the blood to the cerebral cortex, of toxines, alloxurie bodies, uric acid,^ and allied by-products. The deficiency of excretion of solids by the kidneys in a few cases may be the exciting cause for the de- pression of the nerve-cell, and, therefore, induction of active symptoms of nerve exhaustion. Diagnosis. — Neurasthenia is to be told from hysteria, in the latter of which the emotional state of the patient is the salient point. In the hysterical person, too, there is no muscle hypotonia, as in nerve exhaustion; perversions of common sensation, paraly- sis, or convulsions being frequent symptoms in hysteria. The inconsistent s}Tnptomatology is a vital point in determining hysteria. Asthenias following prolonged fevers are to be distin- guished from neurasthenia per se, since in these symptomatic disorders the patient has not the particular irritable symptoms already mentioned. Secondary neurasthenia is to be told from primary or essen- tial neurasthenia by finding a reflex source of irritation for the former, such as uterine diseases, phimosis, or sexual disorder in the male (the so-called sexual neurasthenia). Neurasthenia terminalis is the chronic form that has become incurable. Prognosis. — The prognosis of acute neurasthenia is good if treated at once, depending upon the non-hereditary tendency of the patient. Cases with the hereditary taint are to be given a guarded prognosis. Cases of secondary neurasthenia will also re- cover promptly in proportion to the relief of the primary exciting cause, such as a proper repair of cervical and perineal tear with prolapsus uteri; the correction of errors of refraction, etc. The duration of the average case of simple neurasthenia is about three months. Chronic cases may last for years, with re- missions of periods of several months, or longer. Treatment. — Eevolution in the treatment of nervous exhaus- 1 See Laboratory Studies on Uric Acid in Neurasthenia, etc., American Journal of Insanity, vol. Iviii, No. 1, 1900. FUKCTIOlSrAL NERVOUS DISEASES 299 tion was made by Weir Mitchell in 1874, when the difEerent meth- ods employed in treating this disease with more or less success were correlated and established into guiding principles. These consist of (1) mental and bodily rest, (2) full feeding, (3) isola- tion, (4) massage, as well as movements, and (5) electricity. The employment of this combination is designated the " rest cure." It should be carried out for a period of six or eight weeks to three months. If good results are not obtained at the end of three months, experience teaches that it is useless to continue the treat- ment. It is essential, in carrying out the method, to remove the patient from home, or, if this cannot be, to a remote portion of the house, away as far as possible from the atmosphere of home. The patient is kept absolutely in bed and given two good nurses, the room being kept at an even temperature, at an average of 68° F. All reading is to be discontinued, and even the nurses are in- structed to converse but little over pleasantries of the day, and none as to the patient's vagarious complaints. The instructions, which should be explicitly written by the physician, are further as follows: Patient put on a light milk diet, a glass being given at seven o'clock in the morning, on waking, and then every two hours during the day; thus from 9 to 10 doses of milk will be given the patient in twenty-four hours. Beginning at first with 3 ounces, finally reaching 8 to 10 ounces, which would make 27 to 72 ounces taken within the twentv-four hours. At any time the patient's stomach rebels the increasing dosage of milk is held or lessened, or lime-water or peptonization may be employed to assist digestion. In addition to this dietary the patient may take at 7.30 o'clock in the morning a cup of cocoa, which can be repeated at eight o'clock at night. If there is persistent insomnia, and the stomach is not being taxed for digestion too severely, a piece of dry toast can be given in the evening with the glass of milk to vary the monotony, although it will be found, in the aver- age cases suitable for this treatment, that large quantities of milk can be taken without causing any disturbance. The milk diet is continued for three or four weeks, and when the patient is gaining in weight the diet can be increased to solids, such as proteids, in the shape of red meats and 03^sters, lamb chops, eggs, etc. At this stage it is also well to add a nutrient, as the fluid extract of malt, of which there are several varieties on the market, the Johann Hoff malt being one of these. As regards rest, the patient is not even allowed ta sit up, 300 TREATISE OA" KERVOUS DISEASES except for the moment of taking the food, which should be admin- istered by the nnrse. ISTor is the patient permitted to read. The patient should be given a tepid sponge bath, followed by an alcohol rub in the morning, and an alcohol rub alone at 9 p. m. The braiding of the hair and general toilet should be left en- tirely to the nurse. These little details are essential in the proper carr3'ing out of the regime, if good results are to be obtained. The massage should be given at about 10 a. m., beginning at first with light effieurage, finall}' reaching the deep kneading of the muscles, which is of most value in their nutrition. This also as- sists digestion of so large quantities of food. It is interesting to note the relation of food supply to the proper massage and Swedish movements in a rapidly progressing cure under the rest treatment. Electricity usualh^ is best in the form of faradism, the nurse em- ploying it at about three o'clock in the afternoon, as follows : The extremities are first given the rapidly interrupted current, then the slow interrupted current is applied to the muscles of the upper extremities, lower extremities, abdomen, pectoral region, erector spine, and back group of muscles. (See Massage and Electricity.) When the patient has gained in M'eight and in general nervous health she is gradually got out of bed, which should first be by sitting up in bed for five minutes at a time, gradually increasing this to twice a day, and finally the patient is to be lifted upon a chair. The length of time is increased until sitting up two or three hours, morning and evening, has been indulged. The patient can move about the room and then get back gradually to normal life — a renewed person. As a rule, improvement continues for many weeks after the case has been so treated. The so-called partial-rest treatment consists in having the pa- tient rest for an hour or so in midday, plus the hour's rest after the massage in the morning, the rest of the day being devoted to quiet living, when the patient may do a certain measure of work, if not of a taxing nature. The diet in partial-rest cure is never limited to milk alone, and malt is given with the meals. Frequently the use of phosphorus in pill form, yts of a grain and a capsule ; of extract of chirata, 1 gTain ; extract of ignatia, ^ grain, to be given after meals, will be of value. The simple elixir of iron, quinine, and strychnine is useful in the eases among the poorer classes, and reaches many of the indica- tions.^ In any case of neurasthenia the bowels should be kept 1 See Appendix. FUNCTIONAL NERVOUS DISEASES 301 soluble. For this purpose the Lady Webster pill or the pill of aloin (gr. i), belladonna (gr. tV)j and strychnine (gV) may act nicely when given at bedtime. The fluid extract of cascara, in from 15- to 30-drop doses, is a valuable remedy in these cases. Where there is acidity of the stomach the phosphate of soda, in dram .doses, on waking, will prepare the stomach for better digestion. In this case the pill of nitrate of silver (gr. ^), given three times a day, will be of service as a tonic to the mucous membrane of the stomach. Hydrotherapeutics in neurasthenia is very important, and should be used as indicated, by sponging in rest-cure cases or apply- ing cold douche in ambulatory cases. The Charcot's douche is one of the most valuable methods of applying water, and consists in the circular spray applied to the trunk, chiefly over the spinal col- umn. In hydrotherapeutic procedures for neurasthenia it is best to begin with a tepid sponging or a few moments' bath of the body accompanied by frictions, and at the end of five or ten minutes follow this up by a cool spray, at a temperature of 65° F. This entire procedure is to be followed by a brisk rub with a Turkish towel and rest for half an hour afterward. Flushings of the colon with tepid water every other day is valuable in those cases of an autotoxic nature. The use of warm mud-baths, such as the " fango " of the Mediterranean, I have seen do good in cases ac- companied by the most persistent insomnia. Where there is an irregular excretion of uric acid, especially in rheumatic diatheses, the use of salicylate of soda will be found of value in relieving the general irritability of the patient and painful headaches, probably due to by-products circulating in the meninges. The correction of the eyes should be had in cases of reflex ocular defects. All sources of irritation should be eradicated, as phimosis, etc. The gynaecologist is here closely related to the neurologist, and while too many cases of neurasthenia are assigned as gyngecologic, it must be stated that judicious study of neurasthenia, following childbirth, will determine it to be caused or aggravated by some lesion of the pelvic tract. Other measures to be employed in neurasthenia are fresh air, sunshine, and salt breezes. Iron should be emploj^ed in anemic cases. Good food must be had at all times. Hypernutrition is an essential in the treatment of this disease. The patient should be encouraged at all times. The climatology of neurasthenia is not sufficiently worked out 302 TPiEATISE OX XEETOUS DISEASES at the present time. It would seem axiomatic at all events that the patient should not ascend to an altitude above 2^000 feet. A very stimulating' climate should be avoided^ as should also dis- tricts menaced by iogs, cloudy, saturated atmospheres, with but slight movements of air currents, and the opposite, high-wind localities. Sea level, with continuous heat, non-varying, is bane- ful. Thus the Bermuda Islands and Florida are enervating local- ities. Ideal conditions for the neurasthenic patient include sea- air in a well-wooded country, far enough from the coast to avoid its fogs. Sea voyage is, as a rule, an excellent preliminary to other climatic measures, and, provided it is not stormy, will act both psychicaDy and physically in soothing the nervous system. HYSTERIA This is a functional disease of the nervous system, manifested by psychic (emotional), motor, and sensory phenomena. This disease has been the cause of much discussion as to its entit}^ and to many other misunderstandings in the progress of medicine than any other malady. It is the old " possessions "' of the middle ages: in common-sense garb to-day a disease of emotions. etiology. — Heredity is distinctly a cause of hysteria. Xext in order would come moral shock, phj'sical shock, and overwork, and sudden drain upon the system, as in acute ansemia, tj^phoid, etc. Symptoms — Psyclio-sensory. — These are predominating, being somewhat masked in certain cases, and therefore misleading in the differential diagnosis. There are two t}^pes of hysteria: the gen- eral state associated with stigmata, and the paroxysmal. The following table from Gowers illustrates the differences between epileptic and hysterical paroxvsms : EPILEPSY. HYSTERIA. Apparent cause, Warning, Onset, Scream, Convulsion, None. Any, but especially unilat- eral or epicrastric auras. Always sudden. At onset. Ricridity, followed by jerking, rarely rigidity alone. Emotion. Palpitation, malaise, chok- ing, bilateral foot aurae. Often gradual. During course. Rigidity, or " struggling," throwing about of limbs or head, arching of the back. FUNCTIONAL NERVOUS DISEASES 303 EPILEPSY. HYSTERIA. Biting, Tongue, Lips, hands, other" people or things. Micturition, Frequent. Never. Defecation, Occasional. Never. Talking, Never. Frequent. Duration, A few minutes. More than ten minutes, often longer. Restraint necessary. To prevent accident. To control violence. Termination, Spontaneous. Spontaneous or induced (water, etc.). Among stigmata of hysteria there is the emotional element of the patient, the lack of control of will power, which is induced the more by any slight excitement, particularly of a psA^hic nature. Narrowing of the visual fields and reversal of the colour fields (red heing perceived before blue) is frequently found in hysteria. Hysterical amblyopia or hysterical blindness is a very rare symp- tom. The patient is able to escape objects in walking about, but has no conception of their shape, size, or use. There may be photophobia, achromatopsia, or dyschromatopsia. Other psychic special sense symptoms are the following: Hy- perosmia, anosmia, and parosmia; in the ear we have similar con- ditions — deafness, increased acuity of sense of hearing, tinnitus aurium; the sense of taste may be affected — hypergeusia, ageusia, and parageusia. Hysterical hyperpyrexia may occur.' The so-called h3'sterical zones are frequently found on pressure over the dorsal, cervical, and lumbar regions of the spine, also over the ovaries and beneath the breasts — hjsterogenous zones. Other sensory disturbances may be geographical or segmental or glove-like areas of ansesthesia, or a very sharply defined hemi- an^esthesia. This is quite distinct from organic hemianesthesia, where the loss of sensation p'asses beyond the median line — due to interdigitation of nerve-fibres from each side upon the skin be- yond the median line. Hysterical joint is a rigid, tender joint. The subjective sensation of tingling in the extremities (parses- thesia) is very usual in hysteria. At times this takes on the hal- lucinatory expression of ants creeping over the body, and it is very difficult to convince the patient that this is not so. Motor} — The motor symptoms of the continuing state of hys- teria are, as a rule, of excessive muscular action, with irregular 1 Hysterical ataxia may occur. Astasia-abasia is inability to stand or sit well in hysteria. 304 TEEATISE ON NERVOUS DISEASES and rapid movements of the extremities in any particular voca- tion. The depressive motor states do exist, however, in the minor- ity of cases, where the patient is apathetic, inactive, or even seden- tary, with or without actual palsy. Catalepsy or trance may per- sist for days. Palpitation of the heart, rapid breathing, excessive or deficient secretion of urine, or even hsematuria, may exist in hysteria. Dysmenorrhoea and amenorrhoea are not uncommon. I have not observed any particular alteration of the function of the bowels in hysteria, although regurgitation of food or even merycis- mus and extreme tympanitis {pliantom tumor) are very usual. The paroxysmal stage of hysteria consists particularly of vio- lent motor manifestations, which, as a whole, is described as the attack of hysteria. In this the patient will, after some hours of premonition, of which he will give ample warning, pass into local and general convulsions, which will assume the tonic type in par- ticular, the patient in her contortions being drawn into opisthot- onus or pleurothotonus. The movements of the extremities are more or less vermicular, rather than of true clonic or tonic type. The e3^es are rolled about, although the lids are generally kept closed, and it will be found that the pupils are not dilated, as in epilepsy. The patient will not injure herself as a rule, and falls in the attack upon some convenient spot. While there may be frothing at the mouth, there is never biting of the tongue, nor the characteristic cry seen in epilepsy. The attack is noted for its dramatic effect, and continues the more when the patient is in special solicitude by her friends. An " attack " of hysteria may last from five to ten minutes to several hours or longer, the patient usually passing out of the condition suddenly, and may from sheer exhaustion fall into sleep or a state of. trance lasting some hours. The patient is not unconscious in the attack, and if pricked with a pin or otherwise irritated will frequently resist and give evidence of the disturbance. Certain passionate attitudes are described by the French in the " grand " attack ; these are seldom found in America. They are : 1. Epileptoid. 2. Grand movements. 3. Period of passionate attitudes. 4. Period of delirium. The attack may last twenty minutes or as many hours. Diagnosis should not be confounded with other diseases, ex- FUXCTIOXAL XERVOUS DISEASES 305 cepting possibly with neurastlienia, where the emotional element is wanting ; but it must be remembered that the two diseases coex- ist. Hysterical manifestations occurring as symptoms of brain tumour should be borne in mind, and careful search made in all cases for the symptoms in the latter disease. Hysteria is very apt to be diagnosed in some cases of tumour of the frontal lobe, .and in this class of cases the most mistakes are made. Prognosis is always good as to the paroxysm, and to be cau- tiously given in cases hereditary in type. In acquired hysteria, where the initial cause has been eradicated and impression has not been made too profound upon the nervous system, recovery will frequently occur after proper treatment. Treatment. — This consists of psychic influence largely. Such patients should be got entirely under the control of a physician, away from sympathetic friends, and firmly, though gently, treated. Encouragement should be given when the patient con- trols herself, thereby strengthening the will power, which is so deficient in this disease. If the system is run down, a tonic line of treatment must be enjoined. Change of scene is frequently neces- sary, a long sea voyage being desirable where there has been a great moral shock as the exciting cause. Among drugs bromides are indicated; asafoetida, gr. v, in pill form; or a compound sumbul pill of Goodell, ext. sumbul, gr. j; ferri. sulph. exsic. gr. j ; asafcetida, gr. ij ; acid, arsenicum, gr. -jV? given thrice daily. In the attack the administration of aromatic spirits of ammonia, valerian, or cold douches to the face will be of value. Hypodermic injections of plain water, or where the con- vulsion is serious small doses of morf)hine, guarded by atropine, will be indicated; or a cold plunge may be given. Counter-irritation to the spine, such as by the actual cautery or blisters, will frequently give prompt relief to the paroxysm. Hypnotism is a valuable means for the cure of certain classes of cases, particularly those with local palsies, either motor or sensory. It is of less value in cases involving the entire mus- culature. Patients recovering from hysteria should be placed in an entirely different surrounding, if the cure is to be permanent. The care of the hysterical patient demands a keen insight into human nature. It is in this disease that the doctor and nurse, through judicious sympathy, alternating with rigidity of disci- pline, that the "paralyzed will power'' (for 3uch is not an inapt 20 Fig. 65.— Hysterical Paralysis. Braces and Wheel-Crutch applied to As- sist IN Walking till She Gained Power. — Cured. FUNCTIONAL NERVOUS DISEASES 307 description of the psychological state) greatly assists earlier and complete recovery of the patient. It is essential in managing this disease to know the history, the heredity of the affection or not, and then to learn the predisposing and exciting causes which have led up to the " attack," be it a passing syncope, or convulsion, or other form of the acute malady. It is these cases where especially, as some author has well said, the nurse should have an eagle's eye, a lion's heart, and a lady's hand in dealing with the case, one of those optimistic Greek maxims which gives vitality to all action. In treating any form of hysteria, we will find that 90 per cent of the cases cannot be aroused to sudden cures through such agents as hypnotism, mental suggestion, and the like; and while such measures should be practised in selected cases by the physician (with the nurse's aid), still a happy discretion in knowing when to abandon these more mysterious methods of cure, successful as they are at times, is to be impressed upon us. Therefore, in treating hysteria, it should ever be' present in mind that these at times quicker forms of treatment cannot be continued when we have learned that there has been no rapid improvement in the symptoms. Local paralysis or spasms of a hysterical nature, are in my experi- ence more easily controlled than generalized symptoms, by hypnot- ism.; so that whether it be paralysis, motor or sensory, or of con- tractures, the subconscious state is much more difficult to influence by this means. In these cases the nurse, who is more constantly in attendance than the physician, by lending a spirit of hopefulness in pointing out to the patient from day to day improvements observed by the physician, will re-enforce therapeutics greatly. And our nurses should be better instructed in this fact that, when the lowest ebb of will power is established over months and years in extensive chronic paralytic forms of hysteria, nerve energy occasionally is never restored ; and, therefore, function remains in abeyance with- out any pathological lesion taking place other than those accom- panying the malnutritional state. The greatest exciting cause of hysteria is some form of fright, as is instanced in a case under the writer's care, which was awakened by a rat running across the bed, since which time she has had hysterical stigmata with generalized functional tremor. Another instance is that of a young woman ^ who fell down a flight of seven steps without any serious bodily harm, although a pain in the back led her to believe that she would 1 International Medical Magazine, September, 1901. (See Fig. 65.) 308 TKEATISE OX NERVOUS DISEASES be paralyzed, which she finally was. She has now been bedridden for three years, with hysterical contractures, ansesthesia of the lower limbs up to the knees, and once a clonic hysterical spasm of the abdominal muscles; which latter was cured by producing the initial stage of ether anaesthesia. It took us many months before this woman could be impressed enough to show signs giving ground for hopeful prognosis, and later cure. I mention these rare cases so that the nurses may be taught to understand that nerv- ousness is not all foolishness, and has some basis for its existence, perhaps, in the theory of immobility of the neurones; and there- fore the diverting of the nerve-currents irregularly, which is very likely the fact, as suggested by Duval and Lugaro. jSTerve energy is, to my mind, but the most refined form of electricity. There are some physiological phenomena which tend to prove this, as in the sense of light-flash perceived when the oculist severs the optic nerve in enucleation, or in the sudden res- toration of power and sensation following nerve suture, as in a case of traumatic operation of the ulnar nerve recently seen by the writer. We have in this theory a reason for the efficacy of electricity in nervous diseases. TRAUMATIC HYSTERIA Synonyms: Railway spine; Traumatic 'back; Traumatic neurasthenia Definition and Causes. — This is a form of hysteria, the result of psychic and physical injury. By some it is thought to be a func- tional disorder; by other authorities to have an organic basis, the milder eases not having, as yet, the pathology fully determined. Others describe the condition as entirely mental. Unfortunate^, this is a disease in which the wildest variation of opinion exists as to its nature. We shall give what is accepted by the best authori- ties. Traumatic hysteria is more frequent in neuropathic persons, is precipitated by some form of physical injury, in contradistinc- tion to the idiopathic hysteria, so called, which usually has its exciting cause in some psychic trauma alone. Traumatic hysteria is more common in the male sex, in whom it is more severe, as a rule, than in the female sex. The reason for the more frequent occurrence in males is undoubtedly due to the liability to injury in men. Symptoms and Divisions. — The history of its onset is usually FUNCTIONAL NERVOUS DISEASES 309 as follows : The patient is struck upon the back or thrown from a railway carriage, being discovered in a more or less condition of shock, with or without consciousness ; and when he is restored the physical injiiry has impressed itself so upon him, that with the mental instability induced, the patient imagines that he is seri- ously injured, whether this be actually the case or not. On this latter depends the dividing course in the symptomatology. If the physical injury has been of slight nature the neurotic person will develop symptoms entirely psychical. Or, if an injury to the mus- cles or ligaments, which in time is healed, occurs, the length of time of the actual trouble will be prolonged in such a case by the fixed hysteria established during the course of the real trouble. The second class of cases develop actual disease of the mem- branes and spinal cord of a subacute inflammatory character; or it may consist of heemorrhage within the cord, or to irritable weak- ness (neurasthenia), and finally to degeneration. The first class of cases presents the typical hysterical symptoms, plus some local manifestations, the result or supposed result of the injury. In the first instance, of course, the actual lesion is soon dissipated; in the second subdivision, the history of an accident plus these persisting localizing phenomena make plain the organic nature of the disease. In the purely hysterical cases the patient usually complains of rigidity of the back, which upon physical examination is deter- mined to exist as the result of tonic spasm of the erector spinge groups of muscles. Along the spine there are points of exquisite tenderness apt to be localized over cervical, dorsal, and lumbar enlargements of the cord. This tenderness upon superficial pres- sure is more than upon deep pressure, to which there would be exception only in the cases where muscle or tendon injury still pre- vailed. In the latter case so-called '''' tender-spots " will remain after the muscle is healed at the site of the original injury. The patient becomes irritable, tires at the slightest exertion, mental or physical. Palpitation of the heart, bradycardia or tacliycardia, may exist, and these symptoms frequently are not synchronous with the pulse-beat. Per contra, the pulse may be running, feeble, and irregular, while the cardiac muscle is not especially disturbed in function. This cardio-vascular condition gives evidences of the widespread irritability of the sympathetic nervous system, which is probably the more affected because of the relation of the gan- 310 TEEATISE OX XEEVOUS DISEASES glia to the spinal column, where concussion or a blow upon the back would transfer the physical effect immediately to these gan- glia Mng upon the bodies of the vertebrs. Other vaso-motor changes are local or general flushing and sweating or coldness of the extremities. Seldom is there a true cyanosis, however. Other organs affected largely through the sympathetic nervous system are the stomach, producing gastrectasia, borborygmus, hj^peracid- ity from fermentation of food, and intestines, causing alternating serous diarrhoea, abdominal cramp, and physical signs of pseudo- appendicitis. The kidney secretion may also be affected, so that anuria, polyuria, or even dysuria may occur. Irregularity of the sphincter muscle of the bladder may exist, inducing spasm or re- laxation with symptoms of tenesmus, incontinence of urine, etc. The knee-jerks and other deep reflexes are greatly increased, but the valuable point in diagnosis of this first division is that true ankle clonus is not present. The muscles are flabby and do not show reaction of degeneration nor localized wasting. Seldom do sensory symptoms occur other than parsesthesia or hyperEesthesia ; anassthesia, as in simple hysteria, never occurring. The psychic symptoms are sometimes bizarre, being entirely of hysterical nature, including stigmata and paroxysms of this dis- ease in quite exaggerated form. (See Hysteria.) The symptoms of the second class of cases are again, in the majority of instances, largely of psychic nature. In addition there are signs of organic disease. The milder eases will present the signs of rigidity of the spine, already described, plus physical evidences of chronic injury to the tissues around, between, or within the spinal vertebra. The points of exquisite tenderness, made worse by the slightest move- ment, and perhaps with some superficial swelling, would indicate a myositis. Deeper lying points of tenderness, also exaggerated by slight movement of the spine, with in some eases undue separa- tion of the spinous processes, would indicate relaxation or tear of intervertieal ligaments or disks, in the latter of which great pain would be experienced, when the patient should be assisted to stand on his toes and then dropped cautiously upon the heels. These patients are never in any degree of comfort, are usually harassed by severe pain, though periodic and Avorse at night, preventing sleep. Symptoms induced from the persistent insomnia may end in a mild grade of mania or even of delusions as to their friends, FUNCTIONAL NERVOUS DISEASES 311 especially where the doctor and relatives give out that there is no organic trouble present. The reflexes are greatly heightened, the musculature is frequently in hypertonia, due to irritation, and pseudo ankle clonus may exist. In the severer cases in this second class the membranes of the cord are congested or in subacute in- flammation, which may in time extend to the spinal cord itself, producing passive congestion or low-grade myelitis, which can be determined by the discovery of persistent ankle clonus, involve- ment of the bladder, either incontinence or resultant cystitis, and rectal incontinence similar to an ordinary myelitis. A typical case of this sort the writer has recently seen where hysteria has been pronounced, and yet where, in spite of a large recovery in a suit for damages, the patient still has the evidence of organic disease referred to. Diagnosis. — Simple hysteria is distinguished by the absence pf a back injury. Malingering is told by the fact that the malingerer cannot consistently simulate the symptoms constantly. Prognosis. — The duration of traumatic hysteria is very indefi- nite, the hysterical cases at times being almost as persistent and chronic as in organic change of the cord. Where organic lesions exist we cannot hope for entire recovery. The pure case of hysteria may be well in a few months. That large class of chronic com- plainers are incurable hysterics or are the organic cases. Prognosis depends entirely upon the skill of diagnosis in distin- guishing the different forms mentioned, and in our ability to com- mand proper moral and physical treatment of the respective forms. It is always most guarded, but it is probable that the patient in this disease more than in any other may recover promptly. Pathology. — This will vary from nothing (the first division) to (in the second class of cases) inflammation of muscles, liga- ments, or tendons, or tearing of fibres of the same structures. Periostitis, chronic congestion or inflammation of the meninges, and the final passive congestion, or degeneration of the neurones in the spinal cord, or haemorrhage within the cord may represent the pathological findings in the most serious cases. Treatment of traumatic hysteria consists in rest cure for sev- eral months in the moderate grade, without organic lesion, or of psycho-therapeusis in the most available forms, including .hyp- notism in these entirely functional cases. The rest treatment is, of course, absolutely essential where any organic condition either af 312 TEEATISE OX XEETOUS DISEASES nervous system or surroimding tissue exists. It may be necessary in some cases, in addition, to procure fixation of the spine by the aid of plaster-jacket or body brace, or by means of head exten- sion with the jury-mast. This is to be prolonged until the parts have healed or- are greatly relieved. Counter-irritation over the spine by means of strong tincture of iodine, continued over several weeks, the use of blister or of actual cautery may be of great value. It must not be forgotten that possibly chipping off of a part of a lamina or a vertebral disk may occur, which must be searched for by means of X-rays in all cases, and if found, surgical pro- cedure should be resorted to. These patients ought never be given morphine, else we establish another neurosis, and if drugs are to be used, they should be administered sparingly, the indication being to quiet the central nervous system, in which the bromides, small doses of chloral, hyoscine, and belladonna may be of great service. In the functional cases also change of scene is important, and in any cases where damage suits are pending they should be got rid of at the earliest moment, the phj'sician's duty being simply to give advice from a purely medical standpoint, or upon the wit- ness stand to state his knowledge of the form and severity of the disease from which the patient is then suffering. Much of the dis- credit upon the profession will be dissipated when physicians learn to give their own opinions after sufficient study in order to know what are the underlying conditions in this unfortunate class of cases. SALTATORY SPASM Saltatory spasm is so-called jumpers disease, a hysterical dis- order occurring in epidemics in Maine and Canada. It is known as mlryachit in Eussia, and in Java as lataJi. When the patient attempts to stand there are strong contractions of the leg muscles which cause a jumping or springing motion. SALAAM CONVULSIONS This is a hysterical manifestation occurring in certain nation- alities, particularly the Malay race. The patient usually is in a morbid condition of mind, and without known cause will develop peculiar convulsive seizures, from which he is violently thrown to the ground in a prone position. This will continue for some min- utes, or even hours, the patient finally becoming exhausted and passing into a rigid contraction of the general musculature. FUNCTIONAL NEKVOUS DISEASES 313 WRITER'S CRAMP Synonyms: Artisan's palsy ; Ironer's cramp; Occupation neurosis The above are names given to allied conditions, usually of a localized nature, affecting the muscles of a part in spasmodic con- tractions, associated with more or less pain along the nerve-trunks, and frequently accompanied by wasting of the muscles involved. There are several types of the disease, depending upon the physique of the person affected and upon the nature of the occupation, as above indicated. Causes. — The condition is fundamentally a form of nerve ex- haustion, and is probably central in the majority of cases, the neurones controlling particular movements being exhausted as in neurasthenia. The main predisposing cause is heredity as to neu- roses, and secondarily, confinement and overwork, such as the constant application and overwork of a group of muscles, especially when in a constant cramped position. To this primal pathogenesis must be added the irritation produced by the variety of metabolites formed in excess or improperly eliminated. Leucomaines may be complicating factors. Some cases seem to be almost entirely local in nature. These are the cases in which the central nervous sys- tem is not called upon for a proportional expenditure. The more localized types of occupation neuroses may be divided into muscular, neuriUc (neuritis or not), and arterial, depending upon duration and anatomical structures most injured. There are no absolutely fast dividing lines between these latter forms. Muscular Cases. — This comes on from sudden rather violent overuse of muscles, as in cases of brakemen or motormen. A sub- acute myositis is very likely set up in these cases. They are usually of shorter duration than the other forms, and abate with the removal of the cause — i. e., with rest of the affected muscles. Neuritic Cases. — Here we have a peripheral neurosis, which may pass on to a subacute peripheral neuritis. This class is mani- festly more severe than the other forms. Symptoms consist of tenderness along nerve-trunks, accompanied by spasm of the mus- cles when attempting to use them, especially in the occupation ■which developed the neurosis. Pressure along the nerve-trunks, as is seen in telegraphers, who rest their elbows on the desk, will aggravate the condition. A continuing numbness of the affected part is another prominent symptom. 314 TEEATISE ON NERVOUS DISEASES Vascular Cases. — That these should be given as a type per se may be considered dubious from a neurological standpoint, but undoubtedly the arterio-capillary involvement is the primogene- sis of a number of cases, and the classification seems at least to be warranted clinically. In these cases the nervi vasori and vaso-motor nerves are irritated. In such cases there are none of the cardinal symptoms of the ordinary cases of writer's cramp, no severe spasm or paresis of muscles, but paresthesia of fingers and forearms. Finally, along with delayed sensations of all forms (but little tenderness), there is particularly a clamminess of the parts so affected. These cases are distinguished from acroparges- thesia by the fact that there is evident pressure cause for the peripheral irritation and from the fact that marked arterial scle- rosis is found wanting. The arterial cases may also be divided into the neurasthenic and non-neurasthenic. The muscular class of cases are the more frequent, and from the fact that the muscles are more affected; and in which treat- ment is the more prompt in producing results. The prognosis, therefore, is much better in this class of artisan's palsy. The neuritic class are the usual cases described in classical arti- cles on the subject, and are the most persistent ones, in which there is almost constantly a background of neurasthenia complicating. Such patients are usually emaciated and suffer from insomnia and anorexia. Morris Lewis has best described this disease.^ Prognosis. — In the vascular cases this is good in the absence of neurasthenia ; and the patient will recover, as a rule, with the gen- eral upbuilding of health after the occupation has been abandoned. In a study of some 50 cases of artisan's palsy, at the Infirmary for Nervous Diseases, occurring over some twenty-five years, the writer made a study of the Remote Results of Artisan's Palsy ^ with the following conclusions: That with the proper kind of treatment, and if persisted in, these cases ofEer a better recovery than was formerly supposed. Two to five years seems to be a fair time for cure in the average ease of neuritic type. Where the central nervous system is involved we have the terminal stage of irritation (neurasthenia), most unpromising for complete cure. Muscular types offer the most favourable prospect for ameliora- 1 The Neurologic Disorders of Writers and Artisans. Pepper's System of Medicine, vol. v, pp. 504-542. ^ University of Peima. Medical Magazine, May, 1897. FUNCTIONAL NEEVOUS DISEASES 315 tion; here no remote conditions need be entertained, and stop- ping the progress of the disease will generally produce rapid recovery. The hybrid cases I have designated arterial type are also very persisting. In proportion as arterial sclerosis is absent and external irritation is prominent will the hope for complete recovery be gratified within six months to a year under the proper kind of treatment. Where the disease lasts beyond a year, the remote efl^ects are arterial sclerosis, probably induced by the vaso- motor irritation of such long duration; then the deposit of lime salts will of course continue with some remissions, as is the his- tory of this form of arterial degeneration. Treatment. — The use of antirheumatics, such as potassium iodide, the lithic salts, and sodium salicylate, are of great advan- tage in those cases where rheumatic diatheses prevail. The use of nitroglycerin or ergot will be of value in the arterial cases with constriction or relaxation respectively through action upon the vaso-motor nerves. Nutrient drugs such as cod-liver oil and the hypophosphites Mdll be of help in cases associated with mal- nutrition. Fresh air and sunlight should be insisted upon in all cases, also relaxation from overwork. We should employ hgematics, such as Bland's pills, in cases of anaemia. Since the psychology of the disease is to produce a peculiar morbid depression, it is impor- tant for the physician to gain the confidence of the patient and stimulate him 'to the thorough realization of the need of careful treatment. The local measures of value, which should be contin- ued for many months, are massage, galvanism, and hot local bath- ing to the part from three to five minutes daily, in cases where there is considerable pain or spasm. In some cases a splint should be applied to the affected m^ember in order to afford relief of spasm by enforced rest. Treatment of existent neurasthenia is absolutely essential for success. CHAPTER XYil VASO-MOTOR AND TROPHIC DISORDERS Synonyms: Parry's disease (1825); Graves's disease (1835); Basedow'' s disease (1840), etc. EXOPHTHALMIC GOITRE This is a disease characterized by rapid heart, exophthalmos, enlargement of the thyreoid gland, and by disturbance of the vascular system through functional disease of the sympathetic nervous system. Causes. — There are vari- ious theories for this affection. That it is a functional disease- of the sympathetic nervous system is held by most author- ities. Exciting causes are overwork, fright, auto-intoxi- cation, or infection. It is closely allied to simple goitre, or at least hj^brid cases fre- quently are found. Whether or not disturbance of the thyr- eoid function has primarily to do with Graves's disease is still debatable. Those contending for this consider that there . is an excess of secretion (hyper- thyrea), as against the lack of that secretion as a cause of the development of myxoe- dema (athyrea). The age of onset is usually between the twentieth and thirtieth years, and it is sometimes seen in several of a family. Some observers consider that the affection is due to a lesion in the oblongata. 316 i''lG. 66. — Exophthalmic Goitke. Pkom- INENT Eyes and Thyreoid Gland. (Howard Hospital.) VASO-MOTOR AXD TROPHIC DISORDERS 317 Syni.ptoins. — There are two types of this disease, namely, the acute and the chronic. The former type may develop with great rapidity, following an attack of vomiting and diarrhoea, tachy- cardia, and throbbing of the arteries. Such cases may die in the attack as early as the third day of the affection. Marked cerebral symptoms may be present in this form. More frequently the grad- ual onset prevails, the three cardinal symptoms varying in order of onset. The cardiac and vascular symptoms are usually first to develop, the patient complaining of palpitation and dyspnoea. The pulse is found to be increased in force, the apex beat is in the nor- mal position, and the carotids and abdominal vessels may be throb- bing visibly. Occasionally capillary and venous pulsation may be seen in the hands. At its height the piilse rate may be from 140 to 160, or even more in some cases. It seldom drops below 95 per minute. Emotion tends to increase the heart action, and on exposure of the skin on the chest a transient hypersemia quite fre- quently can be seen. Basic murmurs are not unusual. Long- standing cases may present cardiac hypertrophy. The heart sounds become greatly accentuated, some cases having been record- ed where the heart-beat could be heard several feet away from the patient. Usually exophthalmos follows next, and is readily recog- nised by protrusion of the eyeballs, and also by the lids not com- pletely covering the sclerotic coat. The protrusion may sometimes cause semi-dislocation of the eyeballs. Vision usually remains in a normal state. Von Graefe's sign, consisting of the inability of the particular lid to follow the downward movement of the eye- ball, though striking, is not a frequent symptom. Stellwag's sign consists in a greater width of the palpebral aperture than in health owing to the retraction of the lid, this usually being found. The patient winks infrequently. Occasionally there is lack of convergence of both eyes. The optic nerves are seldom affected, but pulsation of the retinal arteries is common. The thyreoid swelling usually appears with the exophthalmos. It is generally symmetrical, but seldom as large as in ordinary goitre. The blood- vessels are much dilated, and the gland is occasionally seen to pulsate ; in either instance a thrill may be felt, or on auscultation we discover a bruit or even a loud systolic murmur. Motor symp- toms consist of fine general tremors. The patient becomes ansemic and emaciated. He may be slightly feverish at times. Vomiting or diarrhoea may exist and are usually paroxysmal in occurrence. 318 TREATISE OX XERYOUS DISEASES Great comjilaiiit generally is made of throbbing sensations in the heacl^ accompanied by a sense of flushing and heat Avith profuse perspiration. The skin will be found, when carefully examined, to be pigmented, favouring Addison's disease ; or patches of leuco- derma, or atrophy of pigment and urticaria may exist, as may also areas of solid oedema. Myxoedema has been found to coexist with this affection. The patient is also of irritable temperament and of changeful disposition, mental depression very frec[uently occurring. Acute mania ma}" develop. A sense of giving Avay of the legs, a muscular weakness, may exist. There is great diminu- tion in the electrical resistance, which may be due to moisture of the skin from vaso-motor dilatation. Bryson has noticed that the chest expansion is greatly diminished. Breathing is hurried and shallow. Albuminuria and glycosuria are not usual symptoms found present upon frequently examining the urine. Polyuria, hyperidrosis, and cedema are usual. Subnormal temperature might occur. Prognosis. — This disease usually lasts for many years, but after six months' time it may disappear. Complete recovery is, as a rule, very rare. Instances are recorded of the acute form recovering within the same period of time as its development — a few days. Pathology. — This is inconstant. The heart is often dilated. Fatty change of its walls may be present. The lobes of the thyreoid are large, firm, and pulpy. Colloid degeneration and cyst formation may be found. The vessels are thickened and athe- romatous. There is proliferation of connective tissue through- out the gland. In the bulb and cord haemorrhages have been found. Treatment. — This consists in rest, the absence of worry, abundance of sunlight and oxygen ; the use of galvanism, placing the positive pole over the apex of the heart and a Y-shaped divi- sion of the negative pole upon each side of the neck over the cervi- cal sympathetic, with from 3 to 10 milliamperes, once or twice weekly, has proved of value in our hands to lessen the rapidity of the heart. The use of strophanthus in continuous dosage is of advantage for the cardiac irritability; where there is great vaso- motor disturbance prominent, the use of digitalis or its products, especially digitaline (^ grain t. i. d.), will prove of value. The alterative and hsematinic effect of arsenic, especially when com- bined with iron, will prove a boon in anaemic cases. Ergot is VASO7MOTOR AXD TROPHIC DISORDERS 319 recomineiiclcd by some writers. Tincture of belkidonn;! will very frequently give relief, and should be pushed to the physiological limit. Resort to the rest-cure may be a necessity in the worst of cases. The application of Letter's tube, or an ice-bag over the heart or lower part of the neck, frequently gives relief. Organo- therapy has not been successful in the majority of cases. Surgical treatment cannot be recommended, although several recoveries have already been reported after excision of the cervical sympa- thetic or part of the gland itself. GLASS-BLOWER'S DISEASE This is a vaso-motor neurosis, due primarily to sudden increase of blood pressure and the forcing into the blood an excess of oxygen caused by the patient blowing into the blow-pipe, fol- lowed by a deep inspiration when the mouth is removed, at which time the blood becomes overaerated; the latter being the real cause of the cardinal symptoms of the disease. The former is productive of emphysema of the lungs, which, therefore, is a common com- plication. Dizziness is a marked symptom, and is an exaggeration of what can be produced by respirations deeply and rapidly taken during health. In these patients there is a beginning hypertrophy of the right ventricle, accentuation of the second aortic sound, and an increased pulse volume and rate. There soon results ex- haustion, dyspnoea, and a rapid running pulse, the patient com- plaining of fulness of the head, and while exhilarated is unable to co-ordinate properly. This is due to overstimulation of the central nervous system. Mental anxiety is pronounced. Pathology. — This is, as indicated, overoxygenation of the blood primarily, with sequent hypertrophy of the heart and vascular dis- ease in chronic cases. Prognosis. — When once firmly established the prognosis is ab- solutely bad if the patient continues the occupation. These cases very seldom live after fifty-five years if they continue work at the same trade. If the occupation is stopped, it may be that the patient may live quietly in comparative comfort for some years. Treatment. — The patient should quit glass-blowing. Employ antispasmodics, such as lobelia, where the emphysematous s^^mp- toms are predominant ; nitroglycerin to steady the circulation and overcome dilatation of the peripheral vessels. It must be re- 320 TEEATISE OX XEEYOUS DISEASES membered that there is a possibility of cerebral haemorrhage in cases with arterial sclerosis. Here the treatment is directed to apo- plexy. These complicated cases are generally fatal. SUDDEN CHANGES IN HAIR This rare trophic condition occurs, as a rule, as- the result of grave mental crises in life or extreme fright. Symptoms. — The patient after severe psychic shock, as indi- cated, may notice within a few hours to several days a sudden gray- ing of the hair in streaks or in entirety in a given area ; usually of the scalp and eyebrows. In some cases an alopecia will precede, accompanied by erythema or with distinct dermatitis in the area Pig. 67. — Tkophoxeurosis of the Hair, showing Change from Dark to White. (Author's reported case.) ' affected; and when the hair returns the absence of colour will be noted. The hair, as a rule, remains without colour (gray or white) , and may be disposed to fall out from time to time, depend- ing upon the mental condition of the patient as well as the nutri- tion of the body. The hair change may result in universal and permanent alopecia" alone (Fig. 68). Causes. — The writer has records of two cases produced by shock, one in a male, communicated personally by Dr. E. Pearce, of Ohio. Here the hair turned permanently gray in one night, the man having been frightened during the civil war by rapidly fired * American Medicine, Dec. 28, 1901. YASO-]^IOTOE AND TROPHIC DISORDERS 321 cannon. AnotliLT case un- der our care is of a young woman, following a dis- appointment in love, the hair having dropped out and then shortly regrew, being perfectly white (Fig. 67). Psychic trauma is the cause. Pathology. — This is in an indefinite state, consist- ing in the absence of de- posits of colour matter, which must be dependent upon some trophic disturb- ance of the nervous sys- tem similar to other dys- trophies. Metchnikoff has described the amoeboid ac- tion of certain leucocytes which he designates pig- mentophytes. Prognosis. — This is good so far as the health of the patient is con- cerned. The hair seldom returns to its normal col- our again. Treatment. — Rest and tonics are essential. Drugs to stimulate the sweat- glands and to favour the deposits of normal colour- ing matter would be indi- cated, such as pilocarpine and iron. The static breeze *as a stimulant to the surface of the skin is indicated. The use of phosphorus and strych- 21 ^^^^^^^^^H ''^ :^^^^^^^^^B Ml ii ^B ■■ \m ■ lt\ il W{ p^^,^H la ■J r^^^^^^^^^^^^^^H ^^^^^r ^l^^^l ^mt ^j^^^^^^^^^^B BlH ^^^H Fig. fi8.— Universal Alopecia of Nervous Origin. (Philadelphia Hospital.) 322 TREATISE ON NERVOUS DISEASES nine ; or the nuclein bodies^ or organo-therapy, as thyreoid extract, may prove of service in the treatment of this uncommon aifection. HYPEROSTOSIS CRANII (CEPHALOMEGALY) This disease is allied to osteitis deformans, originally described by Sir James Paget, of London, in a report of the first case, November 24, 1876. When the disease is limited to the cranial Fig. 69. — Hyperostosis Cra^jii. (Author's reported case.) ' bones largely, as in the case shown in the two photographs, it is, as already designated, hyperostosis cranii ; and becomes a neurological affection only in its relation by contiguity of the enlarged bones to the brain mass. This affection is a trophic disturbance, involving the bones of the skull, the rest of the bones of the skeleton being but little ^ Transactions of the Pathological Society of Philadelphia, vol. xviii, 1897. VASO-MOTOR AXD TROPHIC DISORDERS 323 or uot at all involved. There are two types ^ of cranial enlarge- ments : (a) Upper-head type. (6) Lower-head type, where the malar bones become involved and produce the leonic appearance. The face and head present an oval with the base up. The bony overgrowth may begin as early Fig. 70. — Skull-cap from same case of HrPEROSTOsis Ckanii. (See Fig. 69.) as the twelfth year, and usually it is not later in onset than the twentieth year. The condition is undoubtedly a bony dystrophy. Symptoms. — The symptoms of this disease are very indefinite. There is usually mental apathy, a state of mental hebetude, and occasionally a condition of what we might call "queer." The * J. J. Putnam, Trans. Am. Neurological Society, June, 1895. 324 TEEATISE OX XEEYOUS DISEASES patient may also suffer from a dull headache. The hony enlarge- ment is gradual, the hearing becomes affected in some cases, and the hairs are noticed to become coarse, and even may fall out to some extent. The ease may die of asthenia after many years, or he may be carried off by some intercurrent malad}', such as pneu- monia, or chronic interstitial nephritis. Pathology. — This consists of a slow ostitis. The chronic in- flammation shows under the microscope irregularly enlarged Ha- versian systeihs, atrojohy of bone cells, loss of osteophytes and osteoclasts, and the conversion of parts of bone into mere fibrous tissue. On the surface of the bone there is, as a rule, a condensing ostitis. There is frequently cerebral arterial sclerosis in marked degree. Diagnosis. — This lies between the disease in question and spurious forms of hydrocephalus; but the lack of exophthalmos after prolonged cephalic enlargement with other signs of bone thickness would militate against the latter. The case reported by the writer (Figs. 69 and 70) occurred in a woman seventy- two years of age. Here the skull-cap proved to be 1^ inch in thickness, and as far as I can determine is probably the thickest on record. Treatment. — The treatment of this condition is, of course, in cognito. Xutritional measures and probable benefit from organo-therapy should be thought of. Antisyphilitic drugs should be tried in all cases. ADIPOSIS DOLOROSA This is described by Dercum as a disease of adults in which there is a deposition of fat in various parts of the body seen in the form of bunches or nodules, becoming uneireumscribed after- ward, and accompanied by pain, diminished sensibility, and great muscular weakness. There is the sensation as of a bunch of worms transmitted to the hand on palpation. Some 15 or. more cases have been reported by Dercum, Henry Ewald, Peterson, Loveland, Spliler, Eshner et al. Diagnosis. — This condition must not be confused with myx- cedema, since in the former changes do not occur in the hands and feet, and there is an absence of mental symptoms. Ordinary adi- posis also affects the hands and feet. It is not painful. Pathology. — This consists in deposition of fat as described, VASO-MOTOK AXD TEOPHIC DISOEDERS 325 ill all probability due to a central trophic disturbance. Degenera- tion of the ultimate nerve filaments has been found by Burr and McCarthy, of Philadelphia. Prognosis. — This condition may last for many years, the patient dying of asthenia or fatty degeneration of the heart. Fig, 71. — Adiposis Dolorosa in a Colored Woman. (Medico-Chirurgical Hospital. ) Treatment. — Hygienic measures are to be employed; living in the open air, the use of thyreoid gland extract, and massage may all prove of value by aiding catabolism. 326 TEEATISE ON NERVOUS piSEASES FACIAL HEMIHYPERTROPHY This is a condition of overgrowth of the soft tissues and bones of one side of the face, being the exact opposite to that of facial hemiatrophy^. Care must be observed not to confuse this affec- tion with facial hemiatrophy, in which the normal side would be mistaken for the atrophied side of facial hemiatrophy (see below). Pathology. — It is supposed to be a trophic disturbance of the central nervous system. The tissues are hypertrophied. 'FACIAL HEMIATROPHY Is a disease characterized by progressive wasting of the tissues, particularly of the bones on one side of the face ; starting in child- hood, but in some instances at middle life. It usually begins dif- fusely, but in some cases at a single point on the skin and grad- ually spreads, involving at first the subcutaneous tissues, then the muscles and bones, and particularly the upper jaw. The atrophy is sharply limited at the middle line, the face looking as though it was made up of two halves from different persons. The colour of the skin changes and the teeth fall out, due to the wasting of the alveolar processes. Even the orbit is seen to become atrophied on the affected side, and the eyeball may become shrunken. There are instances on record in which the disease was bilateral, and in a few cases where the atrophy extended to the back and arm of the same side, the face was also affected. It is a rare affection, only 97 cases being gathered from literature by Sachs, of New York. Pathology. — In one of the few autopsies made by Mendel he determined the terminal stage of interstitial neuritis in all the branches of the trifacial nerve from their origin to the periphery, more severe in the superior maxillary division. In a case reported by Homen a tumour was found pressing on the Gasserian ganglion. Diagnosis. — This is not difficult, since the appearance is most striking. Facial asymmetry associated with wry-neck, which, devel- oped in the early childhood, is the only disease with which it may be confounded. The torticollis would make plain. Treatment. — There is no treatment known at the present time that has a curative tendency in this affection. The hygienic care of the patient should be very strictly pursued as well as supportive VASO-MOTOE AND TROPHIC DISORDEES 327 measures, and no doubt the progress of the disease can be pre- vented to some extent in a few instances. DERMATITIS GANGRENOSA NERVOSA Gangrenous dermatitis of nervous origin is a trophic affec- tion, coming on suddenly and periodically. In individuals of neu- rotic stock it is most commonly seen, and sometimes it is present Fig. 73. — Dermatitis Gangrenosa Nervosa, showing Scars on Dorsum of Left Hand op Young Woman, the Result of this Disease. in patients that are of good health otherwise. The attacks of superficial gangrene in this rare disease the record of the follow- ing case will well demonstrate: A. B., aged twenty-six, white, hysterical, but of good 328 TEEATISE OX NEEYOUS DISEASES physique, no organic disease existing at any time. During one night she may develop patches of irregular serpiginous dry gan- grene of the superficial layer of the derma upon the hands and trunk. This change is most striking, and may occur during a single night. The sphacelus sloughs off, leaving chronic ulcera- tion, which heals sloivly under antiseptic treatment within a few weeks. There is no constitutional disturbance at any time. Pathogenesis. — These cases are very difficult to explain, but they must depend upon some transient trophic functional disturb- ance of the central neuron, vsdth probably an auto-intoxication; the fundamental cause being instability of the central nervous system. Prognosis. — The patient may live for many .years suffering from recurrent attacks, and finally recover altogether. Treatment. — This is largely prophylactic in that of upbuild- ing the nervous system (perhaps by rest-cure). Change of scene, outdoor life, and hypernu- trition may avail towards preventing attacks. MYXCEDEMA This is a disease char- acterized bymyxoedematous degeneration of the subcu- taneous tissues in youth or adult life. It occurs more frequently in males. The affection is due to dis- ease of the thyreoid gland in which there is defect of ' internal secretion of this organ. When the disease begins in early life the name sporadic cretinistii is applied; and when it oc- curs as the result of extir- pation of the thyreoid gland it is designated cachexia strumipriva. Myxoedema occurs more frequently from about the thirtieth up to the fortieth year of Fig. 73. — Sporadic Cretinism Hospital.) (Philadelphia VASO-MOTOE AND TEOPHIC DISOEDERS 329 age. It may follow erysipelas^ rheumatism, persistent hemor- rhages, or syphilis. Symptoms are of mental obtundity with the physical sign of enlargement of the body through a universal deposit of myx- oedematous degenerative material in the subcutaneous tissues. The patient seems fleshy, but the skin is harsh, dry, and sallow-looking rather than normal in colour. There is no true oedema. The ex- pression becomes blank, the patient complains of great feeble- ness, the lips and lobules of the ear and eyelids thicken. The intes- tinal tract is torpid, the secretion of the kidneys is but little. This condition exists for some years without much change from month to month. The face is round, in contradistinction to the face in Paget's disease or in acromegaly. The hands are clubbed and puffy, not " spade-like," as in acromegaly. Prognosis is good as to improvement, wonderful results being obtained by means of the use of the thyreoid gland internally, this making up for the deficiency in the diseased body. Treatment. — The extract of the thyreoid gland may be given in grain doses, three times a day, gradually increased until palpita- tion of the heart may be produced. This must be kept up from time to time as the appearance and weight of the case will indicate. SCLERODERMA Is a condition of diffused or localized induration of the skin. There are two types : the circmnscrihed, which corresponds to the keloids of Addison or to morphoea; and the diffuse, in which large areas are affected. This disease affects females more fre- quently than males, and occurs in early middle life, although it is seen in spurious form in babyhood — the so-called sclerema neonatorum. — by some said to be a different affection. This latter disease has occurred only in the French and German races so far as reported. It may at times be of specific origin. (1) The form mostly seen in this country is the circumscribed type. The' patches range from a few centimetres in diameter to the size of the hand or larger, are waxy in appearance, and to the touch hard, brawny, and inelastic. There may be a precedent hypersemia. Following these manifestations pigmentary changes of the skin occur either of excess or absence — leucoderma. The sensory dis- turbances are rare. Perspiration is diminished or absent. This 330 TEEATISE OX XEEVOUS DISEASES type is much more common in women than in men, and is situated about the neck and sometimes along the courses of the nerves. Patches may develop with great rapidity, and may last but a few days or persist for years. (2) The diffuse form, though less frequent, is more serious. It .appears in the face or in the extremities. The patient notices that the skin is unusually hard or firm, and there is a sense of tense- ness in making accustomed movements. Gradually a brawny in- duration develops, the skin becomes united to the subcutaneous tissues, and it cannot be picked up or pinched. The skin may look natural, but more commonly is glossy, dry, and unusually smooth. This form is apt to affect, in order, the upper extremities, the trunk, the head or face, the upper portions of the lower extremities, and least frequently may become universal. Occasionally sensory disturbances are found, the disease may last many years and recov- ery may occur, or rarely it may be arrested. Eheumatism and endo- carditis may complicate, or it may be associated with Eeynaud's disease as reported by Mackenzie. The patient may be carried off by pulmonary or renal disease. Pathology of the disease is unknown, probably a tropho-neu- rosis dependent upon changes in the arterioles of the skin, leading to connective-tissue overgrowth. Sderodactylie is the same disease manifested by symmetrical involvement of the fingers, which become shortened, deformed, and atrophied. Ulcerations have been met with, also great deformity of the nails. This disease is occasionally associated with sclero- derma proper. Treatment consists in mixed luetic medication and in thyroid therapy. AINHUM This is a rare condition occurring in the negroes of Brazil, India, Africa, and occasionally in the Southern States. It is con- fined to the toes, usually the little toe. It commences as a furrow on the line of the digito-plantar fold, which gradually deepens, the under side of the toe enlarges, usually without inflammation or pain, and the toe drops off. The condition may last for years, however, before spontaneous amputation follows. Treatment has proven futile in all eases. Antisepsis would be indicated. VASO-MOTOE AND TEOPHIC DISOEDEES 331 ACROMEGALY This is a distrophy characterized by abnormal enlargement chiefly in the bones of the face and extremities. The word was in- troduced by Marie/ and means large extremities. The disease occurs as frequently in both sexes and usually begins about the twenty-fifth year, although it has occurred much later. Syphilis, rheumatism, and the specific diseases have preceded the develop- ment of this malady, but probably have no special connection with it. Disease of the pituitary body is said to be causative. Symptoms. — In a well-marked case the signs are characteris- tic. The hands and feet are greatly enlarged; fingers are sau- sage-shaped. The joints are freely mobile. The hypertrophy is general and gives a spade-like character to the hands. The wrists are frequently enlarged, the arms rarely affected. The nails are broad and large. The lips and tongue are enlarged. The head is increased in volume (oval, with base down) ; the face more so in proportion, which latter becomes elongated and enlarged in consequence of the increase in size of the superior and inferior maxillary bones. This was especially noticeable in a case coming under the writer's care, which was also accompanied by bitemporal hemianopsia and mental stupor. The lower jaw in particular enlarges and frequently protrudes beyond the upper. The alveolar processes are widened and the teeth separated. The eyelids are at times thickened, the ears greatly enlarged. At times the tongue becomes hypertrophied, and later in the affection kyphosis may develop and the bones of the thorax may slowly enlarge. With it all the skin may seem quite normal, but occasionally may become coarse and flabby, never having the dry, harsh appearance of the skin of myxcedema. The patient is depressed in spirits and phys- ically weak. There may be hyperidrosis, loss of sexual power, fron- tal headache; or bitemporal hemianopsia due to ventral pressure of the enlarged pituitary body upon the optic chiasm. Pathology. — In addition to hypertrophy of the bones great cystic enlargement of the hypophysis (pituitary body) has been found. The disease is no doubt a nutritional disturbance analo- gous to myxcedema, and is probably due to disturbance of function of the pituitary body. Organic change in nerve tissue is absent. Diagnosis. — The congenital progressive hypertrophy of trunk, » Revue deM6d., 1886. Fig. 74— Acromegaly in a Woman, showing Enlarged Supra-Orbital Kidges, Inferior Maxilla and Hands. (Medico-Chiruigical Hospital.) VASO-MOTOR AND TROPHIC DISORDERS 333 arms, or legs — the so-called giant growth — is easily recognised. In .this there are never eye symptoms. In the osteitis deformans of Paget the shafts of the long bones are involved; and in the head the bones of the cranium, but not of the face, as Marie states. In Paget's disease the face is triangu- lar, with the base up ; in acromegaly it is ovoid or egg-shaped, with the large pole down; while in myxoedema it is round. In hyper- trophic pulmonary osteo-arthropathy, while enlargement of the hands and feet occur it is chiefly in the lower three-fourths of the forearm and legs, but there is not any involvement of the face. (See below.) Prognosis is bad as to cure. Sometimes the patient can be bettered by general hygienic regime. Thyreoid extract and pitu- itary body have been recommended, and much good has resulted from their use. Alteratives, hot baths, rest, and sunshine may tend to stay the process. The liability to sudden death must be remembered, as in the instance of a typical case under the writer's observation. The man apparently died of heart failure of reflex origin, he having fallen over while at work, and when in average physical health. No autopsy was permitted. HYPERTROPHIC PULMONARY OSTEO- ARTHROPATHY Marie has given the name hypertrophic pulmonary osteo- arthropathy to a queer disorder characterized by enlargement of the hands, feet, and of the ends of the long bones, chiefly of the lower three-quarters of the forearms and legs. The bones of the skull and face are not involved. The terminal phalanges are much spread with both transverse and longitudinal curves. The nails are also enlarged and much curved over the ends of the phalanges. Scoliosis and kyphosis have both been met with. It is a chronic disease, and in nearly all instances has been associated with some long-standing affection of the bronchi, lungs, or pleura — hence its name — of which sarcoma, chronic bronchitis, and pulmonary tu- berculosis have been the most frequent. It may develop in those who have had syphilis. It is more common in adult males. Thornburn ^ has collected some 30 cases of this rare disease and 1 British Medical Journal, vol. i, 1893. 334 TEEATISE OX XERA'OUS DISEASES others have been reported since. We have seen 3 cases. Dull pain in the extremities was a symptom in each patient. Pathology. — This is very obscure. Marie suggests that the toxins of the pulmonary disease are absorbed and irritate bony and articular structures. Thornburn believes it is a benign chronic tuberculous affection. The nervous system may be at the bottom of the disease; it is very probably a trophoneurosis. Treatment should consist in combating the pulmonary disease. The use of cod-liver oil, hypophosphites, and nutrients may thus be of service. Protection of the parts from cold is essential. Ichthyol ointment (1 dram to ^ ounce) may have some soothing influence through its sorbefacient effect. Antisyphilitic treatment should be carried out faithfullv. ARTHRITIS DEFORMANS (Rheumatoid Arthritis) etiology. — Dr. John K. Mitchell, Sr., contended that this was a trophic nervous disease as long ago as 1827. There seems no better place to classify this disease. It is a trophic affection in- volving the smaller joints of the hands and feet: occasionally the larger joints. It is characterized by changes in the cartilages and synovial membranes, with periarticular formation of bone and great deformity (see Figs. 75, 76, and'77). The association of the disease with shock, worry, or grief will support the theory of its nervous origin; also its similarity to arthropathies, as of tabes. The symmetrical distribution of the lesions, the skin and nail changes, and muscular wasting out of proportion to the joint mis- chief point towards a trophoneurosis. Ord regards the disease as similar to progressive muscular atrophy due to primary changes in the cord; or to peripheral irri- tation, as of trauma or uterine disease, these causing secondary changes in the cord. Females are much more liable to the disease than males. In Garrod's table of 500 cases it occurs in females 411, and in males 89 times. Exhausting disease, such as prolonged sepsis or typhoid, may precipitate it. Symptomatology . — The disease may begin in children (six to twelve years), in old age but rarely. It usually originates between twenty and thirty years of age. Hereditary influence favours early development. It has no more predilection for the poor than the rich, and I have seen it in the most lowly as well as in the VASO-MOTOE AXD TROPHIC DTSORDEES 535 best stock in America; though in Engiand and on the Continent the poor, from given statistics, suffer most. There are three forms of the disease: (1) The general progressive form; (2) the partial monarticular form; and (3) that in which Heberdeen's nodosities are prominent. In the latter form " little hard knobs " Fig. 75. —Agglutination, Patella to Tibia and Subluxation of Knee, in Rheumatoid Arthritis. X-ray photograph (kindness of Dr. R. P. Cummins, Howard Hospital). develop gradually at the sides of the distal phalanges. These oceui later in life in the average case (thirty to forty years or over). Such subjects may have had digestive troubles. The joints may at first be swollen or red, especially when injured. The dorsal sur- face of the second phalanx increases in size, giving the character- istic appearance of the joint. Charcot contended that urate of soda is never -deposited. These patients seldom have involve- VASO-MOTOE AXD TROPHIC DT80EDEES 33? ment of larger joints, although exceptions do occur. (See Figs. 75 and 77.) Of the progressive form there are two types, acute and chronic. Many joints may be involved at first in swelling, red- ness, distention of synovial sheaths and hursse. It is more com- mon in women between twenty and thirty and after prolonged lactation or rapid childbearing. Eemissions may occur. The chronic form is the most frequent. Pain on movement and slight swellings due to effusion into joints and the periarticular sheaths are the first symptoms?. Pain is, however, an extremely variable symptom. Gradually the shape of the joints is greatly altered, partly by the great thickening of the ligaments, and still more by retraction and atrophy of the muscles. Crepitation can be felt on movement due to eburnation of the articular surfaces. The joints finally become completely locked, not by true ankylosis, but by the osteophites, which, as Osier de- scribes, are like the ring bones in horses. Spurious ankylosis may occur also from thickening of the capsular ligaments and by fibrous adhesions. Contractures and contractions occur and bring about most marked flexion of legs upon the thighs and the thigh upon the abdomen. In other cases the muscular wasting is so rapid that central disease will again alone explain their pathology. Fortunately in some cases the fingers and toes are not so much involved, and the patient is able to knit, etc. Numbness, tingling, pigmentation, and glossiness of the skin exist. In the worst cases all the joints of the extremities become loched and the patient lies curled up in hed helpless. Conservatism of nature and compensa- tory function are beautifully demonstrated in some of these pro- nounced cases, however; the patients frequently accomplishing under great difficulties many artistic designs where the talent exists. The partial or monarticular forms are found mostly in the aged, and are particularly seen in the knee, hip, shoulder, or spinal column (spondylitis deformans). (See Ehizomyelique Spondyl- itis.) If in the hip, the term morbus coxce senilis is applied to the affection. Injury frequently precipitates cases involving one joint. This form occurs particularly in men. We have one such ease. Diagnosis. — Arthritis deformans should not be confused with rheumatism or gout. The monarticular form of simple local 23 Fig. 77— Rheumatoid Arthkitis with Co-ntkactures. Bedridden girl before operation. (Howard Hospital.) (See Fig. 78.) Fig. 78.— Rheumatoid Arthritis, after Operation and Braces AKE Applied. (Howard Hospital.) (See Fig. 77.) 340 TREATISE ON NERVOUS DISEASES arthritis is characterized by more pain than in arthritis defor- mans, also by thickening of the capsule and the ligaments, and if neuritis exists with it, a greater wasting of the shoulder-girdle muscles. Arthritis deformans also differs, from chronic rheuma- tism in the existence of extensive structural alterations especially in the cartilages, according to Adams. Pathologically, too, the changes in the joints differ essentially from those of gout in the absence of deposits of urate of soda. No definite microscopic change has been found in the spinal cord in arthritis deformans, although there must be some morbid physiological process here as a causative factor of this singular affection. Treatment. — It is an incurable disease. Much can be done towards alleviating the sufferings, however, or to arrest its prog- ress. Iodide of potassium or sodium, quinine, the salicylates, and arsenic are all valuable. The use of tonics, and particularly the hypophosphites, is of value in supporting the system and in sup- plying the waste of salts from the nervous tissue. Syrup of the iodide of iron I have found one of the most useful drugs to cor- rect anaemia, and with restored blood pabulum the progress of the disease is often stayed. Morphine in small doses by the mouth often has a favourable effect upon pain, and in some unknown fashion may tend to check the affection. Bloodless operation of extension, or a tenotomy, are means to help these people to get about on their feet. The accompanying illustrations show well a girl who had been bedridden for two 3'ears, a helpless cripple. She now is able to walk about alone, first having had hyperex- tension and tenotomy performed by Dr. C. H. Frazier, then casts applied, and finally braces^ adjusted. The ankles and feet were free of disease. The back cases offer little help from the surgeon. HEAT EXHAUSTION This is a collapse induced by excess of heat to the body, induced through natural telluric conditions, or by artificial heat, as an overheated room. It is generally associated, however, with the state produced by the excess of sun-rays. The condition heat ex- haustion is allied to sunstroke, the clinical difference being in the aetiology — i.e., the heat has not been so intense as a rule or the patient is more resisting; and secondarily in the symptomatology in particular: heat exhaustion being a complex where there is VASO-MOTOK AXD TEOPHIC DISOKDEES 341 subnormal temperature of the body, feeble pulse, a status much allied to shock, the patient being attacked rather suddenly. He complains of headache and faintness, and occasionally he may lose consciousness for a short time. The duration may be from an hour or so to many hours. The pathology merely consists of a disturbance of the heat centres and vaso-dilatation through the development of toxins, on account of superheating of the body. - Prognosis. — This is good if the patient is not re-exposed to the heat, and fatty heart or nephritis are absent. Treatment. — This is the same as in shock — ammonia, strych- nine, and quietude. SUNSTROKE Thermic fever; Heat-stroke ; Coup de soleil ; Insolation This is due to a more intense or more prolonged application of heat to the body, as seen under the heading of heat exhaustion. The symptoms consist of a feeling of congestion of the brain, mud- dled thoughts, as the patient will tell you afterward, and a sense of extreme weakness, he usually falling over at his occupation into an unconscious state in this period. He may pass at once into severe tonic and clonic convulsions. The temperature rises to 102° or 103° F., gradually increasing until it may reach 109° or more ; the highest case authenticated and followed by recovery being 112° F. Urffiinic symptoms usually complicate the disease, due to the fact that the renal circulatory apparatus is disturbed, and occasionally marked transient albuminuria will be ■ found. The duration of the affection is apt to be short and fulminating, ihe i^atient either recovering after a few daj^s or death may super- vene before this time. In those cases that recover there is a great liability for relapse or for a chronic meningitis to be set up. Prognosis.'^ — Cases with prolonged unconsciousness or suffer- ing from a high temperature usually prove fatal in 75 per cent of the cases. Cases with high tem_perature and preservation of men- tal faculties are more favourable. When there is a failure of the kidney, determined by carefully examining the urine, the prognosis can be put down as also being bad. In every case there is a great liability to relapse on slightest exposure, and in a great number of ^ The statements in this paragraph are made from a careful study of 30 cases at St. Agnes's Hospital in 1896. 342 TREATISE ON NERVOUS DISEASES cases there is a great liability to heat exhaustion or sunstroke at subsequent periods. Chronic headache usually follows. Pathology. — There must be some chemical change in the body causing paralysis of the centres; thus more heat is produced than normally. In those cases that recover there is a great liability for a chronic meningitis to be set up in time, which may be incurable. Treatment. — This consists in the application of cold;, prefer- ably moist cold, in the form of an ice-bath. This should be asso- ciated with friction to the extremities with ice. The head should particularly be kept cold in order to prevent aggravation of the cerebral congestion. Antipyretics are of value in sthenic cases. Convulsions must be controlled by the use of chloral and bromides, given per orum, or per rectum in the instances where the patient cannot swallow. Rectal feeding should also be employed in those cases where the stomach is irritable, and in all cases the food should be simple, such as peptonized milk, etc. The patient would better change his occupation to prevent recurrence. MYASTHENIA GRAVIS By this disease is meant the peculiar condition in which the patient loses power, periodically and suddenly, in the muscles with- out any definite neurological symptoms. It is closely allied if not identical with periodic paralysis, as described by Taylor, of Bos- ton, and studied also by J. K. Mitchell, of Philadelphia. The symptom is palsy; the patient on waking in the morn- ing finds that he is unable to move the muscles of certain parts of the body or of the entire voluntary musculature. This may last for a few to twenty-four hours, or even several days. In a very short time the case is perfectly helpless, without any sensory or psychic disturbances, save an indefinite parsesthesia or a mental anxiety not due to brain disease, but to the fear he naturally has of impending death. The patient slowly recovers from the con- dition, and may go about his duties as usual within the space of a few days, only to be stricken down again at any time. Undoubt- edly the underlying condition is an auto-intoxication, either from waste products from within or from absorption from without. Study of the blood has been made, and nothing has been found esxcepting a mild leucocytosis during the attack. As there are no VASO-MOTOE AND TEOPHIC DISORDERS 343 temperature symjDtoms, it is not a condition of sepsis, at all events. It is more likely a failure of the normal chemical changes in the nervous system, and therefore inability to carry on the function -of the neuron, although, the expression of this seems to be alone confined to the muscles. It should also be mentioned that there is no reaction of degeneration, though the reflexes are absent. Prognosis. — This is very dubious, and the disease may last for years, the patient dying in an attack or of some intercurrent affec- tion. Ultimate recovery may take place in those individuals where the normal metabolism becomes restored. Treatment. — This consists in the greatest hygienic care as to proper nourishing, protection from cold and dampness, prevention of overwork, both mental and physical, and particularly to dietet- ics. The food should be simple, consisting largely of proteids, as milk, eggs, and those substances containing excess of nuclein — beans, peas, etc. — also those containing iron, such as spinach, although the patient should never eat too heartily. During an attack the patient should be kept in bed. Strychnine is given in doses of -^ grain up to jV gi'ain hypodermically. While venesection would be a dangerous procedure, the use of hypoder- moclysis of salt solution or even transfusion, if this can be prop- erly done, would be of great value. This subject has not been suffi- ciently worked up by the surgeon. It is to be recommended as an ideal treatment in this disease. The use of thyreoid extract, thymus gland, or even suprarenal extract capsule preparations sometimes seem to meet the conditions and probably be of value in aiding metabolism. Bone-marrow is another organic pre'para- tion that may be of value. The bromides were valuable in a num- ber of the cases coming under the observation of Holtzapple, which is probably due to restoration of vaso-motor tone in the motor horns of the cord. FAMILY PERIODIC PARALYSIS' Cases of this rare disease have been detailed by Putnam and John K. Mitchell and others. The pathology of the affection is unknown ; blood examinations have shown no characteristic ^ The valuable paper read by Dr. G. B. Holtzapple, of York, Pa., at the meeting of the Medical Society of Penna., Sept. 24, 1903, throws more clinical light on these enigmatic diseases than has yet been given to the profession. 344 TREATISE ON NEEVOUS DISEASES .changes, nor has the urine. Some undiscovered toxin, probably of autochthonous origin, is the cause; a tendency to degeneration of this sort passing from one generation to the next. (See Myas- thenia gravis, from which it differs by being a family disease.) Symptomatology. — It consists of periodic attacks (of more or less sudden onset) of wide-spread flaccid motor palsy, associated with loss of knee-jerks and electrical excitability, with little sen- sory or psychic symptoms of any kind. The attacks begin in the majority of cases between the second and third decades of life. In some cases there are prodromata, such as a feeling of weariness, formications, numbness, headache, backache, sweating, and loss of vaso-motor tone. As a rule the paralysis begins when the physio- logic ebb is lowest — i. e., at night — and continues for several hours before the acme of the paralysis has set in. The legs are usually first affected, then the muscles of the arms, trunk, and neck in severe cases. The cranial nerves usually escape palsy. During the attack there is loss of knee-jerk and absolute loss of electrical irri- tability of the muscles, without degenerative reaction, however. But in the interval between these attacks the reflexes and elec- trical irritability are normal. In some cases during an attack myocardial weakness is found, the heart may become dilated, and hsemic murmurs (usually a mitral systolic murmur) are found. This also disappears with the normal intervals. The patient is mentally apathetic during attacks, but never further affected as to his mind. The usual duration of an attack of transient paralysis is from five to thirty-six hours. Eecovery from the attack takes' place gradually. Each succeeding attack may become more pro- found, leaving the patient in a more marked asthenic condition. It is incurable. Treatment during attack should be hypodermics of strychnine and digitalis, bromides, warm baths, and effleurage. Hypodermoclysis of normal salt solution may aid recovery. Thy- reoid should be tried. The disease should practically be managed as is a case of myasthenia gravis, already studied, and from which it differs again in the more pronounced periodicity. (See p. 343.) CHAPTEE XVIII GENERAL TOXEMIC DISEASES OF THE NERVOUS SYSTEM HYDROPHOBIA-RABIES Hydrophobia^ or rabies, is a convulsive disease induced by the virus of a rabid or " mad " dog. The disease primarily must origi- nate de novo, more particularly in the canine. The infection is more frequent in hot weather, when the condition of the blood of the animal favours the growth of the germ. As yet this has not been isolated. The name hydrophobia is a misnomer, in the fact that the patient does not have the fear of water, per se ; but in the symptomatology of the disease, the spasm of the pharyngeal mus- cles prevents deglutition and makes the swallowing even of liquids difiieu.lt or impossible. The usual method of inoculation in the human being is by means of the bite of a " rabid " or delirious dog. As a rule, the wound is slight, so that frequently little atten- tion is paid to the point of infection. Where the wound has been freely opened or cauterized immediately after its inception, the less is the possibility of development of rabies following the bite of an animal suffering from hydrophobia. Symptoms. — Development of the symptoms of rabies seldom takes place sooner than six weeks or after three months from the date of infection. The patient is suddenly seized with ex- treme nervousness and excitability; the muscles remain rigid, especially those of mastication and the constrictors of the phar- ynx; the head is drawn back in tonic spasm. The patient com- plains of his inability to use his extremities well on account of " stiffness " ; the mental anxiety apparently progresses out of pro- portion to the severity of the disease, and in these cases, no doubt, the apprehension of the terrible malady produces a species of hysterical insanity complicating the rabies. Within a few hours the patient may go from the tojiic convulsion into violent clonic 345 346 TKEATISE ON NEEVOUS DISEASES spasms; and these may be brought on, too, by slight sources of reflex disturbance, such as loud noises, sudden throwing of light upon the patient's sensitive retina, or as in attempting to cath- eterize the patient, which is sometimes necessary, due to spasm of the sphincter vesicae; all of these reflex convulsions being the result of excitation of the hypersensitive special sense and general sensory neurones. The patient's mental condition gradually be- comes maniacal, and he tosses about the bed in fear and delusion; there is a prominent feeling of impending death due to contrac- tion of the throat muscles and those of respiration, and even the diaphragm; ^while the cardiac arrhythmia and cramp produce symptoms allied to angina. Any attempt at swallowing, as before indicated, will cause an aggravation of the throat symptoms, although the natural desire to obtain liquids is really nature's effort at producing dilution of the poison in the system, which is defeated by the inability to perform the act of deglutition. Opisthotonus is not an unusual position for the body to as- sume in the interim of clonic spasm, the trunk rigidity always remaining, with but little relaxation; or the body may be drawn in emprosthotonus or pleurothotonus, depending upon the mus- cles of the trunk more particularly affected. This sudden cramp- ing of muscles in the various parts of the body causes violent pain, so that when the mentality is not entirely blunted there will be produced evidences of extreme suffering in the face aside from the general spasm of muscles of expression. The temperature rises in irregular fashion to 103° or 104°, and is proportionate to the degree of infection, especially to involvement of cerebro- spinal meninges. If the patient does not die of exhaustion in the convulsions at the end of the third day the paralytic stage sets in, the temperature drops, the muscles become flaccid, the patient enters into low muttering delirium in profound unconsciousness, showing extensive degeneration of the cerebral cortex; finally he dies of exhaustion, the heart generally stopping before respiration has ceased. Eisus sardonicus usually precedes death. Diagnosis. — The only disease with which it can be confounded is the one we shall next discuss, tetanus, symptoms of which, when given, will fairly accurately set aright this differentiation, which lies particularly in the mode of infection and in the stage of invasion of the acute symptoms. Hysteria may simulate. Prognosis. — The prognosis of hydrophobia is almost univer- VASO-MOTOE AND TROPHIC DISOEDEES 347 sally fatal. Some mild cases have no doubt recovered under treat- ment, just as rarely occurs in tetanus under the most active thera- peutic measures. Treatment. — Treatment is preventive. The antitoxine method discovered by Pasteur is the only measure certain of saving the patient. It should be resorted to immediately upon learning the true nature of the disease in the animal that has been the source of infection; and in view of the severity of the malady, should be done without delay where there is even suspicion of rabies. The antirabies serum should be injected according to the dosage prescribed by the laboratories where it is prepared; that of Gribier in this country being the most desirable product. Treat- ment after the development of the disease is entirely sympto- matic, the use of cannabis indica, of the Calabar bean, the bro- mides, and chloral being indicated. Guarding the patient from noises or extremes of light or cold is an essential point in amel- ioration of the terrible symptoms of this, until recently, usually incurable disease. TETANUS Lockjaw Tetanus, or lockjaw, is a disease characterized by violent con- vulsive seizures beginning in the muscles of mastication ; hence the name lockjaw. Consciousness is preserved. Etiology. — The cause of tetanus is a short, rod-shaped bacil- lus, whose habitat is in the earth. For this reason gardeners and hostlers are particularly susceptible to infection. I have in mind the instance of a splinter which produced tetanus when run under the nail of a farmer while in his stable ; and another case of a boy who received a brush burn over the tibia while driving mule-cars in a coal-shaft. Penetrative wounds, as by a nail, are also sources of inoculation. The incubation of lockjaw is much shorter than that of hydrophobia, being an average of ten days until invasion of active symptoms. Symptomatology is indicated in the definition. It begins with rigidity of the jaw (trismus); difficulty in swallowing; "stiff- ness " in the back of the neck, the patient often complaining at the outset of simply an inability to move the muscles well on account "of this rigidity. Soon the muscle rigidity becomes gen- eralized, and there is a tonic contraction of the entire muscula- 348 TEEATISE OX XEEYOUS DISEASES tare, interspersed ■R-ith twitcliings of the small muscles of the ex- tremities; with this there is great mental anxiety, but the mind remains perfectly clear. The disease rapidly progresses, clonic convnlsions occur in which the patient suffers violent pain and cries out in his torture, although efforts at clear phonation are interfered with by spasm of the phar}Tigeal and laryngeal mus- cles. There is forcible dejection of urine and faeces, also abort- ive efforts at vomiting. With sudden noises, as the slamming of a door, or throwing of light upon the patient, the subject will go into violent convulsive seizures of a clonic nature. The patient will be at times painfully contorted in various parts of the bodv. the picture finally ending with general convulsions, as above stated. There is a continuous tonic contraction during the active course of the disease. There is general hypersesthesia, and also enormous excitability of the special senses, such as photophobia, etc. At intervals between the serious motor explosions, and even under the effect of enormous doses of depresso-motors, the patient may get a few moments of disturbed slumber, only to be aroused by a sudden convulsive attack. The progress of the case is grad- ually downward, the patient finally at the end of three or four days going into collapse, with slight relaxation of the muscles and drop- ping of the temperature below normal. The algid stage now super- venes, also risus sardonicuSy death soon following from exhaustion. [CepJialic, or Rose, tetanus is a chronic form of subacute tetanus in which trismus is the prevailing symptom. The course is longer (weeks), prognosis good, and treatment (same as tetanus) usually curative. A case of Eose tetanus under my care, that of a physi- cian, caused by a kick on the nose by a mule, recovered promptly.] Treatment is as yet but symptomatic and very unsatisfactory, since the cultivation of the tetanus bacillus cannot be grown out- side of the human body : also, as we have not been able to produce the disease in mild enough form in the lower animals to avoid death, the antitoxine has not been obtained. With the rapid ad- vances in bacteriology, it is to be hoped that such antitoxine will be produced in the *near future, when we will have .a prospect of successful treatment of thi? terrible malady. The treatment at present to be adopted is immediately to open up a wound where from the above pointed-out sources of infection any such wound exists. Even after the tetanic symptoms have developed, it would be wise, though late, to excise such a wound in the hope of sta}-ing VASO-MOTOR AND TEOPITIC DISORDERS 349 further infection from the nidns. The patient suffering from tetanus should be placed in the quietest possible surroundings; the room should be thoroughly shaded and kept entirely quiet from all sources of reflex irritation through the general or special senses ; the slamming of a door I have seen the cause of precipitat- ing a convulsion. Chloral is in my experience one of the best drugs at command for the alleviation of convulsion, and vi^hile the heart may be depressed, the excito-motor system is so stimulated in this disease that the use of such depressant far surpasses any ill effect upon other organs, as the heart. This drug can be given in 15-grain doses every three hours, and pushed until some amel- ioration of the convulsive seizure obtains. The remedy can, in cases where the patient is unable to swallow, be administered per rec- tum, and in this case should be given in about twice the dose as when taken by the mouth. Bromides take second place in the management of the disorder, and- can be combined with the chlo- ral in eases where the former fail. By such combination we have ideally what H. C. Wood terms the " crossed " action of drugs — that is, the maximal effect upon one part of the system, in this case the depression of the motor centres in the brain, with a mini- mal effect upon, as in this case, the cardiac and respiratory func- tions. Morphine should be used hypodermically with caution where the case is in a status of convulsions, the idea being here to quiet the nervous system quickly in order to prevent death through continuation of convulsions and consequent exhaustion. This drug should not be used in the interim, since it is not de- sirable to block the kidneys in any way. Venesection in tetanus would seem to be rational therapeutics, for by this measure we could hope to carry off the toxine in part, and by hypodermo- clysis possibly to dilute the blood pabulum and flush out the toxine from the nerve-centres in the brain and cord. The prin- cipal drawback in the procedure would be the tonicity and spasm of the muscles and blood-vessel walls which prevent both the egress and ingress of salt solution.^ Calabar bean I have seen cure one case. It should be pushed, in the form of the fluid extract, to the physiological limit in eases where the chloral, bromide, and opium treatment outlined has failed to produce any amelioration of symptoms within the first twenty-four hours. 1 Normal salt solution is prepared by adding 46 grains of sodium chloride to the pint of distilled water. The water is kept at 110° F. 350 TKEATISE OX NEEVOUS DISEASES It should be mentioned that such patients ought to be espe- cially guarded from hurting themselves, for while they are per- fectly conscious and appreciate the terrible suffering, they are, of course, unable to protect themselves from injuries resulting from the violent convulsions. The tongue should be particularly guard- ed from being bitten, and the saliva should be kept clear from the tliroat, more by the posture of the body (preferably placing the patient on his side from time to time) than by any effort at mechanical swabbing of the throat. The bed should be very large, soft, and placed in the centre of the room, so that attendants can relieve and guard the patient from all sides. If hyperpyrexia should develop, the application of ice-bags to the head and spinal column would be of value. TETANY (TETANILLA) Tetany is a subacute or chronic disorder that is characterized by intermittent or persistent tonic contractions beginning in the extremities and associated with parsesthesia and hyperexcitability of the motor and sensory nerves. JEtiology. — It is a rare disease in America, but quite common in Europe, especially in Austria. It is more common at the sec- ond to fourth years of life, and again at the age of puberty, and is very rare after fift}^ years of age. It is more frequent in males in early life. There is less difference in the frequency of its appearance in either sex after the twentieth year. Eachitis is a predisposing cause. Exciting causes are exhausting influences, like lactation, sepsis, fatigue, mental shock, fevers, or exposure to cold or wet. Dilatation of the stomach and absorption of toxines from the intestinal tract in consequence, intestinal parasites, and alco- holism may also cause the disease. Symptoms. — The attacks are usually paroxysmal, lasting from a few minutes to many hours. In the continuous eases the spasm may last for days or weeks. There may be a feeling of general lassitude or of numbness or pain in the extremities for a short time before the onset. In the majority of cases the spasms are confined to the hands alone or to the hands and feet. The fingers are closely pressed together, the thumbs adducted and pressed against the index-finger, the so-called writing 'posture', or are flexed into the palms beneath the fingers, the so-called "accoucheur's VASO-MOTOR AND TROPHIC DISORDERS 351 hand." The foreariu is flexed and upper arm adducted. In the lower extremities the toes are strongly flexed, the knees and feet extended, the feet also being inverted. In bad cases the muscles of the abdomen, chest, neck, and face are involved. Trismus and drawing out of the angles of the mouth give a peculiar physiog- nomy to the patient (risus sardonicus). Opisthotonus and dyspnoea may result. The orbicularis oris and extra-ocular muscles may develop contractions, closing the eye, thus adding a squint to the patient's grotesque appearance; the muscles of the larynx (laryn- gismus stridulus), oesophagus, and bladder may be affected. There is no pain unless the spasms are severe. Fibrillary tremors may be seen in the contracted muscles. There may seldom be loss of con- sciousness, and this usually occurs in the cases associated with extreme debility or gastrectasia. Usually the mind is quite clear. There may during attacks be hyperaesthesia of the skin of the parts affected. The spasms may arouse the patient from sleep. Fever is at times present in epidemic form. In such there must be some mixed infection complicating the case. (A) In the intervals between attacks continued pressure over a nerve-trunk may bring on spasms (Trousseau s sign). Even a slight tap over a nerve with the plexor may induce spasm of the muscles supplied by it. Thus tapping over the facial nerve at its point of exit from the stylo-mastoid foramen will produce contrac- tion of the muscles of the face, particularly of the lips. This is called the facial phenomenon or Chvosieh's sign. (B) Electrical excitability (electrotonus) of the motor nerves and muscles is increased, a feeble current causing tetanic contrac- tions. Instead of the normal formula we may have AnClC or AnOC>KClC. This is called Erd's symptom. There may be a cathode-opening tetanus, a phenomenon not found in any other affection. Gowers says there may be a reversal of the polar for- mula. Thus a positive-pole opening contraction occurs earlier than a positive-pole closure contraction. (C) Sensory nerves are also more irritable to mechanical and electrical stimuli; a weak current passed through such a nerve as the supra-orbital may cause pargesthesia in the parts to which the nerve is distributed. This is called Hoffman's symptom. The auditory nerve reacts easily. In exceptionally mild cases the symp- tomatology of tetany may be of parassthesia and stiffness of mus- cles without real spasms. In this latter form Trousseau's symp- 352 TEEATISE ON NEEVOUS DISEASES torn cannot be elicited. Infantile tetany is less apt to be severe than that in youth or adults. Symptomatic tetany from brain disease must be differentiated from true tetany principally by the presence of the brain disease and trismus. Duration. — When the spasms are continuous the disease lasts but a few weeks, but when they are intermittent they may last for months, as though it took a certain time for the toxine to be elimi- nated, and in which the spasm assisted in some unknown fashion. (Epilepsy may also be bettered by an occasional attack in toxic cases.) Tetany usually lasts a few weeks or several months. It is liable to recur on a return of the exciting cause. Diagnosis. — The disease is usually told by the symmetrical distribution, the hyperexcitability of muscles, motor and sensory nerves. Trousseau's sign is found in no other affection; also it is very rare to find the " facial phenomenon " and the electrical and mechanical irritability of such quality in any other disease. The acoustic-nerve irritability is also characteristic. Tetany rarely causes death. Tetany is distinguished from tetanus by the intermittent tendency of the spasms, their feeble character, and the fact that they begin in the extremities and extend to the trunk; also the absence of trismus except very late in the disease. It may recur annually for a number of years. Pathology. — There is a congestive and irritative condition of the gray matter of the spinal cord. In epidemic tetany there must exist some infectious poison. In other cases mucin circulation in the blood is found, as in that type due to thyreoid disease (thy- reoid tetany). Eheumatic poison causes other cases of tetany. Ergot may produce symptoms resembling tetany. In infantile tetany the irritation is due to cortical affection, to meningitis, rachitic poison, or to reflex irritation from disorder in the gas- tro-intestinal tract. The latter scarcely ever happens in adults. Tetany is a symptomatic disease, but the primary causes are so many it deserves the distinction of a name on clinical grounds. There. is no definite pathology, no characteristic constant lesions being found at autopsy. Treatment. — Stop the cause, having searched most carefully for it. In cases following the removal of the thyreoid or due to disease of that organ, thyreoid extract should be given. Lacta- tion must be stopped in adults. Diarrhoea, indigestion, or rickets VASO-MOTOE AND TROPHIC DISORDERS 353 should be cured, or removal of intestinal parasites if existent. Symptomatically : Rest, nourishing food, tonics; and for the spasms, bromide of sodium in 1-dram to 3-dram doses combined with chloral for its " crossed action " are indicated. Hyoscine hydrobromate, grain j^j^^ t. i. d., may be of service; or valerian or other antispasmodics may be employed. Warm baths are of serv- ice. Digitalis is of value in nocturnal tetany, as advised by Gow- ers. This dose given at bedtime very likely acts through toning up the circulation and hastening elimination of the poison. The anodal pole of a weak galvanic current may allay the irritabil- ity for a time. Inhalations of chloroform or ether may be neces- sary to control the convulsive seizures. 23 CHAPTER XIX DRUG INTOXICATIONS ALCOHOLISM-ALCOHOLIC INSANITY This is a disease produced by indulgence in spirituous liquors. There are two sorts : acute and chronic. The acute is usually brought on by the excessive indulgence at periodic intervals, the chronic by the result of more or less constant imbibition. The de- velopment of these conditions will depend more or less upon the idiosjmcrasy of the particular individual. Those forms of alcohol containing fusel oils are more apt to precipitate an attack. Symptoms of Acute Foi'tn. — The patient complains of con- fusion of ideas, is mentally excited, the sensorium, however, gen- erally being obtunded, so that exposure to cold, for example, is not well appreciated. There will usually be fine tremor of the extremities, lips, tongue, in the acute alcoholic state. The urine will be found to be of a high specific gravity and often loaded with uric acid, especially with those who have a lithsemic diathesis. The patient will complain of a full feeling in the head, often of palpitation of the heart and symptoms of acute indigestion, such as nausea and vomiting, followed by a thin and watery stool. This syndrome of symptoms is followed by general muscular weakness and exhaustion. The clinical picture may last from a few days to many weeks, depending upon the continued indulgence in alcohol. At any stage of the disease the patient may develop mania a potu or delirium tremens, which is characterized by great mental and physical excitement, by hallucinations and delusions, particularly of seeing weird objects (the seeing of snakes), this being rather a constant illustration. The patient also hears uncanny voices or may describe pctual voices, such as that he hears people plotting against him. With this there is a rapid progressive weakness, and the patient may fall into dementia and death result from failure of the nerve-centres or from an intercurrent pneumonia, especially ALCOHOLISM 355 if he has exposed himself greatly. The kidneys may fail and the pa,tient -go into a state of urasmia, which latter will be the cause of death. Prognosis. — This is good as to recovery if the patient's consti- tution is sufficiently vigorous, but the danger of relapse is always probable. Cases of mania a potu should be guarded in prognosis, since the patient may die of a complication, or a permanent de- mentia may be the sequel. Mild cases usually recover. Pathologij. — There is an alcoholic poisoning of the nerve- centres, producing a chronic congestion of the meninges and the brain, and in the worst cases fatty, degeneration of the cortical cen- tres or neurones and the same parenchymatous change in other parts, as the liver and kidneys. Treatment. — This consists of in the first place withdrawing the drug, which can be done in two ways, (1) suddenly and (3) gradually. The former is the most desired method, immediately stopping the alcohol, supporting the system by means of strych- nine or nitroglycerin ; and by simple food, such as milk, etc. For the mental excitement, chloral and bromides in combination are indicated. Hyoscine hydrobromate in -i^-gr. doses hypodermically is often of great value. The gastro-intestinal tract should be treated carefully ; the use of the blue-mass pill, 5 grains, repeated, should be resorted to where the intestinal tract is sluggish. This should be followed by vegetable tonics given before meals. The patient should be kept quiet and exposed to sunlight and fresh air as luuch as possible. The kidneys should be treated. Symptoms of the Chronic Form. — These are the same as in the acute form of poisoning, but in less degree. The somatic symp- toms predominate ; and the mental consist of obtundity, or of de- mentia in the worst cases. In others the mental symptoms produce the chronic alcoholic insanity or mania, which is a type of excita- bility or excitable insanity with delusions, and is probably due to a chronic irritation of the cortex from meningeal thickening or patches of cerebral sclerosis. Diagnosis of any form of alcoholic poisoning will largely de- pend upon the history of the case and upon the detecting of the drug upon the breath. This, together with the physiognomy of the patient, ' of acne rosacea, or evidence of congestion of the brain, liver, or kidneys, will make positive the source of the disease wh^n taken with the symptoms detailed. 356 TEEATISE ON NERVOUS DISEASES Prognosis of the Chronic Form. — The chronic form is apt, unless the drug is withdrawn or withheld entirely, to end in fatty degeneration of the brain, heart, etc. This fatty degenera- tion of the organs of the body and neuritis will occur if the poisoning continues. Chronic alcoholic mania very seldom, if ever, recovers. Pathology. — Congestion of the meninges of the brain and cord, endarteritis, periarteritis, and sequent fatty degeneration of the brain and various organs of the body, occasionally accompanied by circumscribed ha?morrhages, are all found; as in pachymeningitis hemorrhagica interna, the symptoms of which are given in an- other place. Cloudy swelling of the kidneys, the heart, and liver occur ; while chronic gastritis and enteritis may complete the path- ological picture. Treatment. — The treatment of the chronic form is largely hygienic and supportive. Alcohol should also be withheld entirely, as in the acute form of poisoning. Nitrate of strychnine is the drug par excellence. It is best given hypodermically in -^-grain doses. The uses of cocaine ^ or strong infusion of coffee is of great value as a stimulant in those cases liable to depression after the withdrawal of alcohol. Chronic alcoholic insanity will require treatment in an as3dum. Eesultant alcoholic neuritis has been treated under another heading, (See Neuritis.) TOBACCO POISONING Acute poisoning frequently presents marked symptoms through reflex nervous influence, such as tachycardia, irregular pulse or heart, and palpitation (symptoms that also exist in the so-called tobacco heart in chronic poisoning). There may also be disturb- ances of respiration, mental excitement, and tobacco amblyopia, the latter being common. The poisoning takes place in people who are smokers, or in those who handle tobacco largely, as cigar-makers. The duration of symptoms may be indefinite, and will depend upon the amount of tobacco smoke inhaled and the idiosyncrasy of the patient for or against the drug. The tohacco heart is of chronic ^A. J. Hall (Medical News, October 31, 1903) credits cafEeine with a physiologic antagonism to alcohol in doses of gr. j or gr. ij every one, two, or three hours. The author contends that in twenty-four or forty-eight hours the drug will effectually quench the craving for alcohol in confirmed hahitues. TEA, COFFEE, MEECUEY, AESENIC POISONING 357 nature, often lasting for many months or several years after com- plete withdrawal of the poison. Cardiac hypertrophy may occur in it with all the physical signs of heart disease. Diagnosis. — This is to be made from chronic tea poisoning, which is associated more frequently with chronic dyspepsia, in which latter the amblyopia almost never occurs. Pathology. — This consists in an auto-intoxication, which may set up fatty degeneration in various organs of the body. Treatment. — Withdrawal of the tobacco, and supportive meas- ures with nutritious diet are indicated. In tobacco heart it will be necessary to administer vaso-constrictors, as digitalis, strophan- thus, etc. ; together with rest, fresh air, and sunlight. TEA AND COFFEE POISONING Tea and coffee are drugs which very frequently produce symp- toms in the nervous system. The symptoms produced are mental excitement, insomnia, tremor, and irregular cardiac action. These are rare, but they should be looked after and attended to in order to prevent bad results. Treatment would be the same as for tobacco poisoning. LEAD, MERCURY, AND ARSENIC POISONING A remote common result of these poisons is multiple neuritis. The symptoms of lead encephalopathy are special symptoms of chronic lead poisoning, and consist of mental excitement (mania), or general or localized cerebral convulsions, and are usually asso- ciated with marked arterial sclerosis set up by the lead. In the pathology of this condition there is also a thickening of the meninges, and later in the course of the disease there is a fatty degeneration of the neurones. The prognosis of the disease is bad. The patient may live for many years, however, finally passing into secondary dementia. The treatment should be supportive and eliminative, as potassium iodide for continuous periods. If the mental symptoms predominate, then the same treatment as in insanity should be resorted to. Mercury and arsenic seldom produce nervous symptoms other than the neuritis indicated. The importance of the blue line in chronic lead poisoning and the waxy condition of the skin and the ptyalism produced in mercury are all points which will assist in 368 TEEATISE ON NERVOUS DISEASES making the diagnosis. In arsenic poisoning a point to be taken into consideration is the oedema of the lids (the lower) of the eye. In all of the above poisoning symptoms gastric signs may be expected. OPIUM POISONING This manifests itself in the nervous system in the forms of acute and chronic poisoning. Symptoms of Acute. — These are slowness of the pulse and res- piration; the former may go down to 40 or 50 and the latter to 10 or 12 per minute. The patient becomes comatose, the lips and extremities may become cold, and especially the former blue; besides, the patient may be breathing in a stertorous manner; the secretions of the body are checked, and the pupils become con- tracted or " pin-pointed." The onset is rather slow and follows some hours after the ingestion of the poisonous drug. Even in the milder cases it is difficult to arouse the patient. While he may appreciate his danger, yet the desire for sleep is so irresistible that he will not make any effort to remain awake even where there is no intended suicide. One grain of sulphate of morphine may produce these symptoms, or from 3 to 10 grains of powdered opium, or smoking of the drug, as a habit. In some cases from the reten- tion of urine there is soon set up a cj'^stic irritation. Symptoms of Chronic. — The evidence of chronic opium poi- soning on the nervous system is shown in mental hebetude, vacilla- tion, etc. The patient is inattentive, generally manifesting to a marked degree a condition of ego ; but is indecisive, and also cannot, as a rule, advance into new fields of work, similar to that condition existing in paresis. Such a patient's secretions and excretions become scanty, the skin becomes dry and hard, and the physiognomy loses animation, the pupils becoming and remaining contracted. The patient may sit for hours in a " dopy " condition, again at times being vivacious, especially after taking another por- tion of the drug. It is usually, in most of the cases, seen to be the result of hypodermic medication, the abuse of that form of thera- peusis. In other cases smoking of the drug is the cause of the chronic opium poisoning. Prognosis. — This is rather dubious as to recovery in all cases, since the patient's condition is usually so corrupted at the time he reaches this stage that he is unable to resist the drug which he has COCAINE HABIT 359 been taking. If this can be reduced, however, liability to cure is proportionately large. The patients may live for years as chronic morphine habitues. They are liable at any time to attacks of con- gestions and low-grade inflammations. Treatment. — This consists in withdrawing the drug rapidly and completely, and in addition supportive measures should be resorted to. In some cases mental therapeutics, as through hypnotism, suggesting to the patient while in a hypnotic state that he will not be further able to enjoy the use of the drug, will sometimes be of avail. Hyoscine hydrobromate is the only drug that may act as a specific. It should be given in full dosage. COCAINE HABIT The abuse of cocaine hydrochlorate has become frequent in recent years. Often the hahitue has taken the drug as a substitute for opium or some of its alkaloids. Or, again, the habit may have been formed through a patient having taken the drug locally for relief of pain, as in cases of chronic neuralgia of the branches of the fifth nerve, particularly if associated with chronic disease of a tooth or the alveolar processes of the maxillary bones. In other cases the habit has been induced through cocaine sprays in chronic naso-pharyngeal disease. The drug is usually taken by applying pledgets of cotton soaked with 4 per cent or stronger solution to the nasal mucous membrane, or hypodermically. Symptoms. — The cocaine hahitue usually shows evidence of mental excitement, associated with cardiac acceleration or irregu- larity. The respirations are hurried, more pronouncedly after he has recently taken a dose of the drug ; when also marked mydriasis, wakefulness, and a sense of dimintition of fatigue and hunger. The patient may complain of a sense of " tightness " about the chest. The mucous membranes are dry. In advanced cases the skin is cold and clammy. Other symptoms are impairment of co-ordination, hallucinations, and delirium. Though decidedly diuretic, it lessens the quantity of urea by checking the processes of waste, thus acting as an indirect nutrient, and enabling the body to maintain its energy on a lessened supply of food. On account of the increase of cutaneous circulation local flushings may occur. From the fact that the hahitue usually tries to conceal the habit, observation as to the small amounts of food taken is important in diagnosis. 360 TEEATISE ON" XEEVOUS DISEASES Prognosis. — The cocaine " fiend " is about as difficult to suc- cessfully treat as the morphia habitue. Permanent cure is always dubious. Treatment. — An overdose of cocaine must be combated by amyl nitrite for the cardiac depression, then alcohol and opium as stimulants to the heart ; also artificial respiration. Chloral and chloroform are the most directly antagonistic. The " habit " is best combated by securing full control of the patient, such as placing him on rest treatment. The drug must be gradually reduced, an occasional dose of morphia given in solution that the patient may not detect the substitute. Digi- talis in 5-minim doses thrice daily or oftener may be required to tone up the circulation. During the period of withdrawal of the cocaine the bromides are often valuable to allay cerebral excita- tion and produce sleep. The gradual increase of proteid food, as eggs and red meats, is important as metabolism recovers. COAL-TAR PRODUCTS INTOXICATION Under this heading come antipyrine, antifebrine, and phenace- tine as true coal-tar derivatives, while the salicylates are more strictly of the carbolic-acid series. All of them, when used in excess in gradually increasing doses, may be said to exist as a " drug habit." Symptoms of Poisoning. — As these drugs are used as valuable remedies for pain, the habit is often engendered very insidiously. Especially is this so in the hysterical " remembrance pain " follow- ing true pain of the various painful affections in nervous disease. There is usually no attempt at deception on the part of the patient the subject of the coal-tar intoxications, but frequently he takes the drug with a feeling of its necessity for the real or " re- membrance pain " referred to above, and to which I have called the attention of the profession in another place.^ In toxic doses (in some cases as much as 100 grains a day of antipyrine in tablets has been the limit of tolerance) the patient becomes cyanotic, presenting a leaky skin, feeble, running pulse, singing in the ears, and a reduction of body temperature -nr" to -I-" F. Occasionally the ^The Therapeutic Status of the Coal -Tar Products in Central Nervous Affections. Symposium of the Phila. County Medical Society, Dec. 10, 1902. Vol. IV, New Series. COAL-TAR PRODUCTS INTOXICATION 361 patient is nauseated and vomits. Very rarel}^ there is a peculiar erythematous skin eruption noticed over the face, chest, and on the sensitive skin between the fingers. There is a depressant influ- ence upon the brain. In extremely toxic doses the principal influ- ence is exerted upon the blood, altering the shape of the red cor- puscles, separating the hematin, and causing decomposition of that fluid. " Diagnosis. — Confusion cannot be made with any other intox- ication if the above symptoms are carefully observed. Prognosis. — This is, as a rule, good in chronic poisoning, since the system has become somewhat immune to the poison. Treatment. — Of acute intoxication consists in the administra- tion of strong coffee, stryehnine, and digitalis, with quietude and alcoholic stimulation. In chronic poisoning, the withdrawal of the drug graduall}^, the steadying of the circulation by digitalis or strophanthus, quietude (rest in bed), and full feeding are all essentials. CHAPTEE XX PARESIS GENERAL PARALYSIS OF THE INSANE-GENERAL PARESIS-DEMENTIA PARALYTICA This is a progressive degenerative disease of the brain, distin- guished by abnormal mental symptoms which end in dementia, associated with physical weakness or palsy ; also with other charac- teristic physical signs and symptoms. It runs a fatal course, of about three years' duration in the vast majority of cases. Etiology. — Paresis, as it is usually termed, is a parasj^philitic disease, or, as Krafft-Ebing metamorphorically puts it, a disease of syphilization — in consonance with another fact that it is a dis- ease of modern civilization. A century ago paralytic dementia was rare, now it is seen frequently at clinics, asylums, and in pri- vate practise. The disease is- rare still in Asia and Africa. Cli- mate in these countries must have some immunizing influence upon the system, since the same cases may be as likely to acquire paresis if exposed to specific infection when in Europe or Amer- ica. It is a disease of indirect heredity to predisposition — \. e., the patient is born with a neuropathic constitution, though it is once in a while found to be congenital, occurring in the very young whose parents were. syphilitic. It occurs almost six times as often in the male as in the female. As women take on the follies of men, we find the proportion of cases increasing in the female sex. Excessive mental exertion, as of the intense mind tension of a banker, is a predisposing cause also, as is alcoholism. Sexual excess may deplete the central nervous system neurones to such an extent as to greatly predispose to paresis, but is almost never an exciting cause, as has been thought. This disease, with locomotor ataxia, must be put down as being in 75 per cent of cases (more in our experience) due to syphilis. Krafft-Ebing gives 80 per cent as being specific ; and when occurring in children Zappert makes 362 PAEESIS 363 the proportion of cases of paresis clue to syphilis over 87 per cent. Sunstroke^, exposure, injuries, and acute diseases are also exciting causes in the minority of cases. But once having had syphilis associated with any other of the causes enumerated, such a one is very likely to develop paresis in from eight to fifteen years after the initial lesion. The disease occurs more frequently between the ages of twenty and forty, most usual about the thirtieth year. It is more frequent in married people, and is found oftener in city than country, for obvious reasons already inferred. Symptoms. — There are two stages: one of excitement or irri- tation, the other of dementia and paralysis. Substitution for the first stage may be in a prolonged period of melancholia or hypo- chondriasis. In other cases the dementia and bodily enfeeblement may go hand in hand from the first. The first type is the most common, although the opinion is growing that mental disturbance is becoming less in importance than is the initial physical weak- ness. Thus it is assumed that paresis is becoming much > more a disease of the brain and cord and less a disease of the mind, the mental symp- toms being that of a progres- sive dementia from the in- cipiency of the process. Usual Type. — First stage: The patient shows unusual irritability of temper; he is annoyed by trifles, his fam- ily noting the marked change in disposition to the house- hold ; also a lack of proper appreciation of business rela- tions. He becomes peevish, is easily fatigued, is exhausted without cause, and is unable to fix his attention for any length of time upon his af- fairs. He is apt to be ex- travagant or make some foolish error in judgment. This con- dition of irritability is followed by great exaltation. He becomes Fig. 79.— Paretic Dementia. Ordinakt Ttpe, Second Stage. (Philadelphia Hospital, Insane Department.) 364 TEEATISE OX XEEVOUS DISEASES happy, and possesses a feeling of " well-being." He is effusive of speech, and jocose where he was formerly sober or reserved. He develops great ideas, as of money-making, and all by a conglomer- ate mass of ideas, such as by a meat-market and automobile es- tablishment combined. These delusions of grandeur (megalo- mania) are more or less periodic, and the period of exaltation often gives place to outbursts of violence, this latter being more pronounced if he has developed a transient dipsomania, which is not unusual. "\A'ithin a few months the family usually solicit aid of the physician, and the patient is confined in an institution where he can do himself or others no harm. Often under this re- straining influence apparent remissions occur, and occasionally reoJ remissions occur, as in a case of the writer's where ten years had elapsed since a staying of all symptoms of undoubted paresis has occurred, the man still holding the initial symptoms. Usually, however, after some months in a hospital the patient begins to show marked signs of dementia, memory becomes worse, he misplaces objects, forgets recent matters, commits errors in figuring, cannot write coherently, or may make mistakes in spell- ing or elision of letters. The handwriting becomes wavering, the letters showing irregularities in the strokes. During the exaltation period physical signs develop which are characteristic. Besides the difficulty in writing, noted above, there is decided facial tremor, brought out the more when the patient is told to close his eyes and stretch the muscles of the face so as to show the teeth. Marked tremor of the tongue is present, much like that of acute alcoholism. Speech becomes thick; he stutters; it is very difficult to pronounce long words. These evidences of dysarthria are entirely cerebral in origin. The knee-jerks are usu- ally increased. The pupils are generally unequal; they are apt to react badly to light,^ and even sluggishly to accommodation. The fundi oculi are normal. An early and decided weakness of the sexual function is found. The vesical sphincter may become paretic, allowing " dribbling "' of urine. Appetite may be increased, manner of taking food glut- tonous. Vegetative organs remain normal until very late* in the ^ The tnie Argyll-Robertson pupil, recorded in the books, the writer has not found in twenty-five out of one hundred cases carefully examined. Irreg- ularity and iridoplegia he would beg to submit as being the most characteris- tic pupillary signs in paresis. PARESIS 365 course of the disease. The patient often suffers from insomnia, or he may be subject to vertiginous, syncopal, or pseudo-apoplecti- form attacks, in the latter of which he may fall over and be a suf- ferer from hemiplegia, lasting for a iew days or even weeks. Epi- leptic convulsions may occur. In rare cases there is abolition of the knee-jerks and ataxic symptoms somewhat resembling the pa- retic stage of tabes. In such cases the general muscular power is much diminished, the patient being unable to do any sustained muscular work, as walking any distance. True apoplexy may occur. In the second stage the most striking sign is the gradual onset of dementia. The patient sleeps much in da3^time and becomes more quiet. He is very forgetful now, may not at times even rec- ognise his friends, and, of course, takes little interest in outside affairs. He cannot speak of current events, forgets the day of the week, etc. He soils himself at meals, slobbers his liquids, and takes no interest in his personal appearance. He may be uncleanly at the toilet, and finalh^ becomes as dependent as a small child. Later apoplectiform attacks occur with permanent hemiplegia, as noted above. He may now gain flesh and have a verj^ voracious appetite. In periods of excitement at this stage he may have delusions of persecution or slight delusions of grandeur. Tremor increases and speech becomes distinctly worse. The average dura- tion of the disease is about three years. Some may die within a year, or remission may occur and the patient live in dementia fifteen years in rare cases. [A patient of mine imagined he gained untold wealth from day to day, although he did not name any specific sum. He then quickly became bedridden and helpless.] Dementing Type. — In this form there is a primary dementia, beginning without any excitement. First there is lack of atten- tion to business, forgetfulness, and general incapacity for work. The patient makes mistakes in dates, in calculations; is good- natured to everybody about him, is passively happy. He m.ay have no delusions of any sort. Somatic symptoms of tremor, fixed pupils, exaggerated reflexes, finally appear and become characteris- tic. The scanning speech may appear last of all in this type. There may be increase of phosphates in the urine, particularly showing during any excitable period. Excess of uric acid we have also found in these cases. Leucocytosis is generally present. The red blood-cells become qualitatively changed, there being a relative 366 TREATISE OX XERAT)rS DISEASES increase of the polynu.clear cells, very much as shown in a study with Dr. Xapoleon Boston ^ to exist in idiopathic epilepsy. Hypochondriacal Type. — In this form the symptoms begin with those of hypochondriasis and neurasthenia. The patient complains of a vague feeling of distress about the head, of hemicrania at times; also of pain in the back and limbs. One of my recent cases complained most distressingly of dull pain in the epigastrium, the tongue Ijeing constantly coated, and large amounts of indican were found in the urine. Vague sense of discomfort also occurs, which the patient at his best (in the early morning) is still unable to describe. Frequently these are treated for weeks as cases of neurasthenia, since at the start they scarcely show any physical or mental symptoms. But careful study of anamnesis will reveal in the history syphilitic infection, while a study of the physical signs will show the rigid pupils as perhaps the only clue to somatic failure. After a year or so mental unbalance appears, shown in suspicion, dementia, delusions of persecution, and the like. Occa- sional outbreaks of violence may occur, then all the typical signs — alteration of speech, tremor, etc. — will follow. Syphilitic Pseudo-Paresis. — In some cases of paresis symptoms of exudative syphilis introduce the disease. The patient has at first palsies of the eyes, or attacks of hemiplegia with intense head- ache, followed by convulsions. The specific exudate is found to either be pressing against the convexity or more usually against the base. Under proper treatment resolution of the granulomata occurs and the seizures or paralysis disappear, but it is now found he is emotional, is excitable, his memory is impaired, judgment is weakened ; he has to live a quiet, inactive life, giving up his regu- lar employment or professional work. A pronounced dementia may not set in for eight or nine years in this class of cases. Alcoholic Pseudo-Paresis. — Those who have for a long time continuously indulged in alcohol or who have been debauchees in abuse of alcohol may finally develop — usually do — a condition of mental weakness simulating paresis. I had a ptatient of emi- nently nervous temperament, but of good ancestry, who, follow- ing troubles in his family, drank, not so heavily, but periodically, to the production of mania a potu on several occasions only. This was followed by a typical form of pseudo-paresis due to acute alcoholic intoxication. * Transactions of the College of Physicians of Philadelphia, April 1, 1903. PARESIS 367 In these patients^ there having beeii no syphilitic infection^ there is no true paresis. Such patients are selfish, at times become bestial, while at all times thej" show feeble Judgment ; the memory becomes a blank. There is a gradual loss of the moral sense. De- mentia progresses slowly, but these cases are usually carried off by some intercurrent disease. They never present the physical signs nor typical s3-mptoms of true paresis. If alcohol is withheld they may live many years. Pathologij. — Paresis is a parasyphilitic disease (90 per cent) due to degeneration of the cerebral neurones from the syphilitic toxines developed late in the luetic malady. There is first thicken- ing of blood-vessels due to periarteritis, endarteritis, and prolifera- tion into the perivascular tissue. It is in doubt whether the degen- eration of the nerve-cell is really secondary to the above changes; or is primary, as is the case in tabes. Most authorities cling to the latter view, which is probably the correct one. On examination, the brain shows thickening and vasculariza- tion of the dura mater. This membrane is generally partially adherent to the cranial bones. The brain mass itself has usually undergone atrophy, as shown by decrease of a few ounces in weight over the normal. There is also increase of cerebro-spinal fluid. The pia mater in the fore and mid regions of the brain is much congested. It and the arachnoid are much thickened. The latter is adherent to the brain throughout, and when torn away the cortex is found to be oedematous. Microscopic study reveals increase of the connective tissue and the neuroglia about the blood-vessels of the cortex, thickening of the interna and all the vascular coats to some degree, together with degeneration of nerve-cells at all ages. ISTot only the neurones of the gray cortex, but those of the medulla, are also involved in the fatty change. Lesions of the posterior and lateral columns of the cord may also be found in a third of the cases. Therefore locomotor ataxic symptoms will be found in S3i per cent of cases of paresis. (A less number of cases of primary ataxia (4 per cent) will end in paresis — the third stage of ataxia. (See Tabes.) This is due to the fact that tabetics usually are carried off early by other disease.) Prognosis. — This is invariably unfavourable. The patient may often, however, be partially restored by the use of tonics, gen- 368 TEEATISE OX XERVOUS DISEASES era! remedial and hygienic measures, which includes with particu- larity the removal of the patient from all forms of excitement; also the enforcement of quietude. The use of specific medication in acute early developing cases after the luetic infection may also tend to stay the progress of the disease. Although the use of mer- curials and iodides will not cure or stay the advanced stage, I have seen in the early stage great good result from their use; in several cases apparent cures result. When the frank typical symptoms once develop, cure is impossible at the present stage of our art. Eemissions and the milder type of the affection within the last decade have a more promising hope for greater accuracy in scientific treatment, awaiting only future development. Treatment. — In the early developing cases, as indicated, place the patient promptly on antisyphilitic treatment — K. I., gr.v, t. i. d., HgCla, gr. ^ig, t. i. d., or even the use of inunctions of mercurial ointment, a dram daily. The patient should be kept absolutely under control by removing him to some hospital or institution for mental and physical quiet, with an abundance of fresh air and sunlight about him. Tonic measures, such as the use of the Brown-Secjuard testicular mixture (in glycerine), I have seen do good in stimulating the patient and aiding metabolism generally. The use of the ductless glands, as thyreoid or adrenals, may also, by aiding nutrition and oxidation, be of service in staying the disease. Glycero-phosphate of lime, 10 grains three times a day, I have seen give much benefit. The Charcot douche, cold sponge daily, and light massage aid much in procuring better circulation. Bromides must be employed as periods of excitement indicate. Hyoscine hydrobromate, gr. -^j hypodermically, is of great value in maniacal outbursts. Chloral and morphia should be cautiously employed. APPENDIX DISOEDEES OF SLEEP CoNSiDEEATiON of the physiology of sleep and waking has been studied in the forepart of this work (Chapter I, pp. 42 and 43). The symptomatic disorder, insomnia, has also been treated at length in another place (p. 126). Sleep is that calm to the nervous system that supplies nerve energies for the workingman. There are many theories of the causation of sleep, the latest being that of retraction of the proto- plasm of the cortical neurones. This separating one from another cuts off the association of nerve impulses of the higher centres, while those lower more physical or vegetative functions still are active. This beautiful mechanism is thus well illustrative of the possible gross mechanism of mind action.^ It at least permits of better conception of the ever mysterious phenomena of sleep. The causation of sleep is more universally, however, considered to be due to ansemia of the brain. This theory has its partial proof in the fact that the blood pressure is lowered during sleep, as shown by sph}^mographic tracings. Self-developed catabolites may be the remote cause back of all others; these autochthonous poisons precipitating- the mechanical status of the cells found during sleep. Given a healthy mind in a healthy body, we have the highest type of man : mens conscia recti. So that the wear and tear of life is constantly balanced in part by periods of repose, particu- larly of sleep. There is never an absolute repose of mind or body, however, from birth to death. There is nothing so subtle or important as the study of the disorders of sleep. In the first place, we must recall that there is ' See the discharge theory suggested by Bechterew (Neurol. Centralbl., 1896, N'os. 2 and 3) ; also the studies of Forel, His, and Cajal abroad, and Uercum in" this country (Functions of the Neurone, Jour, of N. and M. Dis., August, 1896). 24 369 370 TREATISE ON liERVOUS DISEASES an individuality about tlie amount of sleep necessary as a restora- tive agent. Some nerve protoplasm requires more hours of sleep than another. ISTor is it the neurotic person that requires most. It is simply a matter of idiosyncrasy, which only, can be judged by the history of any case. In proportion as sleep does service in resting the mind, do we have the only accurate index of the value of a given slumber ; and yet, as some one has well said, a dreamless sleep probably does not occur. We should reason from this that fixing or a resetting of our thoughts during the time of peaceful, quiet sleep is one of its functions. Indeed, too, the merftal impres- sions thus finally fixed during sleep are probably of the most en- during nature — the mainsprings of character; for consciousness brings its artificialities, while the various pitfalls of convention- ality are entirely done away with in sound sleep, and the best things of the mind remain afterward. It is but the demonstration of God's rule as set down by Darwin, " the survival of the fittest." It is a high province of the physician to bring about natural sleep. A. Wakeful Disorders of Sleep I-nsomnia may be said to be the most important disturbance of sleep. Its causes are legion : pain, lack or excess of exercise, toxasmias, excitement, or worriment. In the treatment of it no physician can be successful unless he seeks out the fundamental cause. Pain, if intractable, must be counteracted by a dose of mor- phine. Poisons should be. eliminated. Exercise must be regulated to oxygenate the blood properly ; a happy medium for the indi- vidual ease is to be sought. It is folly to advise long walks for the banker or a series of rigid calisthenics for an overworked lawj^er or physician or student. This I have seen do almost irreparable dam- age in a neurasthenic man attending the regular gymnastic course in one of the leading universities of Xew York State. Excite- ment must be ad minimum in the sufferer from insomnia. It is well also to arrange, for the several hours preceding " bedtime," especial mental and physical quietude. The room should be well ventilated in which the patient sleeps. It should be dry, prefer- ably in a room of northern exposure, since many are easily wak- ened, as by rays of the rising sun at daybreak. All extrinsic causes, such as noises, should be guarded against. I have seen patients APPENDIX 371 immediately improve by being taken to another room when some particular, though slight, noise, not thought of by the sufferer, was the cause of his awakening. General methods to employ are warm water bathing (temper- ature 112° F.), followed by a brisk rub with a Turkish towel; or light massage, especially stroking the forehead at the end of the treatment; or hot milk taken at the moment of retiring. Hyp- notism may be resorted to in the exceptional case where hysteria is the base of the trouble, but it is not a reliable agent, and is liable to abuse. Where high arterial brain pressure exists the cautious employ- ment of depressants, as aconitia, gr. -^^ at bedtime, or several min- ims of tincture of aconite, I have seen of positive service. But any attempts to relieve vascular pressure by nitro-glycerine will aggra- vate the case, due to increasing the flow of blood to the surface, and therefore the meninges, thus causing irritation of the branches of the fifth nerve. Somnambulism is sleep-walking, a state in which the patient acts his part of a dream. In this disorder the subject passes, more or less automatically, through various apparently natural phases of physical and organic life, without full mental inhibition existing as when the conscious mind controls him. Somnam- bulism is, to a degree, evidence of unrest, of inevitable wakeful- ness. I have a patient who walks about at night frequently, talks coherently the while to those who address her, but in the morn- ing she is exhausted and remembers nothing of the phenomena. Thus, too, it is with people who dream constantly. It is evidence that the physiological mechanism is out of kilter, so to speak, especially if the dream is something " horrible " or unpleasant. " Pleasant dreams " are, however, natural and not in any extent exhausting, because they are natural, and any natural event is a stimulation of metabolism without which latter mind action can- not be at its best. The proverbial saying that chronic invalids develop frequently the best mental and moral specimens of men and women is not borne out by the cold facts, as physicians so well know. They are good specimens in spite of their infirmity only. Disorders of digestion have much to do with both of the above states. One so disposed should be instructed to be very cautious about indiscretion in diet. An hypnotic given at bedtime, prefer- ably trional, grs. xv, or chloralamid, gr. xij, will aid to prevent 3?2 TEEATISE OX XERVOUS DISEASES attacks of either. The hygienic care is, in other respects, the same as in simple essential insomnia, a most important matter. B. SoMxoLEXT Disorders of Sleep These are the disorders marked by an irresistible desire to sleep, and they are not so frequent as Class A, but usually imply the same grave organic disease or incurable affection, where the underlying pathology is not as yet definitely determined, except in hysteria, which may simulate any malady. Ecstasy, catalepsy, and trance are accidental somnolent states occurring in hysteria. Ecstasy is a more or less transient emo- tional state when the patient is transfixed, as it were, in self-con- templation. When there is general muscular rigidity associated for some period of "time, catalepsy exists. A trance is a passive condition of quiet somnolence in which the patient lies motionless with all function at the lowest ebb. Respiration and pulse may be almost imperceptible. The treatment of these three conditions will be that of the management of a general hysterical state. It should be mentioned that some complex treatment, such as hypnotism, or a long series of regulated exercises in deep breathing, the mental and hydro- therapeutic value of a cold shower-bath, together with forced feed- ing to the constitutional limit, singly or combined, will offer the best rewards in cure to the caretaking physician. Sleeping sickness, as recently described by Manton and Mott as due to filaria and occurring in certain natives of Africa, is a clinical syndrome in which somnolence appears in intervals grad- ually increasing until tbe patient sleeps steadily for many hours. At first the patient can be aroused sufficiently to take food, and finally awakened with extreme difficulty. In two cases studied by Mott ^ a chronic infused leptomenin- gitis and encephalomyelitis were found, but no infectious organ- ism. In studying the blood - for another purpose with Dr. ISTapoleon Boston, this observer discovered in a rat's blood an ^British Medical Journal, December, 1899. 2 The Blood in Epilepsy : Experiments on Animals. Transactions of the Physicians of the College of Philadelphia, March, 1903. American Journal of Insanity, January, 1904. APPENDIX 373 actively motile micro-organism similar to the one described by Manton very recently as a probable cause of sleeping sickness. Upon a warm slide, with the lower power of the microscope, the organisms could be readily seen pushing the corpuscles about. The organism has been designated Tryfanosomos Castellani from its discoverer. If this organism is the cause of this disease some form of immunization or prophylaxis seems to be the only possible hope for cure in the future. Narcolepsy is a condition in which the patient repeatedly goes to sleep in the day. It is a marked form of epilepsy and requires the same treatment (see Epilepsy). ADDITIONAL FIGUKES Fig. 80.— Spastic and ATnExoiD Movements in Face, Tongue, and Pharyn- geal Muscles. Case of Cerebral Spastic Paralysis. (Philadelphia Hos- pital. ) 374 TREATISE OX XEEVOUS DISEASES Fig. 81. — Attitude in a Case of General ATHEl aa gr. xxiv. Quin. valerianat ) M. et ft. pil. Xo. xxiv. Sig. : One after meals. Also neurasthenia (sexual) "with irritable bladder. ^ Potass, citratis 3 iij. Essence pepsini fl. § j. Aquae cinnamonii ? iij. M. et sig. : Teaspoonful every three hours. For nervous cough. ^ Ammon. chloridi 3 JS3. Sod. bromidi 3 iij. Tr. opii. camph fl. 3 ss. Aq. menth. pip q. s. ad fl. 3 iij. M. et sig. : Teaspoonful every three or four hours. .387 388 TREATISE OX NERVOUS DISEASES For dyspepsia (nervous) with gastrectasia. J}, Tr. nucis vom A' 3 j. Sodii bromidi 3 vj. Tr. aurantii fl- 3 j. Tr. gent, comp q. s. ad fl. | iij. M. et sig. : Teaspoonful a half hour before meals. Also 1^ Ext. chiratta ) aa gr. xxiv. Ext. gentian ) M. et ft. capsule Xo. xxiv. Sig. : One a half hour before meals. Also 1^ Tr. nucis vom fl. 3 iv. Sod. bicarb 3 jss.^ Inf. gent, comp q. s. ad. fl. 3 iij. M. et sig. : Teaspoonful before meals. For nervous syphilis. IJ Hydrarg. chlor. corrosive gr. j . Potass, iodidi fl. 3 ij. Aquae ciunamonii q. s. ad fl. | iij. M. et sig. : Teaspoonful after meals. Nervous syphilis (tonic in). l)t Tr. nucis vom 3 ij. Elix. calisay^ q. s. ad 3 iij. M. et sig. : Dessertspoonful every three hours. For hysteria. ^ Pil. asafoetida gr. iij. Sig. : One three or four times a day. Hysteria and anaemia. r Ext. sumbul gr. j. I Ferri sulph. exsic gr. j. ^ Pil. sumbul comp. ^ ^^^^ ^^ida gr. ij. I Acid, arseniosi gr. ■^• M. et ft. pil. Sig. : One three or four times a day. FOEMULARY 389 Headache (simple). 5 Acetanilid , gi'- ij- Camphor monobrom gr. ss. CafEeiue citratis gr. ss. M. et ft. pil. :N"o. i. Sig. : One pill every three hours until four doses if required. Headache (alcoholism). 5 Tr. nucis vom, ) ._ „ . ir, • • r ^a u.. 3 !• Tr. caprici ) "^ Sod. bromidi 3 ss. Tr. gent, comp q. s. ad fl. 3 iij. M. et sig. : Teaspoonful every three hours. For headache (la grippe). 5 Salol T-,, , • i ^3i 3 ss. rhenacetme M. et ft. cap. No. xii. Sig. : One capsule every two or three Hours for three doses. For headache (cerebral congestion and uricacidsemia). I^ Sod. salicylat 3 iij. Codeine sulph gi*- v. Elix. calisay^ fl- o j- Aquae q. s. ad fl. | iij. M. et sig. : Teaspoonful every four hours. For mental depression (bilious temperament). I^ Acid, nitrohydrochlor. dil fl. 3 ijss. Tr. nucis vom fl. 3 iij. Tr. aurantii q. s. Tr. gent, comp q. s. ad fl. 3 vj. M. et sig. : Teaspoonful a half hour before meals. For pariEsthesia. ^ Ext. cascara sagrada fld fl- 1 ]• Ext. ergot fld | Ij. M. et sig. : Teaspoonful twice daily. For Stokes-Adams syndrome. ^ Nitroglycerine gr. 3^. M. et ft. pil. Sig. : One once or twice daily. 390 TREATISE 01s XERVOUS DISEASES Stomach (irritability and acidity). IJ Sod. chlor 3 ij- Sod. plios 3 iv. Sod. sulph 3 5. M. et sig. : Teaspoonful in seltzer twice daily an hour before eating. General tonic in simple neurasthenia. 5 Strych. sulph gr. -j-fg. Ferri sulph gr- I- Quin. sulph gr- J* M. et ft. elixir q. s. ad fl. 3 j- Sig. : Teaspoonful after meals. INDEX Acromegaly, symptoms, 331. diagnosis, 331. patliology, 331. prognosis, 333. Action, reflex, 2.3. Adiposis dolorosa, 324. diagnosis, 325. pathology, 325. prognosis, 325. treatment, 325. Adjunct medication, 109. ^lilstliesiometer, 65. ^Esthesodic, 26. Agenesis, 226. Ageusia, 73. Agraphia, 189. Ainhum, 330. Alcohol, 78. Alcoholic Insanity, 358. Alcoholism (see Neuritis), 356. diagnosis, 355. drug intoxication, 354. symptoms, 354. pathology of chronic forms of, 356. prognosis, 355. prognosis of chronic forms, 356. symptoms, 355 treatment, 355. treatment of chronic forms of, 356. Alexia, 192. Algesia, 56. Algometer, 68. Amaurosis, 70. Amblyopia, 70, 192. Amblyopic tabes, 229. Amemia, 191. Amnesia, articulative, 193. Ampere, 92. Amyelia, 225. Analgesia, 66. Anaemia, 25. Anatomy, 1. Anelectrotonus, 93. Anencephaly, 196. Ankle clonus, 57. Anosmia, 72, 125. Anterior commissure, 7. Anterior poliomyelitis acuta, 255. diagnosis, 256. Anterior poliomyelitis acuta, pathol- ogy, 255. prognosis, 256. treatment, 256. Anterior pyramid, 16. Antifebrine, 360. Antipyrine, 360. Aphasia, examination for, 194. receptive, 191. sensory, 191. Aphasia, motor, 190. ataxic, 191. auditory, 191. visual, 191. Aphemia, 189. Apoplexy, 198-200. cause, 199. cerebral haemorrhage, 198. chronic state of, 202. coma in, 202. diagnosis, 205. embolic, 202-205. hyperpyrexia in, 201. in cardiac disease, 207. nursing, 205. pathology, 204. prognosis, 205. signs of attack, 200. treatment, 205. Appendix, 369. Apraxia, 189, 191. Arachnoid, 22. Arbor vitse, 20. Argyll-Robertson pupil, 60, 72, 227. in tabes, 231. Arthritic deformans, 340. definition, chronic, 337. diagnosis, 337. Arthropathy in tabes, 229. Articulative amnsesia, 193. ataxia, 190, Artificial salt bath, 84. Ascending degeneration, 9. Asteriognosis, 58-185. Asynergia verbalis, 190. Ataxia, paralytic stage, 229. amblyopic stage, 229. Ataxic gait, 63. Athetosis, 68. 391 392 TKEATISE OS XEKV0U8 JJlJSEASES Axioms, 98. Axis cylinder, 4. Axone, 2. Beri-beri, 141. Biceps jerls, 59. Bilious temperament, 64. Bipolar cells. 2. Blindness, 37. Blood-vessels, 4.j. Blood-vessels in brain. 4.5. Brain, malformation of, 19G. capsule of, 19. compression, 195. disease, symptomatology of, 19."i. irritative symptoms of, 195. tumour. 209. diagnosis, 211. localization, 210. pathology, 211. prognosis, 212. symptoms of, 210. treatment, 212. weight of. 197. Brachial neuritis, 101. prognosis, 162. treatment, 162. Brachial plexus, injury of, 161. Brown-S^quard, 25, 55. paralysis, 5. Bulb, 188. Burdach column, 13. nuclei of, 18. Caisson disease, 217. pathology, 217. prognosis, 217. symptoms, 217. treatment. 218. Canal, double central. 226. Capsule of brain, 19. function of, 38. Catalepsy, 105. Cataphoresis, 93. Cathelectrolonus, 94. Cauda equina. 5. compression of, 241. diagnosis of disease of, 241. disease of, 241. Irritation. 241. symptomatology of disease of. 241. symptom of disease of, 241. Causalgia. 65. Cause of sleep, 43. Central canal, 7. Centre, primary optic, 187. automatic, 34. cardiac accelerating, 35. cardiac inhibitory, 35. detrusor, 37. inductive, 30. thermogenic, 38. Centres in medulla, 17. of consciousness, 41. Centrum, 186. Cerebellar ataxia, 240. pathology, 240. symptoms, 240. tottering, 33. treatment, 240. Cerebellum, 19. Cerebral hemisphere, 39. functions of, 39. localization, 183. neoplasm, 209. peduncles, functions of, 36. varieties of, 209. Cerebrum, 20. Charcot's artery, 28. douche, 84. Joint, 230. Chemical stimuli. 26, 29. Cholesterin, 47. Chorea, 278. definition of, 278. paralytic symptoms, 278, 279. Chorea, 284. minor (see Sydexham's Disease and St. Vitis's DA>fCE;, 278. prognosis, 280-282. symptoms of, 280-282. Circulatory disturbances, 121. Clarke, column of, 9. Claw-hand, 213. diagnosis, 213. prognosis, 213. treatment, 215. Climatology in tabes, 233. in nervous diseases, 112. Coal-tar product intoxication, 2;i.'j. diagnosis, 360. progno.sis, 360. symptoms, 360. treatment, 360. , Cocaine habit, 359. prognosis, 359. treatment, 359-360. Cold packs, 84. Coma, 54. Combined sclerosis. 260. diagnosis, 262. prognosis, 262. symptoms, 260. treatment, 260. types, 260. INDEX 393 Combined sclerosis, types of Putuam- Leichtheim-Dana, 260. Comma tract, 14. Conjugate deviation of tlie eyes, 40, 68, 202. Contractures, 66. Convalescence of nervous functional diseases, 107. Convolutions, 21. ascending frontal, 185. central, 183. parietal, 185. first frontal, 185. second frontal, 185. Convulsions, clonic, 53. tonic, 53, 66. Convulsive (Tic), 268, 288. diagnosis, 287. prognosis, 287. Co-ordinating centres, 33. Corpora quadrigemina, 22, 187. functions of, 16, 30. Corpus callosum, 186. striatum, 22, 186. functions of, 367. dentatum, 20. Cretinism, 61. Crossed pyramidal tracts, 13. hemiplegia, 28. Crus cerebri, 187. Cyclopia, 197. Dance, 86. Deafness, 72. psychic, 193. Decubitus, 64. Deep reflexes, 57, 73. Degeneration, 15, 49. Degenerative reaction, 94, 97. Dementia paralyticus, 362. Dendron, 2. Dentate nucleus, 16. Dermatosis gangrenosa nervosa, 327. pathogenesis, 328. prognosis, 328. ' Descending degeneration, 9. Detrusor centre, 36. Diagnosis, 93. Diet, 79, 106. Diffuse and focal diseases of the spinal cord, 243. disease of brain and spinal cord, 267. disease of motor neurons of cord, 234. spinal-cord functions, 240. Diplegia, 66. Direct cerebellar tract, 14. pyramidal tract, 11, 14. Disassociatiou of sensation, 67. Diseases of brain, 195. membranes, 194. spinal cord, 221. Diver's disease, 217. Dizziness, 113. Drip sheet, 85. Drugs, 24. Dura mater, 22. Dyslexia, 194. Dyssesthesia, 65. Elbow-jerk, 59. Electrical irritability, 93. Electricity, faradic, 101. Franklin, 104. galvanic, 31. generation of, 97. in tabes, 233. sinusoidal, 100. static, 104. Electrolysis, 92. Electro-motor force, 98. Electrotonus, 93. Embolism, 200. Encephalitis, acute symptoms of, 207. causes of, 207. chronic, 208. diagnosis, 208. pathology, 207. prognosis, 207. symptoms, 208. treatment, 208. varieties of, 207. Encephalocele, 96. Erb, electrical reaction of, 161. Erb's symptoms, 357. Erythromelalgia, 76-142. histological examination, 142. I'^xercise in nervous diseases, 80. Facial angle, 41. palsy, 129. diagnosis, 326. galvanism in, 131. hemiatrophy, 326. hemiatrophy, 326. intracranial, 129. intraosseous, 129. pathology, 326. potassium iodide, 131. strychnine in, 131. treatment, 130. Family ataxia, 138. periodical paralysis, 343. symptomatology of, 344. Faradic electricity, 100-101. brush, 104. Fasciculus of Tuerck, 11. Fechner's law, 43. 394 TREATISE ON XERVOUS DISEASES Festination, 63. Filum terminale, 5. Fissure of Rolando, 39. location of, 39. median, 7. Fissures of cerebellum, 39. Flechsig, 9, 11, 21. Franklin electricity, 104. Frazier (C. H.), 340. Friction, 86. Friedricli's ataxia (see Hbkeditaet Ataxia), 238. diagnosis, 239. prognosis, 238. symptoms, 238. treatment, 239-240. Frontal convolutions, 18-5. Forced movements, 37. Formatio reticularis, 16. Forms of disease, 49. Funiculi, 89. cuneatus, 16, 17. gracilis, 5. medulla oblongata, 34. Rolando, 17. Gait, 61, 62. Galton's whistle, 72. Galvanic current, 31. Gangrene, 29. Gastralgia, 120. General functional nerve disease, 277. paralysis of insane, 362. paresis, 362. Generally nervous, 79. Geniculate bodies, 22. Genito-urinary, 60. Gerlacb's bodie.s. Giddiness, 113. Giles de la Tourette's disease, 286. Girdle pain, 170, 227. sensation, 227. Glandular defects, 49. Glassblower's disease. 319. aetiology, 319. definition, 319. pathology, 319. Glia cells, 46. Gliosis, 51. Glosso-labio-pharyngeal palsy, 257. acute form, 258. asthenic form, 258. chronic, 258. pathology, 257. prognosis, 258. pseudo form, 257. symptoms, 257. treatment, 258. Goll, 14. Gowers, 11. Grasp, 63. Graves's disease, electricity in, 97. Guide to note-taking, 55. Gyrus fornicatus, 211. tumour in, 211. Habit chorea, 283. diagnosis, 284. pathology, 284. prognosis, 283. symptoms, 283. treatment, 284. Hsematoma dura, 175. diagnosis, 175. prognosis, 175. symptoms, 175. treatment, 176. Hsematomyelia, 245-247. diagnosis, 246. pathology, 246. prognosis, 247. symptoms, 246. treatment, 247. Haemorrhage in substance of cord, 245. aetiology, 245. Hair, removal of, 97. Hallucinations, 45. Hammer-toe, 166. Hammond, Dr., 68. Headache, 120. causes of, 121. varieties of, 121. Hearing, 72. Heart, neuralgia of, 120. Heat exhaustion, 340. prognosis, 341. Hemianopsia, 55, 69, 70, 192. Hemiopia, 70. Hemiplegia, 15, 39, 196, 204. gait in, 202. in neuritis, 204. secondary contraction In, 204. sweating in, 195. Hereditary ataxia (see Feeidrich's Ataxia), 238. Hereditary spastic paralysis, 238. chorea, 284, 286. diagnosis, 285. duration, 285. Hernia, 197. Herpes zoster in Pott's disease, 163. Heteropia. 225. High flushing of colon, 110. Hippocampal convolution, 18. Hippus, 71. Hoffman symptoms, 357. Holtzapple. Dr., 343. Huntingdon's disease (see Herbditakt Chorea), 284. INDEX 395 Hydrencephalocele, 196-198. Hydrocephalic cry, 178. Hydrocephalus, 177. acquired forms, 180. acute symptoms, 177. chronic, 179. external, 177. internal, 177. pathology, 176. prognosis, 178. symptoms, 179. treatment, 179. Hydromyelia, 212. symptoms, 213. Hydrophobia (see Rabies), 346-347. Hydrorhachis interna, 223. Hydrotherapeutics in nervous dis- eases, 81. Hygiene, 78. Hypersemia, 49. Hypersesthesia, 53, 65. Hyperageusia, 73. Hyperosmia, 72, 125. Hyperostosis cranii (cephalomegaly), 322-323. diagnosis, 323. pathology, 324. symptoms, 323-324. Hypertrophic pulmonary arthropathy, 334. pathology, 334. treatment, 334. Hypnotics, 43. Hypnotism, 104, 105. in tabes, 229. Hyposesthesia, 53, 65. Hysteria, 302. aetiology, 302. definition, 302. diagnosis, 304. Gowers' differential table, 302-303. grand attacks in, 304. hypnotics in, 305. passionate attitudes in, 304. prognosis, 305. psycho-sensory, 302. segmental anaesthesia, 303. catalepsy, 304. motor symptoms, 304. paroxysmal stage, 304. stigmata, 303. divisions and symptoms, 308. pathology, 312. rigidity of back, 309. tender spots, 309. traumatic or railway spine, 308. treatment, 312. symptoms, 302. treatment, 305. Hysterical or hystogenic zones, 303. Ideation, 45, 193. Idiopathic muscular atrophy, 252. juvenile, 254. neurotic, 254. pathology, 254. treatment, 255. Illusion, 45. Incisures Lantermann, 4. Inductive centres, 30. Inflammation, 24, 50. Inhibition, 24. Insomnia and causes, 115. pathology, 116. treatment, 116. Interfascicular arcades, 46. Interpeduncular space, 119. Irritability of nerves, 29. Irritable spine, 221. Irritative lesions, 184. Isolation in nervous diseases, 106. Jacksonian cerebral epilepsy, 40. Jacobson's nerve, 132. Jaw-jerk, 59. Jumper's disease, 287. Jumping disease, 288. diagnosis, 288. pathology, 288. prognosis, 288. saltatory spasm, 288. treatment, 288. Kakke, 142. Kernig's sign, 173. Krause, 47. Labile current, 99. Landry's paralysis, 218. diagnosis, 219. pathology, 219. prognosis, 219. treatment, 219. Lateral column, 11. fillet, 18. Lantermann's incisure, 5. Lead, mercury, and arsenic poisoning, 357-358. Lecithin, 33. Leptomeningitis, 171, 212, 215. cerebral, 177. prognosis, 177. symptoms, 177. treatment, 177. symptoms, 215. Lesions, destructive, 184. in diseases of cauda equina, 242. irritative, 184. of lower end of cord, 241. 396 TEEATLSE O^ XEKVOUS DISEASES Lesions of peripheral nerves, 242. Lethargy in hypnotism, 105. Lissauer's tract, 15. Localization, ascending frontal, 184. parietal, 185. central convolutions, 185. cerebral, 183. corpus callosum, 186. cuneus, 185. frontal convolutions, 185. internal capsule, 187. occipital, 183. precentral lobe, 185. superior parietal lobe, 183. temporal lobe, 183. visual, 191. Lockjaw, 347. aetiology, 347. symptomatology, 347. treatment, 347. Luetic infection, 78. Lumbago, 162. Lymphatic temperament. 63. Malformations, 49. of brain, 196. of spinal cord, 221. Marie, types of family ataxia, 238. Martinotti, cells of, 21. Massage, 85. contraindications, 89. Mattson's thermometer, 77. Mechanical stimuli, 29. Medication, 109. Medulla oblongata, 15, 188. reflex action, 34. Megrim, 121. Meningitis serosa, 182. chronic, 174. diagnosis, 174. prognosis, 174. symptoms, 174. treatment, 174. internal, 212. hypertrophic, 213. treatment, 183. ileningocele, acquired, 198. congenital, 198. of cord, 224. pathology, 198. prognosis, 224. symptoms, 224. treatment, 198, 224, Metatarsalgia, 166. Micrencephaly, 196. Microcephaly, 196. Migraine. 121, 122. Milliampgre, 92. Mind blindness, 191. Mitchell, J. K., Jr. 88. Mitchell, J. K., St., 384. S. Weir, 58, 86, 279. Mixed diet, 78. nerves, 29. Monoplegia, 15, 28, 66. Morton's disease, 166. fluid, 224. Motor centres, 15. decussation, 15. nerves, 7. tract, 19. Multiple neuritis, 267. aetiology, 267. (beri-beri), 141. diagnosis, 268. prognosis, 268. symptoms, 267. treatment, 269. Multipolar cells, 2. Muscle centres, 31. Muscle sense, 56. Muscular dystrophics, 2.50. movements, 89. sensibility, 68. Myelitis (see Ixflamsiatiox of Sprs-tT. CoRD), 262. causes, 263. diagnosis, 264. pathology, 263. prognosis, 264. symptomatology. 263. treatment, 264. Myelin sheath, 9. Myelocele syringo, 223. Myotoni congenita, 94. Myxoedema, 61. Narcotics, 78. Nerve, abducens, 128. causes of, 128-129. paralysis of, 128. afferent, 231. anterior crural, 164-165. prognosis, 165. symptoms of diseases of, 165. treatment, 165. arrangement of fibre, 5. ascending frontal, 185. auditory, 131. disease of, 131. localization of, 191. cells, 1. centres, 1, 5. eervico-occipital, 153. cause of, 153. neuralgia of, 153. prognosis, 153. treatment, 153. INDEX 39? Xerve, circumflex, 153. disease of, 153. distribution of," 153. origin of, 153. paralysis of, 153. prognosis, 154. cranial, disease of, 125. external cutaneous anterior crural, 164. plantar, 166. popliteal, 160. facial, 129. degeneration of, 129. fibre, 1-4. functions of, 28. glossopharyngeal, 132. disease of, 132. interosseous, 132. great sciatic, 165. sensory symptoms, 166. symptoms of disease of, 165. hypoglossal, nerve, 1.33. cause of, 1.34. centres of, 133. disease of, 134. symptoms, 1.34. treatment, 134. intercostal, neuralgia of, 118. prognosis of, 118. internal plantar, 166. popliteal. 166. median, 157. musculo-spiral, 154. disease of, 154. distribution of, 154. prognosis, 154. Nerves of lower extremities, 16.3. trunk, 163. obturator, 165. patheticus, 128. peripheral, 1.35. disease of, 135. recurrent, 132. peroneal, 166. pneumogastric, 133. recurrent, 133. spinal accessory, 133. disease of, 133. superior gluteal, 165. centre, 128. tissue, 47. trifacial, 128. trunks, 163. tumours, 148. false neuroma, 148. hyperplasia, 149. malignant, 148. true neuroma, 148. ulnar, 156. vaso-oonstrictor, 27. Nervous diseases, cause of, 77. endarderitis obliterans, 278. gummata, 273. gummatous meningitis, 273. syphilis, diseases of blood-vessels, 272. temperament, 64. Neuralgia, 117. anterior crural, 119. cervico-occipital, 1.53. facial, 153. of heart (and pseudo angina, see Hysteeiaj, 302. parasthetic, 163. sciatic, 118. visual, 129. Neurasthenia, 298. causes of, 29-5-296. definition, 295. diagnosis, 298. pathology, 298. primary, 298. prognosis, 298. relation of genital organs to, 296. secondary, 298. symptoms, 296. sensory, 297. vaso-motor, 297. Neuraxon, 2. Neuritis, arsenical. 141. aetiology, 139. atrophy in. 137, 147. chronic, 137. deformity in, 144. diagnosis, 141. diphtheria, 140. interstitial, 136. lead, 140. leprous, 143. local, 136. multiple, 136, 138, 139. obturator, 141. oculomotor, 127. palsy, 127. olfactory, 125. parenchymatous, 138. pneumogastric, 133. prognosis, 138. reaction of degeneration in, 136. reflexes in, 138. special, 139. subacute, 137. symptoms, 137. Neurilemma, 2. Neuro-bilious temperament, 64. Neuroglia, 46. Neuron, 2, 74. Nodal change in muscle, 94. Nodes, Ranvier, 4. I Nuclei of Burdach and Goll, 18. 398 TKEATISE OX NERVOUS DISEASES Nucleus ruber, 2, 18. emboliforiuis, 20. fastigii, 20. glabosus, 20. Nystagmus, 37, 69. Object blindness, 191. Occipital lobe, 183. Occupation neurosis, .313. causes, 313. definition, 313. muscular cases, 313. prognosis, 314-315. treatment, 315. vascular cases, 313-314. Ocular disturbances, 69. Q'Mema, 49. Ohm, 49. Ohm's law, 92. Olivary body, 14. Ophthalmoplegia externa, 127. interna, 127. Opium poisoning, symptoms of acut< 358. prognosis of acute, 3.58. symptoms of chronic, 358. treatment of acute, .3.58. Optic atrophy in tal)es, 228. thalamus, 18, 21, 186. Pachymeningitis spinal, 212. cerebral acute, 172. cerebral internal hsemorrbagica. 175. externa, 171, 212. hypertrophic, 215. interna, 212. prognosis. 173. symptoms. 212. treatment, 173. Paget's disease, 3.33. Pantomime, 190. I'aracentral lobule, 185. I'aradoxical contraction, 59. Parfesthesia, 53, 65. Parresthetic melalgia, 163. Parageusia, 73. Paragraphia, 19.3. Paralexia, 193. Paralysis agitans (see Shakinu Palsy), 267. cause. 269. prognosis, 271. symptoms, 270. treatment, 271. Paralytic stage in tabes, 229. Paramemia, 191, 193. Paraphasia, 194. ' Paraplegia, 66. Paresis, alcoholic, 362, 370. alcoholic p^t comprehensive works written on the subject of mental diseases that is available to the general practitioner."— //i/^r-.S/a/f Medical Journal, St. Louis, Mo. " This is a valuable book to the student of psychiatry, and will entertain and instruct the neurologist and the general practitioner. It will also enlighten our legal brethren, who so often aim to make it appear that insanity is not disease, and that experts on mental alienation know little more than themselves of the subject." — Alienist and Xeurologist, New York City. "The medical profession is to be congratulated that a comprehensive, practical work on mental diseases in English has at last in this book been presented to them. To the general practitioner, who is usually the first to see and treat the patient suffering from mental disorder, as well as to the alienist, this work will prove very s^wUcAt."— Journal 0/ Nervous and Mental Diseases. " A worthy product of the scholarly atmosphere of the Johns Hopkins University is this latest volume in the field of psychiatrj' by Professor Berkley, dedicated to Prof. Henry M. Hurd, so well known in Michigan. It goes further and does more than any text -book which we Lave to clearly set forth the pathological basis of the insanities and its immense import- ance." — Medical Age, Detroit, Mich. " The practical character of this work is ampl^' evidenced in the selection of illustrations which, though few, are of the best. The subject-matter is arranged in logical sequence, and each chapter is in itself a comprehensive treatise. Full scof>e is given in the discussion of the elemental brain and nerve structure before the types of disease are considered. While each chapter deserves especial notice, the more notable are those on the Psj'choses of Old Age, the Psychoses of Childhood, the Insanities of the Puerperal Period, Neurasthenia, and those dealing with the pathology of mental diseases. The publishers have spared nothing in the making of the book." — New Orleans Medical and Surgical Journal. D. APPLETON AND COMPANY, NEW YORK PRACTICAL DIETETICS, WITH SPECIAL REFEREXCE TO DIET IS DISEASE. By AV. GILMAX THOMPSOX, M.D., Professor of Medicine in the Cornell Medical College of the City of New York; Visiting Physician to the I'resbyleriun and Belkvue Hospitals, New York. LARGE OCTAVO, EIGHT HUNDRED AND FOURTEEN PAGES, ILLUSTRATED. Cloth, $5.00. SECOND REVISED EDITION. SOLD ONLY BY SUBSCRIPTION. " This is at once the best and most exhaustive book upon this sub- ject with which we are familiar. The best, because, in the first place, it is written by a teacher of thora])eutics who knows the needs of the practicing physician, and yet who has taught in previous years as a professor of physiology all that one needs to know in regard to the principles of digestion and assimilation. For tliis reason the author is unusually well qualified to prepare a useful manual, but it is not until one has perused the vohime that he thoroughly grasps the scope and depth of the manner in which Dr. Thompson has treated his subject." — Therapeutic Gazette. '' The subject of the dietetic treatment of disease is not an attractive one. This fact explains, no doubt, the comparatively little attention given it in college curriculum and daily study. When one proceeds to examine the valuable contributions to this subject, the scientific inves- tigations which have been made by the United States Department of Agriculture at various experiment stations in all parts of the countr5\ he is convinced that it is high time to look into the matter pretty thor- oughly. This book is of value for its summary of the latter and its application of the knowledge to the treatment of the disease." — Brooklyn Medical Journal. "Diet in disease is most expansively considered, and complete and reliable dietaries for every ailment are suggested. The dietetic errors responsible for a large number of diseases are also fully discussed. Altogether, it is perhaps the best work extant upon the subject of dietetics." — Hahnemannian Monthly. "A good book and a practical one." — Canadian Practitioner and Review. "In the seven years which have elapsed since the first appearance of this standard text-book there have not been the many and important changes in dietetics that other departments of our therapeutics have xmdergone. Xevertheless, Dr. Thompson has revised much that was published in the first edition, and has introduced into this one the re- sults of more recent studies iu the economic values of various dietaries. The general arrangement of the work is unchanged." — S'eio York Medical Journcd. D. APPLETOX AXD C03IPAXY, XEW YORK. THE SURGICAL DISEASES OF THE GENITO-URINARY ORGANS. By E. L. KEYES, A. M., M. D., LL D., Consulting Surgeon to the Bellevue and the Skin and Cancer Hospitals ; Surgeon to St. Elizabeth Hospital ; formerly Professor of Genito-Urinary Surgery, Syphilology, and Dermatology at the Bellevue Hospital Medical College, etc. ; and E. L. KEYES, Jr., A. B., M. D., Ph.D., Lecturer on Genito-Urinary Surgery, New York Polyclinic Medical School and Hospital ; Assistant Visiting Surgeon to St. Vincent s Hospital ; Physician to the Venereal Clinic, Out-Patient Department of the House of Relief of the New York Hospital, etc. Cloth, $5.00: halt" leather, $s.5o. Sohi only by Subscription. WITH ONE HUNDRED AND SEVENTY-FOUR ILLUSTRATIONS IN THE TEXT AND ELEVEN PLATES, EIGHT OF WHICH ARE IN COLORS. "it is certainly lefiesiiing that a man of the experience and ability of the author of tliis volume has culled from this mass of literature the essentials, and given us in a well-planned volume the gi>t of the entire subject. " The book is systematically arranged, and each subject is taken up and dealt with in a way tliat makes it easily accessible to the busy practitioner. The style is explicit and never verbose, wiiich, with the fine vein of humor running through it, makes it very enjoyable reading."' — Nortlrui'sleni Lancet. "Gonorrhea is gone into more extensively than in any other work." — Denver Medical Times. " As a text-book on Genito-Urinary Surgery it stands at the head of the publica- tions on the subject in the Lnglish language. Our readers wishing an up-to-date work on the subject can not do better than to buy this latest and newest work." — Medical Century. "The book is well illustrated, well printed, well arranged, and will be more popular tlian its predecessors." — Chicago Medical Recorder. "The chapters on the affections of the posterior urethra, prostate and seminal vesicles are especially good, and many 'pointers' are found in the chapter on the 'Treatment of Urethral Inflammation and their Immediate Complications.' " — Canada Medical Record. "This is a good book on an important subject. Within the compass of 800 pages it gives a comprehensive treatment of the various diseases of this special branch of surgery, and, while not discarding the good of the older work, it embraces all that is new in this field."— yoitr/u?/ of Medicine and Science. " This is so well written as to be exhaustive in character, and needs little or no comment from the reviewer further than to mention its completeness in every par- ticular." — Cincinnati Lancet-Clinic. D . A P P L E T O N AND COMPANY, N E ^\' Y O R K . INTRODUCTION TO THE STUDY OF MEDICINE By G. H. ROGER PROFESSOR EXTRAORDINARY IN THE FACULTY OF MEDICINE OF PARIS MEMBER OF THE BIOLOGICAL SOCIETY PHYSICIAN TO THE HOSPITAL OF PORTE-d' AUBERVILLIERS AUTHORIZED TRANSLATIONS BY M. S. GABRIEL, M. D. WITH ADDITIONS BY THE AUTHOR 8vo. Cloth, $5.00 " Such a work, well conned, provides bepfinners in medicine with a sure and wide founda- tion of systematic science on which to base all their future acquirements. Dr. Roger's unique volume is to be heartily commended, not only to would-be physicians but also to that large class of post-graduates who do not cease to be students because they have left college, and would like to know the reasons and relations of things." — Medical 7 imes, Denver, Col. "The work throughout shows an essentially logical method of treatment, and covers a very wide subject in a manner which amply demonstrates the author's extensive acquaintance with medical thought and medical literature. The book can be recommended not only to students, but also to practitioners in medicine, as giving a wide and philosophical view of medicine and iis tendencies at the present day." — Albany Medical Annals, Albany, A^. Y. " As a resiimS of recent medical advancement we may expect this volume to occupy a unique place. It is something of a novelty to turn the pages of a medical work which will be most valuable to the profession as a whole, not to the specialist or individual student alone. It is, however, well suited to use as a text-book, and will put students in touch with rapdicine as an all-embracing science. But to those of the profess'on— and there are many — who lack opportunity to thoroughly acqiaint themselves with tlie rapid strides which are being made in knowled_:e of the causation of disease, lesions and reactions of the organism which are dis- cussed under pathol igical anatomy and semeiologj', the work will serve as a substitute for lectures and laboratory experience. Some of the principal chapters deal with the mechanical, physical, chemical, and animate agencifis of disease, the general etiology and pathogenesis of the infectious diseases, nervous reactions, disturbances of nutrition, heredity, inflammation, septicemia and pyemia, tumors, Cf-Uular degenerations, examination of the sick, clinical appli- cation of scientific y)rocedures, diagnosis and prognosis, therapeutics, etc. An immense amount of work is evidenced by the text, and much careful and scholarly research. A book of this kind is needed, and will be particularly appreciated by those who, without undervaluing the importance of laboratory investigations, still think clinical methods and the simpler means of reaching a diagnosis and prognosis should not be forgotten or slighted." — New England Medical Gazette, Boston, Mass. D. APPLETON AND COMPANY, NEW YORK THE DISEASES OF INFANCY AND CHILDHOOD. By L. EMMET HOLT, A. M., M. D., Professor of Diseases of Children in tiie College of Physicians and Surgeons (Columbia University) ; Consulting F^hysician to the New York infant Asylum, and to the Hospital for Ruptured and Crippled. SECOND EDITION, REVISED AND ENLARGED. WITH TWO HUNDRED AND TWENTY-FIVE ILLUSTRATIONS, INCLUDING NINE COLORED PLATES. Cloth, $6.00 ; half leather, §b.=;o. Sold only by Subscription. "Throughout the work the evidence of careful revision is everywhere apparent, and the volume represents essentially the best exposition of the latter-day pediatric teaching." — Cleveland Medical Journal. " This second edition is even better than the first, and more than retains the high position taken by its predecessor. No one interested in the diseases of childhood can afford to be witliout it." — Boston Medical and Surgical Journal. "No radical departure from the previous edition has been instituted in this the second edition. Tlie material has, however, undergone a thorough revision, with the addition of new and thoroughly tried methods of diagnosis and treatment which have been accepted since the appearance of the previous edition. The most noteworthy change has been in the cliapter on Milk and Infant feeding. This section has been completely rewritten, with tlie addition of much new and valuable material in accord with the great advance made in this important branch of pediatrics. Old illustrations have been replaced by newer and better ones New charts and diagrams, with twenty- one additional illustrations, enhance the value of an already accepted standard work." — Yale Medical Journal. " Holt is recognized as one of the foremost authorities on pediatrics of America, and therefore of the world. He has made a very extensive first-hand study of the care ot children and their diseases, and so writes from a mind replete with the clinical pictures of suffering childhood. The work is complete t'rom every practical standpoint, and the text embraces 1161 octavo pages. The student or practitioner who has Holt at hand need hardly ever be at a loss for a reliable line of treatment in his pediatric practise."— "Denver Medical Times. " The changes within the past five years have not been very extensive, yet the many new facts that have come out in the rapidly advancing science of pediatrics have here all received their sliare of careful and judiciaf treatment. " The extremely practical question of infant feedins:, as is well known, has been a subject of special study by the author, and one in which medical advances have been made very largely identified with his name. It is a pleasure to find the subject han- dled in a text-book in a comprehensive and yet common-sense manner." — Neu- York Medical News. D . A P P L E T O N AND COMPANY, X E W' YORK. COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrajigement with ' the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C28 (449)M50 RC341 P31 1904 Pearce A tract disease ical treatise on nervous p. 1