Columbia ®ntberfittp tnttjeCitpof J^etogorfc COLLEGE OF PHYSICIANS ANO SURGEONS / Reference Library (iiven by C\ /^ Q?C#£. /^k, £Z~^£r>*&. ^WV", THE Neurological Practice of Medicine; A Cursory Course of Selected Lectures IN Neurology, Neuriatry, Psychology and Psychiatry; Applicable to General and Special Practice. WITH 177 ILLUSTRATIONS. AFTER THE AUTHOR'S CLASS-ROOM METHODS AS A TEACHER OF STUDENTS. DESIGNED FOR STUDENTS AND GENERAL PRACTITIONERS OF MEDICINE AND SURGERY. By CHARLES H. HUGHES, M. D., President of the Faculty and Professor of Neurology, Psychiatry and Elec- trotherapy, Barnes Medical College. Former Major and Surgeon-in- Chief of Schofield, Winter, Hickory Street, and McDowell's College Military Hospitals, Superintendent Missouri State Insane Hospital, Acting and Honorary Member of Many Home and Foreign Medical and Scientific Societies, Etc., Etc. Member Governing Board of Centenary Hospital, Ex- Member Board of Health and Consultant of City Hospital, Insane Hospital, Etc. 1903 Digitized by the Internet Archive in 20TO\^ funding from Open Knowledge Commons http://www.archive.org/details/neurologicalpracOOhugh .-I TABLE OK CONTENTS. TITLE PAGE - _____ 1 COPYRIGHT 2 DEDICATION _____ 3 INTRODUCTORY _ _ - - 4-9 EDITOR'S PREFACE - - - - 10-11 CHAPTER i ------ - 12-22 Preliminary Essential Definitions, Etc. Neuroanatomy, Neu- rology, Neuriatry, Psychology, Psychiatry, Neurophysiology, Neuropathology, Neurotherapy, Psychotherapy, Psychopath- ology, Alienist, Psychiater, Neuriater, the Neurone, Nerve Center, Etc., Etc. Chapter ii _______ 23-35 The Neurone and the Nerve Cells; Their Composition and Characteristics. CHAPTER in ------ - 36-42 The Neurone and the Nerve Centers, Continued; the Neu- rone Conception or Theory, Association Neurones, Projection Fibers, Etc. CHAPTER IV- - - - - - - 43-47 The Neurone Continued; Its Efferent Prolongation or Prolifera- tion. The Axone, Neuraxone, Neurite or Axis Cylinder Pro- cess; the Nerve Cell and Its Belongings. Histological Compo- sition of Nerve Centers. The Neurone and Its Dendrites or Afferent Cell Processes. The Neuroglia. CHAPTER V - - - - - -'- 48-56 Outline Forms and Functions of Neurones. Polar and Apolar, [i] Pace Bipolar and Multipolar Neurones. Neurone and Nerve Cell; Synonymous in a Broad Sense. Disease Changes in the Neurones. CHAPTER VI ------ - 57-69 The Neurones Grouped into Layers or Strata of the Brain Cor- tex ; Further Consideration ol the Neurones and of the Asso- ciated Fiber System of the Brain and of the Projection System of the Brain and Spinal Cord. Functions ot Neuroglia and Mesoglia. CHAPTER VII - - - - - - 70-82 Head Heat in Brain Disease, Cerebral Thermometry, and Ceph- alic Galvanization. Their Value in Diagnosis and Practice. CHAPTER VIII - - - - - - 83-89 The Temperature Sense, Etc., and Its Alterations in Diagnosis. CHAPTER IX ------ - 90-100 Extra-Neural or Adneural Nervous Disease. Systematic States Leading to, Proceeding from and Blending with Nervous Dis- ease; A\alaria, Erythrocytes, Thermasia, Thermesthesia; Their Effects on the Neurones, Etc. CHAPTER X ------ - 101-116 Extra-Neural or Adneural Nervous Disease. Chromatic and Achromatic Neurones, Chromatolysis, Thermal Changes in the Neurones. Brain Neurones as Heat Centers, Adneural Heat Changes of Neurones, Marinesco's and Lugaro's Law of Morbid Neurone Change, Reflex Phenomena and the Neurones. CHAPTER XI --..--- - 117-136 Instruments and Procedures of Precision in Diagnosis and Practice. CHAPTER XII - - - - - 138-147 Instruments of Precision (Continued). CHAPTER XIII - __,--- 148-156 Instruments of Precision (Concluded). The Sphygraograph, the Percuteur and Polygraph in Practice. CHAPTER XIV - - - - - - - 157-163 Ascending and Descending Degeneration. Reaction of Degen- eration; Waller's Law; Its Diagnostic Significance. Mi Page CHAPTER XV - ' 164-170 The Reaction of Degeneration and Its Use in Diagnosis. How to Discover It. Applicable Cases. CHAPTER XVI - - - - " " _ 171-177 How the Reaction of Degeneration is Diagnosticated. CHAPTER XVII ----"" 178-182 Another View of the Reaction of Degeneration. CHAPTER XVIII ----- ~ 183-195 The Evolution of the Neuraxis. Nature's Building of the Brain and Spinal Cord. CHAPTER XIX ------ 196-210 The Evolution of the Brain and Spinal Cord or Neuraxis (Con- tinued). CHAPTER XX - ' 211-225 History of the Evolution of the Brain. Some Further Facts Concerning the Brain. CHAPTER XXI - - - " " " ' 226-241 The Brain's Blood Supply. The Intercranial Circulation in Its Relation to Brain Disease. CHAPTER XXII - - " . " " 243-251 Electricity and Electrical Appliances. CHAPTER XXIII ------ 252-265 The Dura; Its Sinuses and Diseases: A Cursory Anatomical Demonstration. CHAPTER XXIV ------ 266-282 Cerebral Embolism, Thrombosis and Hemorrhage, and Some of Their Sequent Brain Diseases Cursorily Considered. CHAPTER XXV ------ 283-300 The Anatomy of the Spinal Cord, With Brief Reference to Its Morbid States. CHAPTER XXVI ------ 301-307 Nerve Centers (Continued). Psycho-Motor Centers— Visual Apparatus Centers— Other Motor Reflex Centers. CHAPTER XXVII - - - - . - 308-327 The Sensori-Motor System in Diagnosis. The Reflexes. CHAPTER XXVIII .--... 328-344 The Cerebro-Spinal Axis or Neuraxis and Its Nerve Centers. Ganglia. Plexuses, Neurones and Nerve Centers. Importance of the Pupil and other Nerve Centers in Diagnosis. The Basal and Other Ganglia. The Neuraxis and the Neurone. CHAPTER XXIX ----- 345-351 The Neuraxis Again, Diagnosticallv Viewed. A Cursory Dem- onstration of Cranial Nerves. The Columns of the Spinal Cord and the Nerves that go to and from It. The Cord Seg- ments of Impression and Influence. Outline of the Cerebral and Spinal Nerves and Nerve Centers and Their Relation to Nervous Disease. CHAPTER XXX ------- 352-369 Outline of the Cerebral and Spinal Nerves and Nerve Centers and Their Relation to Nervous Disease, Etc., (Continued). CHAPTER XXXI ------ 370-378 The Virile or Genesiac Reflex and Its Symptomatic Value in Practice. CHAPTER XXXII ------ 379-391 Aphasia Defined and Located. Aphasia Physically and Psy- chically Considered. Some of Its Most Essential Phases Dis- cussed. CHAPTER XXXIII ___-- 392-399 The Medico-Legal Aspects of Aphasia. The Case of Wm. T. Bevin. CHAPTER XXXIV ------ 400-406 Psychological Analysis of the Bevin Case Concluded. CHAPTER XXXV ------ 407-413 The Neural and Psycho-Neural Aspects of Surgical Practice. Lumbar Puncture as an Anaesthetic. Tuffier's Lumbar Puncture in Surgical Diagnosis and Prognosis. Lumbar Puncture and Neuro- or Cyto-Diagnosis. Idiotrophic Affinities and Reac- tions of Neurones. CHAPTER XXXVI _-.--- 414-417 The Nutrition and Conservation of the Neurones, or Neuro- and Psychotherapy in Surgery. The Psychiatric Factor in Surgery. Psychical Depression and Neuropathic Diathesis. Post-Operative Insanity. LECTURES ON NEUROLOGY AND NEU- RIATRY, PSYCHOLOGY AND PSYCHIATRY. AFTER THE METHODS OF THE CLASS-ROOM, TO THE AUTHOR'S STUDENTS, AND DESIGNED ALSO FOR GENERAL PRAC- TITIONERS OF MEDICINE AND SURGERY. By C. H. HUGHES. M. D,, Member American Medico-Psychological Association, Honorary Member of New York Medico-Legal Society, British Medico-Psychological Associa- tion, Foreign Member of Russian Society of Neurology and Psychiatry, Honorary Fellow of Chicago Academy of Medicine, Ex-Member of Judicial Council and of the Executive Board A. M. A., Ex-Supt. and Physician-in-Chief Mo. State Hospital for the Insane, Ex-Pres. Miss. Val. Med. Ass'n, American Med. Editors' Ass'n, and Ex-Pres. of Section on Neurology American Med. Ass'n and Pan-American Medt Congress, Ex- vice-Pres. Sections Physiology and Psychiatry, Med. Congress, 1876, Pres. of Faculty and Prof, of Neurology, Psychiatry and Electro - Therapy Barnes Medical College, etc., etc., St. Louis. EDITED BY PROF. MARC RAY HUGHES, M. D., BARNES MEDICAL COLLEGE, ST. LOUIS. Press of HUGHES & CO., 418 N. Third Street, St. Louis. COPYRIGHTED 1902 BY C. H. HUGHES. . DEDICATION. TO MY PAST AND PRESENT STUDENTS NOW LIVING IN THE SEVERAL STATES OF THIS AMERICAN UNION AND IN COUNTRIES ABROAD who have stood about me at the anatomical table or sat around or before me in the amphitheater of the three colleges in which 1 have lectured, the Barnes, the Marion-Sims and the St. Louis, now the Medical Department of Washington University, this book, containing the substance of a selected part of my lectures on the great themes of neurology and neuriatry, is fraternally and cordially dedicated. Like the diploma with which you went out from college or hope to take out as your shield in the battle of your professional life, these lectures represent the com- mencement of your medical career, in its neurological aspects and the neuriatric search light, your friend and servitor has endeavored to throw on your pathway. If by this light your way has been made easier to walk or shall be further illumined, the pleasure of knowing that your welfare will have been thus promoted, will prove ample reward for the author's pains in preparing these lectures in book form, in the midst of a busy professional life. : 'If he hath lent strength to the weak" ***** "Or let in a ray of sunshine" that has made any dark and crooked path in neurology or neu- riatry bright and straight to you, his labor has not been in vain. THE AUTHOR. [3]. INTRODUCTORY. This book aims to lift students along their arduous way, over the neurological obstacles in their path, especially those who have been under the author's instruction. It does not aim to go all the way or point out all the paths, but some of the best neurological roads for the general practitioner to follow. It is hoped, that of the many who have heard the author's lectures, the most of them will look over these pages with pleasure and profitable retrospective memory, as the author does, while others yet to hear or read his teachings, will find them instructive and labor-saving. Among master minds in medicine, neurology and the neurological aspects of disease, and neuriatry and psychia- try, and the management of the nervous system and mind in the conduct and cure of disease in general, are justly claiming more attention than in the past. Through anatomical, physiological, chemical, bacteriolog- ical, cytological and haematological discovery, the views of Cullen and his contemporaries are receiving, of late, more neuro-physiological amplification and illumination than in the days of the great nosologist and clinician of the closing eighteenth and beginning nineteenth centuries. We are approaching and standing upon surer and sounder clinical ground and, as we see with more scientific precision, we begin to discover, notwithstanding the great value of other departments of medico-scientific research, [4] the supreme importance of a knowledge of the nervous sys- tem in the practice of medicine. As I have before predicted,* Neurology is yet destined to reign paramount in clinical medical thought, notwith- standing the conceded just importance of every depart- ment of practical medicine. The successful treatment of disease consists in the proper management of the entire man. With certain local exceptions the problem is a neurohaemic question! and the tone and quality and conditions of the nervous system are evermore uppermost in the study and treatment of disease, whether we aspire to be an especially qualified neurologist or a practitioner over other areas of the human anatomy, but with an adequate knowledge of its important neural rela- tions. Those who have heard the author in his lectures touch on neurology in general, know that he believes that the field of neurology must widen in practice till it ceases to be a special department of medicine, save in its essential manipulations, as many other fields of medical work now regarded as specialties must eventually become. The practitioner of medicine will become the clinical neurologist in ordinary practice, while extremely expert neurologists will become consulting neurologists and neu- riatrists to the profession, advisers and coadjutors in the neural aspects of ordinary disease and masters in applied neurotherapy in such cases as the general practitioner can not have the instruments or manual dexterity or the time or the clinical experience to properly treat. The practice of medicine has become so great a field of human endeavor that it is impossible for any one man to ♦Dedication of Alienist and Neurologist, 1880. tAddress In Medicine Amer. Med. Ass'n, San Francisco, 1887. operate over its entire area. He may think it over, but to work all over it, is now impossible to human capability. \\\ haw reached the epoch of division and exchange of work. Whether or not you who read may coincide with me, this fact you, I believe, will always find to be a truth in practice; the nervous system understood up to date in its structure, functions and management, will prove a constant source of intellectual pleasure and profit in the understand- ing and treatment of all disease. To be a good neurologist, to express it in phrase Chesterfieldian, is to be the "high- est style" of physician. These chapters, as you who have heard my lectures will discern, a r e not complete, even as they were delivered. They omit some and include other matters touched upon in the amphitheater and embrace also some subjects more elaborately referred to in the class-room and clinic and some matters less extensively mentioned, as in the cerebro- neural demonstra tions. It is only as milepost helps and signboard guides to your neurological journey, that this matter is put in book form. You have become accustomed to my ways of pre- senting matters of moment to you in neurology. It will help you some, like the repetitions of phonography, to have this book with you when you wish to review your studies and refresh your minds now jaded with the multifarious demands of college work, after more leisure shall have come to you in the vacation interim of the college curriculum or while in practice. Besides this, the book, I hope, will keep us closer together in that cordial, friendly relationship which is now and has ever been so pleasant to us as teacher and learner. And 1 have myself been a learner, for he who constantly teaches an intelligent body of young gentlemen, continually learns more and more as he teaches. There is an inspiration to further study and research in an earnest knowledge seeking audience of young industrious students energetically determined, as you are or have been, to acquire the highest of all knowledge, neurology, embrac- ing as it does, psychology and psychiatry, in the study and understanding of man. Knowing that you are to benefit or harm the world by what you acquire or fail to acquire from my teaching, 1 have felt the grave responsibility. Many a time after a lecture or demonstration, realizing that I did not come up to my ideal of how the knowledge you needed and how much of it should have been imparted, I have gone to the fountain sources in the late hours of midnight or early hours of morning for more light, in order that you might not be deprived of the neces- sities of your future professional success, in ministering to the welfare of those who are to trust you with their health and their lives. So, though you may not have thought it at the time, you have spurred me on. I have studied with you. We have together, though separated, burnt the midnight oil or early morning lamp, seeking for more light, as Ajax prayed, to win the conquest of Neurological Truth in which you and 1 alike have been interested for the good of our fellow man. 1 have delved in higher ledges of the mine of neurologic truth than you, but my chief inspiration has been to cast the product of my delving into your level in good "pay dirt" from which you might "pan out" the precious metal of neurological fact to be worked by you into instrumentalities of neuriatric relief for man and woman in your respective spheres of influence in the world. 1 have reached up to the ledges where Obersteiner, Obermier, Wundt, Fritz, Hitzig, Heubner, Hugenin, Oppenheim and his master Carl Westphal, Edinger, Hirst, Nothnagel, Mendel, Mickel, Meynert, Morison, Ross, 8 Fournier, Bastian, Ireland, Drummond, Clouston, that English Coryphaeus Gowers, the brilliant Charcot, Fere, and others of his pupils, and the talented Vangehuchten, have worked and I have handed samples of their work down to you. 1 have done the same with the researches of our own geniuses in Neurology, Spitzka, Hamilton, Webber, Shat- tuck, Church, Chaddock, Pearce, Petersen, Putnam, Dana, Fisher, Kiernan, Mills, Sachs, Moyer, Wier Mitchell, Cle- venger, Dercum, Knapp, Lloyd, Mann, Starr, Shaw, Wood, the plates and sections of Fuller, Flower, and the indispensable Quain's Anatomy, Jacobs' beautiful pictures of anatomical art and the contributions of the lamented Seguin, Amidon, Gray and Hammond and the promising but prematurely cut off Shaw, Mink and Hazard of St. Louis. I have sometimes found a jewel in the work of Trouseau and of Watson, those medical Adisonian thought painters, who wrought medical observation into captivating and true speech center work, before ever 1 was brought forth or dreamed of instructing a class of hungry ante partem Doctors in the entrancing mysteries of neurol- ogy. 1 have traveled far and long into the fields of our science and picked a jewel here and there, burnished, or in the rough, and some of them, by no means all, 1 have given to you as generously as they have been freely given to me, hopeful of their helping you as they have aided me. These lectures aim to be up to date so far as they go. In some respects they are a little advanced, especially as regards the reflexes, over current text- books. They make no pretensions to completeness. Their aim is clearer elucidation of already traveled roads in practical neurology. No single volume could compass the entire field of neurology, even exclusive of neuriatry and psychiatry. No author should attempt it or could compass the whole 9 field for the general practitioner or even for college students, in one volume. There are no entirely original lectures in any depart- ment of medicine in these days of community of interest and free research in our noble profession, and it is noble because it is a fraternity of mutual endeavorers for the welfare of the world. Each takes what his fellow produces and adds what he can in turn to the common store for the next one to use for further discovery and more extended utility. Methods of presentation must therefore naturally be more original than the materials of any modern book on Neurology, not excepting the one I now offer you. I give thanks to my worthy sons, Doctor Mark Ray Hughes, now adjunct to my chair, and to Henry L. Hughes, for valuable aid in editing and in revising proofs, etc. C. H. HUGHES. 3860 West Pine Boulevard, St. Louis. EDITOR'S PREFACE. This book, as the advanced reader will see, is intended to cover some ground not quite so minutely covered in my father's, Professor Charles H. Hughes' regular lectures, and other ground more briefly than when delivered before the class. The aim has been, as 1 have it from the author, to be helpful, suggestive, plain, clear, practicable, retrospective and not too technically scientific for the undergraduate nor yet uninteresting for the post-graduate. The author's de- sign has been to present a familiar series of talks like a book that has once been gone over and thumbed and marked by his classes, ' making things already known to them a little better known and more clearly recalling matters perhaps but partly remembered in the course. Where repetitions occur, they have not been entirely unintentional, but have been permitted to remain in order that the impression of the facts may be fixed in the minds of the students. Hence the familiar style of the lecture room appears in the chapters and some sentences perhaps not severely appropriate to an exclusively scientific book. The author pleads consideration of his busy professional life in extenuation of the many faults of this hastily pre- pared volume, especially of facts of omission and undue prolixity of diction, as dictated to the editor. He also hopes his good purpose of serving the needs of the medical student in neurology will contribute to secure generously charitable judgment on the book's defects. The editor's part of this work has consisted mainly in [10] 11 shaping, it for publication. All of the chapters have been transcribed essentially as dictated except the chapter on the Psychological Consideration of the Penitentes, of which the editor is the sole author. For this he invokes the generous indulgence of the critical reader. MARC RAY HUGHES, M. D., Adjunct Professor of Neurology, Psychiatry and Electro-Therapy, Barnes Medical College. 3857 Olive Street, St. Louis. CHAPTER I. PRELIMINARY ESSENTIAL DEFINITIONS, ETC. NEUROANATOMY, NEUROL- OGY, NEURIATRY, PSYCHOLOGY, PSYCHIATRY, NEUROPHYSIOLOGY, NEUROPATHOLOGY, NEUROTHERAPY, PSYCHOTHERAPY, PSYCHOPATHOLOGY, ALIENIST, PSYCHIATER, NEURIATER, THE NEURONE, NERVE CENTER, ETC., ETC. You cannot advance satisfactorily in the study of neurology, which comprehensively embraces neuroanatomy, neurophysiology, neuropathology, neurochemistry, neuro- diagnosis, psychology, psychiatry, etc., without clearly comprehending at least the terms named in this chapter which we will define before proceeding further. Neuro- anatomy is nerve anatomy, as its derivation implies, v€vpov t a nerve and TSfivav, to cut. avarofx-rj, dissection, dra-re/Aveiv, of or pertaining to the dissection of the nerve tissue. For example, veupov } nerve and 7ru#os, disease, suffering, neuropathology, the pathology of the nerves, relating to nervous system or nerve centers, etc. Neurop- athy, disease of the whole or any part of the nervous centers; a condition of general or local nervous disease. A good example of a general nervous disease or disease of the general nervous system is, neurasthenia, a condition of general nervous debility dependent on general functional neuratrophia or deficient nerve center nutri- tion, with often an inherent constitutional predisposition to become nervously weak, and with, consequently, functional [12] 13 weakness and instability or unsteadiness of the nervous system; a general functional disease of the nervous system. (vevpov, a nerve, «, privative or minus — and flews, strength.) Another general nervous functional disease is hysteria, which is a very nervous condition, formerly attributed to the influence of the womb, though men may have it. The influence of the womb's dis- eases, the weakening effects of its functions when acting morbidly and of exhausting nursing, woman's indoor rou- tine, sedentary and monotonous life, etc., the recurring catamenia and its stoppage at the change of life, or climac- teric as it is called, though the life is not changed except to go on to another stage in its evolution till the decadence of. age appears, contribute to bring about states of nerve strain and exhaustion which give the preponderance of hysteria, neurasthenia and climacteric nervous states to the female sex in mankind. Great brain and nerve-strain at the climacteric and senile epochs and from brain overwork or worry tend to cause nervous break-down and grave nervous diseases. Consult the derivations in your medical and unabridged general dictionaries and familiarize yourselves with the deriv- ative terms wherever you can find them, since one term well understood in its derivation or derivations will often give you signal aid in the understanding of many other medical definitions, especially compound words, and thus lighten the labor of study and give a philological zest to it. Thus you have already discovered that the radical word neuron, per- tains to nerve, nerve cell or center, and it is embraced in nearly all the words we have thus far mentioned, and plays a great part in medical nomenclature. Other specially important derivations with which you should become familiar are pathos (^mAos), disease, thenos 14 (flevos), strength, and aesthesias, (-\- KVT05) with the exception that it is not a network of nerves in the older sense, sending out prolongations that blend and intertwine with contiguous nerves, but a nerve mesh, or neuropilem {vtvpomXep.) distinct and disconnected 17 but capable of communicating its influence by contact, as one student in the class may impress another by close or remote contact without grabbing him by the throat or in- tertwining his fingers in his hair; or as bricks standing in a row. Start one and they fall one after another. While the old nerve net of Gerlach is yet described in some of the books you have but lately studied, and the nerve mesh has taken its place, the ganglion cell, with its axis cylinder pro- cess, will still interest you as a fact in neurology, only differently and a little better understood as a nerve unit. The neurone has dendrites; cellulipetal or centripetal, the equivalent of afferent prolongations, and cellulifugal or centrifugal or efferent processes or neuraxons, conducting in- fluences away from the cell body. With reference to the center of the neurone, therefore, the dendrite corresponds in function to the afferent nerve {ad and ferre, to carry to) of the spinal cord, while the axone or neuraxone corresponds to the efferent {ex and ferre, to carry from or eo, 1 go forth). The dendrites receive, and the axones carry, impression to and impulses from, the center, i. e., to and from the neurone or nerve center cell. There are some exceptions to this law, as in those dendrites from which an axone occasionally takes its origin. An example may be found in the retina, but you need not concern yourselves about this just now; you will not be asked about these exceptions as they may be found in the amac- rine cells of the retina, etc. The rule is general, but not universal. Barker would leave the question open, but some questions about which savants may wrangle must be closed to teachers and tyros as we approach the close of this lec- ture. Here again you may for next summer's diversion, after this course is over, take with you the books of the neuro- physiological masters when you go fishing, or retire to the 18 shade of the trees to read and study out this intricate sub- ject between nibbles and bites on your hook, for one of the great masters to whom I have already referred has said that "at present we are well acquainted with the evidence of the passage of impulses in neurones in one direction only, does not exclude the possibility that we may at some later time become cognizant of the facts which may demonstrate the conduction of impulses of some sort in the opposite direction, especially as physiological experiment has shown that impulses artificially exerted in nerve fibers travel in both directions from the point of stimulation." (Barker, p. 274, ed. 1899). Here then, is a chance for you to become famous while you fish, by working out the unsolved problems of nerve conduction, vicarious, alternate or sub- stitutive nerve function, etc. The vagus nerve appears to have both afferent and efferent function. You may yet be able to demonstrate that the first or incoming, and the second or outgoing, impressions go over the same nerve strands. If you do your fame will be made. Neuraxon or neurite means the axis cylinder pro- cess of a neurone, the principal projecting part of the neurone. Schafer also called it a neurone. He gave the name dendron or dendrite (SevSpoi', a tree) to the shorter protoplasmic branchings or prolongations or processes of the neurons. He called the dendron, a dendrite. Neuraxons vary in length from a millimeter or less to many centimeters. The largest neuraxons are in the pyramidal tract, measuring nearly a hundred centimeters. If you have time between the lectures or during your vacation you may consult with signal profit the first chapter of Mills* on the subject and more recent American authors. You will see in the very beginning of his book, on the first page, a cut taken from *The Nervous System and its Diseases by Chas. K. Mills, Lippincott & Co., Philadel- phia and London. 19 Quain's Anatomy and to be found in some other anatomies and neurological treatises to which I shall often refer and which I shall several times draw on the blackboard during this course of lectures, as I do now, with various modifications. I am ac- customed from previous and consequent automatic habit to refer to the cerebro-spinal or encephalo-spinal axis, but I do not so often use the newer and shorter term neuraxis. The term neuraxis does not locate itself with the defined expressiveness (though it is shorter) of cerebro or encephalo-spinal axis, but is quite as expressive when you understand it. Both terms, however, mean the great brain and spinal center of the great neural organism of the body, an organism as omni- present in the animal mechanism as the almost everywhere to be found blood vessels. The neuraxis is the axis for the entire nervous system. Axis is the Latin for axle as you know and means a thing about which something else revolves. It means here central or pivotal, as you have, all of you, learned in studying physics and anatomy. In your anat- omy of the skeleton you will remember the second cervical vertebra above which and around whose odontoid process, the atlas, which holds up the cranium as the fabled Atlas did the world, and around which the atlas and the super- imposed cranium, rotates. The term neuraxis, figuratively, but quite appropriately, answers for cerebro-spinal axis, because the rest of the nervous system proceeds from and figuratively revolves around it. Neuraxon, so like it in sound, means the axis cylinder process of neurone. It is a very essential part of the nerve cell or of the neuron, as you will see as we proceed. You see this little Greek word vs.vpov t with its con- tractions neu, neur, neuro, etc., is constantly recurring in our precursory incursions into the interesting domain of neurology. Term after term will come into use like 20 neurectomy, (vevpov, a nerve, and rgwav, to cut) nerve cutting, a thing the surgeons are sometimes too prone to do, (as neurologists sometimes think) before the neurologist has exhausted his resources or with) it consulting the neurologist as we sometimes think they should, and a thing they often do to our great relief and to the relief of the patient as well, sometimes before neurotheraphy has been thorough- ly tried as we think we know best how to try it, as in that formidable capital operation of the nervous system Gasserian Gangliectomy or Gasserian neurectomy or neuro- tomy, the cutting out of the ganglion of Gasser from the under surface of the brain, an operation which only skilled sur- geons should undertake after wise neurological counsel. You will learn more about this subject when we come to discuss trifacial neuralgia or neuralgia of the fifth nerve (from ver^or, a nerve, and aAyos, pain) sometimes also called prosopalgia, from prosopon, the face, and the Latin algia, pain, a shoot- ing pain involving the branches of the fifth nerve or three branch nerves of the face and its ganglion (Gasserian) ; a nerve which Sir Charles Bell, a great Englishman, once at- tempting to operate upon including with his knife the seventh nerve, and thus producing surgically a form of that characteristic facial expression palsy which now so univer- sally bears his honored name, now so interesting to neu- rologists. Neurilemma (Ae^u?, sheath or husk, sheath of the nerve, epinurium, «", upon, and vevpov, nerve). Neurility signifies nerve power or power of nerve life, impulse, per- ception or power to muriate, if by warrant of philological analogy we may be permitted to use such an expression. In this connection there is one term which, by contrast you will remember, after 1 mention it, as having no just warrant for its derivation, a gelatinous, bad-smelling product of 21 animal or fish putrefaction, a non- poisonous ptomaine when unmixed with other ptomaines. This is called neuridin, which I consider an unfortunate misnomer, for there is little or no nerve in it, though the vagus nerve goes to the viscera whose decomposition sometimes causes it, and nerves go to the muscles whose decay may engender it. It and its poisonous fellow ptomaine called murine, obtained partly from the same source, which acts so much like curare on the motor nerve terminals, causing dyspnoea, convul- tions and death, ought to be substituted by more suitable terms. Neurine should pertain to the nervous system only and not to products of either poisonous or non-poisonous decomposition of fish, fowl, flesh or viscera. Sheppard has used and applied the term more appropriately, though in an unusual way, to the gray matter of the layers of the cere- bral hemispheres, which he called the neurine batteries of the brain. There is also the term psychosis, from ^xq, the soul, the mind, meaning a disease of the mind usually functional, and sycosis, from o-vkov, a fig, used to designate a disease of the hair follicles. The dermatologists should give this term up to us. Everything should make way for advancing psychiatry and its designating terms. I do not like terms that confuse the student of neurological science and make his task of acquisi- tion more difficult than it is. My business is to simplify your work and clarify your course through your curriculum. The ponderous volumes written up to date and by meritorious authors on neurology and psychiatry are paralysing enough to contemplate, but if you will listen to me faithfully and observe the illustrations 1 give you during the session, I will elucidate the subjects upon which they treat to the best of my ability, so that you may comprehend them when you consult the great text- books of the great masters and enjoy 22 the leisure of the early days of your practice and the coming decades of your professional career in mastering them. You are expected to master the salient points only and not the entire science of neurology during your undergraduate life. We expect to make you successful students during your course in neurology and not expert masters of the subject; to blaze a clear pathway and clear out the underbrush of the thickly wooded and tangled forest, so that the light will shine through it, and to direct you aright so that you may traverse alone and better, when without us and at your leisure, in delighted companionship with greater leaders of our great science and art. There are great names in neu- rology, greater than the name of Agamemnon; great names since, as well as before that great Agamemnon in neurophys- iology, Claude- Bernard. Immortal names whose memories you will revere, and yet living names whom you will honor. Charcot, Claude-Bernard, Marshall-Hall, Beard, among the immortals abroad, Brown-Sequard, Seguin, Hammond, Ami- don, Amariah-Brigham, Benjaman Rush among our own honored dead and hosts 1 cannot now recall, and Virchow, the venerable chief among the yet living. May he live for- ever. You may be surprised that 1 mention our Benjamin Rush as chief among my gallery of immortals, for he was only an American, and great names in American medicine are not yet in good form. He lived and died on the wrong side of the Atlantic, like McDowell and Morton, and yet awaits a place in Fame's Pantheon. But scan his works and words well and you will see that even he, an old-time American doctor, deserves a place, if not in the temple of modern psychiatry, yet upon Fame's eternal camping ground. Some day in your time the world will applaud more than now the merits of Benjamin Rush. He was a neuro- logical giant in his day. He saw things in psychiatry with astonishing precision. Bourgery's outline lateral view anatomical diagram of the cerebro- spinaUaxis or neuraxis, from Quain's anatomy, showing the cerebro-spinal cavity from the top of the brain within the cranium to the end of the spinal cord, cauda equina and coccyx. F, T and O are the frontal, temporal and oc- cipital lobes of the cerebrum; C, P and Mo are the cerebellum, pons Varolii and medulla oblongata; M and Ms show the upper and lower extremities of the spinal cord; Ce, the cauda equina at the lower end of the spine be- ginning with the last lumbar spinous process; V, ganglion of the fifth nerve or the trigeminal, or ganglion of Gasser with its three branches faintly shown; C L shows the first of the spinal nerves or first cervical coming out under the occiput, and CviII is the last or lowest cervical; DI is the first dorsal or thoracic and DXII is the twelfth or lowest and last dorsal. The first sacral nerve begins at Si ; SV is the fifth sacral ; S is the sacral plexus and Col is the coccygeal nerve. CHAPTER II. THE NEURONE AND THE NERVE CELLS: THEIR COMPOSITION AND CHARACTERISTICS. Notwithstanding the delicate structure of the higher functioning neurones, their morphological or shape differences, corresponding to their grander activities in the scale of being, eminent physiologists tell us that these high power neurones, like other cells of the body of lower anatomical station and physiological dignity, possess protoplasm and nu- clei, the morphological characteristics of which, so far as can at present be unraveled by the highest powers of the micro- scope, would scarcely seem to differ from those of the cells of less noble tissues, to account for their greater dignity. There are, nevertheless, and there must be, certain deli- cate differences in the neurone structure, since structure and function throughout all nature, are correlative, like the varied mechanical adjustment of varying movement, which, though no eye has yet seen and no glass can now reach them, must yet some day by more delicate means of research than are now at hand be brought to light, by sight of science, just as we know in daytime there are stars above us, though we see them not save by the revelation of astronomy. In fact, notwithstanding the remarkable uniformity in type of the nerve cells in the most diverse parts of the central nervous system, Barker assures us that the neurones are not every- where so similar as to be practically indistinguishable from one another and cites a wealth of morphological peculiari- [23] 24 ties revealed specially by the research methods of Golgi and Ehrlich, which neurophysiologists were formerly unable to obtain. Barker gives differences of internal structure of different cell groups recorded by the method of Nissl, which he regards as of equal importance for purposes of classifica- tion to the external form from relations discovered by Golgi's stain, and "Barker knows his business" as well as Golgi and Nissl, Held, Apathy and Foster, or any other in the profession's galaxy of cytologic stars. "There are many neurones which from the appearance of a single example stained black with silver, permit an absolute decision as to their source" and Barker here mentions the cells of the sensory ganglia, those of Purkinje in the cerebellum, the pyramidal cells of the cortex and certain cells of the hip- pocampus. Some of you may be able to verify in the biological laboratory before your studies here are ended, the truth of this verifiable statement. You must not stop where I leave you, but press on beyond to the entrancing neuroanatomical and neurophysiological landscape, now pointed out and with wider and ever widening microscopical vision, as you grow in knowledge of the wondrous and complicate mechanism of man's marvelous nervous system, till you pass beyond the horizon which now apparently, but not in reality, bounds your progress. There is light for you in the far beyond, and in the sweet by and by, but we have not time to go there now and many suns must rise and set before you may reach the glorious goal. After the bird's-eye view I have given you of the beautiful beyond opportunities of investigation, it will in- terest you just now to know that you are not expected to know all, as only the great masters see the entrancing field of cytology, (for that is what it is called, kvtos, a cell, Xoyos, a discourse), in order to get your degree from his college, but 25 you will be expected to know something of what the master minds are doing, and a good deal of what we show you, that you may wisely follow them after you shall have learned to walk and not creep in their cytologic footsteps. The cytologic way in physiology will interest you quite as much as the Milky Way may have entranced you in your preparatory college survey of astronomy, for it is strewn with marvels of light on the wondrous life and potencies of living animal matter. Cytology is a study of the neurones, or cells, and astronomy is a study of the stars and, used like astronomy in its broader sense, the study of the neurones is a study of all that pertains to the cells, or neuronomy, if the philologists and the linguists will permit the term, in the sense that it means a grazing among the nerve cells and their belongings. The neurone then is the complete nerve cell or ganglion cell, embracing the nucleus, nucleolus, axis cylinder process, or axone and dendrites (all processes, collaterals and terminations) grouped into a nerve individuality or independent unit. The neurone does not, through prolongations, intertwine with processes from neighboring cells; it does not anastomose like terminals of the vascular system as in the capillaries. It is a separate and distinct personality, so to speak, capable of coming into contact, but not of mixing or interlacing or merging with other neurones so as to lose its individual identity. It is not a mixer, but stands upon its own individuality and here are some examples for your inspection of the nerve units which we now call neurones. With this wider and more definite understanding they might as well have been called cells as heretofore; for they are the same cells known before, only we have become a little better acquainted with them and know their nature, relations, and distinctive in- dividuality more familiarly, and talk of them in a broader and 26 more inclusive sense. When we say neurone, we mean all that pertains to the cell; its nucleus, nucleolus, its axis cylinder process or neuraxon, the dendrites, the myelin sheath of its collaterals and its split up end brushes or terminal arborizations. The neuraxons and dendrites of different cells come together, but do not anatomically anastomose. The neurones mingle but do not mix, they associate but do not join together, they are well acquainted with each other, especially the psychic neurones of the several layers of the gray cortex of the brain, and they are of the same blood as their neighbors, but they are neighbors only, units of adjoining families, not married to each other. They are separate and distinct but yet intimate friends, working side by side, often in the same nerve center to the same neurophysical or neuropsychical purpose. The neurones, like cells everywhere, reveal under the microscope evidences of change in composition from excessive and toxic impression. Dexterity and disintegration in exercise, waste and work, rest and repair, are correlative terms in the nervous system, as in the muscular. The microscope shows this among the muscle cells, as it does the ravages of disease, among the neurones. Micro-physiologists have, by diligent labor, made brilliant discoveries concerning the peripheral and central nerve cells. The neurones of the cerebro-spinal nerve centers and the peripheral nerves have been examined before and after exercise, before and after alcohol and mer- cury, nicotine, lead, phosphorous, arsenic, strychnia and various other poisons and after the withdrawal of the blood supply from the neurones, as in anemic ' neurasthenia and before, which experiments have thrown much light on the beginnings of disease, not only in the neurones, (or entire nerve cells) but of disease found in the neurones in con- 27 nection with persons who have died of other than recognized nervous diseases. Neurones directly or indirectly suffer in many diseases, probably in all, as we might learn through more ex- tended research. So that all diseases may interest you in the study of the normal and abnormal nerve cell or neurones. All acute and chronic degenerative processes in the nervous system appear to begin or end in the involve- ment of nerve cells. You will learn in the biological laboratory something of toxic cells, their chromatolysis, cell swellings and cell shrinkages, of- remote and central degenerate reaction from cell or peripheral nerve injury, the effects of infections and intoxications, chronic and acute, from disease, autotoxins from within, or poisons from with- out, or from intense heat and the restitution which follows the restoration to normal temperature. We cannot here discuss these matters in extenso, but a hint to the wise is sufficient. You will not need to seek diversion in novel - reading or the theatre. You will find it in the study of the neurones, beyond what we can teach you in this amphitheatre and there discover how much stranger is scientific neurological truth than any fiction. The composition of the cell body or bulb of the neurone is much like the white of an egg and is called protoplasm, and in cytologic technicality cytoplasm. All nerve cells or neurones have a nucleus and the nucleus a nucleolus or ultimate or lower nucleus. The neurone is not throughout a homogeneous sub- stance, as you are ready to infer from its divisions for functionating purposes, since modifications of structure, in the nerve cells as elsewhere, as we can discern by analogical reasoning if not by search of scientific resource, vary with differences of function. A viscid-like plasma is thrown around 28 and between the net- like work of granular fibers, which make up the body of the neurone (neuroglia). The neu- rone has within it chromophile granules, so- named because they may be stained by aniline, silver and other color agents. Each one of the many meritorious text-books on neurology sanctioned by this chair in the annual announcement has some or several distinctive features of interest in text or illustration, Dana, Mills, Gowers, Ross, Dercum, Church, and Peterson, Potts, Gray, Hamilton, Hammond, Hirt, Ranney, Starr, besides the European authors which some of you have in your mother or acquired European language. Each and all of them will enlighten you further than 1 can today by text or illustration, or both. Many of them have illustra- tions that will aid you further than I can, by taking your time during the hour to show you under the lens or on the board. Refer to your text-books for the picture paint- ing if for nothing else, of any part of my subject which I may not make plain to you during the lecture hour. You often hear it said that "life exists in its simplest form in the cell," that organs are but aggregations of cells, and animal organism but an aggregation of organs intimately associated and related, and that life like "light and sound are modes of motion," yet the neurone is more wondrously complicated physiologically than it looks and as we are yet to learn, probably through higher and greater powers of micro-chemical research. Just what chemistry is constantly teaching us in regard to its so-called chemical elements and some of its so-called simple compounds like N O 2 , the air we breathe, for instance. During your leisure hours of relaxation from the severe studies of your college curriculum and in your vacation you may find profit in scanning, if you have not the time to read closely, some of the leading medical journals of the 29 day. In them you will find articles, editorials and para- graphs that will impress your work on your minds and help to give you valuable stimulus and incentive to study. Apropos of our subject is the following, reflecting current professional opinion respecting the value of the study of the neurones or entire nerve cells":* "The beginnings of disease must necessarily consist in undiscernable alterations in cellular structure and function, and it is probable that changes of this character underlie the so-called functional disorders; namely, those- unattended with evidences of structural or organic lesion. Recent ad- vances in staining methods have, in fact, helped to disclose minute changes in cells subjected to various morbid in- fluences, and thus lend support to the view briefly ex- pounded. Such alterations in cellular nutrition may result from the action of substances normally generated within the body, but now produced in excess or in deficiency, in con- sequence of some derangement in metabolic equilibrium, or in themselves abnormal, or introduced from without in con- nection with infection or intoxication. Bearing upon this subject, Dr. Theodore Klingmannt has recorded the results of some observations on the cells of certain algas and protozoa. It was found that a variety of changes could be induced by artificial means: (First,) Changes identical with the physiological appearances occurring in the cells when they die gradually from natural causes; (second,) changes of a purely chemical character; (third,) changes of a pathological nature due to toxic sub- stances — the results varying with the intensity of the operating influence. In one series of observations metallic substances were employed to induce the changes described. *Conclusion of an editorial in the New York Medical Record, April 20, 1901. \American Journal oj Insanity, vol. Ivii., No. 3, p 519. 30 In the second scries blood serum obtained from patients suffering from various forms of so-called functional, nervous, and mental disorders was substituted. Analogous results were obtained in both series of experiments. A great variety of pathological conditions was found in the ganglion cell of rabbits and guinea-pigs treated with injections of toxic serum in varying dilution, the form of chromatolysis (cell coloring) varying with the strength of the serum and the period of its activity. The use of blood serum from healthy in- dividuals, on the contrary, yielded negative results." You cannot keep yourself in normal touch with the advance in your profession without a few representative periodicals for daily reference and there is a profusion of good journals in this country. Take a few choice ones and you will not forget what you have been or shall have been taught in this college and with the help they will give you, will constantly add to your store of medical knowledge. Morbid changes in the neurones have been found to end in fatty degeneration. Changes in the neurones of the gray matter of the brain have been found in insanity, in acute delirium, delirium tremens, in paralytic dementia, hypothermia or extra high-grade fever, in the bubonic plague, in typhoid fever, in infectious maladies and poison- ings and as I have already stated, in bromide of potash poisoning, besides the other drugs already named. In uremia, in multiple sclerosis, in chorea, in tetanus, ataxia, lateral sclerosis, poliomyelitis anterior, etc., and in the peripheral nervous system, as in polyneuritis, or inflammation in many nerves, neuralgia, that painful paroxysmal affec- tion of the peripheral sensory nerves, as of the face, above the orbits, about the mouth and jaws, in the tongue, etc. Bevan Lewis' and Ford Robertson's illustrations of dis- eased neurones will instruct you much. One thing about 31 the neurone's pathology I wish to impress here, viz.: When the nucleus of a neurone is diseased it seems to die, while its neuroglia, neurites or dendrites may become diseased and yet may recover. But disease damage done to the proliferating neurites or dendrites or neuroglia also affect the function of the neurone body. The loss of the customary peripheral, afferent or sen- sory impression has been shown to cause changes in the central spinal cord neurones and the cord cell changes also contribute to make those departures from the normal ana- tomical and physiological state of the neurones in the cerebro- spinal axis or central nervous system, the peripheral or sensory motor nervous projection system and sympathetic nervous system. This we call the pathology of nervous disease. Pathology in the nervous system, or neuropathology as elsewhere in the animal organism, is abnormally changed anatomy, and disease, as we see it ante-mortem, is abnormally changed physiology. It is physiology perverted by pathology. After the death of a part it is pathological or necroscopic or morbid anatomy. Disease of the nervous system is pathology of the nervous system in action. Its structural causes and results make the pathology, its functional results make symptomatology. Morbid anatomical findings may also be a cause of other disease, than that diseased action which produces them. The real disease, with its strictest definition would be in the nervous sys- tem or elsewhere, that is, the altered molecular activity that leads to the changes in the cells producing the changes in the organic structure, causing the organic functional changes or symptoms. This is true of the nervous system as of every other part of the body. The microbe or bacillus or materies morbi or psychic impress, changes the molecules S2 that change the cell, that change the motion, that change the function of the changed frame that nature built, as we see it in disease. That change, when the nervous system is specially involved, we call nervous disease'. The central neurones and the nervous system are subject to slow chronic inflammation associated with syphilis, tuber- culosis and the poisons already mentioned and by auto-toxic or toxic products generated by and within the body. Be- sides urea, already mentioned, which may so impress the psychic neurones and the vaso- motor centers of the brain as to cause the unconsciousness of coma and may im- press the psycho -motor centers so as to cause spasms and convulsions, the body -generated poisons of gout and rheuma- tism, (uric and lithic acid) and the sugar of diabetes may engender changes in the neurones or proceed from changes in the neurones of the nerve centers as they do in other tissues of the body. Thus you have diabetic coma as well as dropsy which may be caused by irrita- tion in the floor of the fourth ventricle whence the great vagus nerve arises, along with other cerebral nerves, as well as by changes supposed to primarily take place in the liver or elsewhere. The physiologists have generated gly- cosuria by mechanically irritating the floor of the fourth ventricle of the brain. They have also induced it by fret- ting dogs, by keeping them confined in sight of other dogs at play. As uric acid irritates the muscle and joint tissue into inflammatory action, as you see so fatally illustrated in the acute myocardites and pericardiac inflammatory effusions, that impede and arrest this vital organ's action, so it may locate in and similarly damage the delicate structures of the brain, as it so often does the muscles and joints, changing the anatomical and physiological conditions of the neurones and connective tissue or neuroglia into pathological states and sim- 33 ilarly involving the peripheral nervous system, as in the rheu- matic and other auto-toxic neuritides or inflammatory states of the nerves from self-generated or body-generated poisons or from poisons from without the system as alcohol, arsenic, lead, etc. This autoxicity might be called the sub-conscious suicidal tendency of the body. It is in some cases termed a diathesis, which is a congenital or inborn or very early acquired aptitude of the system to actively take on, under slight external influence, certain morbid states. Diathesis is from TiOevai, to place, and &a, through, and thus we have the influence of the gouty or arthritic, rheumatic, strumous, or tubercular, catarrhal, haemorrhagic, aneurismal, psychopathic, neuropathic diatheses, etc. Toxines and habitual or occasional autotoxicities, influence and precipitate the development of mental and nervous diseases through predisposition of the neurones and their connections of the cerebro-spinal axis and the peripheral nervous system, which includes the the sympathetic and its vasomotor system, especially the latter, as when the haemorrhagic diathesis appears in disease. Thus you see in studying the nervous system in all its cell diseases and relations, you must understand the whole man, for it is influenced by so much that affects the body in general and its diseases, as it also so much influences the organism as a whole and in its parts. In this vast chain of being, the neurones make many links and all the organs and viscera are links of strength or weakness. Ancestral organic endowments are links of direct or atavic descent, that go to make the chain of health or disease in the nervous system stronger or weaker, and knowledge, or lack of knowledge of these matters, will make you stronger or weaker as practitioners of medicine. The neurones are nourished by the blood, as all other *Vide author's paper on haemophilia, Alienist and Neurologist, July, 1887, and pro- ceedings St. Louis Medical Society, 1884, 34 parts of the body are, but not in the same simple way as the other and courser tissues. A more intimate relationship appears to exist. Adamkiewicz* in describing the fine anatomy of the blood vessels of the large intervertebral ganglion of the brachial plexus says: "The ordinary arterial capillaries give off finer capillaries, (vasa serosa) which are so fine as to transmit only the fluid constituents of the blood and none of the corpuscles" — finer than those which carry only the white blood corpuscle vessels as those to the sclerotics of the eyeball, for instance. These vessels go to the neurone, spread out and envelop it like a glove and then narrow down to their original size and empty into another arteriole capillary. This demon- stration in the intervertebral ganglion has not been so well proven as yet. But Adamkiewicz reasons that the neurones of the cortex of the brain are similarly nourished in this wise. He points out that the exposed cortex is perfectly tolerant of a forcible stream of distilled water, which if in- jected into the carotid will immediately produce nystagmus, extensor spasm all over the body, and disturbance of the pulse and respiration. His anatomical argument is that the vascular network in the cortex, as demonstrated by the injection of carmine gelatine, is much closer in those parts of the cortex which are richer in ganglia than elsewhere, and concludes, "all arteries which enter the brain and spinal cord of man and of animals, at least of the higher animals, end on the further side of the capillaries in very fine plasma vessels which contain ganglion cells, in diverticular ex- pansions." For ready remembrance the neurones may be likened to little islands surrounded by water. Nature seems to *Stehen Alle Ganglienzellen mil den Blutgefassen in Directer VerbindunK Nurologische Cenlralblatt fur January, 1900. W. H. B. Stoddard in the Join/nil oj Mental Science for January. 1901, Roes over this subject in English. 35 love to invest them, as it does other parts of the nervous system, with serum. The spinal cord hangs in the vertebral canal, closely filling it, like a substance suspended in a bottle of water. The arteries of the brain have their perivascular, serum filled spaces, and the lymph of these perivascular spaces is the same as that of the ventricles and the spinal cord. The brain has its serous arachnoid investment and its serum filled ventricles, and the nerves and the neurones float in microscopic rivers of water, so to speak, the serum surrounding the nerves and cells. The subarachnoid spaces communicate with the fourth ventricle and they with each other except the fifth, and with the cord they contain the spinal fluid. The brain, spinal cord, sympathetic and sensory and motor parts of the peripheral nervous system have systems of irrigation as well as a sewage system, systems of recon- struction or nutrient supply and systems for waste removal, as other parts of the organism do (arterial, venous, lymphatic systems). An idea of the irrigation or nutritional system of the brain, for instance, may be obtained from a study of the circle of Willis and its distribution and from an examination of the fluid filled spaces around the blood vessels and perivascular spaces and the fluid filled spaces of the five ventricles of the brain and of the subarachnoid spaces. The illustration I show you here is one of the cerebral perivascular spaces. The walls of the arteries and veins of the brain cortex are directly enveloped by outer walls of pia mater which secrete lymph and make up the perivascular vessels and lymph spaces. This lymph contributes to the nourishment of the surrounding neurones and neuroglia. 1111 STRATING A PART OF Till: BRAIN'S IRRIGATION SYSTEM. FIG. 2. The D, A, P, giving the memorial word dap, show the relative position from above downward or from without inward of the cerebral minenges, dura, arachnoid and pia, indicated also by numbers 1, 2 and 3. Fig. 1 shows the subdural space, 2 the arachnoid and 3 the pia, between the layers of of which are seen ramifying small vessels of the brain which branch down- ward to penetrate the substance of the cortex, 5, 7, 8 and 9, invested by delicate pial sheaths, with lymph between their walls and those of the vessels of the perivascular spaces 6. ISOLATED ARTERIOLES AND PERIVASCULAR LYMI'M Sl'ACES OF THE BRAIN. FIG. 3. FIG. 4. — An artery from the cortex cerebri in longitudinal section. Mar/n. SO. Numbers of fine fibres are seen streaming into the brain-substance. —Section from the cornu Ammonis, snowing perivascular and pericellular lymph-spaces. Stained with carmine. Magn. 150. — a, Capillary vessel in a perivascular lymph-space ; b, pericellular lymph-space directly continuous- with the former. Two leucocytes are seen in the pericellular space c, and one in the space b. (Q\mx s\fc VtVfcYJ) FIG. 5. Fig. 3, isolated arteriole; Fig. 4, arteriole surrounded by perivascular spaces; Fig. 5, a distended perivascular space with arteriole atrophy, after Milner Fothergill. NEURONES OF THE BRAIN AND SPINAL CORD. "PSYCHIC CELLS" OR NEURONES OF DIFFERENT VERTEBRATES. NEURONES BELOW INVOLVED IN DISEASE. FIG, 7. FIG. 8. FIG. 11. FIG. 6. FIG. 10. FIG. 9. Fig. 8. A pyramidal cell or central neurone from the cortex of the cere- brum with the dendritic ramifications (dendrites, protoplasmic process). Each process gives off a great number of bud-like branches. The nerve fiber of the cell, or axis cylinder process is designated ax. The terminal fibrils of the axis-cylinder process go on some distance from the cerebral cortex to other portions of the brain or cord, where they surround the den- drites of a ganglion cell. This neurone begins and ends within the central organ, and is termed a central neurone. Just below Fig. 8 is (Fig. 9) a ganglion cell with its dendrites from the anterior horn of the spinal cord; among its ramifications are seen the ter- minal fibrils of the nerve fiber belonging to the central neurone. The axis cylinder process (ax) emerges from the central organ and passes to the soft parts in the periphery. The entire neurone is, therefore, called a peripheral neurone. The third illustration below (Fig. 10, from Ford Robertson, Plate xxix) shows in marked contrast, a pyramidal nerve cell (neurone) of the cerebral cortex from a case of chronic tuberculosis of the kidneys and blad- der, showng varicose atrophy of protoplasmic processes (dendrites) . Here is an intra-neural change dependent upon the extra-neural disease tuberculosis. These changes in the psychic neurones account for some of the peculiar psychic symptoms of tuberculosis. Immediately to the left of Fig. 8 is an illustration (Fig. 7) from Ramon y Cajal of the "psychic cell" or neurone in different vertebrates used for comparison. They show also the remarkable morphological resemblances, considering the apparent and generally believed difference in psychic manifestation of these neurones of mental function in animals and man. The upper series of cells shows the "psychic" cell in different verte- brates: A is the psychic neurone of the frog; B, of the newt; C of the mouse; D, of man. The lower series show the stages of growth of a single neurone; a, neuroblast with axis cylinder process just commencing; b, panicle commencing; c, panicle and axis cylinder process more advanced; d, collaterals of neurone or axis cylinder appearing; e, collaterals of cell body appearing (Ramon y Cajal). Underneath this illustration from Cajal is an illustration (Fig. 11) from Ford Robertson, designed to show the neuraxone or axis-cylinder process of a cortical neurone from a case of exophthalmic goiter, a nervous disease in which the sympathetic nervous system is believed by most authors, to be chiefly involved, a vaso-motor and trophoneurosis. Compare its appearance with the proliferations of the pyramidal cortical neurone (Fig. 10) affected with tuberculosis beside it already referred to, showing the varicose atrophy of protoplasmic processes, connected with tuberculosis of kidney, etc. Fig. 6 shows a normal neurone. Illustrations of other neurones will be shown later. CHAPTER III. THE NEURONE AND THE NERVE CENTERS, CONTINUED; THE NEURONE THEORY, ASSOCIATION NEURONES, PROJECTION FIBERS, ETC. Remember the illustration of the standing bricks in a row starting to fall atone end. When first the end one falls toward the others each falls successively in its turn after the preceding one and communicates the impression it has received to its adjoining fellow, it in turn communicates or passes on the impression it has received to the next as in the blocks before us. This is the way the neurones act toward each other. This is the philosophy of the neurone theory. The neurones are anatomical units with an independ- ent, yet communicable function, like the students in this great audience. They are physiologically individual and independent, yet they are members of a neural community like the free independent American citizen who is never- theless so dependent upon his fellows in the community for his welfare that he does not seek to make a hermit of him- self and live alone. The neurones influence each other by contact but not by being blended with them, by contiguity and not by con- tinuity, as Doctor Charles Potts has so aptly expressed it in the excellent little student's manual some of you carry to the class room with you with my approbation. The neu- rones wait on each other, attend to each other's impressions and wants in a manner. They are pretty closely related, [36] 37 engaged, but not married in indissoluble union of function. Yet they are very nearly so, for the destruction of one or more of one group or nerve center in the economy may materially influence the welfare of the other contiguous neurones. A community of interest pervades certain groups of neu- rones in the brain or spinal cord, which make up nerve centers. According to location and description, these centers are called cerebral nerve centers, spinal nerve centers, cerebro- spinal nerve centers, ganglion nerve centers, psychic or mind impression and expression nerve centers, motor or psycho -motor nerve centers or the centers of cerebral locali- sation where motor impulses arise in the brain or cord and go from them. They are sometimes called also kinesodic centers. There are also sensory centers of the brain or cord where sensory impressions are received and sent on to higher centers or across the spinal cord to be there acted upon, and transformed into motion in the anterior horns of the spinal cord. The latter are called aesthesodic centers and the nervous mechanism that receives these impressions has been called the aesthesodic system. This system 'is made up of the different sensory nerves and their receptive centers as in the posterior columns and root zones of the • spinal cord, as the kinesodic or motor nervous system is made up of the different motor nerve centers and nerves leading from the centers of the anterior columns of the cord, the anterior horns or cornuas and the psycho- motor areas, grouped chiefly about the Rolandic area of the brain. PROJECTION FIBERS, ASSOCIATION CENTERS, TRACTS AND COMMISSURES. In your study of the coarse anatomy of the brain in the dissecting room you learned about the brain's great 38 commissure, the corpus callosum and the lesser commissures of the third ventricle and about the conducting strands of the great corona radiata, etc., and from there downward. These, you discovered, connected one portion of the cerebral structure with another. The great corpus cal- losum connected the two lateral hemispheres, its surface forming important landmarks and points of departure in our own dissections, the anterior cerebrals reflecting over it in front the callosal marginal convolutions superimposed and the centrum ovale majus coming into view as we cut away, on a parallel line, the convex gray cortex convolu- tion area, including so many of the motor centers above, and into which corpus callosum, we made Hogarth's line of grace and beauty, and brought into view those wonderful centers of the brain, the lateral ventricles, in which we saw the great basal ganglion, the tenia semilunaris, the cornua ammones, the pillars of the fornix, the fornix itself and the tela choroidea, the velum interpositum and between the lateral ventricles the fifth ventricle, away anterior, and intermediate the third, with its three commissures, downward and posterior the fourth ventricle and between the fourth and third that it en with the long name a tertio ad quartum veniriculnm, and the- cerebellum above and behind the medulla after we had cut away and lifted up the whole corpus callosum as I have done today. These commissures are connections and are called com- missural or connection fibers, but the brain has others which are especially called association fibers. They are similar to what you are familiar with in some of your plates showing the corona radiata. Some of them are dis- cernable with the naked eye or a pocket lense, others are more or less microscopic, just as some of the fibers of the internal capsule are, though you may discern them in 39 the aggregate. They connect convolutions and areas of the brain, fronto-occipital, fronto-temporal and occipito-lateral and nearby convolutions. This great family of neurones compacted into brain mass and lying in close proximity to each other in contig- uous neighborhoods occupying so much territory, must have means of communication. These the cerebro-physiologists have named after Fleschig, projection tracts, and they must have centers for collecting, coordinating and elaborating im- pressions conveyed to them by the association tracts and these centers are called association centers. In the conscious intellectual or psychic areas of the brain the process is called ideation, reflection, ratiocination, cerebration, thought, con- ception, etc. When this association, elaboration and coordi- nation takes place unconsciously", the process is called cerebral automatism, as in sleep, dreams, and if accompanied by sleepwalking, somnambulism, or if done by the will of another, hypotism or somnavolism as I have termed it, which I have defined to be an absence of the normal will by induced sleep. Learned psychologists speak of these states as states of subliminal consciousness. If it takes place in the course of a fever or a toxic state of the blood or of a dis- ease involving the integrity of the psychic neurones and their power of normal association, the condition is called delirium or insanity. If the function of the association centers is overwhelmingly, completely suspended suddenly, it is psy- chic or cerebral shock, coma, etc. If crippled in speech area, it is called aphasia, if temporarily suspended in sight area, it is called psychic blindness, mind blindness, selinblindheii , the mind or soul blind disease. If certain other psychic perver- sions appear as shown by alternate emotional states such as laughing and crying, visions, especially of eroto-illusional kind and moral perversions, we are likely to have hysteria. If the 40 coordinations are markedly above normal, we suspect par- esis or if far below it melancholia. These tracts are the tela- psychica or chorda mentes or tracts of the mind and these centers might be called the puncta mentes or centers of mind, or psychic centers or centers of mental action. If the locus minoris resistentia is under stress of morbific influ- ence and we have the neuropathic diathesis or constitution pre-existing, that is, the tendency of the psychic neurones to act abnormally under psychic stress and haemotoxines, the strained brain may give way to insanity or delirium in some form. If the strain is in the psycho- motor area or motor tracts of the brain and the punctum minoris resistentia is on this part of the cerebrum — either in these centers and motor tracts of the brain, we may have paralysis or paralytic insanity or Jacksonian or grand mal epilepsy, that is, epi- lepsy with limited or general motor or convulsive manifesta- tions, on some form of cerebral tremor of cerebral origin. NEURONES GROUPED AS NERVE CENTERS. The neurones of the brain, the spinal cord and the ganglia of the sympathetic system, are assembled together in groups of action or communities of interest, for purposes of sensation, motion and mental impression or action, groups of control or inhibition or restraint, sensation, mentality and emotion. These groups are called sensory, motor, or psychic neurone centers. Thus we describe the cillio spinal center of the cervical or neck enlargement of the spinal cord which influences the widening of the pupil opposing its sixth nerve contracting influence, and which disturbs the pupil when a violent blow is received in the back of the neck, a blow pugilists guard against, as they do blows below the belt where the semi- lunar ganglion and solar plexus are. In this region also are the cervical vaso- motor centers of the 41 sympathetic system which, when paralyzed, permit dilations of the brain's blood circulation vessels and cause cerebral congestion or fullness of blood in the head to follow, or when irritated only contract and cause facial and cerebral pallor. We have also the psychic centers of intellection, emo- tion and expression in the brain, like the speech center of Broca in the posterior aspect of the third left frontal con- volution, the psycho-motor centers on either side of the fissure of Rolando, the sensory centers of the cord, such as are involved in posterior spinal sclerosis which causes the patient to appear paralyzed, when he is not, and the motor cord centers of the anterior horns such as are involved in polio myelitis anterior or the essential paralysis of children. Then there are the auditory centers concerned in hear- ing naturally located in the temporal region and the olfactory or smelling centers singularly placed in the tempero-sphenoidal region instead of at the point of origin of olfactory nerves from its bulb and the perforated space and the under surface of the middle lobe of the brain, and the sight centers away back in the occipital lobes, as you may have discovered by the flash of light you saw when you fell backward and struck your occiput on the ice when skating in those happy days of boyhood, not so far away from you in memory as from me, but perhaps no less mentally vivid in me. The sight centers, diagnostically considered, are also in the corpora quadrigemina, the angular gyri and all along the optic tracts, a fact which will aid you in focal diagnosis of brain lesions. Then there are the centers of taste, facial sensation and motion and of the great vagus nerve going to the heart, lungs, stomach, etc., in the fourth ventrical, medulla oblongata region within the cranium. Neurones change under touch of disease and the con- 42 sequent symptomatic changes they will reveal to you in the functions of organs whose movements they inaugurate and regulate, cither singly or as syndicates of neurone action organized into nerve centers, will enlist your hest powers of observation and thought in practice to climb and later, a knowledge of them will help you to soar above the common herd in medicine. Fail not, therefore, to appreciate the im- portance of a study of the neurones. They are matters infinitely minute to your vision but yet magnificently grand for you to consider. Their study will lead you, like Provi- dence does all of us, in ways for the welfare of mankind which as yet may be "we know not of." NEURONES GROUPED AS NERVE CENTERS. FIG. 12. — (.'■ gangliou of a calf. Neurons ; (hb) netiraxons ; (c) neurodeodritea ; (d) varieose nerve ni.iils.CVVW'^^crV^ ASSOCIATION FIBERS OF THE BRAIN. FIG. 13. x x ' SI/.** (d'apres Meynert). — Fibres d' association, — Coupe verticale et antero- posie"rieui'e du ccrvcau du ccrcoccbus cynomolgus. F, extremite frontale ; — 0, extremite occipitalc; — H, conic d'Ammon; — RR, substance grise certicale; — SH, sillon de l'hippocampe; . -44, troisiemc segment du noyau lenticulaire; — GT, avant-mur ; — Cs, queue du corps strie ; — P, pulvinar; — corps genouille extenie; — pv, fibres propres unissant deux circonvolutions ; ^~ arc, (asciculus arcuatus ; — vnc, fasciculus uncinatus ; — Ig, faisceau longitudinal inferieur; — C«, commissure anterieure; — inf, corne pos- terieure des ventricules lateraux. Antero-posterior ventrical section the brain of {cercocehus cynomolgus) a long-tailed ape, after Meynert. F, frontal; O, occipital; H, cornu Ammonis; R, R, cortical gray matter; SH, hippocampus; P, pulvinar; Gt, outer wall; Pv, fiber propriae connecting adjacent convolutions of the cortex; Gs, tail of corpus striatum; arc, arcuate fibers; unc, uncinate fibers; Lg, inferior longitudinal fibers; Ga, anterior commissure. RELATION "I IMPORTANT BRAIN REGIONS AND PROJECTION \\T> ASSOCIATION FIBERS. FIG. 14. m BAUOUftrau. — Cctte figure est empruntee a l'ouvragc do M. Meynerl ( Stiickcr't Hamii/ucli, t. If, p. 72J, fig. 213). Ellc rcpn'sente unc coupe longiludinalcct hori- zonlnlc dc_ ],i moitie g-iuche du ccrveau du rcrcoccbus cyno ilgus. F. extremitd frontale; — 0, reyion occipitale; — PT, enfrec de la scissurc do kiylvius ; — I, insula ; — CI, nvanl-mur; — T, corps calleux ; — S, septum ; — O, commissure ant epicure. A, conic d'Ammon; — V, corne anlericure du ycntriculc lateral; — \p, cornc posterieuic ; — Vw, ventriculc du moyen. — Cm, commissure moyenne. — Aq, aqneduc. Li, Lit, Liu, segments du noyau lcnticulairc ; — Na, tele, ei Nc queue du noyau caude. Th, partiedela coiiche optiquesitueeenavant des corps genouilles; — T/i'couche opiique, Pulvinar. Longitudinal horizontal section of left half of brain of long-tailed ape, after Meynert, Strieker's Handbook. F, frontal; O, occipital region; FS, fissure of Sylvius; I, insula or island of Reil; CI, outer region of external and internal capsule and claustrum; LI, LII, Llll, segments of cuticular nucleus; T, corpus callosum, anterior border; S, line of septum- lucidum enclosing the fifth ventricle; V, anterior horn of lateral ventricle with S, the line of the septum lucidum between it and its opposite lateral ventricle, not shown in this cut; VP, posterior horn of lateral ventricle; Nc, head, Na, foot or tail of caudate nucleus; B, Bs, Bi, cerebral peduncle; Gi and Ge, internal and external knees of the corpus striatum; Th, optic bed or thalamus; Th', pulvinar of optic thalamus; Qu, corpora quadrigemina; Ap, aqueduct of Sylvius from third to fourth ventricles; Vm, middle or third ventricle; cm, middle commissure; Om, medullary fibers from occipital lobes to pulvinar and knees of internal capsule; M, ms, other medullary fibers; R, occipital cortex. FIG. 15. FIG. 16. FIG. IS. FIG. 17. The illustration, Fig. 16, is a neuroglia cell showing dendritic branching and mossiness of its processes. From the white brain matter of sheep. This form is common in growing brains. It is to be regarded as a neuroglia cell that has not yet reached full development. Fig. 15 is a large neuroglia cell attached to vessel wall. From the white matter of brain of sheep. Most of the processes show no branching. This is the typical form of the fully developed neuroglia cell. (After Ford Robertson.) Fig. 17 shows a pyramidal cell from the cerebral cortex with the nucleus and nucleolus, while immediately to the left (Fig. 18) is shown neuroglia cells of the Golgi type, after Kolliker. NEURONES, EPITHELIAL CELLS AND NEUROGLIA FIG. 19. FIG. 20. Description over. The upper illustration (Fig. 19) shows ganglion cells or neurones, A and B, alter Ranvier-. C are neuroglia cells, Spider or Dieter's cells; D is an axis cylinder process or neuraxone; P are protoplasmic processes. All from the spinal cord. The lower illustration (Fig. 20) shows epithelium and neuroglia sur- rounding the central canal, section through the spinal cord of a human em- bryo of twenty-three centimeters length. (After Lenhossek). Neuroglia is a peculiar tissue. It belongs exclusively to the central nervous system and the optic nerves. It is a patching, making patchwork connections for damaged nerve connections, as well as being a neurone- sup- porting network tissue or scaffolding. It not only does the work of glue, as its Greek name indicates, between the neurones, scaffolding and holding them in their proper relations, as I have already said, but it acts as a sort of plug for stopping neural holes. The neuroglia is often simply called glia. "Wherever in the central nervous system nerve substance degenerates from disease, the glia (neuroglia) appropriates the empty space. The re- placement with glia has a limit only where its elements are destroyed along with the nerve substance and where its power of growth is not sufficient to rill up the large deficit. "The central canal and the ventricles send long processes into the nerve substance. In man these reach the external surface only in a few places. These fibers as in the figure above belong naturally to the sup- porting tissues. "The neuroglia net differs somewhat in different parts of the central nervous system and forms here and there dense accumulatious in parts quite devoid of nerve substance. Thus, a thick layer of nearly pure con- nective tissue covers the whole surface of the brain and cord and extends a short distance along the nerve roots in the form of a plug. In the same way there is found on the inner surface of the central nervous system just under the epithelium an especially rich development of neuroglia. The net work in the gray substance is in some parts denser, in others less dense, than in the white substance. The large nerve cells are frequently so en- circled that they appear to lie in a fine-meshed basket."— Edinger. GROUP OF NEURONES MAKING NERVE CENTERS. FIG. 21. ' i •\ ~;a v m* x *r. ? * >~ -Pyramidal cells from the frontoparietal region of a cat's feeing at term. {\ obi., no eye-piece.) FIG 22. The Association Fibers Co xvvoVw- AtVo«v%j a. VicoioXo- oer*\.'yoxo-V > '• V> *S' <*- V»*.\X o/vou-wj -<\ve u-y^et bur^occ o^ cof^wfe c«.\\o4i<.y<»^ Jj. IX inc'iyx-oXe. ,ot VvooV- ZLO;OT. W"»*X ce»«^\uu. F.F.F. CeroVaTO-L oot. \V, anterior, and h. W, posterior roots; a, a, association system of fibres; <-, c, commissural fibres. II, Transverse section through the posterior pair of the corpora quadrigemina and the pedunculi cerebri of man — /, crusta of the peduncle ; s, substantia nigra ; v, corpora quadrigemina, with a section of the aqueduct. Ill, The same of the dog ; IV, of an ape ; V, of the guinea-pig. FIG. 25. -Wurzburg Golgi preparation. Cell from the cervical .sympathetic in a calf. (a) The neuron ; (A) the neuraxon: (c neurodendrites ' " , \<>) me neuraxon: (c ■ (VVV o^ ocr^btCkX ooxCex o^ a- &o$j f-Oae Vw^WilaW'^oC^ 1 '^ s\u^l^VcaxiwsA,jy» Corpora- FIG. 28. VvN. g&h Fig. 28 represents the cell of anterior horn of the spinal cord of a normal rabbit, while Fig. 29 is the cell of the anterior horn of the spinal cord of a rabbit with experimental elevation of temperature. Both are after Ford Robertson. FIG. 30. u w* *4Hr x^fttaX xxexve sWw'om^ xevuMxxxa ctaxoxtvo&oW- emo. ox ^N&\,Vx\g <5^ >&& xx^vvcoxxe CVkqw OwpcN- Uw,\V\\R0t6i\M* \U©€ US. AFTER /l/lAR.iNE%lo-KAY- cJoxViaexcucfc, CX , «vcoBm\Q^,3%xxv^xGX\x7ce^re.xV^cv- FIG. 31. o^v^o * JLss > vuw FIG. J2. — From the cornu Ammonis of the rabbit. A, Composite figure from preparations by S. R. y Cajal. n, b, c, Association-cells whose long neuraxons split up into moss-like twigs, which invade the layer of pyramidal cells (A). At the left is a completely-sketched pyramidal cell. Through its descending neuraxon it is in relation with the "brain-pith" and through its ascending den- drites it is in relation with other systems and cells not figured. Through the asso- •ciation-eells many pyramidal cells are brought into combination. HOW CORTEX NEURONES COMMUNICATE AND PROJECT. FIG. 33. Scheme nhowinc thu pri.hnhlc course <>f impulses and the interneu- toual connections in the cortex cerebri. (After 8. Ramon y Cajal Lea nouvellea i.l.Vs. etc, - . Axnulay, Pari-, 1894, p. flfi, Fig. 16.) ,1. srtMlr pvniin- uial cell; II, large pyramidal < .11 . (\ l>. polymorphous cells; /.'. terminal centripetal projection fibre ; /•'. collaterals fnnu the gulistantia alba ; (f, axuue bifurcating in the substantia alba. 3 " if ,pwi Scheme of the fibres propria- connected with the commissural system of the brain convolutions. BERKLEY'S DIAGRAM OF THE PROJECTION FIBER SYSTEM OF THE BRAIN. FIG. 36. Showing the origin and course of the pyramidal and callosal fibers. P, pyramidal tract: C, callosal commissure; A, cell sending an axone directly to the collateral hemisphere; B, H, cells having branched axones; the main fibers descend into the pyramidal ways, and the collaterals cross to the opposite half of the brain through the corpus callosum; 1, I, cells sending fibers directly into the pyramidal tracts without branching. FIG. 38. FIG. 37. FIG. 39. FIG. 40. FIG. 41. MEYNERT'S SCHEME OF THE COMMISSI RA1 FIBER SYSTI M. FIG. 42. For further description see Chapter V CHAPTER VI. THE NEURONES GROUPED INTO LAYERS OR STRATA OF THE BRAIN CORTEX; FURTHER CONSIDERATION OF THE NEURONES AND OF THE ASSOCIATION FIBER SYSTEM OF THE BRAIN AND OF THE PROJECTION SYSTEM OF THE BRAIN AND SPINAL CORD. FUNCTIONS OF NEUROGLIA AND MESOGLIA. The neurones of the cortex are often distributed over six or more layers, laminations or strata. This cut of Mey- nert (Fig. 34) shovys the five motor strata with their neu- rones as usually described. The sensory areas have more. The first zone or stratum is made up of polymorphous neurones of what are commonly called cells of the Golgi type. The second layer is composed of small pyramidal neu- rones with intermediate connecting glia or Dieter's cells. The third layer is composed of medium sized and larger pyramidal neurones. The fourth of compacted small pyramidal cells. The fifth of medium, large, and giant pyramidal neu- rones, and the sixth is made up of medium-sized polymor- phous neurones, mingled with the substratum layer of white substance described only as white substance by Meynert as you may see by reference to the illustration, from that distinguished neuro-anatomist, to be seen in Fig. 34 of this volume. Meynert's illustration which I show you gives the neurones in th^ motor area of the anterior lobes; the five strata layers. [57] 58 The six or more stratifications or layers of the brain do not belong to the motor area but to the "annectant gyri" which connect the occipital and parietal lobes. These six or more layers belong to what has been called the sensory type of neurone layers of the brain. The first layer, beginning in the cortex, just beneath the meninges, contains the so-called tangential fibers. Where a sixth layer is recognized it is constituted of medullary sub- stance containing a few spindle-shaped neurones. The neu- rones of the first layer are irregularly angular with angular nuclei, those of the second are small pyramidal. The third are larger pyramids in shape. There are many varieties of neuroglia besides those of the Golgi type which I have shown and Ford Robertson's mesoglia, like unto them. Fig. 37 shows an ependymal cell from the pituitary body approximating the embryonic type; Fig. 38, ependymal cells of fir-tree form from the margin of the third ventricle adja- cent to the infundibulum ; Fig. 39, long-rayed neuroglia cell from the fourth layer of the cortex, a transition form between the ordinary long-rayed and mossy form; Fig. 40, neuroglia cells of horse-tail form from the peridyme of the brain. The free surface is covered with a felt-work of the longitudinal fibres; Fig. 41, a mossy cell with knobbed branches from the gray matter of the cortex. All are from Berkley. Figs. 37, 38, 39, are from the adult dog, the others are from man. Berkley has transcribed into his masterly work on mental diseases sixteen varieties, some of which 1 show you as tending to confirm the conviction he expresses that in addition to Binswhanger's view of their gliacyte or cell con- necting function already referred to, they serve the double function of support and separation of cells, neuraxones and dendrites besides being "factors in the lymph circulation" 59 which has been hinted at in our reference to the irrigation system of the brain, the perivascular spaces, etc. "In human movements though labored on with pain A thousand movements scarce one purpose gain, In God's, one single can its end produce And yet serve to second some other use." And so it is, probably, with the relationship of the neuroglia to the neurone. And so doubtless you will conclude from an examina- tion of these varied illustrations, a few of which 1 reproduce for your consideration and perhaps some of you may make the necessary investigations to settle the question here pro- pounded, do the neuroglia nourish as well as mechanically support the neurones? Fame lies in the paths that may lead you to a correct, unerring answer to this important question. Remember as you study this subject what 1 have told you of invariable variations of structure corresponding to deviations in function and note how differently in appear- ance and construction is the ependymal neuroglia cell from the pituitary with that fir-tree form of the third ventricle neu- roglia and that of the fourth layer of the cortex and compare these with the mossy glia cell No. 10 of the second layer for the neurones and that, besides mechanical support which is demonstrable, the neuroglia may give the neurones physio- logical support in the way of lymph nutrition, this latter, however, being yet only conjectural and I will pass you on this answer or if you but say the neuroglia act the part of a physiological scaffolding glue to the neurones. Apropos to your future investigations, read Bevan Lewis' discussion of the lymphatic system of the brain and especially before and after the paragraphs I here quote.* *Beyond the system of perivascular channels, adventitial lymph space, and perivascu- lar sac, we have a lymph-connective system which plays an important role in the pathology of the brain. This system is constituted by the larger connective element. These elements, more closely examined, are found to have a definite and constant relationship to the cortical blood vessels; and are always discovered in large numbers in their immediate neighborhood, external to the perivascular channels. — Bevan Lewis, page 83. 60 Are the neuroglia connected with the nutrient lymph system of the brain? 1 think they are. Golgi, Clouston, Robertson, Berkley and others think so, :\nJ Ramon y Cajal says: "They expand and contract the capillaries to which they are attached." Study up this subject. W. Bevan Lewis,! considering that recent research into the general morphology and intimate histological structure of the nerve cell has so far enlarged the boundaries of our knowledge that it becomes essential to start with a definite terminology which includes no ambiguous terms for the complicated apparatus presented as the modern conception of a nerve cell, would thus describe the neurone and its several components. The body of the cell including all its contents, he calls the cell or neurocyte; the protoplasmic body of the cell, in contra-distinction to the nucleus, he proposes to term the neurosome or cytoplasm. If the cell is provided with pro- toplasmic processes he would speak ot the main trunk as the dendrone, and the finer arborizations as the dendrites. If one of these occupy a polar position whilst the others rise from the base or sides, as in the pyramidal cells of the cortex, he would designate the former as apical or primary dendrons, and the others as lateral, basal or secondary dendrons. The dendrone, remember, is not an essential part of the cell, since many nerve cells have no dendrone. The axis cylinder, he thinks, may be much more conveniently termed the axone, which may be naked (non-medullated) or medullated, and such branches as arise along its course as collaterals. The distal termination of an axone or its col- laterals in a plexus he designates as terminal arborization and for the whole system thus embraced, i. e., the neuro- cyte with its axone (collaterals, terminal arborizations, and tText-bonk Mental Diseases, 2d edition, pace 60. 61 if present, the dendritic expansions), we use preferably the term neurone in the original sense adopted by Waldeyer.'" I show you these great things from the great masters to set you to thinking; not that I expect to make you at once great cytologists like these masters are; nor that 1 expect you to remember minutely all 1 tell you. Tell me at the final examination that the neuroglia, though varied in form, are connecting tissue supports to keep the neurones in place and maybe to help feed them, and your answer will be satisfactory. It will even be sat- isfactory if you only know and say the neuroglia are the framework of the neurones, for this is all we now seem absolutely to know. But you may conjecture other func- tions for these intermediate structures between, some of them looking like spiders, others like whips or horses' tails, others like the branches and stems of trees, and to prove new functions for the neuroglia if you can and I expect to hear from you affirmatively in the on-coming days of your higher neurological climbing. Men climb in science as boys climb trees, from trunk to limb and from limb to smaller branch till they reach the possible top. From what I have thus far said it must have already appeared to you, that to know the neurones well is to know neurology. You have seen that a neurone is a min- iature nervous system. It has in its nuclei its central system and in its neuraxone and dendrites its peripheral connective system, afferent and efferent, and neuroglial relations, its association and projection fibers, as I have said. Aggregate these single neurones and neuroglia and you make the brain, made up of the prosencephalon or fore-brain, the thalamen- cephalon or inter-brain, the mid-brain or mesencephalon and the hind and after-brains embracing the pons, cerebel- *Deutsche Medicinalischc Wochenschrift , 1891. 62 lum and medulla. The grouping and "chaining together of the neurones" or their normal integrity, anatomically held together by means of their neurone and neurite prolongations and neuroglia, make the projection paths and association paths and make possible the physiology of the entire nervous system, the entire cerebro-spinal axis and peripheral systems. The severing of a single neurone link in this neurotic chain or the damaging of the neuroglia which hold the links of the nervous chain in normal place, makes neuropathology. It may be very slight, so slight that we cannot detect the anatomical change, as in the so-called neuroses, as formerly more generally understood, or functional nervous diseases. They were originally so called as they are now because the anatomical change into pathological change causing them is not yet definitely detectable. But neuroses are nervous diseases with pathological bases like other diseases-; the symptoms and organ affected being known, but their precise pathology awaiting further discovery. Now then, linked together so beautifully in exact ana- tomical relations, we have the neurones that make up the great cerebro-spinal system of cerebrum, cerebellum, pons Varolii, basal ganglia, crura, medulla, cord and sensory and motor nerve connections. And the association and projection systems and neuroglia referred to, hold all in that normal healthy anatomical relation that makes the physiology of the cerebro-spinal system appear so beautifully and won- drously accurate and simple with all of its complexity. Break the connection anywhere and you have neuraxis or nerve center disease and thus recurs again the poetic aphorism, "From Nature's chain whatever link you strike, Tenth or ten thousandth, breaks the chain alike," and you may have disease as grave as cerebro-spinal scle- rosis with its intention tremor or cerebral apoplexy with its 63 coma and paralysis, or neuroses so slight as the passing tremor or evanescent paresis of stage fright. When the people, your future patients, come to under- stand this, as they will, with the diffusion of medical like other scientific truth among them, they will not wait till the brain breaks under the burden of business or grief or passion's excess or other mistakes of living and bad nervous system care and management, before consulting you. They will seek medical counsel in time to avoid catastrophe to the delicately wrought, yet wonderfully strong nervous system, considering the abusive strains to which it is sub- jected and which it endures before it gives way to the pressure of adverse environment, in our modern strenuous life. The erroneous popular teaching that the mind, because immaterial, is independent of the body, and that will power, which is nothing less nor more than good or ill endowed psychic-neurone power, can do everything or almost every- thing, is responsible for the ignoring of the neurologist, the neglect of timely attention to the needs of the nervous system and the gradual or sudden and fatal brain break- downs and needlessly early deaths among so many of our men of affairs, at the very time when they are most needed and ought to do their best brain work. It will be your business to impress the danger of the reckless prodigal overstrain of psychic neurones and the importance of timely care of them on the people who employ you for wise and prudent counsel pertaining to their health. Man is a bundle of neurones and those people who speak of themselves as bundles of nerves, because they are so irritable, easily frightened, perturbed, sleepless or otherwise nervous, are bundles of unstable neurones which need neurological attention. They need their psychic 64 neurones looked after as much as the implements of their business need repairing from time to time. They need to be sent to pasture from time to time like their tired horses, or to the shop for repairs like their wagons or harness. Teach your patients to be sensibly good to themselves and kindly and timely considerate of their neurones and they will be good to you, by employing your aid more, and kind to themselves, by giving you a chance for timely attention to themselves, when you may save them from those grave neuropathic calamities that now needlessly befall so many good men in all lines of strenuous action. The brain is made an anatomical and a physiological whole, and the spinal cord likewise, by the association and projection communicating systems of the brain and cord. You see you are to have great use for this knowledge, for disease damages or dissevers these normal relations. When it only disturbs or damages relations you have less serious lesions to deal with than when disease destroys relations. Tremors, tremulousness, feebleness,, perverted movements come from disturbances of neuraxial relations short of destruction. Destruction makes even perverted function impossible and then you have paralysis. The destroyed motor centre makes motion impossible. The motor center touched by disease short of destruction that is irritated, gives spasm or contrac- tion, or alternating contraction and relaxation, which is convul- sion or tremor, because there remain undestroyed neurones to be disordered in action and intact projection tracts to convey disordered action outward from the centers of spine or cord. If the projection tracts are impaired you have impaired or altered action, but still action; if destroyed you have no action or paralysis; if partly destroyed you have partial paralysis or paresis. Refer in the study of this interesting projection fiber system to Figs. 14, 24, 33 and compare with 13 and 22. 65 We have already seen and shall presently see more from other illustrations as well as this one, how the projec- tion fibers converge from the cortex to form the corpora striata and pass downward and outward in the crura and cord tracts. Some of these fibers are fine and some are coarse, some longer and some shorter. The projection fibers belong mainly to the neuraxis, connecting brain with spinal cord centers. The association fibers described in the fol- lowing and preceding illustrations belong to the brain. Ford Robertson has called attention to the fact which he has brought out by the platinum method of staining that "the structures described as neuroglia do not consist of one tissue, as has been generally believed, but are composed of at least two kinds of cell elements of which the origin, morphology, functions and behavior in morbid conditions are entirely distinct." The advanced student may be interested in the above note and Robertson's plates xviii, xix and xx, but you will not be examined on this subdivision of the neuroglia in the final examinations. Andreisen, whom he quotes, has described the neuroglia as made up of separate epiblastic and mesoblastic elements but somewhat different from those observed by W. Ford Robertson, who suggests that the neuroglia containing epiblastic elements should only be called neuroglia and those containing mesoblastic elements should be termed mesoglia cells, illustration of which you may see by reference to Robertson's plate xx. But though Robertson makes a beautiful demonstration of his contention by his platinum method, as the illustrations establish, we shall call them all neuroglia. They are both engaged in similar business, these mesoglia and neuroglia or blastoglia and mesoglia, if you choose, viz.: that of sustaining the neurones at their respective stations and posts of duty. Different parts of the neuroglia do, 66 however, seem to behave differently under disease but as they 'belong to some nerve tenter and are manifest with its disease 1 will not discuss either mesoglial or blastoglial diseases, as 1 would term disease of the remainder of the neuroglia for purposes of distinction. We cannot dwell longer among the neurones and neu- roglia. My vocation as educator is to lead you into the ways of Knowledge necessary for your advancement in the essentials of neurology. It is your duty to go on farther in these pathways or in new ones which you may mark out for yourselves. After you shall have become advanced students of cytol- ogy you may have the inclination to take up this subject and pursue it in extenso. We cannot go further now. Ford Robertson concedes that his mesoglia are about as numer- ous as the neuroglia and they are certainly so closely mixed up and interlaced with them that we consider them together. So when I talk about neuroglia or quiz you upon the sub- ject 1 shall mean to include all under the one term neuroglia for the present. Robertson aptly calls them "the guy ropes for the capillaries" as well as the supports of the nerve cells and prolongations, and you may see the neu- roglia often attached to the capillaries. He says they are repair tissues, for the brain is like tissues in other parts of the body and this is in harmony with Bevan Lewis' suste- nance idea. Here our study of the nutrient network of the neurones must close for the present. The further illustra- tions which follow must suffice as objective lessons in lieu of another lecture on the subject. The neuraxones or axis-cylinder processes of neurones are either long or short, terminating close to their parent neurones or far from them. The latter are typified in the pyramidal neurones or projection cells of Shaeffer, which (>7 send their neuraxones down into the cord or across the hrain, through the corpus callosum. They are chiefly motor im- pulse cells. The shorter neurones are called intermediary cells and are connecting neurones to other neurones. They are a type of Golgi cells, so called because described by this great investigator in cytology. He thought they were exclusively sensory cells, a view not generally entertained now, but 1 am not sure this view ought to have been abandoned. The shape of the brain cortex neurones, besides being designated as pyramidal, apolar, bi-polar, multi-polar, etc., are also called stellate, ovoid, etc., but Meynert's division into pyramidal, mixed granule form and spindle- shaped about covers the varieties in conformation. The fibrae propriae, connecting neighboring convolutions of the cortex, and the longer commissural fibers which connect more distant cortex areas with each other, appear somewhat as in illustrations Figs. 22 and 35. They and other fibers make possible the traversing of a cortex irritation, like that of an epilepsia, for instance, from one point, the point of the initial aura, for example, to others distant in the brain. But they do not appear quite so plain under the microscope as in these diagrams. Artifacts, that is, artificial or after- death products resulting from handling of the brain, tissue, rupture, etc., post-mortem appear, under the lense, to in- terrupt and otherwise obscure the appearances of these important fibers. This accounts for the diagrams of different microscopists varying a little. But in the main their out- lines are in accord, those of that excellent one by one of the latest observers, Vangehuchten, with the comparatively small number traced and named by Edinger, whose classical and standard diagram is to be found in many of your text- books, and which shows the following tracts. It will be easy for you to become familiar with all the other details 68 in neurocytology. But you are glad, no doubt, that the number is so limited. These tracts are the uncinate or hook-shaped fibers going from the cortex of the temporal lobe forward along the ventral border of the insula into the ventral regions of the frontal lobe; the arcuate fibers, or fasculi arcuati, which pass over the dorsal part of the insula from the most posterior portion of the temporal lobe to the cortex of the parietal and frontal lobes. Next the cingulum, a long tract that runs in the marginal gyrus — gyrus fornicatus — from the cortex of the cornu ammonis to the most ventral region of the frontal lobe, including the olfactory lobe in the dog, rabbit, etc. Then we have the inferior longitudinal fibers running antero-posteriorly across the brain and con- necting temporal with occipital lobes and the fronto-occipital fibers of the fasculus fronto-occipitalis, as Edinger describes them, "arising from the medullary covering of the posterior and lateral horns of the ventricle, its fibers passing forward as a well-defined bundle external to the lateral ventricle," beneath the corpus callosum and on the dorsal edge of the nucleus caudatus. The arcuate fibers and the fibers of the cingulum belting the corpus callosum are all antero- posterior fibers. Almost all of the inter-lateral or crossed commissural fibers pass transversely through the corpus callosum or anterior commissure or crossing, and are called in the litera- ture, transverse callosal or transverse commissural fibers or fasciculi. There are other lesser fibers called forceps major, forceps minor and the tapetum corporis callosi or the band or tape shape bundle of fibers which pass in either hemi- sphere through the corpus callosum to the temporal lobe. The fibers of the forceps major come from the occipital lobe, run in the corpus callosum and surround the posterior horn of the lateral ventricle like a cap, resembling some- 69 what the fibra? propria?. "That portion of the corpus callo- sum passing into the temporal lobe on the lateral side of the inferior horn of the lateral ventricle is called the forceps minor." These terms are used for the purpose of minute de- scription by brain histologists. You do not need to carry them all continuously in your minds, but only to know where to find them when referring to the plates of the text-books in studying minute brain descriptions. Remem- ber, however, the general direction and arrangement of the connection and projection fibers of the brain. And their courses go crosswise, lengthwise, obliquely and downward in the brain, through and over the corpus callosum, about and over the ventricles, to and through the basal ganglia, the longer tracts going down the cord. They are inter- cerebral, circumgyral, corticle, spinal, etc., as their courses studied in a case of apoplexia, post-mortem for instance, with Marchi osmium stain will often show you, especially in the tracing of the downward or descending degenerations of this cerebral disease. I can not here enter more minutely into this branch of a most interesting subject. But I commend to you for vacation reading, in connection with this and preceding lectures, Meynert, translated by B. Sachs, of New York, on the Anatomy, Physiology and Nutrition of the Brain; Obersteiner, Edinger, Robertson, Morrison, Lewis and others already mentioned. The tumor most peculiar to the neurologlial network bears the name of this structure and is called glioma. The neuroglia of the brain and pons is the most frequent seat of this form of brain tumor. Inflammation and gummata are most common in the meninges and arteries. NEUROGLIA CHANGES IN CEREBRAL DISEASE. (After Ford Robertson.) FIG. 43. • • : • • .;. 00 * * , • w .... %- ft ■••■•• S , Vi*».V» • Description of fig. 43. Fig. 11. Outermost layer of normal cerebral cortex (human) (x300). The dark, rounded nuclei are mostly those of neuroglia cells. Fig. 12. Outermost layer of cerebral cortex from a case of advanced general paralysis, showing great hypertrophy of neuroglia, and thickening of the vessel walls. (x300.) Fig. 13. Outermost layer of cerebral cortex from a case of senile in- sanity, showing a moderate degree of hypertrophy and hyperplasia of the neuroglia, sub-pial felting (containing some colloid bodies), and thickening of vessels. The neuroglia cells are pigmented. (x300.) Fig. 14. Outermost layer of cerebral cortex from a case of epileptic insanity, showing slight hypertrophy of neuroglia, together with marked sub-pial felting. (x300.) Fig. 15. Two greatly hypertrophied neuroglia cells from the tissues adjoining a small secondary carcinomatous nodule in the cerebrum. Analine black, fresh method. (x500.) Tumors, localized centers of inflammation, and recent softenings are generally surrounded by a broad zone of neuroglia cells of this kind. They are swollen to several times their normal size, and it can be recognized that many of them are divided. Note the dendritic branching of the processes. Fig. 16. Greatly hypertrophied neuroglia cells, surrounding an arte- riole in the deepest layer of the cortex, in a case of advanced general paralysis. Analine black, fresh method. (x500.) The arteriole shows periarteritis. The nerve cells have for the most part disappeared. FIG. 44. Neuroglia Cells of the Brais, their Relations to the Blood- Vessels ; also the Sustentacolar Processes of the Epithelial Cells of the Litftiai. Ventricle Otarchi). A, Epithelial cells lining lateral TeDtricle; a, process of S£.mt, 6, upiiier or nenoglia cell; c, blood-vessel. CHAPTER VII. HEAD HEAT IN BRAIN DISEASE, CEREBRAL THERMOMETRY, AND CEPHALIC GALVANIZATION — THEIR VALUE IN DIAGNOSIS AND PRACTICE. Temperature taking since Wunderlich and Liebermeister has become in medicine a routine proceeding and the clin- ical thermometer is almost as familiar as the tongue and pulse in practice. From sublingual axillary and rectal tem- perature taking and the testing of the palmar heat by Couty, the practice has passed in clinical neurology through the studies of Broca, Alvarengo, Maragliano, Sepelli, Albers, Gray, Amidon, Mills, Lombard and others to the head. In that great Italian asylum for the insane at Reggio Amelia where chiefly brain diseases in their extreme and most calamitous degree come under notice, the two distin- guished Italian neurologists and alienists of Reggio Amelia made painstaking studies of cerebral thermometry in paresis or general paralysis of the insane, melancholia, furious mania, etc. These studies will interest you, for these cases will often come under your notice as well as all degrees below them of mental impairment, down to the morbid psy- chic caprices and hallucinations of hysteria and the morbid fears of mysophobia and neurasthenia. Paolo Bert found by self-experimentation when the temperature of the brain was not equal on both sides, it was higher over the left hemisphere in the frontal region. [70] 71 The heat was also highest on the left during intellectual activity. Others have confirmed this observation. Mills found augmented temperature in a tumor of the right frontal lobe which was found on autopsy to have destroyed the anterior half of the first and second convolutions, part of the corpus callosum and gyrus fornicatus, but it did not involve the speech center of Broca, hence though halluci- nated, mentally enfeebled, and with headache, vomiting and having nystagmus, impaired vision, olfaction and general sensation with dilated and fixed pupils, his speech power was intact. He had no aphasia. This is important for you to note with reference to a discussion of speech center disease or aphasia later in this course. My lamented friend, Landon Carter Gray, early put on record a lesion which he claims was the first intracranial tumor diagnosticated by cerebral thermometry. It was a glioma. The clinical symptoms pointed to the base but he located the tumor at the lateral aspect of the cerebrum and the autopsy confirmed the thermometric diagnosis. The average temperature of the right side of the head, the side of the tumor, was QQ ^'; of the left side it was ge !^, and of the whole head 97°84 / . Since then Mills has reported one case of frontal tumor and a gumma of the corpus callosum diagnosticated in part by local head heat increase; Eskridge, a tumor of the cerebellum with monocu- lar hemianopsia, and Putnam Jacobi a tubercular meningitis in the same way. Maragliano proved the thermometers could indicate accurately the temperature of the skull by filling the latter with water at different temperatures and testing thermomet- rically the temperature through the scalp and hair which he did not remove from the cranium. The temperature of the water in the skull and the heat on the scalp surface were 72 shown by simultaneous water and surface heat measure- ment-* to correspond. But do not be misled into concluding th.it, with no cranial increase of temperature existing, there can be no cranial disease. I have had one or two such cases myself. A brain tumor may exceptionally develop so slowlv as to not excite heat developing irritation for a time. Maragliano, Sepelli and Broca selected points behind the external orbital epiphysis for the frontal region; above the insertion of the ear for the temporal region; and along side the median line for the occipital region. The six centigrade thermometers used by them "for better isolation, were cov- ered with a little carded cotton wool and were fixed by means of a circular bandage, special care being taken that the bulbs were not pressed against the surface of the cra- nium. In the women the hairs were accurately divided, so that the elongated bulb of the thermometer might come into close contact with the scalp. The duration of the application was half an hour for each patient. Application was made in the axilla and the rectum in immediate suc- cession to those on the head, with the view of avoiding any false interpretation of the latter; * * febrile states may sometimes interpose, in patients examined, and the aug- mented temperature of the cranium then noted, might be attributed to local influence, whilst, on the contrary, it was but a manifestation of the system." The authors introduce three tables which we refrain from reproducing, substituting this summary, as the temper- ature of the normal brain as measured through the cranium is from 3>£ to 4)4 degrees less than it is in the axilla or rectum. "The mean temperature of the head in these examinations reached its maximum in furious mania {mania confurore), 36.89; and in a progressively decreasing line, in 73 lypemania agitata, 36.81; in general paresis (paralisi progres- siva), 36.63; in dementia agitata, 36.45; in imbecility and idiocy, 36.34; in mania, without fury, 36.30; in simple lype- mania, 36.17; and finally, in tranquil dementia, 36.03, cen- tigrade markings." The easiest way of turning these into Fahrenheit is to multiply by 2; deduct one-tenth the product and then add 32°. Thus 36.89x2=73.78-1-10 = 66.40, plus 32°= 98.40. There were differences between Maragliano's, Gray's, Broca's and Sepelli's results due somewhat to the different season at which their respective observations were made in June, July and August; Broca's and Gray's being in colder weather, Sepelli and Maragliano remind us (see Alienist and Neurologist as previously quoted) that "Wunderlich alluding to the various precautions to be taken in thermo- metric practice, observes that in observations made in sum- mer, it may be useful to take account of the surrounding temperature and that if such an observance is of value in axillary and rectal thermometry, it must be still more so in relation to that on the head." SEPELLI'S CEREBRAL THERMOMETRY MEASUREMENTS. 1st. The medium temperature of the sane man is, according to Sepelli's thermometric measurements, "36.13 for the left side and 36.08 for the right— 36.10 for the whole head. As to the diverse regions the means of the frontal lobes are 36.20 for the left and 36.15 for the right; of the parietal, 36.18 for the left and 36.15 for the right; of the occipital, 36.13 for the left and 36.08 for the right." 2d. "In the insane, except in simple lypemania and dementia, the mean temperature of the head is above normal, the highest degree being reached by mania with fury (36.89); lypemania next (36.81), then general paralysis 74 i.63) ; dementia agitata (36.45); imbecility and idiotism (^6.54); mania without fury (36.30); simple dementia (36.03). 3d. "In all the forms of mental disease the occipital lobes, as in the sane man, give a temperature lower than the other lobes; the temperature of the frontal lobes, which equals that of the parietal in dementia agitata, imbecility and idiotism, excels it in mania, simple lypemania and simple dementia, whilst in general paralysis and lypemania agitata the temperature of the parietal lobes "is higher than that of the frontal. 4th. In all the principal groups of mental diseases, the mean of the two halves of the head is almost equal, except in congenital forms. Here the right half presents figures higher than those of the left. (This tends to substantiate Wigan's idea that it is when the entire brain is involved and the balancing and correcting influence of the opposite hemisphere is impaired by disease that insanity appears. — Hughes.) 5th. The results of cerebral thermometry, placed in accord with what is known of the pathological anatomy of insanity, confirm the fact that in general paralysis, mania and divers periods of exaltation, which are frequently man- ifested even in forms of depression and mental enfeeblement, there exists 'a state of hyperemia of the brain. 6th. The surrounding temperature has a notable influ- ence on the results of cerebral thermometry. 7th. The general temperature of the body in the insane, taken in the axilla or in the rectum, is greater in lypemania agitata and mania furiosa, and in decreasing order it pro- ceeds, diminishing in general paralysis, dementia agitata, mania without fury, imbecility and idiocy, tranquil dementia and simple lypemania." 75 These results were obtained at the insane asylum o1 Reggio Emilia Sept. 20, 1878. They have not been inval- idated by later observations and have served me well in the clinical study of brain disease as they will serve you. Professor E. Maragliano read to the medical congress at Pisa September 26, 1879, the result of a series of experi- ments made by him in his School of General Pathology, in Genoa. He first, by means of experimental investigations* sought to eliminate whatever doubt might arise as regards the capacity of the cranial walls to transmit promptly in thermometers placed on the exterior, the internal oscillations of temperature. With this view he applied thermometers to the exterior of different cranial envelopments, which were filled with water, at various temperatures, and he was able to see that the thermometers on the outside rapidly followed the oscillations shown by those placed inside. He next studied the physiological and pathological tem- perature, and that present during chloralic sleep. The conclusions which he drew from these researches were the following: 1st. The thermometers applied to the cranial integu- ments faithfully follow the thermal internal oscillations. 2d. The cerebral temperature revealed in this manner in physiological conditions is shown more elevated on the left than on the right side, especially by thermometers placed near the frontal region. (The left is the driving side of the brain, or, preferably, active side ordinarily. — H.) 3d. The degree of temperature varies according to age and sex. 4th. In the same individual there are presented in the course of a day, from time to time, elevations or depressions which do not exceed half a degree. 5th. The cerebral temperature may have relations to 76 pathology, but relatively to the conditions existing between the two sides, or between points on the same side. 6th. To have absolute value, elevations or depressions, at least one degree above the physiological mean, arc called for. 7th. In cerebral embolism there is a diminution in the lobe irrigated by the plugged vessel, from which may be deduced an important diagnostic criterion. 8th. During the chloral sleep there is a constant dimi- nution of the cerebral temperature. (Suggesting arteriole contraction. — H.) Thus you see the importance and utility of cerebral thermometry in brain disease has been placed beyond doubt by Maragliano, SepelLi, Broca, Clouston, Gray, Mills, Voisin and many others. It is an element of diagnosis as Voisin claimed "matching in value that of the stethoscope in dis- eases of the chest." In Voisin's experiments on healthy brains the maximum figure for the cranium never exceeded 36° (96.8 F.) even when the brain was in a state of functional activity, and with diminution of this, the cerebral temperature descended concurrently to a lower figure. Voisin, Maragliano and Sepelli proved cranial hyperemia in general paralysis and in all of the cases of insanity with maniacal delirium, also in hyper- emia by cranial thermometry. The case described by Gray of cerebral thermometry, already referred to, was that of a woman aged 34, in which a pupillary stasis, paroxysms of pain in the temporal and superciliary regions, nausea, vomiting, ptosis and paralysis of the ocular muscles, had led the physician to form the diagnosis of intercranial tumors, situate at the base of the brain; Gray having the opportunity of observing it applied 77 the thermometer on various parts of the head and obtained the following results: LEFT. RIGHT. Frontal region 95° 75 98" 33 Parietal " 95 99 75 Occipital " 96 75 100 60 Resting on these data, he was able to conclude that the lesion must be extended from the base of the Sylvian fissure backwards along the right occipital lobe. The autopsy showed the existence of a gliomatuous tumor, situ- ate between the horizontal or posterior branch of the Sylvian fissure, and the parallel one of the right side, whilst the entire occipital lobe was converted into a colloid mass, extremely vascular. The meninges were unaltered. (The above and the following are taken from Maragliano and Sepelli's paper in Revista Spermentali and translated into the Alienist and Neurologist, vol. I, nos. 1 and 2.)* The other case, communicated to the Philadelphia Path- ological Society by Dr. Mills, on November 14th, was that of a man aged 36, in which the principal symptoms were intense headache, vomiting, mental enfeeblement, hallucina- tions, but without delirium, no disturbance of the speech, slight paralysis of the left arm, weakness in the lower limbs, deviation of the head to the right, nystagmus, blunted sensibility, diminution of vision and of olfaction, dilated pupils and pupillary stasis. The cerebral temperature taken for seven days preceding death, gave as mean, the follow- ing figures: Frontal median region 35.83 Frontal left " 34.83 Parietal " " 34.66 Occipital median 35.27 Frontal right " 35.00 Parietal " " :.34.83 *The translation of the cases of Mills and Gray into the medical literature of Italv show a flattering: appreciation of American experimental clinical work, for which the author cordially thanks his eminent Italian confreres in neurology. 7S Bert followed up these by exploring cranial tempera- ture areas corresponding to localities of brain, regarded as the seats of diverse functions and found some exaltations of temperature to follow intense psychomotor activity, but I have not the precise focal results to give you of his subse- quent experiments. 1 think the range, however, did not exceed one degree. Since all tissue are heat producers or thermogenic dur- ing vital activity, the brain is no exception, notwithstand- ing its special thermogenic centers. The liver is probably the greatest heat producer, the blood from its haepatic vein being warmer than that of the portal vein going to it, and muscles in action are thermogenic. "The normal axillary temperature is about 37.5 C, that of the mouth a little higher and of the rectum slightly more elevated. The mean temperature of the blood is placed at 39 C." (Wesley Mills.) The mean temperature of the body accessible to the thermometer varies not more than a degree and a half centigrade. The temperature of the haepatic vein (Wesley Mills Physiology) has been put down at 39.7 C, and it contains, as already said, the warmest blood of the body. The average normal temperature of the head through the cranium is 36.10. THE EFFECTS OF CEPHALIC ELECTRIZATION ON HEAD HEAT AND HEAD CONGESTION. It is more than thirty years since I began the practice of cephalic galvanization for epilepsy, cerebral hyperemia, hyperaemic headaches, cerebral hypothermia and other con- ditions associated with vaso-motor instability and arteriole irregularity in the brain's circulation apparatus. In support of the views 1 long ago held on" this subject 1 published in 7<) the Alienist and Neurologist for January, 1880, M. Ch. Letournian's experimental contribution undertaken to deter- mine what is the effect upon the vessels of the brain, of a moderate electrization with the galvanic (continuous) cur- rent through integuments and the cranial wall as nearly as practicable in conforming to ordinary therapeutic applica- tions. He made bare in a mammiferous animal a portion of the cerebral membranes and proceeded with the follow- ing demonstrations, securing a most valuable and triumphant demonstration of the inestimable physiologico-therapeutic fact that galvanism of the meninges of the brain will con- tract the arterioles of the brain's enveloping membranes, and I can likewise assure you the same agency so applied from os frontes to nuchae, with thoroughly wet sponge electrodes, P. pole to neck, N. pole so as to reach the cerebral vaso- motor centers of other parts of the brain by the current's course, will favorably impress brain congestion and arteriole irregularity and help in the cure of curable cases of epilepsy, etc., of which 1 shall speak in detail later. "Doctor Laborde assisted him in the experiment on a kitten a month old, in which the cranial wall was still very thin and was quite easy to cut, a considerable portion of cranium had been cut on the left side. The dura mater being so exposed it was very easy to see with the naked eye, and still better with a magnifying glass, the arterial and venous branches which ramify upon the surface. They proceeded then to the electrization, making use of the small portable pile for continuous current, of MM. Onimus and Brown. This pile contains eighteen elements and they took care by the aid of a galvanometer introduced into the cir- cuit to assure themselves that the passage of the current was effected regularly. During all the duration of the experiment, the positive pole was placed behind the right 80 . cending ramus of the inferior maxilla and the negative pole upon the anterior cranial region above the eyes. Ten or fifteen seconds after the closing of the circuit, the fine arterial branchings of the dura mater became less and less visible, and a little later, the venous branches them- selves became pale. At each interruption of the current the anemia increased for an instant, then the vessels resumed, little by little, a little larger caliber. The experiment, repeated a number of times, gave always the same results, determined successively by Doc- tors Duval, Laborde, Conderceau and themselves. The dura mater of the right side having been denuded in its turn, the experiment was repeated, which on this side again gave the same results. They pursued the experi- ment, cutting on the left side a portion of the dura mater. The pia mater being thus exposed, and its vascular branches, arterial and venous, being very visible upon the gray ground of the cerebral substance, the same observa- tions were made upon it. There also, we could obtain at will, contraction of the vessels. The experiments just related, they go on to state, added to facts cited in the commencement of this paper, put it beyond doubt thai it is possible, even easy, to produce in man a tem- porary anemia of the brain, by means of suitable electrisation; but the therapeutical bearing of this fact should not escape the physician. For litis temporary anemia can, without the least inconvenience, be renewed a great number of times daily, if one wishes; and ow personal experience permits us to affirm that, with a little persistence one may triumph so over various con- gestive states of the brain, manifesting themselves either by the simple depression of the intellectual faculties or by psychical disorders of varied nature. In support of the preceding statement they cite a typ- 81 ical case of chronic congestion of the brain, which has yielded to electrization repeated persistently, but which we omit. The abbe C, aged fifty-five years, is a corpulent, full- blooded person, with a highly colored countenance; he applied to us in despair because he suffered several times a week from persistent vertigo, during the duration of which he could not take a step without support, and from which he was relieved only by absolute repose. M. C. belonged to a religious community whose principal object is teaching, but he was obliged to renounce, little by little, all work. It had come to pass, he said, that he could scarcely recite his breviary and say mass. After various treatment, there was made to him, at the end of five months, an application of fifteen leeches, with so little effect that the next day he had a severe cerebral congestion, with loss of consciousness and instantaneous fall. This serious accident occurred several times afterwards, and was ordinar- ily accompanied by violent vomiting. To modify this inveterate organic state and restore a proper tonic contraction to vessels habitually dilated, a treatment of long duration was necessary. During five months they electrized the patient three times a week, placing the positive pole of a pile with continuous current at the level of the first cervical vertebra, the negative pole at the level of the superior ganglion of one of the cervical sympathetic nerves. The number of elements employed varied from fifteen to twenty, and they took care to inter- rupt the current every fifteen seconds; for experience shows that vascular contraction is produced especially at the open- ing and closing of the current. Each seance effected an immediate amelioration and longer and longer. Soon the patient was able to resume 82 his occupation, and to work, at first, one hour, then two hours, then four and five hours per day. At the same time the attacks of vertigo became more and more rare and brief. At the end of five months, the patient ceased a treatment which was no longer necessary; and for several months the alleviation has continued.* This fact is so eloquent, they say, that it appears to them useless to accompany it with comments, and it will surely suggest to practicing physicians, therapeutic applications numerous and various." *GazctU Hebdom., 3 Oct., 1879. CHAPTER VIII. THE TEMPERATURE SENSE, ETC., AND ITS ALTERATIONS IN DIAGNOSIS. THE MUSCULAR SENSE AND SENSE OF WEIGHT. The condition of the temperature sense is best deter- mined, after ascertaining the real thermal condition of the patient by means of the ordinary clinical thermometer, by applying to the patient's skin alternately hot and cold and warm waterdiscs or bottles or sponges of water, hot, cold and warm, and interrogating him as to what degree of heat sensation he feels at each application. If you have reason to suspect the patient or wish to exclude the possibility of malingering, apply the temperature tests unexpectedly and out of the range of the patient's vision at the time. He should also be otherwise managed about as in making an ordinary asstheseometric examination with an asstheseometer, i. e., suggestion of what tests you are about to use should be avoided. He should neither see the water heated nor cooled, boiled nor frozen. Besides BecquerePs discsand Lombard's thermo- electrical differential calorimeter they use in some of the Paris hospitals an instrument called Blocq's thermoassthesiometer, but an ordinary bath or water thermometer perforating a rubber stopper or disc of aluminum to keep it stationary and upright, and immersed in a test tube or bottle partly filled with water, capped to prevent the water spilling out and [83] 84 heated or cooled to suit the purpose of your examination will answei quite well. 1 show you the different devices and you may make your own choice. I think mine, like my Texas friend Beall's green straw catheter, is more readily devised for the emergency of country practice and less expensive, besides teaching a lesson in self-reliance in practice. Beall used to make capital fly blisters of potato bugs, mashed and rolled with lard and a rolling pin, and they draw well. If you should be called to a patient with high brain heat, too much blood in the head, a slow, full pulse, stupor and delirium or other apoplectic threatenings, put a sinapism or fly blister to the back of the neck to impress the vaso- motors and through them contract the cerebral arterioles. If neither mustard nor cantharides, or Spanish cantharadin ointment are at hand and the potato bugs are on the vine gather them in and imitate Beall's example. He made his mark on the profession as a successful man of expedients in practice like Tom Flornouy, one of Joe McDowell's patients on whom McDowell first tried Samuel Thompson's number six for dysenteric inflammation on the Hahnemann - ian principle of similia similibus curantur, sending his patient out the window and down the streets of Chillicothe without his trousers, clasping his nates with both hands and crying fire! Flornouy put out the fire in his rectal rear on the more rational principle of plenty of cold water and contraria contrariis curantur morbi. There are principles of practice on which I would always have you mens conscia recti, which liberally and latitudinously translated means, always be right on the management of the rectum, liver and other organs, if you would make a success in neurological practice. Do not treat but one spot and that spot the nervous system only. 85 And this reminds me of an apropos clinical illustration, vi%: a profound melancholia may be brought on; (that is, where a previous psychopathic constitutional proclivity exists which in neurological parlance we call a neuropathic diathesis,) through aggravated drain and irritation of the neuraxis centers, by a blind fistula in ano and cured by its prompt and efficient surgical relief. Such a case impressed me early in my professional career when I was a young military hospital surgeon. Examining the patient as 1, even that early, was accustomed to do, all over, 1 found the fistula and with my bistuary made an open sore of it and healed it from the bottom. Simultaneously with his rectal recovery, the rest and recuperation of his nerve centers came about clear up the cerebro-spinal axis to his cerebrum and lo ! the melancholia was gone. And thus it is in prac- tice we sometimes make both ends meet our purpose. In such a case as this the proctologists are not to be despised. They are useful workers at the other end of the neurolog- ical line and sometimes they may triumphantly exclaim, speaking of their special work, finis coronat opus! For man is a "vast chain of being," as I have said, when we consider the intimate relations of the grouping and chaining together of the wonderful neurones and neurone projection system that make up so much of his wondrous organism. BAROMETERNATUR OR BAROMETER NATURE. Let me now call your attention to a nervous condition especially peculiar to some neurotics in which a not easily describable heaviness of feeling and malaise possesses the patient under low pressure barometric states. It is not Katienjammer but Birometematur, as our German friends would say. It is an indescribable feeling appearing with atmospheric changes. The uric acid and the gouty neuro- 86 path often show it in connection with slight joint tinges and muscular pains and chronic malarial toxhaemics who have lonjj, ago ceased to have periodic malarial attacks, and chronic neurasthenics show it. Study this and see what you can make of it in after years of your medical obser- vations. An irreverent patient will come into your office and say, "this weather makes me feel like h — I;" another will more gently say, "1 feel mighty badly when these changes come," and yet neither can tell why. They expect you to know and tell them why. You will say learnedly, it is barometric or Barometernatur impression and their peculiar nervous susceptibility, A l P°«, meaning pressure, you know, and fitrpov, measure. You give them an insulated seance in the static chair, letting them smell the generated ozone of the battery and give such other prescription as tongue, pulse, etc., may indicate, say encouragingly, it will help them and tell them to come again if they do not feel lighter and better in a day or two. A good static treatment and a laxative relieve this feeling often. But it is wise to see the patient more than once, especially after the weather shall have changed and if such a feeling persists then examine him thoroughly by physical blood test and urinary explora- tion. He may have the beginnings of graver nervous trouble. It is well to examine all patients thoroughly even when they complain of comparatively slight and indefinite nervous symptoms, bearing in mind the sartorial motto, "a stitch in time saves nine," which Hippocrates might have made into a good medical aphorism but I do not recall that he did— though there is a similar one in the saying that "an ounce of prevention is worth a pound of cure." And my friend Marcy says, "an ounce of taffy is worth a pound of epitaphy." 87 When persons born and acclimated to our atmosphere show this Barometernahir their condition should be inquired into. They may need neurological or other medical at- tention. It is well, in all such cases, to establish the habit among your clientele of seeking from expert sources to know the significance of minor and incipient ailments that may be beyond their sight. The physician nowadays may see things by revelation of slide and lens, not visible to ordinary observation, as the astronomer sees the heavens. There are things beneath the over-arching dome of man's brain, down among the neurones of the cortex, basal ganglia, motor and sensory tracts, as difficult to see by common sight, as some distant planets and stars of lesser magnitude are to discern by other than expert astronomical vision. THE MUSCULAR SENSE AND SENSE OF WEIGHT. The exact consciousness of a man's muscular power is different in different individuals. If you know that a man has been accurate in the estimating of weights, you may gain some knowledge of his deterioration in this regard if any exists, by testing him with different weights. Also after ascertaining if he is right or left handed or ambidextrous and comparing both his weight holding and his weight estimating capacity. Through the muscular sense which is really a nerve ending sense the mind is informed as to the state of the muscular tonus, power and capacity of endur- ance. Some men are better endowed in this particular than women and at some times than at others in their lives. Elasticity of step, vigor of muscular movement, erect or stooping posture and steadiness of gait and standing are connected with it, even when there is neither muscula'r atrophy, pseudo-hypertrophy nor sclerosis. Absence of muscular tonus, accurate consciousness of exact muscular 88 strength and power associated with the neurotrophia and the myatrophia and myasthenia of neurasthenia and are to be estimated in diagnosis. The healthy man has an approxi- mative normal conception of his muscular power, a sense of muscular tonus that the neurasthenic, for instance, has not. The neurasthenic is uncertain in this regard, as he is timid and irresolute mentally. He feels constantly tired when in mental and muscular repose and may tell yuu he was born tired. At any rate, he has that constant "tired feeling" the advertising newspaper quacks are always on the lookout for, and which means nerve tone exhaustion, but which the quacks usually tell him mean much more. A healthy man has a normal conception of where his muscles are and the different parts of his body and can find and touch these parts in the dark or blindfolded. He knows where his feet, toes, hands, fingers, nose, mouth, ears, etc., are and can touch them readily with his eyes shut. Flex one of his limbs and he can tell you without the use of his eyes, what you have done. When the muscular sense is defective this can either not be known to the person or it is imperfectly appreciated according to the degree of impairment. In locomotor ataxia for instance this defect is so grave that the ground does not feel natural to the victim of this disease when walking and he cannot find his nose tip, approximate his finger tips or touch his ear lobes with accu- racy when his eyes are shut. This is a blending of impaired muscular sense and incoordination. The sensory nervous system is impaired in locomotor ataxia and the nervous mech- anism of the muscular system misinforms the brain when the muscular sense, as it has been termed, is impaired. The tactile sense or the general sensation sense, is different from the muscular sense, for they may be inde- 89 pendently impaired. It resides chiefly in the finger tips or on the skin and is important in diagnosis, as we shall dis- cover later. The tactile sense is the sense of touch and is measured by touching. The chief instruments for it are the assthesiometer and the thermosesthesiometer, the former already shown you and the latter, thermoa_ j sthesiometer, 1 show you now. The muscular sense is not tested by the dynamometer which 1 now show you but the dynamic power or muscular strength is. (See chapter on Instruments of Precision for further illustrations.) Hammond in this country first called the attention of neurologists to the thermo-electric calorimeter, an instrument used by Dr. Lombard for determining differences of temperature as my thermoaesthesio- meter is. Ranney modified Lombard's instru- ment and described his modification in his very descriptive treatise on neurology. The construction of this device is so simple that its appearance explains itself. It is simply a graded ther- mometer in a jar in which water at different temperatures is poured and the jar or test tube thus filled is ap- vw»raVn - FIG. 49. Axsec^ae o^cxXx^^ txe«.vo»V o»la'm. froitv - Scarce ^cvV\s.^'s book ow"Q.tcuic>a* yv& -'■>*§^ *i>(vfc oervVeoA vevXeVsTeae FIG. 50. A, A, A, A, area of blood clot. The cord is here shown enclosed in its dural sheath. The projections are the spinal nerve sheaths. The smaller cut shows section of cord and spinal nerves with the dura drawn aside. CHAPTER X. EXTRA-NEURAL OR ADNEURAL NERVOUS DISEASE. EXTRA-NEURAL NERVOUS DISEASE; CHROMATIC AND ACHROMATIC NEU- RONES, CHROMATOLYSIS, THERMAL CHANGES IN THE NEURONES, BRAIN NEURONES AS HEAT CENTERS, ADNEURAL HEAT CHANGES OF NEURONES, MARINESCO AND LUGARO'S LAW OF MORBID NEURONE CHANGE, REFLEX PHENOMENA AND THE NEURONES. While traumatism to the brain and spinal cord and disease impression on the heat centers, cause directly induced nervous disease, the over-heating of the neurones and morbid changes in them may take place from superheating of the blood; i. e., by hypohsemothermia, as in sunstroke. Coup de soliel may therefore be either an intra-neural or extra- neural nervous disease; according to the degree to which the neurones are involved and according to the man- ner in which it may be brought about, whether by the direct rays of a broiling sun overheating directly the neu- rones of the brain— or by the long continuance of high temperature, or it may be both, i. e., brought about by excessive heat of blood and by direct overheating of the cerebral neurones combined and heat centers. When appreciably grave nervous disease results from the influence of extra- neural conditions, it is the achromatic portion of the neurone, the nucleus and motor segments of the cells, that appear to be mostly affected. The chromatic [101] 102 or chromophile or stain- receiving portions, if influenced, do not seem to make the subject so markedly interesting to the clinical neurologist. Here is a postgraduate theme for you. We shall however ask you no green room questions on this subject. Here as elsewhere some influences effect only appear- ances, others do the real thing. It is when the non-coloring element of the cell or neurone is involved that the chief real harm is done to the nerve centers. Why this is so cytology does not yet fully enlighten us. It is ready to learn from you as the oncoming cyto-scientists and cyto- savants of the profession. LUGARO'S AND MARINESCO'S LAW OF MORBID NEURONE CHANGE. Now gentlemen, most authorities say that the fibrillar portion of the achromatic substance subserves the function of conducting the nervous waves. Cajal, Lenhasseck, Rob- ertson, Nissl and some others consider that we are not war- ranted in attributing the performance of functions to the fibrils alone. The non-organized portion of the achromatic substance is believed by Marinesco to be the seat of intense chemical phenomena and of such importance for the nervous element as to be appropriately designated the trophoplasm, that is the plasma of nutrition. That this substance is the seat of important metabolic changes is amply confirmed by other observers, more especially by Guiseppi Levi from his study of the fuchsinophile granules. According to Van- gehuchten, Nissl, Lugaro, Lenhasseck, Cajal and many others the chromophile substance of the protoplasm is a material of reserve, destined to serve for the nutrition of the nervous element. Marinesco believes it serves to augment the difference of potential of the centrifugal nerve wave.* ♦Ford Robertson, Text-book of Pathology and Nervous and Mental Diseases, page 222, edit., 1900. 103 The cell body contains, as you know, the nucleus and nucleolus and is the trophic center for the whole cell element as proved by ample experiment which cannot be entered upon today. Structural changes accompany modi- fication of function in the cell and vice versa, functional changes follow structural changes of the cells as I have already shown you. "When the energy of the cell is exhausted by prolonged or excessive activity the cell body and the nucleus are distinctly diminished in volume, the chromophile substance of the cell plasm or cytoplasm is small in amount and appears diffusedly granular. During normal activity the chromophile substance is uti- lized by the cell and slowly diminished in quantity," says Ford Robertson farther. This would seem to me to tend to establish the disintegration of the chromophile substance correlative with cell function and tend to show that it nevertheless has considerable to do with the poten- tiality of the cell fuchsinophile granules of Levi. The nucle- olus undergoes an increase in volume and the particles of chromophine adherent to it consequently tend to become more elongated. During rest the chromophile substance gradually accumulates again, the fuchsinophile granules diminish in numbers and the nucleolus assumes a smaller volume." Thus you see that whatever may be the cause or causes operating to develop nervous disease, whatever cause or gross change takes place in nerve centers or periphery through morbid alterations in blood supply or quality or in the environment of the nerve centers, or from traumatism or other external causes, it is the abnormal impression upon and the morbid response of the neurones, or glial connec- tions and their morbid expression, that gives us generally the phenomena of nervous diseases. Either the mesoglia or 104 the cytoplasm itself, i. <\, the >:ell plasm pFoper of the neu- rone either in its nucleus, nucleolus, neuraxone, dendrite, or gemmule, receives and responds in abnormal, crippled fashion to the morbid touch of its environment, whether this morbid touch be a germ, traumatism or a blood element altered in quantity, quality or toxically depraved, causing a change in the blood quality. Persistent malarial poisoning, chronic alcoholism, re- peated attacks of grip, the opium taking habit, habitual chloral, cocaine, cannabis indica and other narcotic drug habits, all of which are toxic to the neurones and in the beginning extra- neural, being impressions first made through the blood, should have much of your thought in practice. The medical practitioner should be on the lookout for these disturbances. Nerve tire, brain fag, the assaulting and weakening of the neurones are the beginnings of trouble and lead to grave con- sequences. We have here toxic neurones and nerve centers to deal with. As brain fag and nerve strain precede Bright's disease and dyspepsia ordinarily, and complicate other troubles, so do these extra or adneural states of the blood often precede pronounced nervous disease. The blood may be the life or death of the nerve centers and vice versa the life or death of nerve centers may be the life or death of the blood and of the organs the blood nourishes. The moral of this in medical practice is — take care of the neurones and of the blood as well as of the environment of your patients. The difference therefore between extra or adneural and intra -neural nervous disease is, that in the former the lesion of the nerve cell or some part of the neurone is secondary and functional to the extraneous influence imposed upon it, while the primary lesion has its beginning in the nerve cell or in its proliferations. Intra-neural may also follow extra- neural lesion because the extra- neural embarrassment of 105 the nerve or nerve center causes intra- neural change to sooner or later occur, as when nerve atrophy follows pres- sure or starvation of the nerve or neurone or nerve center group of neurones. There is an obvious difference too, in the gravity and permanence of the effect resulting from extra and intra- neural change, especially early in the dis- ease. The degenerations begin more tardily from extra- neural nervous disease and are often more readily removable, as in the adneural changes of syphilis, as I have already told you. Syphilitic nervous disease may be both extra and intra- neural. Marinesco* has recognized this fact. He says, "secondary degeneration of the nerve cell is uniform, beginning with disintegration of the chromatic substance in the neighborhood of the axis cylinder or neuraxone and extending to the rest of the neurone. The cell may repair, or it may atrophy and disappear. In primary degeneration the alterations are variable, grave and many." The achro- matic or non-color change substance is likely to become affected and this may make repair impossible and seal the fate of your patient. The pathology of the neurones, as I have already told you, will interest you in adneural as in other morbid nerve cell changes. They have been a never ceasing source of interest to me and the distinguished observer and author whom I have commended to you will make the subject entrancing to you in your vacation days. He quotes from Lugaro, who has summarized the effects of toxic agents on the nerve cells, much more than I have time to read you or you to listen, but I will give you enough to whet your appetite and in the summertime you may read the rest.t * G. Marinesco Les Polyneuritis en rapport avec les Theorie des Neurones, Bui. Med. 1895, n 97, quoted by Ford Robertson. tVide Ford Robertson p. 225, Lugaro, Recenti Progressi del' Anatomia de Systems Nervosa in Rapport alia Psichologia et alia Psichiatria, Riv. de Patol. Nerv. e Ment., 1899 11-12. 106 And those oi you who have mastered the Italian lan- guage will find floods ol light thrown on the fine anatomy, physiology and pathology of the nervous system by our wonderfully, industrious and intelligent Italian confreres Levi, Marinesco, Lugaro, Chiozzi and others. These extra- neural influences affect the nerve centers through impression on the neurones, their neurites, den- drites, gemmulae, neuroglia or mesoglia. They affect them morphologically by pressure or chemically, as poisons do, or by more or less rapid transformation of the physiological function of the neurone into morbid action by ajiatomical change, and anatomical change in a nerve cell is usu- ally preceded by some sort of molecular change. Now for example the sequellas of typhoid fever, which may be either a delirium or typho- mania (psychic neurones), a paralysis (psychomotor neurones), or neuritis or neuralgia (peripheral neurones). There are some influences which affect one part of the cell without immediately at least affecting the other parts of it. For instance, temporarily compressing the abdominal aorta, as Lugaro has shown, will cause a color change (chromotolysis) in the chromophile or chromatic part of the neurone, which color change in the cell will persist for some time after the cause is withdrawn and the functional disturbance has ceased. Artificially induced hypothermia and melonitril poisoning will do the same. Other slow poisonings will do the same and similarly affect the chro- mophile elements of the neurone while fatal doses of chloroform or ether do not change the chromophile part of the cell, as Lugaro has shown. The chromatic part of the cell seems to be concerned in the metabolisms and to be affected every time they are disturbed. Says Ford Robertson, "they play a very impor- 107 tant role in the functional metabolism of the nervous element, its alterations are a direct index of a nutritive alteration and that function will be entirely suppressed when the structural dispositions of the achromatic (or non- coloring) part of the cell which seems more strictly related to nerve conduction, are altered morphologically or chemic- ally." Among the new problems therefore in the pathology of the neurone is Lugaro's* and Marinesco's law for them, now generally accepted as true by expert cytologists, to which 1 have already referred and which 1 repeat to impress you, and that is that changes in chromatic cytoplasm, or color preferring cell tissue or chromophile plasma, as it is differ- ently termed, represent the reaction of the neurone to the cell coloring influence that disturbs the neurone and color causing changes in the neurone. These chromatic changes in the neurone, and the same is true in neurology as in psychiatry, are reparable, while achromatic changes in the neurone are irreparable and degen- erative. Robertson quotes this law with approval in his excellent discussion of the morbid conditions of nerve cells and from whom I would like to read in extenso did time permit. Remember 1 have commended this splendid author for reference during your leisure respite from the exacting demands of this course. It will prove a source of great enlightenment to you on the relation of cell pathology to mental diseases especially and also of cytopathology to neurology. Now this is the conclusion of the matter. Disease is impressed on the neurone, the neuroglia or mesoglia of nerve centers through either chemical or mechanical or morphological change. These neurones have chromatic and achromatic parts and are said to be chromo- *Nuovi data e nuovi problemi nella patologia della cellula nervosi, Revista ii Palologia Nervosi e mentali. 1896. f 8. Vide ante from Robertson. 108 phile or achromophile, chromatic or achromatic; that is, to have either a color selection, love or color aversion or repulsion and love is an affinity in cytology, as well as in psychology, and chromophile cytoplasm or neurone changes arc capable of regeneration and repair, while achromophile changes in cytoplasm are degenerate and irreparable and this reparability and non-reparability of the different parts of the neurone is Lugaro and Maranesco's law and by this law good diagnostic judges pronounce the verdict of life or death to nerve element and they declare prognoses of chron- icity or death to your patient in the grasp of a nervous affection. It is a valuable criterion for necroscopic conclu- sions in the cytopathology of neurology and psychology. That brilliant observer, Ford Robertson, to whom you note I love to refer as I do, to the masterly Maudsley in matters physio-psychical, (vide p. 240) unconsciously touches upon the subject of extra- neural nervous disease without especially mentioning it in the following words under the head of morbid conditions of the nerve cells: "It is necessary to distinguish clearly between special diseases of the nerve cell, and mere types of morbid change that may be observed to affect it. Changes such as chromatolysis, vac- uolation and the pigmentary degeneration, cannot be regarded as diseases of the nerve cell, but only as types of morbid alteration occurring in several forms of disease. At present the only definite diseases of the nerve cell that are known are primary degeneration (in which, however, future research will, without doubt, enable us to recognize various distinct forms and secondary degenerations)." I do not, however, concur with him in regard to vacuolation. Vacuolation may be a structural intra-neural as well as neu- roglial change. It is destruction of nerve cell or nerve ele- ment, or of the connecting neuroglial framework of the neu- 109 rone, and this is entitled to be regarded as structural nervous disease. If an egg basket is destroyed while it holds the eggs in place as the neuroglia hold the neurones in place, the eggs are apt to be displaced and damaged, if not destroyed. The neurones must similarly suffer in their glial framework under vacuolating change, as in that singular paralytic spinal nerv- ous disease, syringomyelia, whose pathology is revealed in gliosis or gliomatosis or abnormal proliferation or hyperplasia of gliomatous tissue and vacuolation, a disease whose path- ology I have sometimes curtly called in the clinics holes in the spinal marrow, as its Greek origins signify. Syrinx, o~vpi.y t a tube or canal and myelos, /^eAos, marrow, a chronic, painful, parassthetic, thermo-anaesthetic hollowing out disease of the spinal cord with trophic changes in skin, joint and bones, which we will discuss more fully later on. Likewise porencephalia. "Chromatolysis," is a color change or disintegration of chromophile cytoplasm, according to that eminent cytological authority, Marinesco, introduced by Robertson, who defines it as a disintegration of the chromatic particles of the pro- toplasm, breaking up the aggregations of the granules that form the Nissl- bodies and gradual disappearance of the indi- vidual granules, accompanied in transition stages by their diminished affinity for basic dyes. But it has been frequently used in a wider and more general sense, namely, to indicate the whole series of changes in the constituent elements of the cell, of which dissolution of the chromatic particles is merely the first that is recognizable. Its employment in this wider sense can only lead to confusion, and ought to be abandoned he says; but the clinicians and pathologists will continue to give it this wider meaning while the cyto-micro- scopists may restrict its pure cytological description. Van- gehuchten employs the term "chromolysis" as a synonym. 110 Chromatolysis or chromolysis has already been indicated. It accompanies primary and secondary degeneration in almost all their forms. Moreover it occurs as a physiological con- dition in fatigue of the nerve cell; as tar as can be deter- mined by microscopical examination, the chromophile part of the cytoplasm is the most sensitive constituent of the nerve cell under abnormal nutritional conditions. (It is both primary and secondary in cell change). The exact mechanism of the production of chromatolysis in pathological states is little understood. Probably in certain instances there is especially an increased consumption of the chromo- phile substance, in others especially an arrest of its func- tion." "Chromatolysis has been observed in the human sub- ject in a very large number of different morbid conditions. Indeed, it is now known that it occurs in some degree in a proportion of the nerve cells of almost every individual on the face of the earth dying a natural death. Even in non- nervous diseases it is very commonly a very extensive and well marked accompaniment of morbid change in the cells of the cerebral cortex, spinal cord, etc. In such cases it is to be attributed to the action of toxic substances generated in the course of the particular disease, to pyrexia, terminal auto-intoxication or local vascular lesions. At the same time abundant evidence has now been accumulated of the special incidence of chromatolysis in various forms of nerv- ous disease. But in these cases it is generally accompanied by other morbid alterations in the cells which at once give to the pathological picture a much graver aspect." "Marinesco has applied the term 'achromatosis' to a change which consists especially in an extreme degree of chromatolysis — complete disappearance of the chromophile elements of the cytoplasm. In preparations stained with Ill polychrome blue, the cytoplasm appears pale or absolutely colorless, resembling dull glass. He has observed this con- dition of achromatosis in the cells of the anterior root after evulsion of spinal nerves and in those of the cerebral cortex in diabetes insipidus, leprosy, pellagra, etc. It corre- sponds morphologically to the extreme degree of the lesion observed to attend experimental elevation of temperature." This discussion of chromatolysis is a little more complex for advanced students of cytology than we have presented it and you will find much in the same line to interest you farther in Barker and other advanced cytologists, enough to entertain your leisure hours like a story and to reveal to you how much stranger than literary fiction are the truths of advancing neurocytological science. The changes other than chromatolithic which take place in the neurone, consist of varicose hypertrophy of the axone or of the axis cylinder process as Golgi described it, the granular changes of Bevan Lewis from which Ford Robert- son dissents, nucleal displacements, total or partial neurone obliteration or necrosis, homogeneous degeneration and atrophy and other changes not yet designated by name in cytology and other transformations of cells yet to be described. These will add to the marvels of your micro- scopes, as you may find time to look for them and search out the mysteries of microcosm for yourselves. Lugaro's more recent views also upon the pathological significance of lesions of the chromatic and achromatic parts of cells considered of so much interest and great practical importance that he quotes as follows, which 1 give you as still apropos to our subject and in proof, from higher author- ity, of what 1 have already said. "From the complex of the studies that have been made we may also form criteria of the reparability of the lesions. 11-' We know that the lesions of the chromatic part of the neurone . are the first to appear, in all cases in which the harmful action dues not act suddenly and with such energy as to paralyze function; that they are in every case repar- able even when very grave, provided that ether parts of the cell have not suffered serious damage. It is very doubtful if lesions of the achromatic parts can be repaired, more especially since they very often appear contempora- neously with lesions of the nucleus, the integrity of which is indispensable for the conservation of the cell. Of great importance is the question if functional dis- turbances ought tn be considered as an expression, pure and simple <>t the lesions revealed by Nissl, that is to say, of those that concern the chromatic part of the cell. The results of experimental researches tell us clearly that an exact and constant relation there is not; that function can be disturbed without there being any apparent lesion of the chromatic part, which on the other hand may be altered, even gravely, without our being able to discover any evident functional disturbance. In acute poisonings, especially by substances which exhibit rapid diffusion and action, such as chloroform and ether, when there is really an imposing symptomatological picture, or when the toxic action has already determined death, one cannot recognize any apparent modifications in the chromatic parts of the nerve cells. Modifications are, on the other hand, very evident in sub- acute poisonings, even before functional disturbances have appeared. This shows without doubt that the functional activity of the cell can continue even when the chromatic part is injured, and that this part does not possess structural arrangements necessary for the fulfillment of its function, which depends therefore, upon chemical composition, and 11 ! not upon morphological disposition. If to this we add the fact that the chromatic part is rapidly affected every time that metabolism is disturbed, locally or generally, and that it diminishes in quantity in consequence of protracted func- tional activity, we can hardly doubt that the chromatic part plays a very important role in the functional metabolism of the nervous element, and that therefore its alterations are a direct index of nutritive alteration. In other words, they are not exactly proportional to the functional disturbance; within certain limits of structural alteration function can remain intact, and will not exhibit disturbance with certainty except in cases of grave alteration, when the nutritive alteration is also grave. On the other hand, function will be entirely suppressed when the structural dispositions of the achromatic part, which seem more strictly related to the nervous conduction, are altered, or when they are suddenly affected by energetic chemical action, and Ford Robertson considers it also very probable, that purely local degenera- tive changes in the branches of the dendrites and in the collaterals of the axis-cylinder processes are of considerable importance in nerve cell pathology." And why not? For as I have told you in a previous lecture, no change can take place in structure without that change being corre- spondingly felt in function even though it may be so slight, like the ripple of a pebble dropped into the ocean at night time, as not to be revealed to our vision. The chromatic part of the cell may be likened in its relation to the achro- matic portion of the neurone, to the porch of a house. The house does not greatly suffer if the porch gets a coat of paint. The neurones and all the nerve elements of a nerve center, while definitely affecting certain nerve centers so as to attract one's special attention there and give the symp- 114 torn grouping especial designation of a particular nervous disease,, may involve other centers — certain systemic diseases of the spinal cord, for instance, implicating the medulla oblongata and other important centers without its being the chief location of the disease Take for illustration, locomotor ataxia, called also tabes dorsalis or posterior spinal sclerosis, the latter to designate its special pathological seat in the posterior root zones of the spinal cord. Its characteristic lancinating pains, which show sensory disturbances origina- ting in the posterior column and the later trophic changes in the joints from trophic center invasion of the spinal cord, are not all of the symptoms, though they prominently engage our attention. In this disease we have also the implication of the cilio- spinal center, high up in the cervical segments of the cord, giving the Argyll-Robertson pupil, and we have the involvement of the medulla in the laryngeal and pharyngeal crises and even the implication of the fourth ventricle of the brain as shown in the vagus disturbance which comes on later in the disease, contribu- ting to cause the gastric crisis, as it is called, of locomotor ataxia. Myelitis or inflammation of the cord may also involve the medulla. So also may progressive muscular atrophy, amyotrophic lateral sclerosis, multiple or disseminated scle- rosis and gliosis, of which you are yet to learn much. These diseases may attack this vital nerve center in their onward and upward progress. Reflex functional nervous disease is also of the nature of extra -neural or adneural disease, as when an intestinal irritation excites the so-called convulsive or spasm centers of the medulla, as Nothnagle designated them, since contro- verted by Oppenheim and others. This is only the morbid touching of vasomotor centers whose irritation from ec- 115 centric or peripheral disturbance impresses the blood supply of the arterioles or nourishing blood vessels of the psycho- motor or other areas of the brain and medulla, throwing the brain into convulsive states* causes fainting,, nausea, etc. the nausea itself being a reflex impression back to the stomach through the vagus center impression, as the head may be affected from the stomach, the condition causing nausea by sending its impressions up through the vagi or paralyzing the vaso-motor centers and making the brain hyperaemic as I have seen it from an intestinal tape worm. Disturbances of the brain from visual defects are of this nature and from sudden peripheral injuries such as cause fainting, nausea, etc., by its impression up through the pneumogastric. Extra- neural states affecting the nervous system in one part may also be the result of nerve center disorder in another as when the heat centers are so deranged that the normal balance between heat production and heat distribu- tion is not maintained and hypothermia or hyperthermia and their consequences follow. A good deal of see-saw reflex impression both eccentric and centric takes place throughout the nervous system by means of its wonderful central and peripheral connections, as you are soon to discover, as we proceed in our elucidations of neurology. The cerebro-spinal and sympathetic neural chain is a chain of many marvelous links and of wondrous mechanism as you will learn before you become finished neurologists. When we contemplate its "vast chain of being," "as we see it in the cerebro-spinal axis and its allied sympathetic and other parts of the peripheral nervous system, we are prompted, from a higher possession of neural *"Bechterew, who confirmed Nothnagle's observations, showed that these spasms appearing in a lesion of a definite pontine area (Vasomotor centers?) are derived from the cerebrum." — Mayer's Oppenheim, 1900, p. 626. 116 knowledge than the psalmist to exclaim, "how wonderfully wrought." Parasites and the parasitic growths which they develop about them in the brain or elsewhere in the nervous system are extra-neural causes of nervous disease like gliomata in the neuroglia or mesoglia between the neurones. Echino- cocci and cysticerci are the chief parasites, and they usually attack the brain surface, causing hydatid cysts. Morbid involvement of the neuroglia and mesoglia are in the nature of extra- neural disease, coming under the head of what Lugaro would call inter- neuronic in contra distinction from intra- neuronic or within the neurone proper. A distinction has also been made between disease of the cell prolongation and of the cell itself by this author. A physio- chemical change takes place in an efferent nerve fiber, which causes a physio-chemical change in its neigh- boring neuroglia and adjoining neurones, which may be partly inter-neural and partly intra-neurai. But we will not further discuss this subject now. FIG. 51. it ii MJb >TvAYu.mewXs rectstorv otaectnx>raeA.e A, spiral surface thermometer, B, Seguin's flattened bulb surface thermometer. C, Immisch's watch-shaped surface thermometer. D, ordinary water thermometer for bath. E, Landon Carter Gray's covered surface thermometer. F, ordinary self-regulating clinical thermometer. ELECTRICAL APPLIANCES. Besides its use in testing for the reaction of degeneration, electricity is employed for the treatment, regulation and control of arteriole circulation, (irritating or paralyzing the vaso-motor system), restraining or stimulating circulation, stimulating the function of the heart and other organs, tranquil- izing the sensory nervous system and alleviating pain, (by altering the molecular activities and transmissibility of sensory nerves), promoting nutrition, destroying germs and morbid growths, electro-massage, curing paralysis and paresis, improving and restoring defective or lost sight (in Seelinblindheit especially), and for various diagnostic purposes, the latter including the use of the x-ray and the electric lights in various forms of endoscopes, of which the polyscope is a combination. It is used in general as well as neurological specialties, and in most of the specialties as well. Special appliances for its application are brought into requisition in special electro-therapeutic work, as in electro-cautery, electro-catophoresis, etc. GALVANO-FARADIC DRY CELL BATTERY. The various forms of batteries and electrical machines and- special ap- pliances may be seen in the illustrated catalogues of the manufacturers. CHAPTER XI. INSTRUMENTS AND PROCEDURES OF PRECISION IN DIAGNOSIS AND PRACTICE. The perceptive powers are enhanced by methods and instruments of precision in diagnosis and practice. The sight is improved by lenses, as when with the opthalmo- scope we search the inner chambers of the eye; the tactile sense is helped by the probe, and our estimate of sensation is assisted in its measurement by the assthesiometer. The dynamometer helps us to appreciate the patient's grip and other muscular power; the degree of heat, though it may be felt and approximately estimated by applying the hand is accurately recorded by the thermometer and the calorimeter. The patient's power of heat appreciation is shown by the thermoaesthesiometer and of his sensitiveness to weight by the baraesthesiometer. The perimeter measures the range and area of the field of vision; the tuning fork and the acoumeter are used for testing the sense of sound, the com- pass points, blunt and sharp, for testing anaesthesia, hyper- esthesia, hyperalgesia and analgesia; the stethoscope for ascertaining arterial and thoracic and abdominal sounds, the ophthalmoscope, the endoscope and x-ray for seeing into the cavities beyond normal vision, and surgical sounds and probes for feeling beyond normal touch, etc. The constant current battery is used for testing the reaction of degener- ation, the faradic for ascertaining the degree of normal [117] 118 muscular reaction, etc., in practice. All of these and other appliances used by the advanced neurologist in his practice will now be shown you, and briefly described. The thermometers, general clinical, and local have already been shown at the end of the preceding chapter. FIG. 52. For sampling muscular tissue for microscopic examination, pseudohypertro- phic muscular paralysis, progressive muscular atrophy, etc. A is the handle with D, the blade, all ready for use; E is a sliding receiving cylinder at- tached to and under the blade ready to be thrust forward to catch a minute piece of flesh; C is the 'slide button which you push forward when ready to secure on the cylinder the piece of flesh; D, D, shows the blade closed and ready for withdrawal. FIG. 53. \vxxc^«si»«v &Vvo*\tv« o\AvCe.-oo2vvo;A, ^^ * Hammond was a worker in his day and wrought well in the neurological vineyard. You will hear more of him from me later. Here is a sample of his diagnostic work with the harpoon of Duchenne or Duchenne's trocar, as he 119 called it. (See Fig. 52). The cut shows a sample of thi muscle striae or what is left of them, taken from the low portion of the tibialis anticus of a boy in an advanced stage of organic infantile paralysis. "The transverse striae have nearly disappeared, but globules are seen in large numbers and fat corpuscles are also abundant." But there is not, as Duchenne affirms and as Ham- mond says, this degeneration in every case. In two cases which had lasted over four years, Hammond "found the structure of the muscle unchanged." 1 only show this one of the seven samples given by Hammond under the caption of "infantile spinal paralysis" to illustrate one of the uses of this sometimes useful little harpoon. It is especially of service in determining a doubtful ques- tion concerning progressive muscular atrophy of the degen- erative type, as distinguished from simpler myasthenic forms of muscular wasting. Hammond also in this country first described the diagnostic use in neurology of the dynamograph in the Journal of Psychological Medicine, New York, January, 1868. THE DYNAMOMETER AND ITS USES. FIG. 54. \A u vci -XtXcuWv e\x U v^xvOvXuatn etc r The ordinary dynamograph (from the Greek Sum/us, power and ypacfrav, to write, is a dynamometer with an 120 attachment for automatically registering power. In this sense the instruments of Hamilton and Burq are dynamo- graphs also, for they automatically register strength, but the medical dynamograph makes a written record of muscular power. The neurological dynamograph is used for recording muscular contractions, and is also of value in diagnosis. The neurological dynamograph is made by blending the features of a Burq dynamometer with those of the sphygmograph for recording muscular action. It transcribes to paper a record of the muscular tonus and power of the individual and the perfection or imperfection of the muscular sense. The use of this combined instrument is of value espe- cially for record of cases. But sampling the patient's hand- writing with pen and pencil and requiring him to make straight and curved lines, etc, in connection with the dynamometer will answer most purposes of this feature of diagnosis, without this somewhat expensive instrument. A healthy person, young or middle aged, makes a fairly straight line and a fairly steady signature. Incoordination modifies pen or pencil strokes or signatures and senility, nervous debility, paralysis agitans, sclerosis, chorea, paralysis or insanity are often so marked by changed hand writing that the latter is diagnostic, so that the pen is sometimes as mighty as the knife in diagnosis. The surgeon sometimes makes explo- ratory incisions for a purpose similar to that of our pen pictures of palsy and incoordination. Our records are blood- less. Their pathways are strewn with blood. The best of all hand dynamometers now at the com- mand of neurologists is the excellent rubber bulb upright one devised by Dr. Allen McLane Hamilton of New York City. It does not hurt a tender hand like the Burq-Matthieu's and does not require in its use such an extensive grip as the 121 latter. Its only disadvantage is that the rubber after a time hardens and breaks, but the springy resistance of Matthieu's also weakens after awhile and impairs its utility. THE DYNAMOMETER. FIG. 55. T-n ' m One of the most valuable instruments in neurological practice for testing sensibility is the assthesiometer as devised by Sieveking, and one of the most important dis- coveries in neuro-diagnosis was that of Webber's distance sensation points. Here is an illustration of an assthesiometer, devised by myself: THE AUTHOR'S yESTHESIOMETER. FIG. 56. Three-fourths Actual Size ('open). The points of this instrument fold up like a pocketknife. It has reversible sharp and blunt points, the English or decimal scale and Weber's distance points engraved on it. It is constructed of aluminum or silver and steel. 122 FIG. 57. H.6.&M.I.C0. NK.POST Af?M BK LG" THl FT.DOR I SAC j PTA .... V.F NK.ANT. D.HD . . . . D H. MET. - • ZYG . . ■ ■ 6T.T0.PmcK N.D 32 F ._ AlP Z°FTIP~ F TIP. . . T.TIP . • • . Exact size closed tor carrying in the pocket. showing the distance points engraved and named. The Eesthesiometer was invented by Sieveking, of London, in 1858. E. H. Weber utilized this valuable instrument in the making of an important discovery, namely, that the power to recognize two simultaneous but distant impressions (cutaneous, lingual, etc.,) varies accord- ing to the distance of the points of contact apart from each other in differ- ent parts, in a longitudinal line with the body in health. That is, there is a normal variation according to the region tested. There is also a comparative variation or departure in tactile sensibility from the normal perceptibility of the points in contact with the body, when nervous disease exists. The tongue, lips, finger tips, back and palms of the ^ hands, wrists, cheek, chin, dorsum, nucha, middle of the thigh, etc., all have physiological distance perception, especially in line parallel with the distribution of the sensory nerves. Any departure in recognition of two points of the ajsthesiometer from the normal distances for the several localities, indicates disease, anaesthesia, hyperassthesia, etc. In the most sensitive parts, as tip of the tongue, palmar surface of second and third finger and red surface of lips, the points are distinguished at from half a line to two lines distant, while on the dorsum of the tongue and back or an 123 inch on its sides, the points must be separated four lines or more to be perceived in health. The distance is a line greater for the dorsal aspect of the second finger, the palm of the hand, skin of the cheek, external surface of the eyelids, etc., while the normal recognition distance widens at the zygoma and lower forehead to ten, at the lower occi- put to twelve and at the back of the hand to fourteen lines. The vortex and upper jaw require a distance of fifteen lines. The normal perception distance of the patella is six- teen lines, that of the sacrum, accromion, leg, knee and dorsum of foot near the toes is eighteen lines. The nerves of the skin of the sternum perceive the points at twenty lines. Over the five upper cervical vertebra? and the spine under the occiput and in the loins we must separate our points twenty-four lines distant to have them separately recognized by the sensory nervous system at these locali- ties of the back, while over the middle of the neck or back, or arm or thigh, only a separation of the assthesiometric points to thirty lines apart will elicit distinctive recognition. There are other distance points, but these 1 have condensed from Weber's table and classified them so that you may easily remember them. This is a remarkable property of the sentient nervous system. 1 suppose if we could get at the fundus of the eye we should find it so sensitive that it could not be thus measured. Sieveking's aesthesiometer consisted in adapt- ing to a graduated measuring bar a pair of sliding points making a sort of beam compass, adapted by means of a graduated curved bar to a pair of carpenter's compasses and Hammond substituted a straight measuring bar. You may utilize a hairpin and any measuring scale that shows the inch divided into twelfths or decimals for approximative measurements. Two toothpicks with a Web- 124 er's table and measuring scale will do, but for absolute record, accuracy and rapid and ready use, 1 think the instrument 1 show you of my own devising is the best ex- tant. It will save the time of reference to Weber's tables and aid your memory as to the normal distance points. THE BAR/ESTHESIOMETER, PIEZOMETER, ETC. FIG. 58. \LiTpoY, a. icxAKk^vv**. An instrument devised by Eulenburg for testing the sense of press- ure in different parts of the body. It consists of a button at the eud of a spiral spring which, as it is pressed upon, turns a rer ' tering needle on an index. .^ rt - .. The distinguished German neurologist Eulenburg, used this little device for testing degrees of the weight sense or surface pressure feeling. Press the button over corresponding spots on opposite sides until discomfort is complained of, then register the tender or painful spot. Practice pressing it to the skin of healthy persons and the neurotically hyperass- thetic and note the difference. It will also register degrees of neuritic and other forms of hyperesthesia. Some of your patients cannot tolerate the static electric roller applied ever so lightly or the lightest Franklinic spark, because of extreme cutaneous hyperesthesia. Try this instrument on them and 125 record your observations. I have modified the dial by increas- ing in number the index spaces, and the button by enlarging it one-fourth in diameter. It has been of some service to me in determining a degree of neuritis associated with circumscribed meningitis verticalli. When patients come to you revealing sense disturbances of any kind on their cutaneous surfaces as heat spots, cold spots, circumscribed assthesias or algesias (plus or minus)or other forms of sense hallucination like for- mication, etc., classed as paresthesia, it would be well to make also a barassthesiometric test and other like examin- ations to find out, precisely if you can, the exact condition of the sensory nervous system as to the normal or abnormal manner in which it perceives cutaneous impressions. BEARD'S PIEZOMETER. FIG. 59. Piezometer (mefav, to press). Dr. George M. Beard, author of the best-known treatise extant on neurasthenia, also devised an ingenious instru- ment for testing the cutaneous appreciation of pressure, in examinations of the sensory nervous system, which I here show you. The ordinary piezometer is used for testing the com- pressibility and pressure power of gases and liquids. This instrument consists of a tube, a graduated slot, spring and and piston, with indicator thereon sliding over the scale on the side of the slot, to measure the sensitiveness of the skin to pressure. It shows the forehead, cheeks, finger tips and tongue to be most sensitive to pressure, and the 126 calves of the legs, dorsum of the thighs and fleshiest part over the flexor muscle group of the forearm to be the least sensitive to pressure. rhe sensory nervous system is one of the vital organ- isms ol the body, a part of its most important physiological machinery. It has important centers in the neuraxis and puts man in close touch with all parts of himself, within his organ- ism, and with his environments without, and by means of gesthesiometry we are brought into intelligent touch with man in disease. For instance, the girdle and lightning pains and paresthetic sensations of posterior spinal sclerosis, the darting, painful paroxysms of neuralgia, the throat globus of hysteria and the aura of epilepsia. These are all aesthetic perversions, revealed through disorder involving sensory nerve centers. Slight appearing conditions of the sensory nervous system often have graver significance than the patients attach to them, as for instance the paresthesias (formications, numb- nesses, tingling sensations, etc.) which precede cerebral paralysis and the graver hallucinations of mania a potn and delirium tremens or epilesia. On the other hand, patients sometimes have apprehensions graver than the fact of nervous disturbance warrant, but these are usually asso- ciated with pain disturbance, though often underestimated. A persistent headache may presage a brain tumor or gumma, a grave meningeal disturbance; or an evanescent headache may indicate the slight meningeal irritation of transient hyperemia or a passing toxaemia as after an alcoholic drunk; "katzenjammer" for example. Marre's and Pond's sphygmographs for recording pulse and Masso's plethysmograph and balance, devised to demon- strate changes in the vascular system, are likewise useful in neurodiagnosis. Then there is the chronoscope for testing or measuring thought reaction time, the neuromobimeter or nerve 127 reply measurer, as Dr. Joseph Warren called it; also the knee reflex measure and devices that readily suggest them- selves, as salt, sugar and pepper, for taste, and the color- blind tests of ophthalmology. The watch, the tuning fork and Politzer's acoumeter are used in neurology for measuring the acuteness or dull- ness of hearing in certain suspected brain diseases and for topical diagnosis in cerebrology. By them we may be aided in locating tumors of the interior of the brain, as the ophthalmoscope also aids us in this particular, but not so much as the eye symptoms independently of what the ophthalmoscope reveals. OPHTHALMOSCOPE, NORMAL AND ABNORMAL EYE FUNDUS. These illustrations show for comparison the normal and abnormal fundus of the eye and the instrument by which they are revealed. The chief value of the ophthalmoscope to the neurolo- gist is in the determining of the existence of optic retinitis or choked disc, evidencing blood pressure or altered circu- lation in the brain states caused by tumors gumma within the cerebrum or cerebellum. Optic retinitis is associated also with the interstitial nephritis of morbus Brightii, which very often is a sequen- tial condition of profound brain strain, in my medical experience, as are also the tube casts so often found coex- isting with the albuminuria. A good deal of practice will be necessary before you become sufficiently expert to use the ophthalmoscope as an instrument of diagnosis of intra-cranial disease. If a thor- oughly expert ophthalmologist is convenient to you, I would advise you to call him to your aid where the nervous 128 symptoms may lead you to suspect a cerebral tumor or other serious brain disease, or when you have that nervous breakdown which precedes and goes with tube casts and albuminuria and where you likewise should look for con- joint and confirmatory optic retinitis. The fundus occult is likely to befriend you, if you take it into your confidence in the diagnosis of these grave brain nervous system conditions. Our lamented colleagues, Drs. Murrell and Dickinson, in the chair of ophthalmology, and their able successor, Dr. Henderson, have been of signal help to us in this sphere of cooperative neurodiagnosis, as have Drs. Green, Post, Alt, Saxl and others of this city and elsewhere. LORING'S OPHTHALMOSCOPE. FIG. 60. 129 NORMAL EYE FUNDUS. FIG. 61. a v nasal "A s d sa n se para* B —Head of the Optic Nerve. A, Ophthalmoscopic View.— Somewhat to the inner side of the center of the papilla the cen- tral artery rises from below, and to the temporal side of it rises the central vein. At the temporal side of the latter lies the small physiological excavation with the gray stippling of the lamina cribrosa. The papilla is encircled by the light scleral ring, (between c and d), and the dark chorioidal ring at d. B. Longitudinal Section through the Head of the Optic Nerve. Magnified 14 x 1.— The trunk of the nerve up to the lamina cribrosa has a dark color because it consists of medul- lated nerve- fibers, n, which have been stained black by Weigert's method. The clear inter- spaces, se, separating them correspond to the septa composed of connective tissue. The nerve-trunk is enveloped by the sheath of pia mater, p, the arachnoid sheath, nr, and the sheath of dura mater, du. There is a free interspace remaining between the sheaths, con- sisting of the subdural space, sd, and the subarachnoid space, sa. Both spaces have a blind ending in the sclera at e. The sheath of dura mater passes into the external layers, sa. of the sclera, the sheath of pia mater into the internal layers, si, which latter extend as the lamina cribrosa transversely across the course of the optic nerve. The nerve is represented in front of the lamina as of light color, because here it consists of non-medullated and hence transparent nerve-fibers. The optic nerve spreads out upon the retina, r. in such a way that in its center there is produced a funnel-shaped depression, the vascular funnel, b, on whose inner wall the central artery, a, and the central vein, v. ascend. The chorioid.. d', shows a transverse section of its numerous blood-vessels, and toward the retina a dark line, the pigment epithelium ; next the margin of the foramen for the optic nerve and correspond- ing to the situation of the chorioidal ring, the chorioid is more darkly pigmented, ci is a posterior short ciliary artery which reaches the chorioid through the sclera. Between the edge of the chorioid; d, and the margin of the head of the optic nerve, c. there is a narrow interspace in which the sclera lies exposed, and which corresponds to the scleral ring visible with the ophthalmoscope. ~ fo.^»fo* $»&£) 130 ABNORMAL EVI£ FUNDUS Revealed by ophthalmoscopic examination in cerebral tumor and asso- ated the interstitial nephritis of other forms of disease brain. FIGS. 62 AND 63. —Optic Neuritis (Choked Disk).* A, Ophthalmoscopic View of the Papilla. Magnified 14 x 1.— The papilla appears consid- erably enlarged and without distinct outline. It is of a grayish-white color, clouded, and covered with radiating striae which extend into the adjoining retina. The retinal arteries, M/i$y through which a pencil of light from a loop of platinum- wire ren- dered incandescent by a galvanic current may be thrown by the aid of a prism, and through which the observer views the vesical mucous, membrane, the whole being surrounded by a larger tube through which cold water is kept flowing. [W. Meyer, " N. Y. Med. Jour.," Apr. .2JL1888, p. 426.] You do not need to become as expert as my friend and former pupil, Professor James P. Tuttle, now of New York, in the use of the cystoscope, for its use belongs to his daily, even hourly, business, but you should know enough about what it may reveal, to be able to diagnosticate by exclusion a neurotic from an organic disease of the bladder. There are various modifications of this form of endo- scope, one excellent one by Dr. Bransford Lewis, of this city. But 1 need not go further in the description of this instrument of precision in diagnosis, as it is not used chiefly for neuro-diagnosis, except as I have said for the excluding of the possibility of organic bladder disease or of finding it associated with nervous disease, as it and the whole genito-urinary system are sometimes associated with extreme genital hyperaesthesia, making life miserable and 136 even beyond the resources of our ordinarily exceedingly resourceful coadjutors, in practice, the genito-urinary special- ists. My genito-urinary colleague Dr. Boogher may en- lighten you further on this subject. Dr. Phillips is also au fait in this business, and so is Bryson. They all come to our aid sometimes in confirmatory diagnosis. FIG. 73. The perforated holes in the straps are for receiving the Seguin surface thermometer when head heat measurements are being taken. The uses of this adjunct to cerebral thermometry sug- gest themselves. These straps should have been shown you when we were on the subject of cerebral thermometry. PERIMETER AND VISION FIELDS. FIG. 74. -Schwcicccr't perimeter. A perimeter is an instrument for finding and mapping out the vision fields. 137 -Normal field Division . . Fields of vision recorded by the perimeter are called perimetric field charts, but the vision field is not called the perimetrium. The perimetrium has an entirely different meaning. It means the peritoneal covering of the womb. fig. 76. f^lQlijgS' QwCjOvfte of (Xcto'o^eaQ.W-^ooolj 'Pa&ko.Tc&Af (ie. ScV FIG. 77 -Field of Vision of the Left and Right Eve. (After Forster.) CHAPTHR XII. INSTRUMENTS OF PRECISION (CONTINUED). WILSON'S CYRTOMETER perforated with holes and the stem of a Seguin surface thermometer passed through them to its broad expansion and the latter applied next to the skin might be substituted in head heat testing for Carter Gray's thermometer straps. It could be thus used to serve the double purpose of locating cerebral motor centers and excessive heat spots in the brain. Wilson's Cyrtometer was first described in the London Lancet in 1888 by A. W. Hare March 3rd, page 407, and is fully illustrated and defined in Foster's dictionary. The name is formed from the Greek ki'/otos, signifying convex and /xeVpov a measure, meaning a device for measuring curves. Callipers come under this definition and can be used for measuring the curved surfaces. of the cranium and for locating the psychomotor centers of the brain. But this device of Wilson's is a special one for readily locating the fissure of Sylvius and approximating the fissure of Rolando and the centers grouped about the Rolandic area or motor center area of the cerebrum. Cyrlomelrnm is the Latin term, the French use the same term, but the Germans have a less euphonious sounding expression for it. They call it Wolbungomesser, which means better than it sounds to American ears. It signifies a knife to cut curves with. But you must "get onto the German curves" of language to appreciate terms like these. [138] 1 V) THE CYRTOMETER. FIG. 78. ■WILSON'8 CYRTOMETER. (ASTER JURE, I. C.) FIG. 79. WILSON'S CYKTOMETER APPLIED. (AFTER HARE, I. C) The broadest transverse strip of the cyrtometer passes coronally round the forehead, corresponding with the gla- bella or hairless space between the eyebrows, as its origin, (glabellas, implying hairless,) and the external angular process. The narrower longitudinal strip passes backward from the glabella in the middle line to the occiput. This strip is marked with two scales of letters; capitals in its posterior 140 fourth, and small letters about the middle of the strip. These two scales bear an exact relation to each other, calculated to suit in the application of the instrument to the ordinary head. Measured from the glabella backward to any given small letter is 55.7 per cent of the distance from the glabella to the corresponding capital letter; thus, when any capital letter falls directly over the inion (rnov, back of the head or external occipital protuberance), the corresponding small letter will coincide with the top of the fissure. A third narrow reversible strip slides on the lon- gitudinal strip of the metal, marking an angle of 61° open- ing forward, and marked at 3 ;, 4 inches from ils attached end, thus giving the length and direction of the fissure on the surface of the head. CRUSE'S DIABETOMETER is a half shade polariscope showing one gramme of sugar to the litre of urine. It is an instrument whose use, like that of the test tubes and modern sugar test papers, comes within the scope of neurological practice and diagnosis. It is important to know whether or not there is sugar in the urine. For besides the intimate association of diabetes with coma and comatose states, with diabetic melancholia and hypo- chondriasis, various other nerve center states engender or are associated with diabetes. It appears often in connection with giantism and acromegally. The sugar test of the urine, its presence, its absence and its recurrence, like that of albumen in the progress of certain neuropathic conditions of the central nervous system, may enlighten you as to the progress, upward or downward, a case may be making. Look for its presence in the urine in all cases of profound nerve center shock, especially in the great psychic shock of an overwhelming business reverse or of an overmastering sor- row, after a severe and prolonged strain of vigilance, or of 141 business or great loss of sleep, terminating in profound depression of spirits that will not be eased or comforted. And you will sometimes find it where the books do not direct you to look for saccharine urine. Melancholia and diabetes melliius or glycosuria are often found intimately associated as I have said. Profound nervous exhaustion may engender both. Thinking as a neurologist 1 would designate the associated urinary phenomenon as nerve depression or psycho-neural diabetes, but it is often called diabetic melancholia, putting the cart before the horse or the liver before the fourth ventricle and associated nervous system as being concerned in the morbid metabolisms that permit an excess of sugar to form and get into the blood and out through Ihe kidneys. You may put the hepatic cart ( glycoglnic liver ) before the neurologic horse if you want to, but remember the fact of the frequent association of profound cerebro-psychic depression and sugar in the urine and look for the latter and remedy it, not only by diet but by brain rest and a new exhilarating, diverting, restful psychic and better physical environment for your patient. Codiae, mix vomica, chloral, laxatives, good nutrition and haspatic and systemic tonics will help also. The essential pathology of mellituria or diabetes has not been located. It is not in my judgment primarily in the liver. It is not in the kidneys. The sugar accumu- lates in the blood and is called glycohsemia. Some altera- tion has taken place in the metabolic processes and glycohasmia and glycosuria are the results. Behind there are nerve center changes which have not yet been cer- tainly located to the satisfaction of pathologists. Having seen glycosuria come and go in the course of grave nervous depression and keeping in mind the fact that irritation of the floor of the fourth ventricle develops it in animals, I 14.' look upon diabetes mellitus revealing glycohaemia con- sidering the many melancholiacs in whom 1 have seen it appear, as a brain strain sequence in many if not all instances. The amount of glucose in the urine may reach from eight to ten per cent in grave cases. And such grave cases usually become chronic and fatal, though 1 have had an occasional recovery where the saccharine polyuria was excessive and the melancholia profound. When the water dribbles from your patient's bladder or passes involuntarily in larger quantities, or passes vol- untarily too often or will not pass at all, or passes during sleep, (eneuresis) or if a constant desire to micturate exists, it is important for you to be assured that no organic con- dition exists to cause the trouble. A belladonna or opium anointed catheter with bromide of potassium and acetate of potash, etc., internally, will help these conditions if only neural hyperesthesia and a heavy irritating urine are the causes. But the cystoscope will aid you in assuring your- selves whether the fault is only in the bladder. A cyto- scope will help you in neurology as well as in general medicine and surgery. Accustom yourselves to see as far into and through your patients as you can and you will escape the reproach and help to spare the profession one of its chief reproaches, namely, that of inadequate and complete diagnosis. They are made in neurology as well as elsewhere. THE DETECTION OF ABNORMAL SENSATION. Hallucinations are false perceptions of sensation. The hallucinations of the special senses of sight, hearing and smell, connected with disease of their special sense centers, as in epilepsy and certain forms of insanity, have been well studied, as well as the special nerve center and per- 143 iphery changes that lead to real disorders of sight and taste and hearing. Disorders of the general sensory nervou system, too, as I have told you in a preceding lecture, have received some consideration, giving us the anaesthesias, hyperesthesias, paresthesias, etc., recorded in the literature of neurology. But exact measurements of these abnormal impressions or false .sensations, that is, methods for detect- ing whether they are real or not, whether they have a local cause or result from sensation disturbing disease in or near the centers of sensation in the brain, have not been so well studied. Disease in the lower part of the corpus striatum, one of the basal ganglia, may cause alterations in peripheral sensation. Spinal cord center disease likewise. In psychiatry which is the study of mental aberrations t great pains are taken by men who aim to be certain and val- uable in their opinions, (and all should so endeavor in so important a matter), to be sure that the apparent delusion is not really a fact of the body and not a fancy of the mind; though delusion is, however, an impression on the gray cortex of the brain deceiving the mind. If a patient has formication and slaps himself and you find on examin- ation that his bed or body is really full of bugs which disappear when lights are lit, he is not "buggy" in the slang sense of that abominably vulgar synonym for insanity, but he is really and truly buggy, and the remedy consists in treating the bugs and not the patient. So too, a patient may imagine pediculae and have them on his person or may have lately had them and the mental impression still abides as it will sometimes for several days after. The first impression would be no delusion. The second would be an illusion persisting after the exciting cause is removed. Do you remember the first time your good, tender, patient, loving, anxious mother found the hirsute of your 144 caput in the possession of a tribe of pediculi and went through your hair with a line-toothed comb, how you felt for several days after the enemy was cleared from the field as if they were still there, though you had faith in your mother and knew she would never let an enemy to your peace and comfort and rest and happiness of that kind escape her comb while she had breath and power to wield it? The first sensation was the real thing. You had them. The second was an illusory impression. Some- thing had been there to excite the impression. You believed they were still there but actually they were not. That was a delusion pure and simple. You got them from the boy you had the scrimmage with. That was no delusion. You thought you got the better of him. That was a delu- sion, for though he got the licking you got the pediculae. The scratch was on you. Such is life in our boyhood days. It has its illusions, hallucinations, delusions, even rationally founded, as later periods of life have. Later in the session I will tell you what morbid cortex hallucinations, illusions and delusions are and how we may distinguish them from deceptions that are rationally and healthily founded. The subject is a moving and timely theme for profitable discourse, and irrational delusion must be rationally studied by the physician. It is well to test the discriminating sense or power of perception of the sentient nervous system in various ways. For while the sensory nervous system, when it or its cen- ters are diseased, reveals hallucinations of insects or snakes creeping over it, or of water being poured over it or upon it, or hot or cold air being blown upon it, scalding, burning, freezing sensations, when surrounding temperature does not account for these feelings, the absence of power to detect real impresssion of this sort sometimes exists in varying 145 states of anaesthesia. You may try artificial formication; draw hairs or fine wires or strands of silk over the cuta- neous surface to ascertain if the sensory nerve endings properly recognize them and the peripheral nerves transmit the right impressions of their presence on the surface to the brain. This will help you in diagnosis of nervous disease. fig. 80. 23 22 21 20 1 ° 2 o 3 o 4 O 5 O 6Q AMERICAN SCALE. GakWTer GuoUj > e Q V Pu,p\loinN&e.TC- o o 17 o *o o OOOOOO 8 9 10 11 12 13 14 15 /O ^Co /■$" WV^x'teJCvc ^v»,£V\, Ct*V<3p lao-ij ; ^'CVojC'voxrv^ A pupilometer will aid you in measuring the size of the pupil, and in estimation of its variations from the nor- mal in form. For this purpose a catheter graduate card or scale will answer every purpose, though some neurolo- gists use a special device like the one 1 show you. The pupil dilates after division of the motor oculi nerve, contracts after division of the cervical sympathetic and from disease affecting the centers whence these nerves arise and proceed to the pupil from brain or cord. The pupil is also altered in size and shape by disease involving the sight areas of the brain, the optic tracts, the cilio-spinal center. 146 Disease implicating the iris, like iritis, the lens, like cata- ract, the chambers like glaucoma or the retina like paraly- sis and amaurosis, change the appearance of the pupil. So that here, as elsewhere in neurology, your diagnosis must be differentiated. The Rhomberg symptom of swaying forward and from side to side when standing with the feet together and the eyes shut, one of the locomotor ataxia signs, may be measured by a light bar attached across the head, and so arranged as to slide over a scale frame like the one I show you or by the ataxagraph, a cut of which you may see in Dana's invaluable neurological text-book. Exact measurement of this sign is not very essential, except perhaps, for record in certain cases and for comparison. Still it is well to have some means of exact record and comparison. THE MUTAMETER, MOVEOMETER OR AMEBIMETER; A MOVEMENT RECORDER. Two adjustable bars wide enough apart to permit the head to rest and sway some between them are secured across a hoop. On these bars are secured carpenter's scales. A band is adjusted to the head with front and lateral roller secured to them firmly and resting on the bars. The degree of to and fro and side to side tremor is shown in the movement record on the scale. An arm from the top band on the head with a pencil attachment makes a movement record of the tremor also on card-board between the bars and the hoop walls. This instrument may be adjusted to the feet also to guage impulse, knee- jerk and heart foot tremor. You may construct a moveometer out of a cyrtometer and a scale graded frame by attaching square cork blocks 147 to the sides of the fronto-occipital band or the glabello- inion band, as it is more technically called. These blocks slide to and fro and from side to side on the scale bars and the range of tremor or swaying movement of dissemi- nated and posterior spinal sclerosis' are thus shown. FIG. 81. srder A AAA Ho»p fta.»J brR3£T»pao„ oo. mo.eo^ , •fe"«M« «*• f«w t , nfljjD.a., wW «. f „ ^ w r.i., M«W,..wl, FFJ<«^».»^a- lI> .. wA .G.GG.G.a«. Span. f«t M „fa, HKHKare«*Wv^€tv t to write,) is an apparatus, as you are now prepared to understand, designed for measuring and recording the blood pressure in the arteries and the varia- tions in the heart's beats as shown by the pulse. It usu- ally consists of a lever or a system of levers placed upon the arteries and connecting with a registering apparatus. Its value in diagnosis depends on the fact that the heart 150 and pulse beat are usually synchronous. Sometimes the heart's' beats and pulse beats are not synchronous — they are asynchronous and this is not a good omen in diagnosis. The cardigrahh measures the heart beats and the yolygraph combines the features of the cardigraph, sphy- gmograph, etc. The sphygmogram is the tracing and also the name of the slide showing the record of the sphygmograph as dis- tinguished from the sphygmograph itself. The sphygmogram is traced on mica, as with Pond's sphygmograph or on paper as with others. This tracing makes for the normal pulse wave a curve showing an abrupt rise (primary eleva- tion) followed by an abrupt fall, after which succeeds a gradual descent, more or less interrupted by secondary ele- vations. The primary elevation (percussion wave) and the first secondary elevation (tidal wave) correspond to the systole, the third (dicrotic elevation)and fourth wave to the diastole of the heart. The paper or mica used for the sphygmograph is blackened by holding it over a smoking lamp and the tracing moving in accord with the pulsations of the artery, indicate the strength, rapidity and conformity or otherwise of the pulsebeat. The most important matter connected with the use of this delicate instrument of precision in pulse testing, after accurate and perfect adjustment is to guard against the normal tremor and jerky moevments <>f muscle strain and muscle tire and recording the same on the tracings of your sphygmogram as abnormal pulse movement. To this en<\ a complete arm and wrist rest must be secured before or after fettering the wrist with the strap and buckle, prepar- atory to taking a record of the pulse wave. Some sphyg- mngraphers have not duly guarded against this complicating and confusing factor. The fingers should also be kept 151 quiescent, as their movements effect the tracings and Jike- wise, with arm tremor, may become deceptive tracings which might be recorded as belonging to the artery whereas the fault would really be with the muscular tremor. To secure the fingers, rubber bands had better be placed about'them, somewhat as we do in steadying them where pen paralysis exists, except that all the fingers of one hand should be embraced in one band, before applying the button over the pulse to receive impressions. The hand should be kept steady, as hand movements as well as finger movements, and wrist movements, will effect the tracing on the sphyg- mogram. The sphygmograph is a valuable aid and supplement in diagnosis to the stethoscope, pleximeter and thermome- ter. Its tracings are almost as valuable and certain, though requiring extreme care in recording them, as the revelations of the speculum or endoscope. In direct and accurate differential diagnosis, neural as well as general, its use is sometimes indispensable and always a satisfaction, if you have the time, opportunity and skill to use it rightly. But you should not attempt to supplant the skilled touch of the fingers with this instrument. The tactiis eruditus in neu- rology is as essential as in surgery or physical diagnosis. Like the bruit of an aneurism and the sound of anaemia to the skilled ear, the touch of the full bounding pulse of hyperemia, and feeble, small short pulse wave of anaemia are matters of skilled perception which no machine can impart. The finger record of the fluttering, quick, irregular, shal- low wave pulse of approaching dissolution is as unerring to the mind, through touch, as the tracing of the sphygmo- gram. They both tell their tragic tale of the near ending of mortality as unerringly as the incoherent delirium of impending somatic dissolution. 152 The sphygmograph gives you a pulse record. It reveals arterial degeneration states as in cerebral and other arterial scleroses. It records states of altered cardiac innervation as in dropped beats, swtft beating tachycardia, slow beat- ing bradycardia, etc. rhe sphygmograph is a good means of testing the action and efficiency of medicines. It is good for making comparative records of the two sides and of the pulse of the extremities with the heart's beat. It is useful in diagnosticating aneurisms, anaemia, hyperaemia, sclerosis. It should be used more than it has been for recording the pulse of and sequent to shock, the pulse of neurasthenia, exophthalmic goitre, the pulse of general paresis, hypochondria, melancholia, chorea, epilepsia, hystero-epilepsia, mania, etc. Dr. Francis S. Kennedy, in a recent valuable and practicable article*, introduces some pertinent tracings, which are here shown. THE PEN-HOLDING, TREMULOUS HAND ATTITUDE OF PARALYSIS AG1TANS. (After Eichhorst.) FIG. 83. *"The Sphycmocraph. Its Practical Value." Brooklyn Medical Journal, July, 1902 153 SPHYGMOGRAM TRACINGS. Tracing of tremor of paralysis agitans. 1, Tremor of extensors of carpus, right hand, 5.3 per second; 2, tre- mor of extensors of carpus, right hand, 5.1 per second; 3, tremor of head while hands held chair, 4.4 per second; 4 tremor of head while hands held chair, 4.6 per socond; 5, tremor of head, no effort with hands, 4.S per sec- ond; 6, tremor of single fingers, 4.5 per second. FIG. 84. Ten Seconds. 154 FIG. 85. /, W'V / .-'; f r ^A^\„ &*&&$$!$ \h J ''AwW^/iV a ' A COMPARATIVE SERIES OF MYOGRAMS OF TREMOR. 1, Paralysis agitas; 2, Basedow's disease; 3, multiple sclerosis; 4, hysterical tremor; 5, neurasthenic tremor; 6, delirium tremens. Tremors modified rapidly recurring mincature spasms or as Peterson says they "are a modification of the rhyth- mic discharges of energy from the motor ganglion cells, which occur at the rate of ten per second. Consequently, 155 when we have fewer per second, it is because of fusion of two or three impulses." Petersen found the tremor vibrations in various dis- eases at his nervous clinic to be "from 3.7 to 5.6 per sec- and, thus agreeing with all other investigators excepting Cowers." fig. 86. E, in^ the figure, shows the connection with the battery. A regulates the length of the vibration, and. »B, C and D, are appliances which only a study of this instrument itself will render perfectly clear; pressure on F sets the percuteur at work. Other vibrators accom- pany the instrument be- sides the one seen in situ. Dr. Granville began his observations using clock- work, instead, of electric- ity, but for-office work he prefers electricity, and uses the clock-work only at the patient's house. Dr. Granville uses the percu- teur in locomotor ataxia, some cases of chorea, for the relief of cerebral and cerebro-spinal irritation .and distress, and to elicit energy from torpid centers . An American substitute for the percuteur is the vibra- tile. It is less expensive and answers quite as well for 156 ordinary purpose s oi nerve excitation. The principle of its construction and action are the same, :/{., power, and in- both instruments electric power, converted into vibratory motion and this vibratory impression applied along the course of a nerve or over a nerve center, if one could be reached with it, as for instance a vaso-motor center, with a view "I bringing about a change of action in a morbid nerve. It acts as a sort of a mechanical counter irritation and massage combined. This principle may be applied successfully for the relief of pain and improving nutrition in a part, and it is a good method to use in the relief of spinal irritation and tender spine in women, for suggestive psychical effect and for spinal myalgia, which is often a morbidly sensitive condition of the sensory nerve endings in the muscles along the spine. When in practice you need to stimulate and change molecular activity in a peripheral nerve, employ the per- cuteur, the vibratile friction or other mechanical or chemical irritation. It will probably some day be brought into use, with suitable adjustments, for the purpose of influencing the brain through the eyeball and the ear, as nerve stretching and electricity and excessve peripheral nerve irritation effects the respective peripheral nerve centers. There are many other instruments and appliances to minutely satisfy scientific curiosity and interest in precisely diagnosticating states of your patients' system with which you may wish to become familiar after graduation. Among these are Huter's cheiloangescope, a microscopic adjust- ment for seeing the living circulation in the lip. Another is Antelme's cephalometer and Zernoff's encephalometer which you will find illustrated in Foster's Dictionary. The circulation in the human ear and in the frog's foot may also be seen with a microscope and suitable adjustment. CHAPTER XIV. ASCENDING AND DESCENDING DEGENERATION. REACTION OF DEGEN- ERATION; WALLER'S LAW; ITS DIAGNOSTIC SIGNIFICANCE. If a lesion involve the neurone or neurones of a motor center, up in the gray cortex of the brain, for instance, in any part, where those fan -like striae called corona radiata and projection fibers pass down to go through and between the two great basal ganglia especially, through the corpus striatum in that contracted white bundle of fibers which we call the internal capsule, which proceed down and contrib- ute to make the cruri cerebri or peduncles of the brain, as we have so often pointed out to you in our dissections, and which fibers go mainly to make up the direct and crossed pyramidal tracts of the brain and cord, sending some fibers down the cord directly, but chiefly obliquely across and down the cord 'in what is called the decussation or crossing of its pyramids or corpora pyramidalia, and neurone degeneration begins up there in the cortex, this degeneratiou goes on downward until it meets with the first sub-station or lower motor center in an anterior horn of the cord. All of the motor fibers connected with the degenerated motor neurones of the brain cortex above, become involved in the degener- ative process, from the higher to the next lower center, or from station to station, in the neuraxis; that is, if the motor neurone or its neuraxone is so completely involved in dis- ease as to become degenerated or atrophied. [157] 158 The neuraxone is practically prolonged from the neu- rone of the cortex till its end tufts meet and touch the den- drites of the lower neuraxone in the anterior horn of the cord. Investigations into the histogenesis of the structure of the cord have proved this. Degeneration may be arrested here or involve only these neurones of the spinal cord, or it may continue down the cord and outward along the peripheral nerve. The inflammatory or other destructive action may stop at the first anterior horn or may involve it and go on down the pyramidal tract or lateral column of the cord on the side opposite to the brain lesion or on the same side of the cord lesion, if the injury or disease of the cord be below the crossing of the fibers in the pyramids. If the anterior horn becomes involved along with the lateral columns in the diseased process, as in antero-lateral-sclero- sis we have motor nerve degeneration and debility or tremor or paralysis, contracture, etc. Later atrophy of the innervated muscles and electrical impression changes appear in the muscles whose innervation is dependent on the affected centers. This phenomenon is called the reaction of degeneration, and it is an almost, if not quite, unerring sign that the muscle tone and its innervating nerve center integrity is lost. A like lesion of the ganglion neurones of the posterior roots of the spinal cord will similarly in- volve in degeneration what represents its neuraxone, the tropho-sensory nerve fibers so far as their distribution in the skin. If trophic fibers from the anterior horn are involved, certain skin changes result, called trophic neurosis or trophoneuroses of the skin. Degeneration in connection with disease of the posterior column nerve center neurones may also extend to the posterior columns in the same manner as that of the anterior or antero-lateral columns extends downward, to the next higher nerve center, paral- 159 leling, in its manner of extending, anterior spinal cord de- generation. This degeneration may go on till it reaches the sensory neurones in the gray matter of the brain, but it will not necessarily involve them. Downward degeneration of the anterior and antero-Iateral columns is called descending degeneration, and that of the posterior columns is called ascending degeneration. Transverse section or disease of the cord causes degeneration downward along the pyramidal or motor cord tracts and upward along the columns of Goll and cerebellar columns. The trophic centers of the sensory nerves are in the intervertebral ganglia of the posterior roots. Their fibers enter and cross the cord immediately after their entrance, to ascend through the posterior columns to the brain. This is the deep decussation. The inner, column or columns of Goll are made up of long bundles of fibers. The outer columns are shorter, running to the gray posterior horns and make up the column of Burdach. Long bundles of fibers also go up to the cerebellum in the lateral columns of the cord on either side. In trau- matic transverse injury to the cord these long and short bundles of ascending fibers that make up respectively Golfs and Burdach's columns degenerate upward from the injury. Long bundles in the lateral columns also pass upward to the cerebellum and help to make the cerebellar tract. Traumatic or disease lesion of the neurones and col- umns of one side of 'the cord below the crossing of the fibers at the decussion of the pyramidal strands cause motor paralysis on the side of the lesion or injury and anaesthesia of the opposite side and also a circumscribed encircling band or bands of anaesthesia around the body on a line or slightly below the damaged spot in the cord ac- cording to the distance below at which the sensory nerves 160 from the injured cord center or segment involved, pass into the cord. >( Brown -Sequard's paralysis.) See Gower's spinal cord segment and nerve exit and Brissand's schemata for illustration of Brown -Sequard crossed cord paralysis at end of chapter. Ascending and descending degenerations cause the truest and gravest types of tropho- neurosis. WALLER'S LAW OF DEGENERATION OF NERVE TISSUE. This extension of disease in the nervous system from center to center, according to the direction of involution and of function is called the Wallerian law. That is, to repeat it in another way for illustration, the cutting off of a nerve fiber or neuraxone from its neurone or nerve cell, the neurone from which the neuraxone has developed and proliferated, causes degeneration along the course of the neuraxone or nerve cell prolongation. Let us begin our diagramatic illustration with a point of disease, a single neurone or group of neurones in a motor center of the cortex and follow it downward and out of the cord as it involves section after section in the projection fibers of the motor tract within and without the brain. This lesion, starting with a neurone up there in the cortex passes along the neurone's neuraxone to the dendrites of other neurones and is there sent down through other neurones going in by means of their dendrites and out at their neuraxones. From cortex, for instance, down the corona radiata, internal cap- sule, and cms cerebri of either side through the pyramidal decussation of the medulla into the opposite lateral column and thence to peripheral distribution. A small number of fibers pass down directly and escape decussation. There ap- pear to be more direct fibers in some neuraxes or cerebro- spinal axes than in others, but not enough to vitiate the ana- tomical rule and the consequent physiological law of crossed motor action from right or left side of brain to opposite side of 161 spinal column in health and the Wallerian law of descending degeneration from cerebrum or cerebellum to cord in degen- erating spinal cord disease, or cord center to peripheral motor nerve in peripheral descending degeneration. The neurones of the motor area of the cerebral cortex contain the trophic centers of their neuraxones. These neurones appear to form, with the pyramidal tract fibers, nerve units, just as a psychic neurone and neuraxone does in the gray cortex of the brain. Cut off the neuraxone or axis- cylinder process from the neurone and the neuraxone or fiber that goes down the cord atrophies and dies as in the accompanying illustration. Central brain disease, destroying the neurone life and causing it to atrophy and die, causes atrophy and death in the projection connecting fibers and connected neurones below it. This is called descending degeneration. Ordinarily the degeneration is irreparable, but not always. The central neurones of the corpus striatum, the pons, the cerebellum or the medulla may suffer, (exception- ally only), from external pressure as in neighboring extra- vasation, gummata, etc., which may be removable and the neurone degeneration may be arrested and recovery may follow. (Adneural disease.) Incurable transverse myelitis (inter-neural disease), may cause incurable degeneration of the pyramidal tracts below the lesion; or a removable ad- ventitia may oppress the cord but be removed by specific treatment and electricity and the descending degeneration may be arrested. (Extra-neural disease also.) The law of Waller briefly stated is that the motor conducting paths degenerate downward while the sensory paths degenerate upward, and while this law is "not abso- lute and may be shattered" as Mayer, who has so ably translated Oppenheim, says, it is a good general law, and its understanding will aid you in prognosis. 162 In main- matters in neurology we stand yet, as Edinger Ikis stimewhere so well said, "in the current of changing opinions, receiving daily new contributions." The myelin sheath of the neuraxone or axis-cylinder process of a cen- tral neurone and of a peripheral nerve is formed from many cells, which have an independent though common epiblastic origin and conditions of central irritation going to periphery may modify or arrest central control degenerative influena , such as persistent well regulated exercise in the thera- peutics of locomotor ataxia; the exercise connected with the dorsal decubitus nerve-stretching, and bathing, swim- ming in warm sulphur water pools, which latter I especially recommend in this formidable disease of posterior columns of the cord. The exercise treatment of tabetic ataxia by Frenkel, of " Friehof " Sanatorium, in Heiden, Switzerland, trains the central, through peripheral impression neurones, though this author does not appear to see the subject in this light, for he rejects both the center and the sensory theories of locomotor ataxia. Section of a nerve causes the death of its axis-cylinder. The axis-cylinder of a nerve seems in health to modify and regulate the nutrition of its surrounding myeline cells, main- taining their activity in a certain normal way and promoting or keeping up the fatty metabolisms of the myeline cells and regulating the growth of protoplasm. On the death of the axis-cylinder of a nerve the myeline cells suddenly increase for a time in size and activity, and then exhaust and shrink and become atrophied and degenerate. A peripheral nerve loses its irritability in man completely within forty- eight hours after section and its conductivity immediately, from center to circumference and vice versa. I could tell you much more on this subject than you could now receive, if we had the time, and more than you might now in the rush of this 163 course fully comprehend. When you have leisure for it, consult Obersteiner on neurohistogeny and secondary degeneration, or Barker, His, and other authors on this inter- esting subject. Artificially produced secondary degeneration as first practiced experimentally by Waller has been of great serv- ice to neurology and to neuriatry, enabling us to know the location and effects of certain diseases, for the results of experimental injury to a part of the nervous system are quite similar to those caused by destructive disease. And this is the reason experimental physiological science cannot yield to the clamor of the anti-vivi-sectionist, though it should be as humane and painless as possible and it ordi- narily is painless in most of its methods. Waller showed by vivisection that when an anterior spinal nerve root is cut the fibers below the section died and it could have been demonstrated in no other way. The distal portions of the root degenerate and the fibers which supply the anterior root to the compound nerve and that when the posterior root is cut proximately to its ganglion, that is between its ganglion and the nerve root origin in the posterior columns of the cord, all of its fibers die between the point of section and the cord, while all the fibers between the section and the ganglion, /'. e., all the fibers distally to the section live. A small portion of fibers of the posterior root (not many) have trophic centers beyond the posterior root and external or distal to it toward the periphery. This accounts for the slight modification of the law. It is one of nature's conservative ways, such as we are accustomed to see so often and elsewhere, in her wise provision for the saving of man from total destruction; such as we see in some of the lesser vicarious paths of motor conduction down the cord, as we see in some of the com- paratively few strands that go down the direct anterior columns of the cord — the columns of Turck. FIG. 87. FIG. FIG. S9. -ascending and Descending Degener- ation in the Spinal Cord. A, primary area of degeneration (lesion). fl, degeneration of Coil's columns (ascending). C, degeneration of Ihe crossed pyramidal tract (descending). (After Gowers.) SCHEMA OF GOWER'S SPINAL CORD SEGMENTS AND NERVE EXITS. FIG. 90. FIG. 91. cd< The mutual relations of the vertebral bodies and spines to the segments in the eordi and to the exits of the nerves- (Gowere). Wallerian degeneration of nerve Sores after section. /, nor> mal nerve fibre ; II and IJJ, gores ■showing different degrees of degen- eration ; .« neurilemma j m, medul- lary sheath ; A, axone ; i, nucleus of neurilemma cell ; L, marking of Lantermann ; R, node of Ranvier ; mt, drops of myelin ; a, remains of axone ; jr. proliferating cells of neurilemma. Partlv s-hematic Utter Thoma.|_^ m %&gj* CHAPTER XV. THI: REACTION OF DEGENERATION AND ITS USE IN DIAGNOSIS. HOW TO DISCOVER IT. APPLICABLE CASES. We have seen how peripheral motor nerves and motor conducting nerve paths in the neuraxis degenerate when separated from their proper centers — their trophic {Tpofai — nutrition) or nutritional centers, so closely connected with motor centers that motor center disease, (and motor centers and tro- phic centers are near neighbors in the cord), often causes decay of nutrition and also peripheral inaction as in mus- cular debility from lack of muscular exercise. Well, when the cerebro-spinal centers of motion are gravely diseased or injured so as to cause central destruction or solution of continuity in the cells of the central or peripheral nerve mechanism, of course conductivity of willed impulses is impossible, the neighboring trophic centers often become likewise involved and a corresponding change in the nor- mal response of nerve supplied muscle appears on applica- tion of electrical tests. This was named by Professor Erb, of Heidelberg, who first described it, the reaction of degen- eration. It is a nerve muscle degeneration reaction to ordi- nary electrical impression characterized by these peculiari- ties, vi%: Muscular contractility diminishes for both the faradic and galvanic currents when neuro-muscular degeneration exists. After about two weeks from the beginning of the [164] 165 degenerative process, the effected muscle ceases to respond to the will or direct electrical current. The direct faradic current irritability of the muscle diminishes and then disappears. The galvanic irritability disappears also. Responsiveness or irritability to electrical excitation returns again after a time for the galvanic current, the muscu- lar contractions occurring from a very weak current, but with a peculiar deliberation of movement not to be seen in any other muscular contraction under electric excitation. It is what might well be called the retreating wave of neuro- muscular degeneracy. It is like the secondary retreating wave that follows from the shallow shore back to the sea after the great sea waves have spent themselves on the strand. These electro-neuro-muscular waves are sluggish, slow, long drawn out muscular contractions which suggest expiring or spent power. They are singular and suggestive of exhaustion, reminding one of the protest of weakness in a hopeless struggle. And so they are. In contrast, normal neuro-muscular contraction under the stimulus of certain faradic currents are short, quick, abrupt and vigorous. The same intensity of galvanism that gives the peculiar degeneration contraction would not contract the healthy muscle at all. The electrical formula is changed, i. e., the polar reac- tions alter in sequence, and muscular contractions are changed in contrast with ordinary muscular reactions under electric- ity. The cathodal (carbon, positive pole) closing con- traction of the reaction of degeneration takes place under the same or under a weaker current than cathodal closing (zinc, negative pole) contraction. A cathodal closing tetanus like contraction and the anodal opening contraction appear as the same. This is a change in electrical con- 166 traction compared with healthy electrical excitation — a change in the formula, in the language of electro-diagnosis. If the nervous disease is above the trophic center in the neuraxis which innervates the nerve going to the supply of the muscle we are examining, the paralyzed muscle, as for instance in apoplectic disease of the brain, there will be no reaction of degeneration, unless secondary degenera- tive change sets in as a chronic sequence, which is rare. In accordance with Waller's law the disease descends down to the trophic centers of the cord and implicates them in destruction. That is, if a degenerative lesion, for ex- ample, attacks the cms cerebri of either side of the brain it passes down the antero-lateral pyramidal tracts, (following the projection tracts which we have been talking about), to the tropho- motor centers of the cord and destroying them, then degenerative muscular atrophy appears and with this destruction of the motor and trophic cord centers appears Erb's characteristic reaction of degeneration to electrical stimuli. You must carry in your mind a little electrical knowl- edge in order to intelligently apply the diagnostic test for the reaction of degeneration, which we might more defi- nitely call the galvanic electric reaction degenerative change. For this is what it is. Its peculiarly slow contraction to galvanism is the chief characteristic of the reaction of degeneration and to very feeble galvanic currents. The current goes from anode (that is the plus or positive carbon pole) to cathode (that is the negative or zinc pole) always. The positive pole must be a diffuse, wet sponge, chamois or cloth electrode. The negative pole should be a smaller sponge or metal point, disc or brush electrode. But always applied to a moist surface. Both electrode or the skin should be wet. The cathode is the negative 167 pole or electrode. The anode is the positive pole electrode. Contractions occur on opening, closing or suddenly altering the strength of the electric current. The effects of the current are uniform on all healthy muscles. Effects are variable where muscular innervation is diseased; i. e., im- paired or destroyed. The faradic current is a succession of rapid interrup- tions. To produce contractions the galvanic current must be interrupted with an interrupter to break the current, located in the handle of the electrode or on the battery, or the current otherwise broken or suddenly changed. (Those of you who use the little book of Seifert and Muller for reference must fix in your mind well the German words, Oeffnung, meaning opening, symbol O; Schliesing, meaning closing, symbol S; and Zuckung for contraction and they are not pronounced as they are spelled, either. The first is pronounced effnunk, the second sleezing and the third zookoonk or else 1 am no philologist, which is probably the fact,) Thus you have C. C. C, A. C. C, A. O. C, C. O. C, in health. In reaction of degeneration the formula of contraction would be like this: A. C. C, C.C. C, C. O. C, A. O. C, English formula. Compare them. The reaction of degeneration is electrically revealed in destructive peripheral nerve lesion, like rheumatic, plumbic diphtheritic, cerebro-spinal meningitic, syphilitic and alcoholic paralysis, with destructive neuritides and in poliomyelitis anterior, where the gray anterior cornua are destroyed by inflammation and in transverse myelitis, amyotrophic lateral sclerosis, progressive muscular atrophy, bulbar paralysis. In brain paralysis not involving lower trophic centers, as we have said, when discussing descending Wallerian degenera- tion, we do not find the reaction of degeneration sign. Continuing fibrillary contractions, such as those of pro- 16S gressive muscular atrophy, often appears In the muscles that show the phenomenon of reaction of degeneration. The neuro- muscular action change in athetosis and tremor being caused by defective innervation, is somewhat akin to some phases of muscular reaction in partial reaction ol defeneration. In s >me cases of central nerve degeneration you may have hyper- excitability to direct galvanic irritation of muscles, anodal closure contraction, then cathodal closure contraction and always, if real reaction of degeneration be present, the peculiar characteristic deliberate contraction already re- ferred to. As galvano-muscular irritability and the peculiar reac- tion of degeneration disappear entirely in a few months after degenerative motor nerve disease appears, the sign of reaction of degeneration is not of diagnostic value in very chronic cases. Muscular tissue in its normal condition of healthy moisture, is itself a good conductor of electricity and even dead muscles, as in Galvani's celebrated laboratory discovery and subsequent experiments have amply proven, so that something more than loss of nerve conductivity takes place where the reaction of degeneration shows and where all muscular contractility finally disappears, under electricity. The atrophied muscle itself ceases to be so good a conduc- tor as it was before. The remaining bulk and moisture (oil globules, etc.,) in pseudo-hypertrophic muscular paralysis (in which the muscle circumference is great and power feeble) is perhaps the reason why the reaction of degener- ation does not show in this disease and the muscles do not correspond in normal like contraction, notwithstanding the persisting integrity of some of the muscular libers. The chief value of the reaction of degeneration sign, is in helping us to detect true degenerative, from the false 169 hysterical evanescent functional paralyses. You may have use for it in litigation cases before the courts. When found, this sign is a pretty good and positive proof, like the microscopic evidences of degeneration in the piece of har- pooned muscle taken from a progressive muscular atrophic, but the absence of this sign does not disprove the existence of real degenerative motor paralysis. The time for the test may have passed before you apply it. There may be conditions that supplement the change in muscular conductivity and impressibility ordinarily wrought by the degenerative forms of paralysis. It is a proof when you find it, but not a disproof when you fail to find it. The estimate of the force or intensity of electricity is made by the number and size of the elements employed or by the galvanometric or millimeter record. "According to Ohm's law I=JJ; that is the strength of the current or intensity (I) is in proportion to the electro- motive force (E, number of elements) and is in inverse proportion to the whole amount of the resistance present in the electric current. Now an ampere is that strength of current (1) which is generated by the electro- motive force (E) of 1 volt in an erectric current of resistance (W) of 1 ohm. An ampere then, is equal to { ™£. One volt is equal to nine-tenths of the electro -motive force of a Daniel ele- ment; one ohm is equal to a column of mercury 106 centi- meters long, and one square millimeter in section (1.06 Siemen's unit). For medical purposes, no strength of cur- rent higher than twenty thousandths (milli) amperes is used. With motor nerves superficially situated cathodal closing contraction occurs normally with currents of li MA strength." The strength of the current may be varied either by inserting many or few elements, or by means of a rheostat, 170 by which resistance of different degrees may be inserted into the current. In the recent clinics you have noticed that the reaction of degeneration has not been elicited. That is because the cases shown have been so chronic that the time for any electro -muscular excitability has long since passed in the chronic myelites and progressive muscular atrophies, etc., exhibited. fig. 92. CHAPTER XVI. HOW THE REACTION OF DEGENERATION IS DIAGNOSTICATED. The reaction of degeneration is elicited by electrical test. The electric impressibility to both galvanism and faradism diminishes and disappears after about two weeks from the commencement of the nerve center or nerve tract degenerative processes affecting the connected muscles which are involved atrophically in the degenerative process. Conductivity to both the current and will, are lost simultaneously. The first thing to note is that direct irritability in the muscles lessens and finally disappears for a time. The next thing to note is that the muscular irritability reappears to galvanism in about fourteen days. The next thing to note is that the very weakest gal- vanic currents cause contractions and finally it is to be noted that the resulting contractions are peculiarly slow, jeeble and very deliberate. The sensori motor nervous system now seems dead in its responses to faradic impression and to feebly stammer in its responses to galvanic electricity. If it could speak it would only slowly stutter in speech. The voluntary musdes supplied by the sensory motor nervous system are therefore peculiarly changed in [171] 172 responsive reactions to electric excitability in the morbid nervous- phenomena called the reaction of degeneration. This much you need absolutely to know in general in order to assure yourself that reaction of degeneration is present in a given case. But there is a farther test in the changed electric for- mulary. The normal muscular reactions to indirect electricity (gradually increasing the intensity of the current) are as follows: a. Cathodal (negative) closing contraction, C. C. C. (or in the German formula Ka. O. Z.). /'. Anodal (positive) opening contraction, A. O. C. or (An. O. Z.). c. Anodal (positive) closing contraction. A. C. C. or An. S. Z. d. Cathodal closing tetanic, (longer continued) contrac- tion. C. C. T. (Ka. S. Z.) lasting through contraction. Cathodal closing. C. C. or (Ka. S.) and finally cathodal opening contraction. C. O. C. or Ka. O. This is the law of response to healthy indirect elec- trical irritation of the nerves as shown through the action of the muscular system. It may be likened to a man in see-saw movement of the muscles and reads C. C. C. ; A. O. C; A. C. C; C. C. C. (tetanic). On the contrary in the reaction of degeneration the formula of contraction is changed to read thus: A. C. C. (An. S. Z.), takes place with the same current as the C. C. C. (Ka. S. Z.), or a current of less strength and the C. O. C. (Ka. O. Z.), shows the same as the A. O. C. (An. O. Z.), that is the anodal closing con- traction and the cathodal closing contraction give the same result and the cathodal opening and the anodal opening contractions show the same. \7S In a month or so galvano-muscular instability dimin- ishes and by three months has usually disappeared entirely not to return again ordinarily. Should recovery take place (which is exceptional) electric irritability returns tardily to the normal reaction display. Trophic central and volitional influences however are more potent than the electric fluid to excite muscular re- sponse when the degenerative processes are replaced by reconstructive regeneration. Muscular tones and voluntary motion then reappear markedly, while normal electrical reaction comes back to the affected muscle slowly. When the reaction of degeneration is modified in de- gree, it is called partial reaction of degeneration and shows that the motor center or motor conduction paths are not completely destroyed. Some of the neurones of the center and some of the nerve fibers remain intact. In such case nervous irritability to both faradism and galvanism permit, if the currents are applied directly and contractility is the result. We sometimes have partial reactions of degeneration from incomplete lesions of the peripheral nervous system, as in alcoholic, rheumatic, diphtheritic, spinal meningitis, la grippe or other neurotoxic conditions and from hystero- neurotic influences. Sometimes these toxic adneural influences are power- ful enough and destructive enough to destroy reaction of degeneration altogether but they do not do this so often or so completely as the inter-neural organic changes. Com- plete peripheral traumatisms also cause reaction of degen- eration. But the most usual conditions causing complete reac- tion of degeneration are poliomyelitis, anterior infantilis or 174 other involvement of the gray matter of the anterior horns of the spinal cord and transverse myelitis or other dis- eases implicating the spinal cord clear across in destruc- tion. When the gray nuclei of the medulla are destroyed by extensive plumbism we may have complete the reac- tion of degeneration in lead paralysis. We find this reaction often in particular muscles in progressive muscular atrophy and sometimes in bulbar paralysis, amyotrophic lateral sclerosis and other nerve -center diseases. WHEN THE REACTION OF DEGENERATION MAY PERSIST WITH NERVE-CENTER DISEASE. Whenever the entire nerve center connection is or its peripheral nerve connections are almost entirely destroyed we may have this peculiar reaction. When the higher centers of the neuraxis above the medulla are destroyed we do not have the reaction of de- generation unless the disease descends down the cord and involved its centers and tracts (descending degeneration.). The reaction of degeneration is therefore not present in recent apoplexies causing brain hemiplegias or in those exceptional basal brain apoplexias which cause paraplegia. In plain local myopathic paralysis you would not be apt to find reaction of degeneration. The spinal cord center must be involved in destructive disease to give reaction of degeneration to muscles innerv- ated from that particular center of the cord. Degenerative atrophy of muscles is associated with trophic atrophy— the two go together— the atrophy giving the reaction is the atrophy of degeneration. Atrophy from central disease does not necessarily give reaction of degeneration. 175 Feeble fibrillary contractions appear in muscular areas once innervated by degenerated nerve centers showing re- action of degeneration. They are characteristic of progressive muscular atrophy. Limited central cord disease or disease of its circum- ference not involving the gray cornua as aneurism, embolism or tumor, does not give reaction of degeneration. Absolute and entire destruction of all nerve fibers and nerve center neurones do not take place in such palsies as show reaction of degeneration until after all reaction phenomena disappear entirely, after the second or third month. A solitary central neurone or so and a few con- ducting nerve fibers must remain, with some functioning form to show even the feeble response of the phenomenon of the reaction of degeneration. A muscle undergoing atrophy from degeneration of its nerve center or connecting peripheral nerve, ceases to re- spond to the different forms of electricity in the following order, viz. : first to static electricity, then to faradic, then to the interrupted galvanic and finally to the galvanic cur- rent, the voltaic alternative, that is by suddenly reversing it. Gentlemen — it is the vaso motor influence of the gal- vanic current and its precedent influence on the neurones upon which we rely in its therapeutic use. If it can so demonstrably affect the vaso motor centers as to contract abnormally dilated arterioles through their influence and thus physiologically regulate blood supply and promote normal neurone nutrition by overcoming abnormal blood pressure we need not invoke a hypothetical catalytic action to justify the employment of constant galvanism in all hyperasmic states of nerve centers that may be impressed through the vaso motor system and its constrictor fibers. Erb in his "Handbuch der Electrotherapie" doubts 176 this, and he is a great German neurologist of repute. He doubted it twenty years ago but so did others. 1 was then demonstrating the contrary and so, 1 think, were La- borde and Latournian. Erb employed a large head electrode covered with a sponge like the one shown in the cut of your text-books, but an ordi- nary wet sponge electrode the anode or positive pole to the forehead and the negative to the nape of the neck will answer. He passed weak currents through the head with- out break from one to two minutes. One minute is ordi- naiily enough. When you take off the current take it off very gradually so as not to cause vertigo by sudden with- drawal and filling of the contracted blood vessels. You would nut suddenly take off the abdominal bandage after tapping for dropsy. The oblique currents are preferable. That is, from right or left forehead to center of neck behind. 1 do not advise the transverse currents, /'. <'. from temple to temple. 1 must caution you while you search for the reaction of degeneration or for evidence of that advanced chronic degeneration which has passed all reaction stage and shows no response in kind or quality to electricity, that con- ductivity in the dry skin is nil, or resistance as the elec- tricians say is extreme, so that you must thoroughly moisten the epidermis, (with warm water preferably). You must also keep the current on a long time, and closed, and without changing the number of elements, before giv- ing up the test. Sometimes currents which are not felt in the beginning finally, if applied this way, break down re- sistance in the skin and cause contraction and even pain. Apply the current long enough to feel assured that the skin is wet through and permeated with it. If you reach the superficial motor nerves with your moist electrodes cathodal closing contraction ought to occur normally with 177 currents of from one to three milleampere meter strength. Be not too hasty to conclude that there is no reaction. Make the test thorough before deciding. A current may not be felt at first and yet by constant and persistent ap- plication its intensity increases and its effect is seen and felt. CHAPTEK XVII. ANOTHER VIEW OF THE REACTION OF DEGENERATION. Objection has been raised to the views presented in the preceding lecture, which 1 here give from the best and most eminent source, together with my views thereon. Barker, who sustains his statements with excellent con- firmatory illustrations, in discussing the other side, after presenting the current conception of Waller and his fol- lowers, says: ' The application of the Wallerian doctrine has aided immensely in unraveling the complicated relations existing inside the central nervous system. Thus, in a transverse lesion of the cord, for the bands of fibres which degenerate in sections above the site of the injury, the 'trophic centers,' /. c, their cells (of origin) are to be sought below this level, and vice versa, the cells of origin for tracts which degenerate in sections below the level of injury must be situated somewhere above this level. "Since the time of Waller and Turck the histology of the degeneration of nerve fibres after separation from their cells of origin has been studied by many — notably by Ran- vier, Homen (of Helsingfors), Howell and Huber, and Tooth. The last, in the interesting Gulstonian Lectures for 1889, has reviewed succinctly the facts up to that date. The studies of von Notthaft are of especial value, in that they [17S] 179 have yielded definite information concerning the state of nerve fibres at various periods after the lesion. This in- vestigator divides the changes which occur in a nerve after section into two stages. The first stage includes those which occur during the first three days. These alterations, which consist in fragmentation of the myelin and of the axone in the first one or two internodes on each side of the lesion, are, Notthaft believes, the direct result of the trauma. The true Wallerian degeneration (or the second stage) begins on the second or third day in the fibre distal to the lesion, and is the result of severance of connection with the central end, and not the direct result of the trauma. The axone swells and fragments, and the myelin breaks up into droplets along the whole length of the nerve. Multiplication of the nuclei of the neurilemma is ev- ident at the fourth day. At the sixth or seventh day liquefaction of the myelin commences, and this continues until the sixtieth or eightieth day, by which time all the myelin has been liquefied and a large part of it has been absorbed. After three or four months the myelin has en- tirely disappeared. "During the secondary degeneration of the white fibres within the central nervous system there is a proliferation of the neuroglia. The multiplication of the neuroglia cells begins in the white matter, according to Ceni, some forty- five or fifty days after the lesion. The neuroglia cells cease to multiply at about the hundredth day, after which there is a gradual disappearance of neuroglia nuclei with gradually progressing sclerotic change. "Owing to the shortness of the dendrites (unless we look upon the peripheral sensory fibre as a dendrite), we possess no exact studies concerning their fate when sev- ered from the cell bodies of the neurones to which they be- 180 long, but we have every reason to believe that they would undergo speedy and complete degeneration." Barker then views and discusses another aspect of this interesting subject. Viewing now the question from the other side, he says: "The study of portions of the nervous systems from individuals who had died, a certain length of time alter amputation of an extremity, soon afforded data which apparently stood in direct contradiction to the doc- trine of the trophic centres as formulated by Waller. For, while Waller demonstrated the complete degeneration of the portion of the nerve fibre disconnected with the trophic cen- tre, he maintained the integrity of that portion of the fibre left in connection with it. "As early as 1829 Berard had noticed that in the spinal nerves supplying a limb amputated some time be- fore, there was, at autopsy, distinct atrophy of the ventral roots. Vulpian, Cruveilhier, Hayem and Gilbert, Dickinson, Friedla^nder and Krause, Homen, Vanlair, Grigorieff, and many other investigators busied themselves with the subject, and came to conclusions which were often at variance, owing, as has been shown by Marinesco, to the fact that the authors studied and described different phases of the alterations. Marinesco convinced himself that after amputation of a limb, or after section of a peripheral nerve, there occur in the central part definite pathological changes, the intensity of which depends upon the species, and especially upon the age of the animal and upon the length of time intervening between the injury and death. The younger the individual at the time of amputation and the longer the time elapsing between the operation and death, the more marked are the alterations. The degeneration in the central stump of the divided nerve, although it appears much later than that in the distal portion, presents similar morpho- 181 logical appearances and is apparently an analogous process, although" — and herein, thinks Barker, lies the vulnerable point of the Wallerian doctrine — "the central end still maintains its continuity with the 'trophic centre.' Not only do the sensory fibres distal from the spinal ganglia degenerate, but after a time large numbers of fibers in the dorsal roots proximal to the ganglia and their cor- responding fibres with their collaterals and terminals in the dorsal funiculi of the cord undergo pathological changes and totally disappear. The motor fibres of the central stump gradually diminish in number; in some instances they ap- pear to vanish almost totally, and a large number of the motor cells of the ventral horns dwindle in size and may after a time be actually lost. The spinal ganglion cells do not show gross alterations for some time after both peripheral or distal fibres have degenerated (Friedlander and Krause, Homen, Vanlair, Mannesco), a finding which denotes that their trophic mechanisms differ in some way from those which are concerned in the nutrition of the cells of the ventral horns. I have thought that this may depend upon the possession by the spinal ganglion cells of a cel- lular capsule," concludes Barker. Another point is to be remembered, he thinks, in ex- plaining "the difference in effect of division upon the peri- pheral motor and sensory nerves is the fact that, if current ideas of conduction are correct, on section of a motor fibre, it is perhaps the discharge of impulses which is prevented, while in the case of the sensory fibre it is at first the re- ception of impulses which is interfered with. It must not be forgotten, however, that even when a peripheral sensory nerve has been cut through, the corresponding cells in the spinal ganglia may yet perhaps receive some centripetal im- pulses from the viscera through the rami communicantes." 182 The life prolonged of the central neurones with peri- pheral sensory connections depends, in great measure, on the continuance of normal peripheral function, sending up to these centers those normal irritations which keep up the cen- tral neurone life — "uibi irritaiio ibi fluxus nutrieus." With- out this healthy excitation which conditions healthy neurone nutrition and permits and causes neuratOny and neuratrophy to set in, the nerve center must degenerate. This seems to me to be a more rational explanation than the conjectural possession of a spinal ganglion cellular capsule. It would be interesting to note, as this author says fur- ther on the subject, "that if the sympathetic ganglion cells, which are also encapsulated, act similarly and preserve their gross integrity after section of the nerve fibres belonging to them." He refers to gross integrity alone, inasmuch as there is much evidence, some of very recent date, from which we are compelled to believe, he says, "that the finer structure of the nerve cell is always altered by the cutting through of its axone." CHAPTER XVIII. THE EVOLUTION OF THE NEURAXIS. NATURE'S BUILDING OF THE BRAIN AND SPINAL CORD. I am not the first teacher in a medical school to make the observation that the study of anatomy and physiology of the brain, spinal cord, and connected nervous system is not generally pursued with that intensity of interest which its importance deserves, by the majority of medical students. Students of medicine seem inclined to ignore the minute study of the neuraxis, as many of them also seek to avoid as much as they can, the details of chemical and biological study, but the successful treatment of the nervous system demands of them a thorough knowledge of the exact rela- tions between nervous function and structure in health for proper comparison with the changed nervous manifestations of disease. Beginning with the brain, that great English Corypheus of modern histological cerebro anatomy, Samuel Solly, who, following Tiedemann, the great German Vesalius of neuro-anatomy, in his day, also sought to impress upon the medical world many years ago, when biology was yet young, the fact that the only philosophical method of simplifying and giving interest to the anatomy of the human brain, is by commencing with the structure and functions of a nervous system in the lowest and simplest forms of animal exist- [133]. 184 ence, and from this rise by degrees to the highest, care- fully observing each addition or part and the relationship borne by these to an addition of function. "By pursuing this course we shall be rewarded by finding that the en- kepalon," Solly said, "this apparently most complicated organ in the human being, is but a gradual development from an extremely simple fundamental type on one uniform and harmonious plan and that the seeming complexity of the cerebro-spinal axis in man really arises from the great concentration, as opposed to extreme diffusion of its com- ponent parts in the lower order of animals; for in no par- ticular are the higher orders more strikingly distinguished from the lower than in concentration of function within circumscribed spaces." As we proceed in our studies we shall, by the aid of this early master cerebro- anatomist and the help of other and later eminent teachers, see how important it is to look below us in the animal scale in order to clearly comprehend man at the top. The study of comparative embryology in this way has not only contributed largely to our knowledge of the cerebro- spinal axis, but the highest interest of embryology centers in the light which this study has thrown on the nature and evolution of the entire human nervous system, in which this chair as teacher, and you as learners, are so intently and specially interested. As the chief aim of your life will be to care for the brain, spinal cord and allied peripheral system, including the sympathetic and the organs of the body governed by and influencing this nervous system, it is proper that you should have, at least, an outline idea of its embryonic birth and development. By knowing something of its evo- lution you will be better qualified to delay or prevent that premature involution which morbid processes tend to bring 185 about and may be, to delay the ordinary involution of age and promote longevity. The human embryonic nervous system starts its life from a small beginning, a protoplasmic vesicle born of the union of an ovum and a spermatozoon. In the beginning a spot of protoplasm merging into a streak of epiblast called the medullary plate and developing first into an elongated neural tube larger at one end, (the an- terior) than the other, from which are evolved the different antero-posterior segments of the brain described by neuro- anatomists, and from the lower end of this tube develops the spinal cord. Of man's origin as the poet has said of man's entire life, it may be said, — his time is but "a moment and a point his space." fig. 93. Cells of discus proligerus. rammatic— /, secondary uucleoli. — Portion of o\nm extruding a polar body, and showing a spindle and diaster. The iunec star surrounds the female pronucleus, the outer is beneath the polar body. The male pronucleus is close to the female. 186 A PROTOPLASMIC VESICLE BORN OF AN OVUM AND A SPERMATOZOON FIG. 94. fVv.wv.'vCWtt 3Vve single layer, rabbit (after His). A round eerm-cell lies between the proximal ends of two supporting cells. O b«,x s\e.>.o.e v. The accompanying diagram, much like one of Kollman of Jena, which I have taken from MacAlister's Anatomy, and the embryonic sections following it, will serve to show us how small and simple are the beginnings of neural life and to cause us to marvel at the mysteriously and wondrously wrought nervous mechanism of man and the lower vertebrata. 187 THE GERMINAL TUBE OF THE EMBRYONIC NEURAXIS. FIG. 96. FIG. 97. 7k I \^A hi MA — -Mr- — Uw- -Diagram of anterior end of nearal canal — All, optic vesicle; H, heart; Mh, wall of mid-brain; Vom, omphalomesenteric vein; Uw, protovertebrre. — Section of embryo, showing formation of vertebral body around the notochord — csp, spinal canal ; vsp, spinal nerve ; v:h, body of vertebra forming around (ch) the notochord ; mp, muscle plate ; a, aorta ; p, coelom ; bw, somatopleure. The germinal embryonic tube of the neuraxis closes interiorly in the process of development. It then swells first into the three and later into four and finally into five vesicular centers located one after or below the other. The first three divisions constitute the anterior, middle and pos- terior germinal cerebral vesicles. The anterior cerebral vesicle is then soon divided by the development of the falx cer- ebri growing out of what is called the secondary vesicle of the fore- brain, which is the beginning of the division of the anterior cerebrum into its two hemispheres. The falx cerebri being the product of the secondary vesicle of the fore-brain does not descend into and bisect the other ves- icles in their evolution, but stops above the corpus callosum, basal ganglia and the other more posterior and lower or basal divisions of the brain. 188 The cerebrum and cortex, caudate and lenticular nuclei (these two latter being cortex formations) with the fornix and corpus callosum, are developed from the secondary anterior cerebral vesicle. This forms the anterior or fore- brain, prosencephalon or telencephalon as it is variously termed. The primary cerebral vesicle (Vh) makes the tween - brain including the optic thalami and commissure, corpora albicantia and infundibulum. The secondary vesicle having evwlved out of the primary cerebral vesicle. The mid -brain (and this is an unfortunately confusing term as distinguished from the tween- brain) is formed from the middle vesicle (Mh) and includes the corpora quad- rigemina and peduncles or crura or legs of the cerebrum. Mid and tween are so near alike in meaning that it might have been well to have included the near enough related parts which make up these two divisions under one com- mon designation viz., the quadrigeminal bodies and crura. The fewer and simpler these divisions the better, but as I did not make them 1 make no further apologies. The mid brain Hh., is made up of the cerebellum its peduncles and the pons Varolii. It is developed from the anterior of the two under or lower vesicles, Hh. Last of all comes the after brain and this is an ill chosen designa- tion to distinguish it from the hind brain, hind and after being so nearly synonymous. But it is the language of neuraxis embryological evolution and we must accept it as faithful followers of the Masters. Fortunately its meaning is easy to remember. The after brain is made up of the medulla oblongata alone and is developed from the posterior (Nh,) of the two under germinal cerebral vesicles. Brain structures are also divided into brain mantle and brain stem or caudex. All structures developed from the 189 secondary vesicle are included in the brain mantle. The structures formed from the remaining vesicles, excluding the cerebellum, constitute the brain stem or caudex. The mantle or cortex structure of the brain envelops the most of the surface of its three primary vesicles after they have evoluted into brain structures. Mantle and cortex meaning respectively covering and rind, the latter the same thing only more closely fitting. The germinal vesicle cavities evolute into ventricles and aqueducts or canals. Thus, that of the cavities of the sec- ondary forebrain evolves into the lateral ventricles, that of the primary forebrain (Vh) before division and the hind brain re- spectively, furnish the third and fourth ventricles and spinal canal, while the mid-brain germinal vesicle cavity makes the aqueduct of Silvius which connects these ventricles. Lower down the germinal tube in the diagram (Mr) is the cavity of the central canal. The vesicle cavities become the per- manent brain ventricles and the foramen of Monroe. FIG. —Vertical longitudinal section of brain of human embryo of fourteen weeks. 1x3. (After Sharpey- and Reichert.) c, cerebral hemisphere ; cc, corpus callosum beginning to pass back ; /; foramen of Munr.o ; p. membrane over third ventricle and the pineal bod}' ; th. thalamus ; 3, third ventricle ; /, olfactory bulb ; eq, corpora quadrigemina : cr % crura cerebri, and above them, aqueduct of Sylvius, still wide : c\ cerebellum, and below it the fourth ventricle ; pv, pons Varolii ; m, medulla oblongata. The frogs of the bogs, the crocodiles of the Nile and alligators of the Mississippi, the codfish and whales of the sea, the giants and dwarfs of the jungles and forests, the lizards 190 and toads and reptiles oi the fields and the fowls of the air as well as those anthropoid apes which make Darwin's con- necting link in animated nature with man, have helped us to know our brain and other portions of our neuraxis. Man's nervous system begins also with the outer of the three vesicle layers of the primitive embryo viz. — in the epiblast as we have said, which gives origin to the nervous system along with the intimately connected epi- dermis, with its hair, nails and glands and the mucous mem- branes of mouth, pharynx, anus and the perceptive surfaces of the special sense organs. This is also called the neuro- blast, vevpov, a nerve and /JAuo-tos, a bud, because the neuroblast is the bud of and evolves into the nervous system. The mesoblast is also important as it gives rise to the neuroglia, the derma and connecting tissues generally, the serous and mucous wall linings of the bodies, cavities and vascular system, the non nervous internal genital system, the muscles, bones and bodily excretory organs. And we note here that a division begins with the very beginning of organic life. The germinal vesicles are assigned spec- ialties of work in the animal economy from the start and the evolved organs keep up the work to the finish of ex- istence. The mesoblast is the middle and the hypoblast the innermost layer of the primitive embryonic growth. Von Mihalkovics has given to embryological science a microscopic section of the brain and medulla of a chicken four and a half days old, which Edinger and other delineators of the embryonic central nervous system have reproduced. It shows the five brain vesicles fairly well developed, so well by comparison with the much further advanced human foetus, as for example that of His at about four weeks,* that it may be preferably used for our instruction today. *See Duane's Dictionary, Plate iv. 191 Look on this embryo chick and upon the other illus- tration and delineations of man's evolution in the depart- ment of embryology and note how man is inexorably chained to nature in his evolution and environment, and realize how important it is for you to keep close to the FIG. 99. Commtss.post. Vierhugel. Hupophysenanlatje ■e&eHurrji Longitudinal section through the head of an embryo chick of 4J< davs. The five brain- vesicles are pretty clearly marked. In the roof of the inter-brain is a fold which later on becomes the pineal gland. The epithelium of the pharynx is being pushed up toward the b;ise of the brain, and is the tirst rudiment of a portion of the hypophysis. (After Mihalkovics.) Hinterhirrihbhle, Hind-brain cavity. llifpiipliynentinluge. Rudiment of hypophysis. Mitlelhirnhohle (aquvuduct), Mid-brain cavity Nacliliirnhohle, After-brain cavity. Vierhui/el, Corpora iniadrigemina. Vorderhirnlcohle, Fore-brain cavity. Zioiachenhirnhohle, Inter-brain cavity. (J5>(H) FIG. 103. Outer surface of human foetal hrain at six months, showing: origin of principal fissures (after Sharpey and K. Wagner). F, frontal lobe; P. parietal; 0. occipital; 7", temporal ; n, n, a, faint appearance of several frontal convolutions ; x. x, sylvian fissure ; s\ anterior division of same ; C. central lobe of island i>''. Reil ; >', fissure of Kolaudo ; p,, external perpendicular fissure. ' Upper surface of braiu Rafter Sharpey and R. Wagner). FIG. 104. ¥« 6V\oxyvw<5 \.v\tv«.*\oweT \jo«. 201 The precise anatomic details and other elaborate de- scription are fully given in the pages of Meynert, Edinger, Foster, His, and other embryologists, and in your physiolo- gies and microscopic anatomies, but it is obvious we can not use them all here and now in a single hour. The diagrams and figures of His will especially instruct you if you have time to study them. Meynert copies from Reichert this frontal aspect of a fcetal brain, with its germinal spots for the prosencephalon V, thalamencephalon Z, mesencephalon M, and meten- cephalon N, "to show what an insignificant part of the original brain mass the prosencephalon is." fig. 105. I/U Frontal As- pect of a Fcetal Brain ; after Reichert. V. Prosenceph- alon. Z Tha- lam enceph a- lon. M. Mesen- cephalon. N Metencephalon. Dr. Alexander Hill, Master of Downing College, Cam- bridge, and translator of Edinger, an indispensable book for your leisure hours, gives an interesting account of the epiblast, a small part of which we draw upon to embellish this lecture. Barker's chapter on the histogenic relations of the neurones will still further instruct and entertain you on the theme of this lecture, as will also His and other embryological histologists. The portion of the epiblast which is marked in the illus- 202 tration as the seat of origin of the central nervous system con- stitutes the floor and sides of the medullary groove. It is not simply a uniform plate, but the central portion, out of which the spinal cord will be formed, is distinct from a row of thickenings which lies on either side of the large main fossa. It is these lateral thickenings of the epiblast which develop into the spinal ganglia (His). The medullary folds grow up until meeting in the mid-dorsal line, they convert the medullary groove into a canal. Closure occurs in the neck-region first, and spreads rapidly forwards over the head and more slowly backwards through the dorsal, lumbar, and sacral regions. The rudi- ments of the sensory ganglia (both cranial and spinal) are formed by delamination from the lateral thickenings just described (Beard). fig. 106. .-Transverse sections through a developing cbick, showing the forma- tion ol the scifsory root-ganglia (after flcavl). — <7a, Ganglia; <)>, epiblast; Ay, hypoblast; m.p medullary plate: «, uutochord : ntf, neuroepithelial tube; e.e, central canal. Ob^tsievAe* FIG. 107. 203 Sul.ch .-Nuc.caud. W-Pulv. --Lat.lem. W 7%. **—D.Tn.f. , f . ■P. sul . — Sul. eft., Chorioid sulcus. Flic. ca«d., Nucleus caudatus. Thai., Thalamus. St. m., Stria raedullaris. P. b., Pineal body. C. q.. Corpora quadrigemiaa, Pulv., Pulvinar. Fr., Frenulum, hat. lem., Medial lemniscus. A. p. c, Anterior peduncle of cerebellum. M. p. c, Middle peduncle of cere- bellum. St. a., Acoustic strias. C. r., Corpus restifonne. C. tub., Cuneate tubercle. F. G., Funiculus of Goll. D. m. f., Dorsal median fissure. P. sul., Paramedian sulcus. L. tr., Lateral tract. D. I. sul., Dorso-lateral sulcus. F. B., Funiculus of Burdach. CI., Clava. Al. tin., Ala cinerea. T h., Hypo- glossal triangle. A. a., Acoustic area. C. f., Colliculus facialis. S.. Urn., Sulcus limitans, • E. m., Eminentia medialis. V. V. t Anterior medullary 1 velum. TV, Trochlear nerve. C. g. m., Medial geniculate body. C. g. I* Lateral geniculate body. P. br., Posterior brachium of mesencephalon) (After Van Gehuchten.) .^A.-eejS,'^c\j VYfru^CeWcs-Jfe Q.*o*oXov^\^ e ^ AA<\e \svoA-c\j 204 THE EVOLUTION OF A Ml RAXIS. FIG. 108. V ; " 1 1 ■ As delineated by Samuel Solly, the English Corypheus of modern neuro- anatomy. This illustration is not so clear as we should have been pleased to have made it, because of the tarnishing of the plate by age. The work is marvellous, considering the remote year in which the work was done. LATERAL VIEW OF FULLY EVOLUTED HUMAN CEREBRUM, SHOWING CONVOLUTIONS, FISSURES AND ARTERIES. (After Testut.) FIG. 109. -Or' ^sJ 2. artfre fror-ialo ioftriouro. — 3, arte re frouullo ascendamo. — i, artere panclalo asceouaato. 205 The sum of this matter of the embryonic evolution of the brain, from the three primary vesicles stated in an- other way, is as follows: From the anterior vesicle de- velops the optic nerve and its retinal expansion or retina in the posterior part of the eyeball. The anterior vesicle then undergoes subdivision into the anterior and middle vesicle. From this develops the prosencephalon (fore-brain), from which are formed the cerebral hemispheres. Budded off from the prosencephalon are two lateral vesicles, the cavities which constitute the lateral ventricles, cor- pora striata, and olfactory lobes ( rhienocephalon ) . "The floor of the thalamencephalon or diencephalon (inter-brain) forms the optic chiasm and infundbulum; its walls the optic thalami; its roof the pineal gland, anterior and posterior commissures, velum interpositum, and choroid plexus; and its cavity the third ventricle. The floor of the middle vesicle (mid-brain, mesencephalon) forms the crura cerebri; its roof the corpora quadrigemina; and its cavity the acqueduct of Sylvius." The posterior vesicle divides into two parts, an anterior (hind-brain, or metencephalon, the floor of which develops into the pons and the roof of the cerebellum; and a posterior (after-brain) myelen- cephalon (Wilder) the floor and sides of which form the medulla, and the cavity of the fourth ventricle. {Vide Duane.) 206 ILLUSTRATION OF A PORTION OF UNDER SURFACE OF BRAIN IN IMMEDI- ATE CONNECTION WITH, AND CONTINUATION UPWARD FROM, THF. SPINAL CORD. ALL THE CRANIAL NERVES ARF. HERE SHOWN, VND NEARLY ALL THF UPPER (CRANIAL) PART OF THF CEREBRO-SP1NAI. AXIS. THE OPTIC NERVE DISTRIBUTORS DO NOT SHOW NOR DOES ANY OF THE LEFT HALF OF BRAIN APPEAR EXCEPT THE OPTIC THAL- AMUS, THE LEFT CROSS CEREBRA, OPTIC TRACT, ETC., DE- SCRIBED UNDER THE CUT. THE ANTERIOR UNDER LOBE ON RIGHT APPEARS AS LIFTED AND PRESSED UP AND FATTENED SOME. FIG. 110. Superficial Oric.ins op Craw I'. Olfactory tract II Optic nerve. It' Optic tract. HI. Third or oculo-motoi IV Fourth nerve. V. Filth nerve, sensory root V , Fifth nerve, motor root 1,3,3 Main divisions of fifth VI -i Ml, nerve. VII. Facial nerve. VIII Auditory nerve IX. Glossopharyngeal X. Vagus. XI Spinal accessory rl LU brvus (/rum Qunin i " Anatcmy"). XII. Hypoglossal. x Posterior perforated CI. First cervical nrrve. space. C. Island of Reil. P Cerebral peduncle. Th Optic thalamus (the It- pv Pons Varolii. land of Keil having been Ce Cerebellum. removed). [turn / Fillet I. Internal corpus gemcula- . Jl . Flocculus <■ External geniculalum />/i Anterior pyramid h. P.iu.t.iry body. o Olive ic Tuber cinereum d Anterior median fissuri n. One of the corpora albi- of cord."" c.-intia. I V. Lateral tract of medulla 5y. Sylvian fissure. I .< Anterior column. »• Anterior perforated i Ct. Lateral column. space 207 DESCRIPTION OF FIG. 108, PAGE 204. The figures in Fig. 108 represent different stages in the development of the human brain. The first three of this series exhibit the form of the fcetal brain at seven weeks, with a side and a posterior view of the cerebro- spinal axis at that early period. Fig. 6 shows the amazingly rapid progress which development has taken at the ninth week, while Figs. 7, 8, 9, and 10 show the brain of a foetus of twelve weeks and point out still more decidedly this steady ad- vancement. Fig. 11, showing the brain of a foetus of fifteen weeks, teaches us how gradually this important organ advances towards perfection; and 12, ex- hibiting the brain of a foetus of nearly five months, is interesting, as it demonstrates that even at this advanced period the brain is still smooth like the brain of a rodent animal. Fig. 3. Foetus of seven weeks. a. Projection of the neck. Fig. 4. Brain and spinal marrow of the same foetus seen laterally. a. Spinal cord. b. Enlargement of the cord. c. Cerebellum. d. Optic tubercles, or quadrigerhinal bodies. e. Optic thalami. f. Membraniform hemispheres of the brain. g. Protuberance analagous to the corpora striatum. Fig. 5. Posterior view of the same brain, split and open in all its length. a, a. Spinal marrow. h. Orifice of the canal of the spinal marrow. c. Swelling of the spinal marrow. d. d. The cerebellum split in the median line, and laid like a bridge over the fourth ventricle. e. e. The quadrigeminal bodies separated from one another in the median line. Fig. 6. Brain of an embryo of nine weeks. a, a. The two principal columns of the spinal marrow, separated from one another by a longitudinal fissure. b, b. Cerebellum. c Parts which give rise to the quadrigeminal bodies. d. Thalami optici. e. Membranous hemispheres, turned backwards and inwards. 208 Brain of an embryo ot twelve weeks seen in the cranium. a, .i. Fragments removed from the cranium, which has been opened. /'. Spinal marrow. S welling of the spinal marrow, which is bent inwards. ./. Cerebellum. f. Elevation which gives rise to the quadrigeminal bodies. <;. Cms cerebri, or a cord of the spinal marrow which comes down again and is directed forwards. //. Membranous hemisphere of the cerebrum, broken down behind and betore; it does not yet cover the eminences destined to form the quadrigeminal bodies. Fig. 8. Brain and spinal marrow of the same fietus seen posteriorly. a. .;. Spinal marrow, with its posterior longitudinal fissure. b. Cerebellum, and beneath it the fourth ventricle. c. .'. Hemispheres of the cerebrum. J. Eminences which are to become the quadrigeminal tubercles, with the fissure which they present. Fig. 9. Inferior surface of the brain of the same fietus. a, .?. Spinal marrow, with the anterior longitudinal fissure. />. b. Swelling of the spinal marrow bent forward. <-. c. Peduncles of the cerebellum, which arise from the cerebellum. ./. Hi HlNDSRAIM AT 1 V Str AFTSRBRAIN. ZpiuauCobd, MeisEnhat^. Hie brain-structures from the thalamus to the -].in;il cord (the brain item"). The cerebellum divided^ and removed on the left. Practically the brain mantle is all of the brain above this. CHAPTER XX. HISTORY OF THE EVOLUTION OF THE BRAIN. SOME FURTHER FACTS CONCERNING THE BRAIN. In 1819, before these plates were made, Arnold, Reich- ert, Foville, Burdach and others had made important contributions to embryologic and fully developed brain structure. Burdach's book on the life of the brain was published as early as 1819, and Reil had already, according to the testimony of Edinger, practiced the hardening process and discovered the corona radiata, the nerve course of the tracts of the crura cerebri and their relation to the corpus callosum, "the lemniscus and its origin in the corpora quadrigemina, the lenticular nucleus, the island of Reil and many other parts." In his first lecture Dr. Ludwig Edinger, of Frankfort- on-the-Main, gives an interesting resume of the advance of discovery and methods of study, bringing the record of work down to the days of Ramon y Cajal, Lenhossek, Nissl and the other men of mark in our time in neuro- cytology. This is of such interest that I abstract the es- sential part of the record. "Up to about the middle of this century the most prominent methods of investigation were anatomical dissec- tion with the knife and teasing out fibers from hardened specimens of brain with forceps. By the latter method [211] 212 Gall, Burdach, Reil, F. Arnold and Foville discovered much that was new. Vo Tiedemann and Reicherl is due the chiel credit of introducing the study of embryology, from which \w have learned much concerning general morphological conditions. In 1833 a delineation of the brain's evolution by Sam- uel Solly, one time Lecturer on Anatomy and Physiology in St. Thomas Hospital, appeared in England, based on his own and the researches ol Willis and Vieus^eus, (the latter first having demonstrated (in 1864) the fibrous structure ol the medullary portion of the brain), and those of Reil, Gall, Spursheim, Vicq, d'Azyr, Rolando, Sommering, Serres, Tiedemann, Sylvius, Nepper and Van Leuwenhceck, the lat- ter having first instituted microscopical examinations oi the brain. * * * About this time Ehrenberg proved that the brain consisted of innumerable microscopic "tubules." Remak (1838) had given a more accurate description of the ganglion-cells, and Hannover (1840) had shown their connection with the nerve- fibers. After this Edinger states that "a simple process of teasing could never give the desired insight into the structure and arrangement of the central nervous system. To B. Stilling is due the great credit of originating and bringing into use a new method, viz., the preparation of thin sections, or rather, of whole I sections, which are made in different but in definite directions through the organ to be examined. In a foot note Edinger says: "Thin sections of the central nervous system had been made be- fore Sti Ming's time [e.g., B. Rolando, 1824). but the recon- struction of the organ by the combination of extended of sections was first done by Stilling." ' The sections so prepared were carefully examined throughout, the pictures they presented combined, and thus 213 the structure and arrangement of the central nervous sys- tem were determined. By means of this method and the studies which he. instituted by its use, Stilling laid the foundation of the modern anatomy of the spinal cord, the oblongata, the pons and the cerebellum. On the 25th of January, 1842, Stilling froze a piece of spinal cord at a temperature of 13° R., and then, with a scalpel, made a moderately thin cross-section. 'When I placed this under the microscope,' he writes, 'and, with a power of 15 diam., saw the beautiful transverse striations (central nerve- tracts), I had found a key which would reveal the mysteries of the wonderful structure of the spinal cord. Not more joyfully did Archimedes cry out, "Eureka!" than 1, at the first sight of these fibers.' " Stilling's method was, up to within two decades ago, the one most used in investigations of the central nervous system. "It is rendered very much easier by the splendid hardening which these organs undergo in dilute chromic acid, or in a solution of chromic salts, — a discovery of Hannover and Eckhardt. "The sections are made 'free-hand,' with a razor, or, better, with a microtome, which cuts much more exactly and enables us to make larger and more even sections. Welcker, Rivet, Weigert, Thoma, Gudden, Schiefferdecker, and others have been of service in constructing microtomes adapted to the purpose. We can now divide an entire human brain into an unbroken series of sections, less than to millimeter in thickness. "These sections may be examined unstained. All that Stilling discovered was found in such unstained sections. It is better, however, to use staining fluids. "To Gerlach is due the credit of first calling attention (1858) to the advantages to be derived from staining the 214 sections in carmine. As time passed on, many new stain- ing methods were devised, particularly with aniline colors (nigrosine, etc.). "But it is only very recently (1883) that we have learned from Golgi a method which brings out ganglion- cells more distinctly than the old one of Gerlach. This method rests on a production of a deposit of silver salts in the cells and their processes. The course of the fibers in the central nervous system is not made much more distinct by staining with carmine. It is possible, however, by a method of staining with hematoxylin introduced by Wei- gert (1884), to color even the finest nerve-fibril a deep blue-black, and so, making use of Stilling's method, it is easy to trace the course of the fibers much farther than was formerly possible. ' The stained sections are, in accordance with the special instructions of Clark (1851), dehydrated by placing them in alcohol, and then cleared up in some ethereal oil or xylol. But unstained sections also reveal the course of the fibers if cleared up in xylol, as was done by Henle and Merkel. This, however, does not always succeed. Beautiful pictures may be obtained by using the gold stain- ing methods of (Gerlach, Flechsig, Freud, and many others). Also, by staining the nerve-fibers with osmic acid (Exner)." Stilling's method has, up to very recently, been followed by most of the investigators of the latter half of the nine- teenth century, but has been later succeeded by the method of Golgi, of which you are to learn much as you advance in the study of microscopic neuro-anatomy. The revelations of brain evolution under the difficult and meager methods of investigation prior to the hardened brain slicings and the advent of the microscope were won- 215 derful testimonials, as some of these illustrations show, to the indefatigable spirit of research of our forefathers on the field of neural embryology. But the later sections and micro- scopic discoveries of brain and cord and nerve, startle cre- dulity and almost surpass the bounds of possible belief. They astonish us like the telegraph did our fathers and as the phonograph, graphophone, mimeograph and marconi- gram surprise us. Yet their revelations are astonishingly true. Science now places its penetrating finger upon the neurones, whose dwelling place is at the seat of perception, reflection and psycho-motor function, as we have already seen, in our survey of neurological research and as we shall yet see further in our progress of discovery along the pathway of the neuraxis. Electrical discovery too has aided us, espec- ially in the direction of cerebral localization, which will en- gage our attention in another lecture. For by its means, with insulated electrodes, Fritsch and Hirtzig proved the fo- cal electrization of the brain and Ferrier, Horsley and their followers have localized its psycho- motor functions, most of which have been confirmed by demonstration, pathological processes and associated cerebral symptoms. There are some general facts concerning the brain which may profitably be recounted here, before we discuss the subject, as we shall, later on, more specifically. BRAIN SIZE AND BRAIN WEIGHTS AND THEIR RELATION TO MIND CAPACITY. The aggregate complexity of the nervous system seems greatest in what naturalists call the primates, or man and apes and the vertebrate animals. Invertebrates are consid- ered by the same authority to have no brains, and the ex- ample of the sanguisuga, or common leech, the house fly, 216 etc., are cited. The latter is an unfortunate illustration, for the fly's intellig revealed in various ways, not to the same extent as the ant and the bee, but sufficiently to indi- ■ that it has an organ ol limited intelligence, like the I, the mosquil Even the leech, though he knows not when to let go, knows when and' where best to hold on, as I once discovered when 1 got into a colony ol them while in swimming in mv boyhood days. In man and apes the cerebellum is covered above and in front by cerebrum. In all the lower animals the cover- ing is imperfect. In man and apes the cerebrum is highly convoluted, the convolution becoming shallower and less complex as we elcscend the scale of vertebrate and mam- mal life and in imbeciles and idiots. The weight of man's brain is 1 in prop irtion to body weight, of all vertebrate animals. Man's brain is said to average ten per cent greater in weight than woman's, but the new woman knows a good deal and does not believe it. The average weight of the male brain is about 49 oz. Average weight of the female brain 44 oz. Heaviest normal male brain 65 oz. Heaviest normal female brain 56 oz. Lightest normal male brain 34 oz. Lightest normal female brain 31 oz. Idiots 23 oz. The composition of the brain is albumen, different phosphates, salts and water. The normal brain averages in weight therefore from 34 to 50 oz. The normal female brain averages in weight from 31 to 44 oz. Mental development and power is said to depend, all things being equal, upon the size and weight of the brain, the com- plexity and depth of the convolutions of its gray matter. Fine- ness of texture has much, however, to do with quality" of brain and the relation of brain weight and size to size of the frame with capacity. The power of the neurone of the gray cortex is not yet exactly measured. It has been said that Byron's 217 hat was too small for the head of any of his contemporaries; Gambetta's brain was the smallest of any European states- man, while an American senator of ability (Dunn of Indiana) is said to have had the smallest head, compared with the heads of his colleagues (he wearing a 6% hat), while the biggest heads were owned by Benjamin F. Butler and a colored porter at the Capitol. Professor Waldeyer reported to the Prussian Academy of Sciences measurements of the skull of the Philosopher Leibnitz, which was discovered a few years ago in repairing a church in Hanover. The cran- ial cavity measures 1,422 cubic centimeters, indicating a brain weighing 1,257 grammes, which is unusually small. The contour of the skull shows that Leibnitz was of Slavic origin. Gottfried Wilhelm Leibnitz was born in Leipsic in 1646. He died in 1716. He studied law and in 1678 was made a counselor and member of the Supreme Court by the Duke of Brunswick- Luxemberg, but his fame was made by his writings on philosophical subjects. Dr. James Morris records a brain weight of 67 oz. belonging to a bricklayer, who could neither read nor write. Gambetta's brain was light weight, being about 41 oz., while Byron's was heavy, being near 64 oz. We know that the intelligence of the ant, the bee and the beaver are proverbial, while the eye of the fly is quite as perfect as that of the ox. Hydrocephalic children and some idiots have enormous heads. The heaviest adult male brain on record weighed 68^ oz.(Nancrede) . A brain weigh- ing 66 oz. belonged to the cranium of a Louisville baker, whose chief merit in the world consisted in his ability to make a fairly good loaf of bread, and the brain of an epi- leptic is recorded as weighing 64 oz., about 10 oz. more than Daniel Webster's. Cuvier, the naturalist, had a brain weight of 64.5 oz. ; Abercrombie, the physician, of 63 oz.; 218 Schiller, the poet, the same, while Agassiz, an American naturalist, had a brain weighing 53 oz. Goodsir, the anato- mist, had a brain weight of 57.5 oz. Dupuytran's brain weighed but 50.7 oz. ; Hughes Bennett, physician, 47 oz., Hausman, the minerologist, 43.2 oz. Brain of an idiot (Holden's Anatomy) 23 oz. (Nancrede) 31 oz. Epilepsia and chronic insanities show high average brain weights, while in imbecility the general male average is below, the general female average is above the general averages for the respective sexes, according to Crowley Clapham's deductions from extensive research. In senility and in senile dementia the brain shrinks in size and loses in weight in both sexes. Clapham found brain shrinkage in general paralytics, but that was in chronic insane asylum cases, after the dementia stage. There is no evidence of loss of brain weight in the earlier stages of general paresis. The commissural fibers of the brain enter into the com- position of the corpus callosum, the anterior middle* and posterior commissures bridging the third ventricle. They compose the fornix and connect the two lateral hemi- spheres; they enter into the composition of the middle pe- duncles of the cerebellum, which in part serve to connect the two cerebellar hemispheres; and into the decussating fibers in the medulla and pons. "The longitudinal fibers and ganglia comprise five systems: (1) The pedal system in- cludes the pyramidal tract starting from the parietal cortex, the anterior cortical fibers from the frontal cortex, the lat- eral and posterior cortical fibers from the temporal and oc- cipital cortex, and the caudate and part of the lenticular nuclei with the fibers descending from them; these fibers *The middle commissure being of gray matter and not strictly a commissure, though it is called the gray commissure. 219 all pass through the internal capsule and pedes crura cer- ebri into the pons, where all terminate except the pyram- idal tracts, which pass down to form the anterior pyramids of the medulla, which are continuous with the pyramidal tract of the cord. (2) The tegmental system includes the thalami optici with radiating fibers connecting this system with the cortex, the longitudinal fibers of the tegmentum of the crus cerebri of either side with the imbedded nuclei (red nucleus, substantia nigra, corpus subthalamicum), the tegmentum of the pons, with the locus ceruleus, fibers con- necting the tegmentum with the cortex, the superior pe- duncle of the cerebellum connecting the cerebellum with the tegmentum, the fillet, connecting the nucleus gracilis and nucleus cuneatus of the medulla with the tegmentum, the longitudinal posterior bundle of the pons, the brachia of the corpora quadrigemina and the reticular formation of the medulla. (3) The system of central (ventricular) gray matter comprises the gray matter lining the ventricles, in- cluding the nuclei of the cranial nerves adjoining the fourth ventricles and the tuber cinereum on the floor of the third ventricle. (4) The system of outlying cerebral ganglia comprises the corpora quadrigemina and the external and internal geniculate bodies. (5) The cerebellar system com- prises the nuclei of the cerebellum (corpus dentatum), (emboliform or wedge shaped nucleus, roof nucleus, etc.), with the cerebellar tracts (inferior peduncles of the cere- bellum or restiform bodies, connected below with the olivary bodies and nucleus gracilis and cuneatus, and with the cerebellar tract and posterior median and external pos- terior columns of the cord). Look at this brain. It is composed outside, of cin- ercious or gray matter, made up of basal ganglia, cortex, corpora quadrigemina, geniculate bodies, ependyma or lining 220 oi the ventricles, etc., nerve cells and connecting fibers or communicating neurones; within its white matter is made up of neurones forming longitudinal and commissural fibers called medullated nerve fibers. The neurones receive, ■ up, au^ manufacture nervous energy and the nerve fibers transmit nervous energy and nervous impulses and impressions. The brain is covered by these three mem- branes or meninges, first, internally, the pia mater, which covers it closely, next the serous membrane or arachnoid, and the external fibrous membrane or dura mater. The arachnoid bridges over the large fissures of the brain cov- ering subarachnoid fissures filled with cerebro-spinal fluid. The ventricles of the brain are continuous with the central canal of the cord and the subarachnoid spaces. They are lined with a layer of ependymal glial cells and filled with cerebro-spinal fluid. The brain is continuous with the cord, its gray matter becoming internal and its white mat- ter becoming external. It is the function of'the brain in its cerebral cortex to receive mental impression, conduct intellection processes evolving and expressing emotion and thought. Reception of mental impression and conscious appreciation of sensations are here located. They reach the cerebral cortex through the nerve nuclei, corpora quadrigemina, tegmental system, ipital and temporo-sphenoidal cortex, and the peripheral communicating sensory nervous system. The cortex of the brain initiates voluntary motions, including speech, and receives conscious and unconscious impressions from with- out it. This takes place in the fronto-parietal cortex or psycho-motor area and is expressed in connection with the motor nerves and pyramidal tract, The brain produces and regulates bodily heat (caudate nucleus, tuber cinereum). Its medulla maintains respiration, inhibits the heart's action and 221 initiates and maintains deglutition and vomiting, accelerates or inhibits peristalsis and the various visceral operations are increased or diminished by the cerebral cortex, as urination, defecation, etc. Complicated movements and coordinate movements take place through the cerebellum. Consult your anatomies and physiologies here and dictionaries and medical encyclopedias on the subject of brain function often in connection with this course. Much of this description will be found in Duane's Dictionary. ANTEROPOSTERIOR SECTION THROUGH CEREBRUM. FIG. 112. Showing association neurones passing from fronta to occipital lobe and manner of connection of pyramidal cortex neurones. A, C, B. a ter- minal axone at D, collaterals of association axones at E, and cut ends of crossing corpus callosum fibers at f. (After Ramon y Cajal.) This illustration was shown farther forward in this course of lectures. FIG. 113. o.£\.r«x\ Ck.^iru.Q.^tvic'v^xxv o.x^4 C\.r\vrvo-t>«.\a-vott\-s. . (atll ■ .(Kbatirj. .. . f byp«rtrcmbl«ehc P»rti l dB boi t h arum-btld*t<* -*"*' :, .!rt KLfcvlir* II tch* Fomtd in dor i i-i. d pair of Eighth {nerves. Ninth Tenth ; \ pair of nthj nerves - Twelfth pair of Cerebellum. vA^xlevo-^o^CaVvftx Ttteo v«xxv tx-xvri V&evoX w,wtar 8w*- vessels, o^ c\t>c\)& ©^WVYVU, o-xxS We.\yev x>ox\.& Ce.>ce\QeXVvvTrw. C Vxoxvv cva/3CVvoxs re'du chiasma des nerfs optiques. — Artires da corps strie; — Ch, chiasma des nerfs optiques; — B. seclion de la bandelctto optii|ue; — L, noyau lcnliculaire du corps strie; — I, capsule interne, ou pied de la couronnc rayonnante de Red ; — C, noyau caude ou inlra-ventrirulairc du corps strie: — E, capsule cxterne; — T, noyau tcenKorino ou avant-mur; — R, circonvolution de ('insula; — VV, coupe des ventricules lateraux; — P,P, pilicrs du trigone: — 0, substance grisc du troisiemc ventricule qui so continue cij arrii'rc avee la couche optiquc. Terriloires vasculaires; — I, arb"'re cerebralc anteriuurc ; — 11, arlerc tyl- vienne ; — III, artere cerebrate posterieure ; — 1, artere carottde interne ; -'S, arterc sylvienne; — 3 artere cerebralc antericure; — 4,4, arlercs exlenies da corps strie ou lenticulft-striecs ; — 5,5, artercs internes du corps strie (arlerC3 lenticulaires). Cft.. OW\cvSrrv.,5- SecX'vori. O-pCvc. xvcxve, L. lex>A\cu.\oje XXU.O- Vew.& o^ ^tS-cxXo. bodu, C. Ccx\.v<5oi , C«, txux.W\a.s, £. E*rfexx\ai\. VV Sccfo-oxv o^ XoXexcxX Nje.x\?(x'\.c\e,&, P.P. PxYVo.xi o t ^CvveFoxxcYx, O. Gfrcx-v^ sv.'bs'Co.xx.ce. o^Wvro v«,xAt'vc\e, vol.^cvxXcocAax'c^Co'cvc.^ L Q.x^'Ce.-c'v.ox Cecc^broX cv-xXa-cu, ,X. Sy^vlcocv CVa^-CX ^ , IT "5os 1 Cex\x}Y CctcVcoX Cv/cCexu, , J. "ixxXc x:\noX ooocoV-i Ck-Acx^, Z. Sv^-vvolXv exxXfcxv^ 3. C±vXe.x:\t>v CexabxcCV. CX-cvex^, V-.V-. S^er *\c>.\ CLrKe.x've.'b ofj-'CY-vje, coxpu.& ^tx\.oAu.w, ox> Vex_9. cox^oxo_ s&rvoXo-, or VexvX\.c.\A.^. The lenticular striate artery is the principal artery of cerebral hemor- rhage. 243 FIG. 127. ^o^<cxfe*a\ Cross Section o^ FoX^CeWbrV t-JWf OF D ofjA O up. Long. Sh z.— Inf. Long S/flWS JhowiivQ £/vd view op Superior AND inferior lon^ituoinal qinuses. — CR0& &£CTt0*, (SCHEMATIC) /.2\t3. Line or fj\l% } uiPPwgsoWA/ ffemeeN cerbgral H£/v\/$pH£Res. cerebri, showing schematically a cross section of the supe- rior and inferior longitudinal sinus. They are lined by the same smooth membrane continuous with that of the venous system. Their unyielding walls resist the pressure of the brain about them and the blood pressure within them. The dura mater has fifteen of these sinuses. Let me recall them again: Five pairs and five singles. The five pairs are: the lateral, superior petrosal, inferior petrosal, cavernous and the occipital. The five single are: the su- perior longitudinal, inferior longitudinal, circular, transverse 256 and the straight. They all eventually discharge their venous blood into the internal jugular vein. The superior longitudinal sinus, caused by a triangu- lar downward division of the dura, as shown schematically in the accompanying illustration of the falx cerebri (Fig. 132), FIG. 132. The blood-vessels of the dura mater. Lateral view. (After HciUmann.) begins very small at the foramen coecum, it gradually increases in size in its course backward, and opposite the internal protuberance of the occipital bone, opening into a large vein somewhat triangular, the torcular herophili or the confluence of the sinuses. "It then divides into the right and left lateral sinuses, they being generally the larger. Besides numerous veins from the cancellous texture of the skull cap, the superior longitudinal sinus receives large veins from the upper part of each hemisphere of the cerebrum, and an emissary vein through the parietal foramen. Do not forget "that these veins run (as a rule) from behind forward, contrary to the course of blood in the sinus, and 257 that they pass through the wall of the sinus very obliquely, like the ureter, into the bladder. The probable object of this oblique entrance is to prevent regurgitation of blood from the sinus into the veins of the brain. The superior longitudinal sinus is triangular, with its base upward, and its cavity is intersected in many places by slender, fibrous cords, termed chorda? Willisii.t Their precise use is not understood." You noticed that after stripping it from the cavity of the cranium and taking the brain out of the cavity, we cut through the dura mater with a pair of scissors, on a level with the sawn calvarium. We now strip the dura mater from the brain leaving its smooth, convex surface exposed. "Two white, flat nerves, the optic, come into view prior to their leaving the skull through the optic foramina; these must be divided and the ophthalmic arteries which lie un- derneath the corresponding nerve, cutting each pair of the twin nerves first on one side and then on the other, from before backward. In the middle line fixed firmly in the sella turcica, lies the pituitary body, attached to the brain by the infundibulum." This is the important body which Sajous has lately brought into prominence. "The round, white nerves, the third, are on each side, lying on the inner free border of the tentorium cere- belli, immediately behind the anterior clinoid process of the sphenoid. Dividing these, we cut through the tentorium cerebelli close to its attachment to the pos- terior clinoid process and the upper border of the petrous portion of the temporal bone, as far back as the lateral sinus. Immediately external to the third nerves are the slender fourth nerves; and still further outside are the fifth nerves. We cut these through, when the seventh pair tSo called after Willis, who first described in his work, De* Gerebri Anatome, 1664. 25S come into view as they pass backward and outward toward the internal auditory foramina. Cutting these we notice the two sixth nerves running directly forward to pierce the dura mater covering the basilar process of the occiput. Dividing these three, other cranial nerves come into view, behind and internal to the seventh; anteriorly is the glosso- pharyngeal immediately, is the pneumogastric and poster- iorly is the spinal accessory, whose origin is in and below the medulla and foramen magnum. These all emerge through the jugular foramina. Below and internal to these are the hypoglossal nerves, which usually pass through the dura mater into fasciculi." The spinal cord has, you see, been cut through far down so as to show the relation of the two vertebral arteries, and the spinal portions of the spinal accessory nerves, before this brain was taken from its bony incasement. The inferior longitudinal sinus, smaller in size, runs in the inferior free border of the falx cerebri and terminates in the straight sinus at the anterior margin of the tentorium. The straight sinus is the continuation of the inferior longitudinal running along the line of junction of the falx cerebri with the tentorium cerebelli, and terminating in the torcular herophili at the divergence of the two lateral sinuses. It receives the inferior cerebral and the superior cerebellar veins and also the two vena? galeni (Figs. 132 and 133) which return the blood from the lateral and the third ventricles of the brain. The cavernous sinus is so called because intersected by numerous cords extending along the side of the body of the sphenoid bone, outside the internal carotid artery, receiving the ophthalmic vein from the orbit through the sphenoidal fissure and the anterior inferior cerebral veins. It commun- icates with the circular sinus which surrounds the pituitary 259 FIG. 133. Communication through- parietal foramen with external vein* of tkutt. Ext. Jugular oath Int. jugular vein Interrelations between the superior longitudinal sinus and the transverse sinus with the external veins. (*) (After Leube.l FIG. 134. AnCfaoialveia ■Ext, fuguX «\rjv (a canal or gutter) employed by Herophilus." [Holden.] 261 LATERAL SINUSES. "There are the two great sinuses through which all the blood from the brain is returned to the jugular veins. The right being usually larger than the left commences at the internal occipital protuberance and proceeds at first horizon- tally outward, enclosed between the layers of the tentor- ium, along a groove in the occipital bone and the posterior inferior angle of the parietal. They then descend along the mastoid portion of the temporal bone, indenting the oc- cipital bone, turn forward to the foramen lacerum posterius, terminating in the bulb of the internal jugular veins, where they are joined by the inferior petrosal sinus, having also in some subjects other outlets through the foramen mastoideum, or the posterior condyloid foramen of either side. They receive blood from the inferior cerebral and cerebellar veins, from the diploe and the superior petrosal sinus, and communicate with the veins of the scalp through emissary veins, which pass through the mastoid and pos- terior condyloid foramina. The diseases to which the dura mater membrane and its sinuses are liable are chiefly traumatic, general and specific inflammations, thrombosis and compression and thrombi resulting therefrom. Inflammations seldom involve the dura alone but usually conjointly implicate the subjacent membranes, the arachnoid and pia or, more properly called, I think, the pia arachnoid, as these two membranes appear to be an infold about the brain like the pleura about the lung. Remember the memorial word which 1 have given you in our dead-room demonstrations, d. a. p., (meaning from without inward) dura, arachnoid and pia. Meningitis may be entire, or circumscribed to different meningeal areas as basilar and vertical. It may be cerebro- 262 spinal, as in the epidemic form of that disease, called by the older writers spotted fever or cerebrospinal fever. It may be due to syphilis and give the gam- matous form, or to phthisis and appear as tubercular meningitis, or it may be caused by the pneumo-coccus or gonococci, and appear as pneumonic or gonorrheal forms, or it may be prevalent or come from various other kinds of blood-poisoning. Phlebitis may involve the brain sinuses from causes that produce inflammation elsewhere and such inflamma- tions may cause coagulations and adhesions of the venous blood to the walls of the sinuses or pial veins, causing the condition known as thrombosis, to which we have referred, from which small sections of fibrin may be detached and carried into the current of the circulation as thrombi, and these may lodge elsewhere and act the same as emboli, closing up blood vessels and causing distant embolism. Much mischief may be done to the delicate brain by the pressure and destructive change wrought in the brain even by a single thrombus located in a vital spot. Systemic meningitis usually involves the pia-arachnoid, while the traumatic meningeal inflammation generally in- volves the dura. More harm is done to the brain by involvement of its meninges than by implicating its deep substance, De- pressed fractures of the brain and direct and counter stroke or contre coup concussions, often seriously involve the dura and its subjacent membranes and their blood vessels and give rise to congestive blood pressure states and epilepsy and epileptiform disease. If you remember the distinction we made in a previous lecture between neural and ad- neural nervous disease you will recognize that meningeal 263 and sinus diseases, deranging the brain's functions often begin as extra-neural brain disease. When the dura mater is involved exclusive of the other meninges in inflammation, this condition is called pachy- meningitis. When the pia arachnoid is involved to the exclusion of the dura in inflammation, the condition is called leptomeningitis. The under or inner surface of the dura is usually the seat of inflammation except when caused by external trauma and then cranial ostitis may be associated with the endostitis or epidural inflammation. Extravasations of blood often occur in connection with dura-matritis and then the condition is called pachymeningitis hemorrhagica interna, and when these hemorrhages become encapsulated they are called hematomata durce matris. These hematomata of the dura mater often harmfully press on the brain, compromising its functions and causing coma, convulsions, paralysis, delirium or insanity. The meningeal arteries supply the central dura mater and its innervation is derived chiefly from the trigeminal nerves. The pia arachnoid is similarly innervated and from the facial and spinal accessory, glosso-pharyngeal, pneumogastric, the third and the sympathetic. This last nerve accompanies the many vessels of the pia. The dura mater is what its name implies, the hard membrane, in contrast with the other two brain coverings which are soft and easily torn, one of which, the pia mater, being very vascular as we have seen, and the other being without vessels and both being delicate. Although the brain is pretty much a plenum, the peri- vascular spaces and ventricles have communication with the spinal canal and thus the cerebro-spinal fluid admits of some arterial hyperemia and increased vascular distension, 264 and pressure in localities of the brain especially, if not gen- erally, throughout the brain and the turgid arteries and in- creased rapidity of their circulation may cause cerebral congestion, giving pressure states of the brain in the arterial and venous areas and causing hebetude, coma and paralysis. Sometimes the venous blood pressure is fortuitously relieved by epistaxis through the foramen coecum, passing out through the nares. You may also have anaemia as well as hyper- emia cerebri for the same reasons. In anaemia the cerebro-spinal fluid of the perivascular spaces around the arterioles and the ventricles increases, after maintaining a semblance of normal blood pressure on the neurones, without normal nutrition, and the brain may functionate in consequence in a feeble but normal manner in anaemia. Besides, there may be hydremia. It is not good therapeutics to arrest an epistaxis while the pulse is full and strong and rapid (above seventy-four to seventy-eight). Sometimes, in some highly congested states of the brain, it would be wise to bring on bleeding from the nose or arm. A weak pulse, bleached features and faintness demand the immediate arrest of epistaxis. It usu- ally stops spontaneously when fainting takes place. If the bleeding is known to be connected with previous or present anaemia, and blood depraved states, as in the adynamia of typhus or typhoid fever and other pernicious blood states, even though there be delirium and other head symptoms, bleeding from the nose is not to be encouraged. If you have a plethoric, full-blooded patient with con- gestion of the brain, in whom nose bleeding begins every day and finally stops of itself each day, let this bleeding go on daily unless your patient faints from it. Give him a daily chologogue cathartic and bromides, half minimum doses of digitalis, some pepsine, other digestives and a mod- erately low diet and keep him free from all brain ex- citement. Give him no alcohol stimulants. 265 FIG. 135. i-Intima mlt Enilotfael.- h Erasti • Virchow-Robin — Lyraphi fntravascuJArer FIG. 136. XXa**wvoJVVe"vtv o^ Pvew XXVck?Ce.- e.vve.xdkvoxx o^ \V\fc peciCVcoc (XvKaxx^. Atheromatbse Degeneration der Art. basilaris. a gewueherte. kemreiche Intima. * in fettighyaliner Umwandlang begriflene gewnchene Intima c Fragmentation der veranderten Elastica int d Atrophie der in hyaliner Degeneration befindlichen JIu-.1ul.1r15 t Adventitia. /' Spaltraum zwuchen der Elastica interna und der tayalin degenerirtsm Intimasklenose- Eigene Beobacbtung (Nacli No/we und Luce.) SECTION OF BRAIN, SHOWING GUMMATA. Original observations by M. Nonne and H. Luce. — Flautau, Jacobson and Minor's Handbook of the Pathological Anatomy of the Nervous Systems. FIG. 138. Partie aus einem Cummi an der Hinibasis HamatoxylinF.ubung. In samratlichen Gefiissen ist das Lumen stark vercngl. bei o obliterirt . ill den. Lumni .1-1 auderen QeflSM tindet sicb noch ctwasBlut (M (rothe Bliukm-perchem Di<- \ erengeruiig des l.i. ns k.niimt »uf Rerbnang der Proliferation der Intima (el Media und Adventitia Sim von gleielim.isMg .-„i- jitndlicb innltnm-m Gcwebe - das an dlener St.- ,00b nielli nekrotiscb 1st - verdecki Eigene Beobacblung CHAPTER XXV. THE ANATOMY OF THE SPINAL CORD, WITH BRIEF REFERENCE TO ITS MORBID STATES. In your dissections of the spinal cord when the arches of the vertebrae are sawed through and removed, the spinal cord comes into view. The cord does not occupy the entire cavity of the spinal canal. The dura mater does not adhere to the vertebrae clear down the canal and does not form their internal periosteum or endosteum as in the skull. Between the walls of the spinal canal formed by the spinal bones, and this membrane, a space intervenes, which is filled with soft, reddish looking fat, with watery cellular tissue and the ramifications of a plexus of veins. "The spine is remarkable for the great number of large and tortuous veins which ramify about it inside and outside the vertebral canal. These veins are the dorsi- spinal or posterior external veins which form a tortuous plexus outside the spinous, transverse and articular pro- cesses, and the arches of the vertebrae, communicating with corresponding veins above and below, ending in the plexus inside the vertebral canal. They join the vertebral veins in the cervical region, the intercostal in the dorsal, and the lumbar and sacral veins below." "The veins of the bodies of the vertebrae {venae basis vertebrarum) emerge from the backs of the bodies and [283] 284 empty themselves into the transverse veins, connecting the two anterior longitudinal spinal veins.*' The tortuous anterior longitudinal spinal veins run the whole length ol the spinal canal and receive opposite each vertebra, the venae basis vertebrarum. "The posterior longitudinal spinal veins run also along the whole length of the spinal canal." The anterior and posterior longitudinal spinal veins are situated between the spinal canal and the dura mater of the spinal cord, and are called the meningo-rachidian wins, and the medulli-spinal or proper veins of the spinal cord within the dura, form the fine plexiform arrange- ment of veins over the surfaces of the cord. They ap- pear so distinct that they can with difficulty be injected from other spinal veins. These veins discharge themselves through the intervertebral foramina in the several regions of the spine, the cervical emptying into the vertebral veins, the dorsal into the intercostal veins, the lumbar into the lumbar veins. They are not provided with valves, and often become congested, in spinal disease. They may be the seat of embolism in sluggish states of the spinal cord circulation and in spinal phlebitis. The membranes of the spinal cord are the same in number and continuous with those of the brain, but they differ from the brain membranes in their attachments. Tlie dura mater of the cord is tough and fibrous, like that of the brain in structure, but it does not adhere to the bones, being separated from them by fat, loose areolar tis- sue, and the plexus of veins referred to. This loose arrange- ment or absence of attachment of the dura mater to the inner spinal canal wall permits the free movement of the vertebrae. Adhesion would impede this, neither is the cerebral dura mater everywhere adherent to the inner 285 walls of the cranium, being most markedly adherent along either side of the falx cerebri and great longitudinal sinus, where the Pacchionian bodies are mostly found in our dis- sections. The spinal dura mater is attached firmly above to the margin of the foramen magnum, and by slender tis- sue to the posterior common ligament, and may be traced downward as a sheath, as far as the second bone of the sacrum, from which it is prolonged as a fibrous cord to the coccyx, where it becomes continuous with the periosteum. It forms a complete canal or bag or sheath {theca) which FIG. 139. DIAGRAM OF A TRANSVERSE SECTION THROUGH THE SPINAL CORD AND II MEMBRANES. i. Dura mater. 2. Arachnoid membrane. 3. Ganglion on posterior root of spinal nerve. CHel^tx) 4. Anterior root of spinal nerve, 5,. 5. Seat of sub-arachnoid fluid. \oPosterior branch of spinal nerve 7. Anterior branch of spinal nerve. surrounds loosely the spinal cord, and is relatively larger in the cervical and lumbar regions than in the dorsal. On each side are two openings in the dura mater for the an- terior and posterior roots of the spinal nerves, and the mem- brane is prolenged over the trunk of each of the spinal nerves. These prolongations accompany the nerve only so far as the intervertebral foramina, and are there blended with the periosteum. The inner surface of the dura mater is lined with a smooth layer of polygonous or many-sided secreting cells, yet sometimes called the parietal layer of the arachnoid membrane. If you cut through the nerves which proceed from the spinal cord on each side, an J remove the cord with the dura mater entire, then slit up the dura mater along the middle ol the front of the cord and examine the arachnoid membrane you will, from its anatomical structure, note that the functions of the dura mater of the cord are not identical with the encephalic dura mater since it does not here form internal periosteum to the bones of the spinal canal; nor does it send in partitions to support the cord; and it does not split to form venous sinuses, as the dura does in the brain. The arachnoid membrane of the cord is a continuation from that of the brain, and is reflected over the spinal nerves as they pass from the cord to the apertures in the dura mater. This membrane invests the cord, and is in contact by its superficial aspect with the dura mater, there being an interval between them called the subdural space, although, in some cases, they are more or less connected by connective tissue bands. On its deeper surfaces it is in contact with the pia mater, but is loosely connected with it by delicate areolar tissue, so there is a considerable in- terval between them (sub-arachnoid space), which is occu- pied by a transparent, watery fluid (cerebro- spinal fluid) contained in the meshes of the sub-arachnoid tissues. The separation between the arachnoid and the pia mater varies in the different parts, and is greatest in the lowest part of the cord. The cerebro-spinal fluid will claim attention from you in practice. It amounts to one or two ounces or slightly more or less and makes the watery cushion of the cord to protect it in a measure against spinal irritating motion and slight concussions of brain or cord. It consists of ninety- eight and five-tenths per cent water and one and five- tenths solid matter. It distends the theca or sheath of the 287 cord and softly cushions the cord against violence, in run- ning, jumping, falls, etc. An old physiological anatomist, Haller by name, discovered it and another distinguished physiologist, Magendie, demonstrated it. He sawed away the arches of the vertebras of animals and, puncturing the dura mater of the cord, saw jets of fluid issue from beneath the punctured sheath. He called this cerebro-spinal fluid, the cephalo-rachidian liquid. If we could get out all the serum of the perivascular and subarachnoid spaces we should find more than two ounces of this fluid. The spinal fluid is called cerebro-spinal fluid because it communicates through the fourth ventricle, as stated, with the general cerebral and ventricular serum cavities and with the serum of the spinal cord. The cerebro-spinal fluid comes into notice, especially in early infancy, when the fontanelles distend or flatten, ac- cording to the extent of the pressure of this fluid and in spina bifida where the spinous processes do not unite at the proper time of evolution for them to come together. If you press over the fontanelles of such a child the tumor in the spine will enlarge, and if you press back the distended fluid from the spine, the fontanelles will swell out. If you confine the fluid in the head by steady uniform pressure and press on the spina bifida tumor at the same time, you elicit symptoms of neuraxis (or cerebro-spinal axis) pressure, such as vertigo, or suspended consciousness, suspended ability to feel or move. This experiment of nature con- firms the results of laboratory experimentation. The cer- ebro-spinal fluid should be allowed to escape but sparingly in the therapeutic procedure of spinal puncture for cocain- ization of the cord. Spine puncture and cerebro-spinal drainage is coming into use in these days of the mar- velous medical advance now on and before you, for relief 288 in certain conditions of excessive brain or cord pressure, like hydrocephalus, serous apoplexy, etc., and for purposes of cerebo-spinal medication besides anaesthesia and for diagnostic purposes. We are probably on the threshold of a new cerebro-spinal therapy, a neuraxis cerebro-therapy. The cerebro-spinal fluid has indirect relation to the serum, occupying the perivascular spaces about the blood vessels of the brain and thus becomes related to states of pressure about the blood vessels, as we have seen, and to anaemia and to the healthy tone of the brain. This sub- ject will occupy our further attention at another time. To find the cerebro-spinal fluid on dissection the cord must be examined soon after death and before the brain is removed. The nerves proceeding from the cord are loosely surrounded by the sheath of the arachnoid. But this only accompanies them as far as the dura mater, where the two are continuous. The cerebro-spinal fluid of the cord communicating with that of the brain, and also with the general ventricular cavities and perivascular spaces has important neurological bearing, as we have seen in dis- cussing the brain's circulation. The pia mater of the cord immediately invests the cord and its protection differs in structure from that of the brain. It is not a membrane filled with minute arteries, but it sup- ports and strengthens the cord, as the dura does the brain. It is less vascular and more fibrous in structure and more adherent to the substance of the cord. It sends down thin folds into the anterior and posterior median fissures of the cord, and is prolonged upon the spinal nerves, forming their investing membrane or neurilemma. Along the anterior median fissure runs a well-marked fibrous band formed by the pia mater, the linea splendens. Below the level of the second lumbar vertebra, the pia 289 mater is continued as a slender filament called the filum terminale, or central ligament, which runs down in the mid- dle of the bundle of nerves (the cauda equina) into which the spinal cord breaks up. About the middle of the third sacral vertebra it becomes continuous with the dura mater of the cord, and is then prolonged as far as the base of the coccyx. The spine of the third sacral vertebra marks the level to which the cerebro-spinal fluid descends in the vertebral canal. It is supplied with nerves from the sympathetic and from the posterior roots of the spinal nerves. FIG. 140. A < M I. Dura mater. 2,2,2. Ligamenturn denticulaum QioUtr?) The ligamenturn denticulatum connects at each side of the cord along its whole length with triangular or dentate fibrous bands. This series of processes steadies and sup- ports the cord in its place in the spinal canal. The bases of these dentate bands are attached to the cord, and their points to the inside of the dura mater. There are from eighteen to twenty-two of them on each side of the cord and they lie between the anterior and posterior roots of the spinal nerves. The first process passes between the vertebral artery and the hypoglossal nerve; the last is 290 found at the termination of the cord. It is composed of fi- brous tissue and is covered with nucleated cells continu- ous with the arachnoid membrane. The membranes of the cord will interest you in con- nection with spinal meningitis or cerebro-spinal menin- gitis, which is an inflammatory condition, also tubercular meningitis, diphtheria, and the tumors of the cord. About all the tumors of the cord, except glioses and gliomata, originate in the membranes. Gliomata and glioses are developed from the glia tissue, called also neuroglia. Glio- mata are malignant. Neuromata and sarcomata form in the spinal nerve roots, brain or cord substance and cranial nerves. Gliomata, tubercles and sarcomata often originate in the gray matter or the cord. Echinococci are generally found external to the dura. Cysticerci are found in the brain and cord sub- stance sometimes. Lipomata are indolent, slow-growing, fatty, painless tu- mors often found in the skin on scalp. Their super- ficial existence might warrant us to suspect them to be also deep seated, in certain states of the nervous system. Pay close attention to the chair of surgery, when tumors are discussed there. Most tumors of the coverings of cord are small, of slow growth, growing by preference up or down the cord and beginning after an injury to the cord or spinal trauma, as spinal cord wounds are surgically called. Syphilomata and certain cancers grow rapidly. Spinal men- ingeal tumors lie in the cord like an egg in a nest. They press upon the cord slowly but do not cause the cord ab- sorption and may be enucleated with relief of all symptoms sometimes. Tumors external to the dura do not immediately disturb the cord functions for obvious reasons, connected with what 291 we know of the cerebro- spinal fluid and the floating of the cord in the spinal canal. The favorite seat of cord tumors is dorsal and caudal. The circulation of the cord will engage your study in connection with congestion or hyperaemia and a diminished blood supply or anaemia of the cord or spinal irritation. The circulation is also involved in inflammation of the envel- oping membranes or meningitis and in inflammation across the cord or myelitis, the columns and horns of the cord, will interest you in spinal paralysis and spasmodic states like tetanus and the scleroses, lateral spastic, and posterior. The arteries of the cord are first the anterior spinal arteries, which commence at the medulla oblongata, branch- ing from the vertebral of each side and running down the middle of the front of the cord. Other branches are de- rived from the vertebral, ascending cervical, intercostal and lumbar arteries, which pass through the intervertebral fora- mina, and assist in keeping up the size of this anterior ar- tery. "And the posterior spinal arteries which come also from the same source, vertebral, intercostal and lumbar ar- teries, ramify irregularly over the back of the cord." "The spinal arteries of the opposite sides communicate by numerous transverse branches along the entire length of the spine" on the anterior part of the bodies of the verte- brae, "thus resembling the arrangement of the venous plexuses of the cord." Accompanying are illustrations of the cord's circulation. The venous from Holden (Figs. 141 and 142) and the arterial from Brissaud (Fig. 143) and by Gowers (Fig. 144), the latter modified by Church (Fig. 145). Our modern anatomists, those painstaking followers of the great Vesalius, who made the first human dissect- ion, who by their clear delineations of the spinal cord and 292 its relations to the spinal canal and the vertebrae that con- tribute .to make this remarkable nerve center channel of protection and conduction, have enabled us to understand intelligently the remarkable power of resistance of the cord and its membranes to ordinary movements and lighter in- juries of the spinal column and even to what would other- wise prove to be very considerable shocks to the delicate structures of the cord. FIG. 141. ACBAM.OE.THF. SPINAL VE1KS. (VERTICAL SECTION.) Z,. PoT6i-6|>vwcxX\e\'cvs. VSp'vtt«iX ve'vtvo. The arrangement of the cord within the spinal canal, floating as it were, like an anatomical or pathological specimen suspended from the neck of a bottle, immersed in a sack of fluid, enables the cord to swish a little back and forth and from side to side without having its function de- stroyed. The dentate ligaments, as seen in the accom- panying illustration and the loose relation of the dura of the cord to the cord and canal walls and cushioning veins, also here shown in these drawings from nature of the cord's cir- culation, make plain still farther Nature's kind conservation of the cord against ordinary violence. 293 A concussion of the cord at either side, as from a sud- den or violent fall on the head or on the ischial and sacral bones, would disturb the cerebro-spinal fluid from one end to the other and give the delicate neurones of the cord cen- ters and their prolongating neuraxone or dendrite connect- ions, into the motor or sensory nerves, a comparatively less delicate shock than they now receive under Nature's kind fig. 142. DIAGRAM OF THE SPINAL VEINS. (TRANSVERSE SECTION.) & T^c-y-AA/- /O^a^vvoJL' \t€a^v^^ . protecting anatomical safeguard. 1 say comparatively deli- cate shock, because of the water wall of the cerebro-spinal fluid and attachment of the dentate bodies of at least twenty of the spinal cord segments of the cord and extend- ing the cord's entire length. Injury to the cord from vio- lence is often therefore slight and microscopic, compared to what it might be from the same degree of violence, were 294 it not for this wonderful conservative arrangement of this most delicate and important structure, which condenses ca- pacity for so much power and force of function in so little space. Nature here, as so often elsewhere in the human framework, is preeminently wise and kind to man in her wondrous adjustments of structure and function. Extreme delicacy of texture, greatness in nerve force, engen- FIG. 143. Kin. circulation in oord BegmenfcMDu iii vi-illL-al directions (Rrissaud). ©CfV©»%V&- dering capacity and marvelously strong protective ar- rangements make up Nature's marvelous mechanism as displayed in her building, bounding and locating of the spinal cord. It can be damaged by great concussion, but not by the slight jars and disturbances of ordi- nary human movements. It takes extraordinary violence to harm it, like falls from heights, inadvertent stepping 295 downward to an uncalculated depth or the momentum of a railway train suddenly stopping or a head-end collision, or the sudden drop of an elevator or the violent jerk of it, or a ponderous street car's too suddenly checked momentum. fig. 144. AfcS —Semi-diagrammatic representation of the arteries of the spinal cord ; A s, anterior spinal. Central arteries. — A M, anterior medial ; c a, be- tween the right and left commissural arteries; a, anastomotic artery, divided transversely, to which a branch goes from the commissural artery, which then divides into a c, anterior cornual, and m c, mid-cornual arteries. Peripheral arteries. — p m, po-terior medial ; p i, post- intermediate ; p c, posterior cornual; p r, posterior radicular; p I, m I, a I, regions of the posterior, middle, and anterior lateral l>ranches ; ar, anterior radicular. In the rght half of the figure the more deeply shaded part indicates the region supplied by the central arteries. £0u£teT \fO VW^C S) One of the problems for you to work out, is why an inadvertent previously uncalculated step into mentally unmeas- ured depth, even though slight, should harm the cord, when the same step anticipated does not. Does the will regulate the flow of the cerebro- spinal fluid to protect the cord against effects of the concussion, or what does take place? What 296 help do the intervertebral cartilages give, and how? Does the will > regulate these as it Joes the muscular tension of the back muscles? Is there something like a vasomotor mechanism for the cerebro- spinal fluid channels? Work this problem out in your minds and tell me what you think about it at our next meeting, or later in the med- ical press. The true nature of the tumors of the interior of the cord is generally best diagnosticated post-mortem. We de- FIG. 145. trteriea of the Bpinal cord. A S, Anterior spinal ; A -V, anterior median ; re, commia- u, uuastoniotic ; a e, anterior contra! ; />, posterior central ; a r, anterior root arteries ; a/, anterior lateral; m/, median lateral ; p /, posterior lateral: jj r, postcrloi I artery; pc, postcrjoi con intermedial" . i.ial ; p m, iiosterlor median Oliersteinei by Cku/GcA ) tect their existence through unilateral or bilateral neuralgic symptoms and circumscribed hyperesthesias encircling the trunk hemiplegias, monoplegias, paraplegias or, if in the neck regions, general paralysis. Irritation at the posterior spinal nerve roots causes pain usually unilateral, because tumors are generally one-sided, at least in the beginning of their development. Besides pain, their extreme pressure causes belt lines or half belt lines of anaesthesia. Motor weakness 297 sets in and later spinal paralysis and spastic states appear and bladder and rectum functions are affected. The spinal cord, only from sixteen to eighteen inches in length in man, and a little shorter in woman, weighing about an ounce and suspended in the vertebral canal down to the second lumbar vertebra, with a swing movement in the spinal canal of from a half to three quarters of an inch, or a little more, is a source of remarkable power in health, a power greater than any mechanism of man's contriv - ance of many times its size and weight. It is also subject to very remarkable diseases. Like the brain, the cord's inflammatory diseases are congestive, anaemic, adventitious, hernial profusions, degenerative states, tumors, specific dis- ease, like tuberculosis and syphilis or toxic disease, like tetanus and functional states, like neurasthenia, and the secondary conditions of its inflammations classical in the sclerosis and softenings, degenerative states of the cord, like the ataxias or scleroses, posterior or disseminated. The meninges of the spinal cord, like those of the brain, are liable to pachymeningitis, hemorrhagic and hyper- trophic pachymeningitis and the pia mater to leptomeningitis. The substance of the cord is subject to myelitis and syrin- gomyelia, as the brain is to porencephaly and cerebritis. The circulation of the cord suffers, like that of the brain, from embolism, thrombosis, hemorrhage, plus and minus blood supply states, and the cord is subject to disorder from injury or deficiency of its incasing vertebrae, as in Pott's disease or spina bifida. 298 THE SPINAL CORD, AFTHR QUA1N AND FERRIER FIG. 146. In A the anterior surface of the cord is shown. The anterior nerve root being divided on the right. In B a transverse section of the cord is exhibit- ed, showing the crescentic shape of the grey matter in the interior. 1, The median anterior fissure. 2, Posterior median fissure. 3, Anterior lateral depression over which the anterior nerve roots are seen to spread. 4, Pos- terior lateral groove into which the posterior roots are seen to sink. The anterior column is included between 1 and 3; the lateral column between 3 and 4; and the posterior column between 4 and 2. 5, The anterior root. 5' in A equals the root divided. 6, The posterior roots, the fibers of which pass into the ganglion 6'. 7, The united or com- pound nerve. 299 FIG. 147. Section of the spinal cord after Ferrier, in the lumbar region, magnified. — A, The anterior column. L, The lateral column. P, Posterior column. 1, The anterior fissure. 2, The posterior fissure. 3, The anterior cornu with multipolar cells. 4, Posterior cornu the letters placed on the sub- stantia gelatinosa. 5, The anterior roots of the spinal nerve. 6, The posterior roots. 7, The anterior commissure. 8, The posterior commissure. 9, The central canal of the spinal cord lined with epithelium. 300 FIG. 148. . * ?ot\Xtle&.?v&artce 'olumn tflissauer (SAjJL fyx-v^^'v o.j I smnal cord; allowing its anatomical Mihil i visions (S, lined.! CHAPTER XXVI. NERVE CENTERS (CONTINUED). PSYCHO-MOTOR CENTERS— VISUAL APPARATUS CENTERS— OTHER MO- TOR AND REFLEX CENTERS. Nerve centers are somewhat shadily circumscribed re- gions in the nervous system made up of groups of neurones, as we have seen in a previous lecture, having a common function, to which concentric or afferent nerve influences travel or converge and may be there acted upon by the nerve center and from which efferent or eccentric impres- ions emerge or are sent out. If the peripheral impression going to a nerve center is simply transmitted into a motion or pain or other sensation and sent back to the point from which the afferent or peripheral impression originated or started or to .some related peripheral organ, the action is called a reflex action, as when a smart tap below the knee sends up an impression afferently to the posterior col- umns of the spinal cord, then goes across the cord to the anterior motor poles or horns or cornua of the cord and comes back (efferently) to the knee again, as a motor im- pulse, making the classical knee jerk or knee phenomenon in healthy states of the posterior root zones of the cord, but which can not be elicited in posterior spinal sclerosis or locomotor ataxia and in that suddenly oncoming disease of the anterior horns called poliomyelitis, anterior or infan- [301] 302 tile paralysis, or the essential paralysis of children, and which is also absent in a similar condition of the anterior horns of the cord in adults. The reflexes are all over the body. The eye has its reflexes, as when a grain of dirt impinges on the eyeball and the eyelids wink till it is removed, or as they wink when we tap the supraorbital or infraorbital region over their respective nerves of the fifth pair emerging from the superior or inferior orbital foraminae. The nose has its reflexes or reflex starting points, as in sneezing, which is a medulla reflex, and there is a peculiar reflex or rather transmitted impression which runs over the body in some people when the external canal of the ear is tickled. The larynx and pharynx have their reflexes, as when coughing or swallowing are excited, the stomach as in vomiting, the bladder in urination, the rectum in defecation, the bowels in peristalsis, the genitals, the chest, the plantar region, the toe, the sole of the foot and so on. These re- flexes are really nerve center reflexes only manifested in these localities. But we shall recur to them again and more in anatomic and diagnostic detail. When a nerve impression is not transformed and sent back in motion or reflected in pain, it is often transmitted further along or higher up the cerebro-spinal axis, it is called a transmitted impression and a good deal of what is often inconsistently called reflex action is really of this na- ture. True reflex action is usually sensation transformed into motion and sometimes pain with it, and sent back to the point of origin of sensation or near to it. Other varieties of what has been loosely called reflex action are really transmitted or sent on impressions, exciting action in some other point or nerve center. There is probably not so much pure reflex action in nervous disease as has been supposed, 303 but a good deal more of transmitted nerve center action dependent on physiological nervous connections made to act morbidly and reveal disease by reason of intimate, though sometimes distant, nervous relations as you may see, and study with diagnostic and therapeutic profit in the pain point tables and pain transmission of your text-books, notably, in the instructive table of Dr. Allan M. Starr and Mills. In addition to the psychic and sympathetic system cen- ters, the centers of the nervous system are designated sen- sory centers, for the reception of sensation, motor centers for the sending out of impulses. Reflex centers at the top of the reflex arc where sensory impressions are converted into motor impulse or expression, inhibitory centers which inhibit or arrest or prevent action that would otherwise be pure reflex movement. Motor centers are either spinal mo- tor or brain motor, that is, psycho-motor or cortical motor centers. The most important motor centers are the corti - cal, as they are also anatomically located highest in the cer- ebrospinal axis. Cortical centers are gray matter brain centers. They are called cortical motor centers or psycho-motor centers, because impulses to direct movement originate there, and psychic impression centers because voluntary movement thought, originates in them or rather starts from them. Im- pressions go to these psychic centers from without the brain, principally through the nerves of special sense as those of smell, taste, sight, hearing. Special touch and general sen- sation and impression pass up to them through and from the periphery and posterior columns of the spinal cord and through the optic thalami, as the latter go to the spinal cord from the surface of the body. The motor centers of the brain, called psycho-motor cen- ters, are mostly l'ocated and grouped about either side of the 304 fissure of Rolando, in the ascending parietal, the ascending frontal- convolution and the third frontal convolution or speech center of Broca, the location of aphasia. Impulses from them outward from the corona radiata or project in fibers down- ward through the crura cerebri and pyramidal tracts and antero-lateral columns of the spinal cord. The auditory center or cortical sensory center for the conscious reception and discrimination of sounds is in the superior temporal convolution below the fissure of Sylvius ither side, but probably more active in the left side like the speech centers, in right-handed persons, the left hemisphere with such persons being the specially active or driving side as Ferrier called it. Several subordinate dis- tinct or subsidiary centers are supposed to make up the au- ditory center, but you need not puzzle your brains with this matter just now. Remember that the hearing center, with alliits real or fancied subdivisions is located in the temporal region. The final termination of visual impression is in the oc- cipital lobes. Visual fibers of the optic nerves and optic nerve tracts conveying visual impression go to the lateral geniculate bodies, the anterior corpora quadrigemina, the pulvinar of the optic thalami, and the angular gyrus or pli courbe and are distributed over a great part of the occipi- tal lobes. Their whole area appears to be full of light, as Munk's slicing experiments on dogs have shown where the optic apparatus is normal in structure and function. The vis- ual center is more definitely located in the left cuneus, lin- gual and fusiform lobules and the angular gyrus for the ap- preciation of external objects, but 1 think' the side of the brain depends on the matter of use. We may be ambiauditory as we are ambivisual and as we may be ambidextrous. Witness the once clumsy but now dextrous violinist, who, 305 after training, like Ole Bull, Kubelik and other skilled per- formers, make the world marvel at the skill of their hands in delicacy of touch. Equal nucleal, though latent, central possibilities, are in the right side of the brain, as well as in the left. Our brains, as yet, are only partly educated. There is a distinct auditory, as well as visual word center, by which neurologists account for some of the va- rieties of aphasia, by which word symbols are understood and word sounds are not and vice versa by the aphasiac person. The olfactory center has been located in the un- cinate gyrus, but the sense of smell may be impaired or destroyed and anosmia may be produced by injury or disease at any of the origins of the olfactory nerve or along its course anteriorly or at its middle turbinate bone point of distribution as in oezoena. Hyperosmia, that olfactory su- persensitiveness, which exists sometimes in hysteria and other nervous diseases and which Alexander Pope may have had in mind when he referred to the possibility of one dy- ing of a rose in aromatic pain, may depend upon hyper- excitation along the distinctive course or at the brain origin of this nerve, as from a tumor impinging upon or a cerebritis or inordinate activity. Grouped within the medulla oblongata, not far from the fourth ventricle, which seems to have been assigned the duty by Dame Nature of providing resident centers for most of the cranial nerves, is located a whole colony of vital nerve centers. We marvel at the centers of power and in- fluence concentrated in the fourth ventricle. We wonder even more at the number and strength of the nerve centers of the medulla. This subject surprises us quite as much as the nerve force and influence carrying capacity of that little band of nerve strands collected and compressed, and carrying down from the brain through the internal capsules 306 of the corpus striatum. This little streak of strands and bundle, of nerves that carries the supreme power of the cer- ebral cortex down to the lower centers of the spinal cord and sends it out in channels of expression over motor tracts and the nerves to the muscular system, viscera and outside world is a marvel of force conduction and the ponto-med- ullary region is a marvel of force generation. Respiration, sweating, swallowing, coughing, vomiting, sneezing, bowel peristalsis, cardiac inhibition and arteriole blood vessel tonicity and vaso- motor centers all have their seat and centers in the medulla. The latter in the me- dulla and cord and some one has imposed vaso-motor func- tion on the little tuber cinereum. The tuber cinereum has also been charged with being the fons et origo of the dog's panting and the seat of our own pants, as it were, when we are physically overwrought or overrun or rapidly overworked. The thermotaxic or heat generating centers were well placed in the medulla by our investigator, Isaac Ott, and by foreign neurophysiologists, among the latter, notably, Schiff, Owsjaniskow and Leigois. To the caudate nucleus of the striate body has also been assigned heat centers and the general sensibility per- ception center has also been placed in another part of the .)wer portion of the corpora striata. The thermo-inhibitoiy or heat controlling centers have been conjecturally, but not very definitely, located in the fissure of Silvius and the tu- ber cinereum, and the thermolytic or heat dissipating center has been placed there also. But you need only remember for the present that somewhere in the gray matter of the brain part of the cerebro-spinal axis, are heat generating and heat controlling regulating centers, the former in the medulla, especially. 1 think a good deal of work has been assigned by the 307 physiologists to the tuber cinereum, but very small centers in the neuraxis do a large amount of work. Every part of the gray matter of the brain, however, has something im- portant to do. Its neurones are aggregated into working communities. They are centers of action and power. The only part of the brain which seems to have gone out of business since Descartes assigned to it the regal seat of the soul, is the pineal gland. This pine cone shaped attach- ment of the anterior twins of the corpora quadrigemina is waiting for a new physiological discovery. It may be for one of you. Descartes is dead. There are also to be con- sidered as specially important in diagnosis and treatment, the cerebral and spinal pupillary centers already alluded to. The genital, vesical, anal and parturient reflex centers and contraction power are all in the lumbar cord. A wonderful mechanism you see, is the nervous system, and the wonder of all this wondrous organism is the nerve centers of the cerebro-spinal axis or neuraxis. It is little wonder that the cord enlarges in the lumbar region to do all of this won- derful work. It has a big job on hand and a steady one. When its special centers cease their vigilance and go to sleep or die from paralysis, there comes a trying ordeal for the poor patient and for the attending physician and the trained nurse, the rectum and bladder neglect their busi- ness, the urine is retained or dribbles away, faeces escape and the undertaker waits his turn close at hand. The fear- ful fatal sequel of extensive transverse myelitis or complete across inflammation of the spinal marrow, which more often than otherwise is caused by profound injuries to the back, when the back is broken for instance, gives us a pitiable spectacle of the helplessness of man, when the spinal cen- ters have lost control over the pelvic viscera. CHAPTER XXVII. THE SENSORI-MOTOR SYSTEM IN DIAGNOSIS— THE REFLEXES. Bioplasm is all about us in animated organism respond- ing in reflex action, to the impression of environment and the unanswered question, which it suggests, "what is life?" recurs to us as it did to Pilate and the philosophers of old. Lional Beall, applying the term bioplasm of life to the pro- toplasm through which animate movements appear to us, has not answered the question to the satisfaction of the scientific world. Will you in your studies of neuro- biology, endeavor to solve it for the enlightenment of mankind and the satisfaction of the soul's longing for clearer light on the subject? Man still asks the question. The great law of nerve reflex action responsive to per- ipheral impression, that transforms the knee-tap below the patella, for example, into a knee-jerk; that causes response with a gentle inspiration to the presence in the bronchi and pulmonary air cells of a congenial breath of air and an ex- piration to the presence of carbonic acid, generated by the pulmonary air change, or in cough or spasm to an uncon- genial breeze, or gas or other irritation; that makes the sneeze similarly responsive, or the strangling effort at ex- pulsion of food or water going down the wrong way, into the trachea instead of the gullet; that moves the bowels or bladder or regulates the sphincter; that causes the face [303] 309 to smile with joy or mantles it witli sadness, responsive to a voice or written word; that makes the pupil move to light or to the withdrawal of light in darkness; that moves the eyelids, lights or dims, moistens or drys the eyes; blanches the cheek with fear or suffuses them with blushes; gives the fierce glare of anger or the expressions of vengeance, despair or hope; that causes weeping, laugh- ter or tears and all the different facial expressions of the varying moods and emotions of the mind. That makes "Soft eyes look love to eyes that speak again," reflecting love in smiles of reciprocal joy; that show sad- ness in tears, joy in mirthful laughter and shame in the downcast look, are all psycho-neural reflex phenomena. Psychic reflection flashes back the wit responsive to other psychic impression that is "wont to set the table in a roar." It tunes the voice of the warbling nightingale and excites response, in the human brain and related vocal cords to spellbinding oratory, swaying the multitude, or to Poesy's enraptured song, flying on the wings of Pegasus, far beyond the ordinary psychic dwelling places of man. Even the value of the bath Diana takes at the fountain, besides its purification of the skin, which fills her body with the glow of health, comes through a vaso- motor reflex blush of the cutaneous capillaries and nervous internal stimulation. Poesy, song, oratory and the entrancing influence of truth and the wondrous power and revelations of science are shown in the full knowledge of the physiological signifi- cance of reflex function. As this knowledge has come and is yet further coming to us, it is bringing us nearer and nearer to that knowledge which is yet to reveal the still concealed mysteries of organic life. And our friends, the great, studious, painstaking cytolo* 310 and cyto-chemists and indefatigable microscopists will yet show to us through their great labors and re- searches, the full truth, not dimly and darkly, as we now see, as through an obscuring glass, but in the full glare of the coming sunshine of an onmarching cytological, neurolog- ical and psychological science. Study the reflexes of organic life so far as they are now revealed and search further for others. The final rev- elation of the now hidden mysteries of life are the possi- bilities of their unfolding knowledge. It brings the sper- matozoa and the ova together in the consummation of "two souls with but a single thought, two hearts that beat as one" and by it new lives are born. It presides over the quickening of the unborn foetus in utero and causes the child to begin its later search for the pabulum of life in the lacteal fluid of the generous mammary gland of the mother. When evolution is complete at puberty it "causes the passionate heart of man to enter the breast of the wild dreaming boy" and the mind of the maiden at maturity to fill and her heart to throb with new emotion. It translates instinct into function and heredity into physiological or pathological action. The philosophers of science are yet puzzled to find the boundaries of reflex and free will, so closely allied is reflex with apparent will power. "The chemical stimulation of food in the mouth will in certain animals set the jaws and mouth into masticatory action." A bee's mouth will suck honey after its head has been cut from the body. "Other stimulations" notes Edinger "will cause a forward movement of the head and such move- ment can be of sufficient force to lead to very serious re- sults. Thus a planaria on which two heads have been bred will sometimes tear its own body in the effort of mov- ing each head separately." (Loeb). Two arms of a star 311 fish sqjsezed into the small neck of a bottle, will drag the whole body after them, although the creature must inevi- tably perish. The head part of the lob-worm, separated from the body and covered with sand on the slate, will immediately start a boring movement, and the lower part of a bee when cut from the rest of the body will apply the sting, if interfered with. This is evidently the mechanical result of a particular stimulation and has nothing in com- mon with anger, vengeance, venom or self-defense. "It is a well-known fact that frogs couple in the spring time and no knife can part them." Earlier experiments by Golz have shown that at the coupling time the skin of the female and even that of the male, even though they be dead, if stuffed with ova, gives rise to the reflex action of embracing as soon as it is brought into contact with the inner side of the frog's feet. We might cut up the frog from behind up to the cervical cord, or crush it from the head down- ward, the result will remain the same; i. e. f the ring formed by the cervical cord and the two arms, even when entirely separated from the rest of the body, will continue in the position and action of coupling frogs." (Edinger). Search for and seizing of food can be ascribed directly to reflex movements. The frog does not search for the worm, but the moving worm when sufficiently perceived by eye and ear, sets into motion the process of catching it on the frog's part. This can be easily perceived in places where animals are kept in a cool temperature, and pro- cesses run their courses slowly. The well-known fact that lower animals mostly feed on moving objects, is thus ex- plained. It is easy to deceive them by setting objects in motion. Artificial bait fishing is based on the same prin- ciple".* *Edinger in April Monist, 1901. 312 While independent reflex mechanisms are in the viscera, skin, and probably in the forebrain also, the medulla and the cord below are preeminently their seat. The life of the spine is in its reflexes and much of all organic life else- where in the cerebro-spinal axis is. Gentlemen, reflect well on the reflexes of animal life, for in them you may find much of the philosophy of life, and much to aid you in the intelligent understanding and practice of your pro- fession. Suitably recipient nerve endings receive, and conduct- ing or afferent nerves carry peripheral impressions to the posterior columns of the cord or directly to the brain. If the impression goes to a posterior center in the cord and is passed over to the anterior columns and transforund into motion without the intervention of the brain, the whole phe- nomenon, sensation and involuntary motion resulting, is called a spinal reflex — and these reflexes may be either physi- ological (/. e., natural and normal) or pathological (i. e., not natural but abnormal to particular nerve arcs). For exciting a normal reflex a sudden, generally a surprise impression and a healthy nerve center are requisite. An abnormal reflex generally depends on central morbid irritability or commenc- ing degeneration. The reflex arc is the track of sensation from the distal end of a sensory nerve to the cord center, passed over across the cord from posterior to anterior horns and there converted into sudden movement from central to distal end of motor nerve, completing the reflex arc. 313 REFLEX AND INHIBITORY CENTERS. FIG. 149 Scheme of peripheral spinal sensory neurone showing the peripheral process, d, extending to a peripheral sensory surface D and a central axone c, entering the spinal cord through the dorsal root of a spinal nerve, there bifurcating at e into an ascending and a descending limb which give off num- erous collaterals. The cell body is shown in the spinal ganglion G. Other neurones are shown schematically high up in the gray cortex of the brain at g, to which the arrow points, receiving the upward going peri- phero-spinal sensation and at A to a with the downward pointing arrow between, showing the origin and outflow of a motor impulse from a cortex neurone group to its spinal cord ending at b, and its final peripheral ex- pression atC. The whole showing impression from environing influence carried afferently to the brain and sent back from a psycho-motor center to to environment again in active impulse. X represents the sensory impulse as having undergone a modifying or inhibitory change through contact with cortex inhibitory influence, slightly modified in description. (After Ramon y Cajal, description modified.) 314 The phenomena of a reflex, therefore, is a peripheral sensation transmuted into responsive motion. Reflexes or jerks have been divided into skin or super- ficial reflexes and tendon or muscle or deep and visceral re- flexes and into organic or physiological and pathological. Some authors, Gowers for instance, do not consider the tendon jerks as true reflexes, hut 1 so regard them and think - they are quite as emphatically entitled to be consid- ered as true reflexes as the skin reflex phenomena. All re- flexes are dependent on spinal cord or sympathetic or gang- lionic or brain central connections, and 1 see no need of any confusing differentiation, since the principle of their dis- play is the same, namely: an impression made at one end of a sensory nerve exciting a corresponding motor response through a connecting motor nerve and central communica- tion. The so-called superficial reflexes are those of the foot (dorsal flexion), and the withdrawal that results from tickling or making a sudden painful or cold or hot impres- sion on the sole of the foot, the abdominal, etc. Every one knows how, in sleep, the foot will flex and the leg draw up when the sleeper is -tickled or scratched on the sole of his foot. The reflex of the testicles or cremasteric reflex, by which the testicle is made to draw up by pinch- ing or applying electricity to the inner side of the thigh are other skin reflexes so-called. They are organic reflexes, though not always so termed by authors, because they be- long physiologically to the organism in health like the knee, or quadriceps extensor femoris tendon reflex, as it is some- times otherwise lengthily termed. There are many other organic reflexes which are active in health and impaired in disease. The true organic reflexes are those which are necessary to some physiological function of the organism lil-e those of 315 the stomach and bowels in peristalsis and the contractions that promote the downward movements of the intestinal in- gesta and excreta, or like those of the oesophagus and the closure of the epiglottis in swallowing a drink or a bolus of food, the rhythmical movements of the lungs and heart, the sneezing excited by a sternutatory, the coughing of a bronchial irritation or the blinking of an irritated eye, (an Augenblick) , a movement so rapid and brief and sure that the Germans have coined this unerring function into a most expressive phrase significant of celerity and certainty. The rectal reflex through which defecation is per- formed and by which the involuntary discharges of destruc- tive brain and cord disease, (dysentery and diarrhoea), some- times occur when the inhibitory brain centers and fibers com- ing down the cord from them in the brain are exhausted or spinal cord communication from the brain down- ward is intercepted or destroyed, as in spinal injury, coma, some states of delirium, or when the patient is in articulo mortis or the condition of death, just following the death stroke. It is the same with the reflex controlling the urin- ary excretion, but the bladder reflex generally contracts the sphincters under withdrawal of the cerebral inhibitions, ex- cept when bladder distension is very great, unless there is a conjoint general convulsive condition, as in epi- lepsia. The antagonizing reflexes of the sphincters and the bladder fundus, the preponderating weakness of the one over the other and the state of the brain inhibitions, ex- plain the differing bladder phenomena of urinary retention or expulsion. The enuresis of childhood is a weakening of bladder sphincter control reflex conjoined with general nervous debil- ity, which is irritability, which causes the bladder to contract 316 on its contents when it is full and expel them, while the inhibitions are off guard dining profound sleep. There are also a perineal, genital, genesiac, virile and many muscular tendon reflexes which are normal. Others appear only when there is disease. The lubo-sacral plexus of nerves; the fifth lumbar and the first, second, third, fourth and fifth sacral nerves presides over the bladder, rectal, sexual, includingthe cremasteric and virile reflexes, and over the reflex of the perineum and the quivering nates that tremble when they are slapped. Thus you see the whole subject presents interesting aspects to physiologist, pathologist and clinician. The abdominal and scapular reflexes are made possible through the dorsal nerve supply — sensory and motor — distributed to the skin and muscles of the thorax and abdomen. The pudic nerve, in its reflex relations, as 1 shall show you later, is exceed- ingly important and likewise the vagus. The deep or tendon reflexes, the clonus and other con- tractions, the paradoxical contraction of Westphal, the pu- pillary reflexes, including the Argyll-Robertson pupil, the nerve reactions especially of degeneration under electric stimulation and the conditions and terms of disturbed sen- sibility will engage our attention again in subsequent lec- tures. 1 give you on the board a simple schematic diagram of the reflex arc with an imaginary line of inhibitory con- duction from the brain to the center or the reflex arc. I stop here purposely in order not to embarrass your under- standing of the wonderful phenomenon of reflex which is in reality not quite so simple as thus far appears, though, so far as this lecture has proceeded, 1 have been scrupu- lously correct. But there is another and very important feature to the 317 physiology of the spinal reflexes and the cerebral too, in fact, which often has valuable pathological and diagnostic significance, and that is the fact that the spinal reflex re- sponses to peripheral irritation are often exaggerated, some- times very greatly exaggerated by pathological conditions of the brain and spinal cord, as apoplexia, chorea, anterolat- eral sclerosis, the late state of the epileptic paroxysm, hys- teria, neurasthenia and emotional and debilitated states of the brain, which goes to confirm the view that there are also downward conducting nerve paths from the brain which serve to intensify the spinal reflexes as well as those which serve to restrain them, so that as the reflexes are said to be reinforced or exaggerated by restraining or diverting the cerebral inhibitions, they are also intensified by certain ex- citable states of the brain as well as the cord. In that para- doxical disease, hysteria, so much like the sex in which it is most frequently manifest, when they are neuropathic, "Variable as the shade By the light quivering aspen made," you will find many reflex contradictions; intensification in one direction and impairment or lost reflex in another. Intense feeling in one side and lost sensation in another, just as alternating psychical states rapidly succeed one another, as shown in the weeping that succeeds laughter and vice versa during a paroxysm. So that we must now make another diagram in order to be perfectly plain on this subject. The emotions which give rise to erectio penilis or which stimulate the bulbo-cavernous or virile reflex center in the cord from the brain cortex, restraining or causing urinary ejaculation and defecation or the voluntary influence, which increases as well as resists them, are confirmatory of rein- 318 forcing influences and communications with spinal reflex centers. Education is the upbuilding and culture of the in- hibiting neurones of the cortex that regulate the lower re- tlex :\\\J m )tor neurone centers of the brain and cord. There are many important reflexes not yet recorded. The virile is one which 1 have recently recorded in the lit- erature and the lately recorded bulbo-cavernous, by Onan- off, is another of the recent reflex records quite similar to and associated with it. It presides over the virile erection and when 1 first made communication on the subject at about the same time that Onanoff did in France, 1 thought it was the same, but it is not precisely. It is a downward jerk of the organ, not a twitch or an erection. The following are the other principal reflexes: The patellar tendon or quadriceps extensor femoris, vastus intima and sub-crurens muscle reflex caused by briskly and suddenly tapping the tendon patella- just below the knee cap while the legs are crossed or dangling loose from a table. This is the typical reflex. The others are like unto it. Next we have the ankle reflex and ankle or foot clonus. The wrist reflex, the hamstring muscle and tendon re- flex behind the knee, a reflex well known to school boys, elicited by striking the hamstring tendons while the man is standing upright. The triceps tendon reflex or elbow jerk. The biceps re- flex. The shoulder and scapular reflexes. The jaw jerk or chin reflex. The pupillary and ciliary reflexes. The pectoral reflexes. The plantar reflexes. The lesser toe extensor reflexes. The great toe extensor reflexes. 319 The reverse extensor response of the great toe or sign of Babinski, said to indicate lateral sclerosis of the cord. The cremasteric and scrotal reflex. The penile and virile reflex. The abdominal and epigastric reflexes or rectus abdom- inalis reflexes. The erector spinal reflex. The scapular reflex. The palmar reflex (not easily elicited in the waking state). The conjunctival or eyelid retinal reflex to light and mechanical irritation. The retino-papillary reflexes. The skin pupil reflex from irritating skin of anterior lateral side of neck, cheek or chin. The cilio-spinal pupillary reflex from irritating cilio- spinal center of cervical cord. The reaction of degeneration reflex ending in lost reflex. Then there are tremors of muscle, tongue or extremi- ties indicating wasting, exhaustion and degeneration of muscles and chores movements and tics, all dependentupon disturbance of the reflex function, as likewise are certain spastic states, important to consider in diagnosis. There are many more reflexes yet to be discovered. Look for them gentlemen, and when you find them, study their significance. Make a record of your findings and your names will become famous in diagnostic neurology. The flexor digital and thumb reflexes are other re- flexes to which I call your attention, though they are not yet in the literature. 320 ADDENDUM. BABINSKl'S SIGN.— H. Schneider has found that, while it is practically true, nevertheless the assumption that the presence of Babinski's phenomenon indicates a lesion of the pyramidal tracts is open to certain theoretical objections. The normal response to stimulation of the sole of the foot consists of two reflexes having different origins. One of these, plantar flexion on slight stimulation, is a cortical reflex, while the other, dorsal flexion of the toes, with asso- ciated movement of the leg, is evoked by strong stimuli and is of spinal origin. Babinski's sign is present when slight irritation is sufficient to produce dorsal flexion without the occurrence of plantar flexion, and is always due to gen- eral increase in reflex excitability. It may be caused in two ways: first, through a break in the pyramidal tracts, whereby the cerebral reflexes are cut off (which is the true Babinski), or, secondly, in conditions of increased spinal activity {e.g. strychnine poisoning), or of decreased cere- bral excitability (stupor), when the dynamic excess of the spinal response suppresses the cerebral reflex and simulates the true condition. — Berliner klinische IVochenschrift in Kansas City Med. hid. Lan. 321 FIG. 150. covrf' I, Scheme of the brain. — C, C, cortex cerebri ; C.s, corpus striatum, N./, nucleus lenticularis ; T.o, optic thalamus ; v, corpora quadrigemina ; P, pedunculus cerebri ; H,. tegmentum ; and/, crusta; I, I, corona radiata of the corpus striatum; 2, 2, of the lenticular nucleus; 3, 3, of the optic thalamus; 4, 4, of the corpora quadrigemina; 5, pyramidal fibres from the cortex cerebri (Flechsig) ; 6, 6, fibres from the corpora quadrigemina to the tegmentum ; m, further course of these fibres; 8, 8, fibres from the corpus striatum and lenticular nucleus to the crusta of the pedunculus cerebri; M, further course of these; S, S, course of the sensory fibres ; R, transverse section of the spinal cord ; <■. W, anterior, and h. \V, posterior roots; it, a, association system of fibres ; c. c, commissural fibres. II, Transverse section ihrough the posterior pair of the corpora quadrigemina and the pedunculi cerebri of man — ■/, crusta of the peduncle ; s, substantia nigra ; v, corpora quadrigemina, with a section; of the aqueduct. Ill, The sameofthe dog; IV, of an ape; V, of the guinea-pig. 322 MOTOR CELLS OF ANTERIOR CORNUA OF CORD OF A PUP. I [G. 151. LENHOSSEK'S CROSS SECTION OF HUMAN SPINAL CORD, SHOWING COLUMN CELLS AND INTER-COMMUNICATIONS. FIG. 152. 323 The reaction of degeneration, which we have already discussed somewhat, is a neuro- muscular phenomenon de- pendent upon the relation of the central and sensory motor nervous system to the muscles involved, and the muscles are usually involved in atrophic degeneration, too, as well as the connecting nervous system. Progressive myatrophy or muscular atrophy is the nervous system disease, in which this phenomenon is most typically displayed. It is, in fact, a progressive neuro-myatrophy. Rapid degeneration and slow reaction to electricity characterize Wallerian degener- ation and its reaction to degeneration. Degeneration of the pyramidal tracts follows degenera- tive nerve change at the top or the pyramids, as in the en- eapsular or destructive inter-ventricular extravasation or syphilitic or atheromatous cerebral artery degeneration and destruction of brain. According to Russell, if the vermis of the cerebellum is removed, the vestiform bodies degen- erate. Von Gudden removed the eye of rabbits at birth, and afterwards found their optic chiasma and optic tracts degenerated. Nissl showed alterations in neurones after cut- ting off their neuraxones. As we have already seen muscles and nerves in cer- tain diseases of the nervous system respond differently from the normal reaction to electrical impression. Their impres- sion excitability to this stimulation is changed both in quan- tity and quality. The muscular contractions vary in in- tensity, in promptness and in character, and after a time they cease to respond at all. Irritability, responsive to electrical stimulation varies here remarkably, as the reflex responses in various parts of the body differ to percussional impression, being unduly rapid jerks, slow or irregular. Usually when the reflexes respond in exaggerated manner to the sharp stroke of the pleximeter or hand, the muscles 324 respond or fail to respond likewise to electrical excitation, as they do in chorea, tetanus, antero- lateral sclerosis, pos- terior sclerosis, transverse myelitic paralysis, progressive muscular atrophy, etc. It has also long been known that nerve center changes take place after amputation, disuse or injury to peripheral nerves, etc. Toxa-mia. anaemia, peripheral irritation, shock, etc., may derange and disease central neurones of cord or brain and even of ganglionic centers. Spinal cord changes follow operations. Switalski re- ports the results of an examination of five spinal cords re- moved from subjects upon whom amputations had been per- formed — four amputations of the thigh and one of the leg. In every case there was found atrophy of one-half of the spinal cord corresponding to the side of the operation, both the white and grey matter being implicated in the atrophy. In three cases the atrophy was traceable from the lumbar part of the cord to the dorsal region and in two cases up to the cervical region. Coincident with the atrophy there occurred a sclerosis of the posterior columns — in three cases in all levels of the cord, in two cases in the cervical region. While the spinal hemiatrophy showed a tendency to diminish from below upward, the sclerosis of the posterior columns increased from below upward. Pierre Marie also draws attention to the occurrence, not only of atrophy, but also of sclerosis after amputation, and states that such sclerosis may be noticeable, even on the opposite side of the cord. — Switalski, {Rev. Neurol. Jan. 15, 1901), Gould's American Year Book. These changes illustrate Von Gudden's law of peri- phero-central change, while Waller's law is one of centro- peripheral change. The accompanying illustrations from Marinesco and Raymond show the neurone changes resulting from section of a peripheral nerve. 325 FIG. 153. FIG. 154. Ecorcc- rcrebraZo fibre. pyramuLale. N.c neurone central. — iV.p., neurone periphoriquc. =C.p.s., cellule pyramidale. — C.m.- cellule motrice des comes an- terieures de la moelle. 1 (Testut : Anatomie). 1, segment anterieur de la capsule interne. — 2, son segment posterieur. — 3, son genou. — 4, noyau lenticulaire. — 5, noyau ca" ' \ — 6, couchc optique. {After Raymond.) Fig. 153. Origin, course and termination of a motor impulse. A pyramidal fiber, coming from a neurone. C. p. s., in the cerebral cortex or central neurone, with it neuraxone, N. c, to the anterior cornua of the spinal cord and pyramidal cell C. m, A motor cell prolongation neuraxone or motor nerve goes out at N. p. to the muscle. Fig. 154. 1, anterior segment of internal capsule; 2, posterior seg- ment of the internal capsule; 3, genu of the internal capsule; 4, lenticular nucleus; 5-5, caudate nucleus; 6, optic thalamus or optic bed; 12, claus- tram; 13, external capsule. 326 CEREBRAL TRANSVERSE SECTION. FIG. 155. a, a , b, group of pyramidal cortex neurones; a, a, cortex neurone sending its axone or neuraxone directly down c, the pyramidal tract into the cord, a cerebro-spinal fasculus or true axone of the pyramidal tract; a, an- other pyramidal cortex neurone sending its neuraxone the same way and also a bifurcation of its neuraxone across the corpus callosum to the oppo- site hemisphere of the brain; b, cortex neurone sending its neuraxone through the corpus callosum; c, pyramidal neurone with bifurcating neu- raxone, one arm going across to the corpus callosum opposite, the other to cortex of the same side; d, collateral; e, terminal callosal fibers. [Further illustrations of this chapter may be found in Figs. 151, 152, et seq.] s Z o > 5 i/7 z 3 5 o o z £ o ■x - "C 2 & T3 to £ - O 1) 13 as ■= > 6 <" 3 C c 5 "O M rt cc e 3 rt t/3 u rt •3 £: fc- "S. _j rt (/) rt E u So 33 & rt rt hi h/l rt c, J- w StUCTld 1VIH3VttS CHAPTER XXV111. THE CEREBRO-SPINAL AXIS OR NEURAXIS AND ITS NERVE CENTERS. G W ILIA, PLEXUSES, NEURONES AND NERVE CENTERS. IMPORTANCE OF THE PUPIL AND OTHER NERVE CENTERS IN DIAGNOSIS— THE BASAL AND OTHER GANGLIA— THE NEURAXIS AND THE NEURAXONE. The cerebro-spinal axis, also called the encephalo-spinal axis and designated also as the neuraxis, must not be con- founded with the neuraxone of a neurone, which has already been briefly considered. These terms might be confounded nominally, but the respective regions of the neuro-anatomy designated by them could not be confounded from observa- tion. The neurone, though it has itself a nucleus and nu- cleolus as we have already seen, is an integer of the neu- raxis or cerebro-spinal axis. I prefer the latter term, as most of your text- books do, for the present, because it is less confounding. The neurones are the nuclear nuts, so to speak, of the cerebro-spinal axis, out of which the neuraxis is developed. They are nuts for you to crack. In them is the meat of the nerve centers. The neurone is a microscopically discernable organized element of structure. The cerebro-spinal axis (neuraxis) is an aggregation of organs and centers of action, sensation, perception, reflection, motion, etc., made up of groups of neu- rones and their receiving and projecting fibers, and located [328] 329 within the bony cavities of the head, neck and back. Nerve- centers are made up of aggregated neurones, which, as we have seen, are nerve cells with all of their micro-anatomi- cal attachments. The relation of the nut to the developed tree and the tree to the forest will give you a conception, though not a perfect one, of the neuroses and their nuclei and nucleoli to nerve centers and organs. The neurones, however, are completely developed microscopic individual- ities and make up by anatomical and physiological group- ing, the several centers or neurone aggregations of the spinal cord and cerebrum and making with their sensory and motor attachments the incoming and outgoing nerve connections, the cerebellum, pons Varolii and the spinal cord. The upper portion of the cerebro-spinal or encephalo-spinal axis is made up of all the nervous mat- ter within the cranium above and down to the foramen ovale, called the encephalon, including the great brain or cerebrum and lesser brain or cerebellum and the interme- diate connecting or mid or tween brain, made up of the pons Varolii, the medulla oblongata, the crura-cerebri, are here lo- cated. The lower portion of the cerebro-spinal axis is all of the spinal cord and attachments located within the spinal canal and sacral cavity down to the coccyx. The cauda aquina is the lowest attachment of the cerebro-spinal axis. The cerebrum and cranial nerves make up the uppermost part and belong to this great nerve axis, while the peri- pheral nerves (motor and sensory) including those of the sympathetic system, constitute the intervening connections of this great nerve center line of nerve impression and ac- tion within the body. The cerebro-spinal axis or neuraxone is, as you see, an aggregation of important centers of nervous impression and expression; centers of nerve energy or ganglionic centers, 330 as they are often called in your treatises on neuro- physi- ology. But there are other centers of nervous energy or force. These are aggregations or enlargements or knots of substance, from yayyAiov, a swelling. There are ganglions in automatic and surgical nomen- clature or swellings of the muscular tendons. The latter are serous tendinous tumors sometimes called "weeping sinuses" and often found on an extensor and sometimes on a flexor tendon of the wrist, etc. But the ganglions we are now dealing with is a neural ganglion or hunched aggrega- tion of neurones or nt-rves. The ganglia of the peripheral nervous system are those of the sympathetic nervous sys- tem and those on the roots of the posterior spinal nerve roots, which you will see in the accompanying illustrations of the cerebro-spinal axis, and the ganglia of the roots or trunk of the cranial nerves, the most important of which from the standpoint of neuriatry or the treatment of ner- vous disease, is the great Gasserian ganglion or the great center of the three roots of the fifth or tri-facial nerve, with which we become familiar in practice, in connection with the treatment of tri-facial or trigeminal neuralgia or prosopalgia or tic doloureux, as it is called. The geniculate ganglion of the facial or seventh nerve, is a peripheral ganglion which will not interest you as much as the Gasserian ganglion, of the fifth or tri-facial nerve, for the Gasserian ganglion is the one the surgeons will want to take out of your tri-facial neuralgics, some of them, before you have a fair chance at curing them. Our surgical friends in the faculty, Profs. French and Keifer, wield the knife so deftly that they like to use it in these cases and sometimes surgery is the only source of relief. Some of my cases in my life time of practice have been passed over to the surgeon and been finally relieved after many years of recurring suffering by 331 this formidable, but in extreme cases, when the nerve be- comes degenerate, very necessary operation. They were successfully operated on by a surgeon specially skilled in Gasserian gangliectomy.* Drs. Bartlett, French, MacCand- less, Lutz and others have also succeeded in this operation. The glossopharyngeal, vagus and auditory nerves have ganglia and the visual expansion of the optic nerve has like- wise. It is called the retina, and includes all of its nerve elements concerned in the reception, elaboration and trans- mission inwards of sight impression. It has been called the retinal ganglion or ganglion of the retina. This ganglion will interest you much in practice, as well as the pupil and movements of the iris and action of the retina, that make up its many interesting movements in disease, as well as in mental emotion. The ganglia of the sympathetic system comprise the ophthalmic (lenticular or ciliary) in the orbit, the spheno- palatine, Meckel's or nasal ganglia, in the spheno-maxillary fossa and at the other extreme the ganglia of impar on the anterior aspect of the coccyx. Arnold's ganglion, the otic, lies beneath the base of the skull, the sub-maxillary or lin- gual, located as its name implies, likewise the superior mid- dle and inferior and inferior cervical or neck ganglia, the middle of which is called the thyroid, from its relations to that gland. Then there are the thoracic ganglia along the thoracic spine, the semi-lunar ganglia and solar plexus back of and abtve the umbilicus and below the diaphragm, the sub-diaphragmatic ganglion under the surface of the dia- phragm, the ganglia of the lumbar and sacral regions ; the mes- enteric and renal ganglia supplying the kidneys, mesentery and renal and mesenteric arteries. Then there is the gan- glion of the coccyx, (impar), which, unlike the other spinal * Dr. Carson. 332 sympathetic ganglia, we have mentioned as lying on each side of the vertebral column is placed, as its name implies, solitary and alone on the front of the coccyx. You may retain approximate remembrance of the location of those ganglia of the sympathetic system by recalling the fact that the ganglions of Meckel and Arnold (the nasal and otic) are in pairs at the upper extreme of this region and itnpar (not paired) as its name implies, is solitary and alone at the other and lower extremity of the trunk, while the other ganglia intervene and derive their respective names from their anatomical location and relations to viscera or regions of the body, except the ganglia of the cochlear branch of the auditory nerve, which unfortunately for your remembrance, is not called the auditory or aural or cochlear, as I would have named it for your sakes, had 1 been the discovering anatomist, keeping in view all the hard names you have to learn, but the spiral ganglion or ganglione spirale. Fortunately you will not have to keep constantly in mind all the names or all the ganglia of the sympathetic system in order to make good practitioners. You will only have to locate them from time to time, as you may have to describe particular parts on study particular viscera in disease. The main thing for you not to forget is that these ganglia are connected with involuntary visceral and vascular functions, that they are in the main centers for control of the unconscious life-maintaining movements of the organs and circulation vessels. They and their neural prolonga- tions or nerve fiber connections have to do with uncon- scious motion, sensation and inhibition. They keep the involuntary machinery of our wondrous mechanism in normal movement. When disease damaged, they permit the marvelous machinery of man to go wrong or aid in its morbid movement. 333 The possession of involuntary sensation will be denied to the sympathetic system, but do not believe the conten- tion. There is probably more in the philosophy of the mechanism of the sympathetic system movements than has yet been described in your physiologies. Unconscious sen- sation in the sympathetic system is as rational as reflex movement and inhibition without sensation. It is here largely through the sympathetic system and its mechanisms of impression and control movement, that we live and move and have our being in our unconscious life, especially below the encephalon. There is an organic consciousness, if 1 may so express it, of which we may conceive, though we may not prove it; an organic consciousness to be dis- tinguished from psychic consciousness or the self-conscious consciousness, if I may so recall it, which appears to reside in the psychic neurones of the conscious mind areas of the grey matter of the brain. The semilunar and solar plexus ganglia have been termed the ventral brain. CENTRAL NERVOUS SYSTEM GANGLIA. Notwithstanding the number and importance of the ganglia already mentioned, they have been called the lower or lesser ganglia of the nervous system. There are ganglia of far more primary importance called the great ganglia of the central nervous system or cerebro-spinal axis. The principle of these are called the basal ganglia and the chief or these are the corpus striatum and the op- tic thalamus. These two are generally referred to as the basal brain ganglia, as if there were no others. The corpus striatum is located anteriorly a little superiorly and ex- ternally and the optic thalmus is placed posteriorly and in- teriorly and slightly internally, nearer the median line in relation each to the other. The hemispheres of the cere- 334 brum are called the hemispheral ganglion, making the striate bodies and the optic beds intermediate ganglia. Below these are the geniculate bodies, tuber cinereum, olivary bod- ies, etc. The two ganglia, which all authors agree in call- ing the basal ganglia, that is the thalami optici and the cor- pora striata, 1 show you here in the lateral ventricles, bor- dering the fifth ventricle of the system, the most anterior and superior. The third ventricle, you see, is situated poster- iorally and the fourth ventricle is out of sight, but posterior and below the third with this canal with the long Latin name, in which 1 have placed the probe leading to it, the iter a tertio ad quartum ventriculum, or acqueduct of Sylvius. Note their situation with reference to these two important ventricles, the two largest ventricles of the brain, as these two ganglia are also the largest and most important of the ganglia of the cerebrum except the two hemispheres of the cerebrum, which are themselves called ganglia, hemispheri- cal ganglia. These two ventricles are on either side of the median line with their longest diameters antero- posterior, while two of the other ventricles are in sight between them, the one, the fifth, within the pellucid septum which divides the lateral ventricles from each other, and the other, the third, on a straight line backward and emptying into the front end of the Sylvian acqueduct. The encephalo-spinal axis is originally described as con- sisting of the frontal, temporal and occipital lobes of the two hemispheres of the brain, the joined hemispheres and lobes of the cerebellum or little brain (the cervellet, as the French call it), the bridge of Varolius or pons Varolii or pons as it is variously called, the oblong marrow or medulla oblongata or simply medulla, as it is generally designated, and the cord or spinal cord. 335 The accompanying illustrations ( Figs. 153 to 161 in- clusive) will explain the subject more clearly. The spinal cord is brought into proper relation with its environment within the system by means of the sensory and chiefly the sympathetic systems; the latter may properly be regarded as a system of subsidiary spinal nerves of communication with blood vessels and viscera. By means of the spinal nerves proper and the nerves of special sense of the brain this great nervous axis is brought into contact, for sensa- tion and motion, with the environment of the outside world and the environing body. It is the greatest aggrega- tion of nerve centers of the body. But as most of the ganglia of the nervous system, encephalic, spinal and peri- pheral, including also the sympathetic system, have been demonstrated to be centers of nervous energy, that is, to possess power of transmuting sensation into various kinds of motion and to modify, transmit and arrest sensa- tion, the central nervous system can not be properly con- fined exclusively to the cerebro- spinal axis. Since this is the fact, the term neuraxis might well be restricted to the brain and spinal cord, taking care, as 1 have already en- joined, not to confound the term with the still more re- strictive and microscopic term neuraxone, the efferent pro- longation of the neurone, as we have seen. The neuraxis is nevertheless the greatest part of the nervous system, the head and backbone nerve center arrangement of the entire neural framework of the human body. The many anatom- ical illustrations now shown, with the brief descriptions that follow, will illustrate more forcibly than words alone, how important this great cerebro- spinal system really is. The neuraxis, like Banquo's ghost, continually comes up before us in the study of neurology with its psycho-neural daugh- ters, psychology and alienism, and will not down at our 336 ILLUSTRATION OF A PORTION OF UNDER SURFACE OF BRAIN IN IMMEDI- ATE CONNECTION WITH, AND CONTINUATION UPWARD FROM, THE SPINAL CORD. ALL THE CRANIAL NERVES ARE HERE SHOWN, AND MARLY ALL THE UPPER (CRANIAL) PART OF THE CEREBRO-SPINAL AXIS. THE OPTIC NERVE DISTRIBUTORS DO NOT SHOW, NOR DOES ANY OF THE LEFT HALF OF THE BRAIN APPEAR EXCEPT THE OPTIC THALAMUS, THE LEFT CRURA CEREBRI, OPTIC TRACT, ETC., DE- SCRIBED UNDER THE CUT. THE ANTERIOR UNDER LOBE ON RIGHT APPEARS AS LIFTED AND PRESSED UP AND FATTENED SOME. FIG. 157. Superficial Origins I'. "Olfactory tract. HI. 1 Mil hi,d otulo-motor IV. Fourth nerve. V. Fifth nerve, sensory root. V -f Fifth nerve, motor root. M.j Maindivis.onsoffiflh VI. Si*»h nerve. " VII. Facial nesve. VIII. Auditory nerve. IX. Closso* pharyngeal X. Vagus. XL Spinal accessory OP Cranial Nervks {Jrom XII. Hypoglo - CI. First cervical nerve. C. Island of Keil. Th Optic thalamus ItlTe Is. land of Rcil having been removed). [mm i. Internal corpus gemcula- t External gcniciilatum A. Pituitary body. Ic Tuber cinereum a, Ooe of the corpora albi. £y Sylvian fissure. xx Anterior perforated space Qucim s " AnMcfiy"). x Posterior perforated space. P. C«rcbral pcdiioclc. PV Pons Varolii. Cc Cerebellum. / Fillet JI. F'loccuITrs. /cwow su*- VOvTeovVv o^W\ei"o^©-Oj, i«vvW^ft«v5 too SX^'v^c ViVi^t o"£ ;, uc\A2, c^TceVcvvwcv o*x*&* ^ve, \wo \.©\acs ©"^ > &>sz, 344 FIG. 163. FIG. 164. 3 ., fe • : ass • -'JB ...... 5 __ a Thp mutual n lal of the to the Bagmenta In til and to tke exits nf the Derves! (Qoweit). Bourgery's outine later.il view anatomical diagram of the cerebro- spinal axis or neiraxis. from Quain's anatomy, showing the cerebro-spfnal cavity ttoTi the top of the brain with the cranium to the end of the spinal cord, cauda equina and corcyx. F, T and O are the frontal, temporal and oc- cipital lobes ot the cereorum; C. P and Mo are the cerebellum pons Varolii and medu.la oblongata; M and Ms show the upper and lower extremities of the soinal cord; Ce. the cauda equina at the lower end of the spine be- ginning with tne last lunnar spinous; V, ganglion of the fifth nerve or the trigeminal, or ganglion of Gasser with its three branches faintly shswn; Cl shovs the tirst of the spinal nerves or first cervical coming out under tie occiput, a 'd Cvm is the last or lowest cervical; DI is the first djrsal or thori:i; and D.XII is the twelfth or lowest and last dorsal. The first sacral nerve begins at S ; Sv is the fifth sacral; S is the sacral plexus and Col is the coccygeal nerve. CHAPTER XXIX. THE NEURAXIS AGAIN, DIAGNOSTICALLY VIEWED. A CURSORY DEMONSTRATION OF CRANIAL NERVES— THE COLUMNS OF THE SPINAL CORD AND THE NERVES THAT GO TO AND COME FROM IT— THE CORD SEGMENTS OF IMPRESSION AND IN- FLUENCE—OUTLINE OF THE CEREBRAL AND SPINAL NERVES AND NERVE CENTERS AND THEIR RELA- TION TO NERVOUS DISEASES. To fasten this important matter firmly in your minds, we introduce again Bourgery's outline lateral view anatom- ical diagram of the cerebro-spinal axis or neuraxis from Quain's anatomy (Fig. 163) its relations to the cerebro- spinal cavity, from the upper infeiior surface of the cra- nium to the coccyx, and an illustration of the under surface of the brain, the crura cerebri, pons Varolii, medulla ob- longata, showing apparent or external cerebral nerve exits, together with a brief outline of the spinal nerve origins. F T O are the frontal, temporal and occipital lobes of the cerebrum. G P and M O are respectively the cerebrum and pons Varolii, medulla oblongata; Ms, Ms show the median line above and belcw of the spine; Ce, shows the cauda equina at lower end of the spine beginning with the last lumbar spinous process; V, if you scan it closely, shows the ganglion of the fifth nerve, otherwise called the [345] 34 i trigeminal ganglion or ganglion of Gasser, with its three brandies faintly shown. Now look at the base of the brain and the fifth nerve bore. This nerve is the seat of an often trying and sometimes intractable and excruciatingly painful trouble called prosopalgia, tic douloureux, trigemi- nal or t ri - facial neuraglia, its diagnostic characteristic being a paroxysmal pain, passing along the course of the branches or twigs of this nerve and suddenly changing, often from one branch to another. This is the large nerve that I have often demonstrated as seeming to sprout out from either side of this beautiful bridge, about the middle of .it, as we look across from be- fore backward, more beautifully curved and delicately and strongly constructed for its wondrous purpo.-es tl an any bridge of man's contrivance, as the poets have described it. The origins of these nerves are deeper down from the nuclei in the floor of the fourth ventricle on opposite sides, (from whence so many other of the cranial nerves arise), eight of the twelve nerves of the brain, leaving out only the fourth, third, second and first pairs. The nerves of the brain seem like the twelve apostles, to have one chief end in view, namely: the salvation and service of the soul of the human organism, that is the neurone centers of the brain. If you look a little farther beyond the pons Varolii, fol- lowing these two roots till we reach the pars petrosa ossa temporalis, as they say over in Berlin, but as we say in English, as far as the petrous or especially hard portion of the temporal bone, we find a lump or enlargement or igl.ion developed in the sensory root, after the manner of the ganglions on posterior sensory roots of the spinal nerves. This expansion or ganglion may be likened to the stubby trunk of a palm tree with three principal 347 branches, one the ophthalmic nerve going to the eye and its vicinity (lachrymal, palatin, nasal) branches with numerous sub-divisions, another going to the teeth and mucous mem- „branes of the upper jaw and face, the superior maxillary, and the third, the inferior maxillary, going to the cheeks, teeth, temple and tongue and many facial muscles. We will not present in minute detail all of the distri- butions of this nerve. It is in one of its branches only a compound or motor and sensory nerve. The combined sensory and motor branch is the inferior maxillary nerve. The ophthalmic and upper maxillary branches are only sen- sory. You will need to keep handy for purposes of diag- nosis, accurate anatomical tables like those in some of your text-books or in Flower's diagrams. If you do not you will get the origins, distributions and functions of the fifth and seventh nerves mixed. This might result disastrously, es- pecially in the practice of surgery, as it did once in the practice of that eminent surgeon, Sir Charles Bell, giving the profession as a result a more intimate knowledge of that distorting form of seventh nerve or facial paralysis, called after the great surgeon's mistake in cutting the fa- cia! for the tri-facial in a case of tic douloureux, Bell's palsy or Bell's paralysis, that form of palsy resulting. A man's blunder sometimes makes him famous as well as his successes and we always think of Sir Charles when we see a poor devil who used to whistle, but who can no longer pucker his mouth (for that ordinarily distress- ful performance to unwilling auditors), and one of whose eyes stands wide open when lie would close them both at your request, if he could, and whose mouth draws to the oppo- site side of the victim's face when he tries to speak. We know Sir Charles Bell by the facial palsy he unwittingly demonstrated, better than we know him by the respiratory 348 nerves that bear his name, and quite as well as we know him as the discoverer of the motor and sensory nerves as separate nerves of the cord. The tri- facial nerve is a fa- cial nerve as you also see, as well as the seventh nerve. It supplies the skin of the face chiefly. It supplies the cornea, mucous membrane of mouth and nose and dura mater, with fibers of sensation. Its branches supply the skin of the cheeks, lips, chin and temples and anterior part of the sur- face of the tongue. As a motor nerve it has more to do with the movement of the lower half of the face than its prototype, the facial or seventh nerve. The fifth nerve motor brandies move the muscles of mastication, the masseters, the temporals, the pterygoid, the stylohyoid and the anterior belly of the digastric muscles. The tri -facial nerve or fifth nerve is more of a sensory nerve than a motor. The facial or seventh nerve is more of a nerve of motion, for the expressions of the face especially. It has been called the mimic nerve of the face. The fifth nerve has ganglionic relations other than with the Gasserian ganglion, viz: The ophthalmic, lenticular or ciliary ganglion, Meckel's or the spheno-palatin ganglion, the otic and the sub-maxillary. All connection with the fifth nerve is by the sensory root, an important thing to remem- ber, for when sensation dies in the root, connection is nil. The otic, Meckel and submaxillary ganglions have motor connection with the seventh or facial nerve and the ciliary or ophthalmic with the third nerve, while filaments from a vaso-motor sympathetic plexus go to all of these ganglia. We feel most with the fifth nerve about the face, and sen- sory nervous diseases belong, like toothache and neuralgia, especially to it. We express most with the seventh. It is a nerve of facial mimicry, pantomime and facial expres- sion. It is the chief seat of faeial paralysrs, palsies and 340 tics, facial tremors, through close sympathetic relations with the fifth. The fifth nerve is a wonderful nerve, the seventh is likewise. Here is the seventh clear across the Varolian bridge, coming out from the lower under surface of the bridge, from between the restiform and olivary bodies. So also are the sixth or motor oculi externus or abducens nerves next to it. When they are paralyzed the eyeball can not be turned outward. They come from under the bridge, too, between the bridge and the tops of the pyramid on either side of the median line. Here is the fifth com- ing from the middle of the side of the bridge almost in a direct line, antero-posteriorly with the fourth or pathetic nerve which comes out from under the bridge, too, but su- periorly where the outer line of the crus cerebri or brain leg passes downward with its many fibers of motion and sensation under the bridge to the cord and other connec- tions. It comes from under the bridge, not from the fourth ventricle where eight of its neural companions originate, but from the way there, from the acqueduct of Fallopius, not like the Appian way from Rome to Brundesium, paved with stones by a great Caesar's command, but paved by a greater than any Roman Emperor, and with precious neurones, which are the centers of life and neural power, the way from the third to the fourth ventricle, iter a tertio ad quarium ven- triculum. This passage way between the third and fourth ventricles gives origin to the fourth cranial nerve. But yet another cranial nerve, the third or motor communis, arises deep-seated from the floor of the Sylvian way or acqueduct of Sylvius and here it is, nestled here be- tween the crura of the brain, where they appear to join in the median line anterior to the pons to pass under the bridge and go down the spinal cord. And a wonderful 350 nerve too is this common motor oculi. It has wonderful motor connections and receives fibers from the cavern- ous plexus of the sympathetic. We have seen already that it lias connection with the ciliary ganglion and it is through this relation that it reaches the ciliary muscle and has power to contract the pupil. It is the sphincter pupillae muscle nerve of your anatomies. It connects with and innervates all the rotary muscles of the eye except the superior oblique and external rectus. Wonderful nerves are these eye -moving nerves. They move the hearts of man and woman figuratively, not ana- tomically speaking, except only retlexly from the brain and mind and they move the world, not with an Archimedian lever, but by means of men and minds influenced through their movements. But we shall recur to these nerves and other of the cerebral nerves again and again. They and the others of the twelve, have much to do with our ability to diagnosticate what is going on in the brain when disease attacks this important, commanding, superior part of the neuraxis. Let us go forward before *ve leave the subject to the two brain nerves that have no connection with either the third or fourth ventricle or the iter, viz: the first and the second. Here is the nerve of smell which we test with odors for anosmia, hyperosmia and other defects of smell in trying to make our diagnosis. These are often damaged in function when the anterior median under surface of the brain is diseased. Its origins are here in the anterior and middle lobes and in this perforated space. The fifth nerve, as we have seen, has two roots and three branches, but this has three roots and branches down into the nasal cavity walls like the hairs of a dusting brush. Here is the optic or sight nerve, with its crossing fibers making the crossing, or de- 351 cussation, as it is called in the chiasm. It also has non-decus- sating or non-crossing or lateral fibers, going back to find final- connection with the occipital lobes, but connecting on their way with the corpora quadrigemina and optic thalamus here. Here is the eighth or auditory nerve, one of the eight cranial nerves coming from the fourth ventricle. It goes to the internal ear. It joins the facial in giving off a filament, which, blended with that of the facial, makes up the nerve of Wrisburg, the chief source and origin of the chorda tym- pani. Here is the ninth or glosso-pharyngeal coming from the fourth ventricle and going to the posterior third of the tongue, the seventh nerves here supply the anterior two- thirds of the organ.* Here is the vagus, that vagrant nerve which wanders to the larynx, aesophagus, lungs, heart, stom- ach, intestines, liver, kidneys and supra renal capsules and spleen and is often in evidence clinically and diagnostically, as when it is irritated, the heart is abnormally slow or par- alyzed. And it is the heart movements and the respirations that are, in consequence, abnormally fast or cease altogether. Here are the accessories supplying the sterno-mastoidii and trapezii, as evidenced in wry neck or scapular palsy or spasm, and the hypoglossus that moves the tongue drawing it toward the paralyzed side when it is paralyzed. It inner- vates for motion the genio-glossus, hyoglossus, genio-hyoid, omohyoid, hyothyroid, sternothyroid muscles. It has a good deal to do with keeping up appearances about the tongue and throat. Vide Figs. 162 et sequitur. *These two tongue nerves, when diseased at their distributions, or along- their course, give abnormal sensations of taste or pyraguesias. When destroyed in their course, distri- butions or at their origins, taste is destroyed. This condition is technically termed aguesia. Hemilingual aguesia sometimes results from central bulbar causes like hemiglossoplegia. Hemiaguesia sometimes results, like hemianaesthesia, from hysteria. It may result from a unilateral organic brain disease involving the bulbar origins of either the ninth or seventh nerves or from disease of the cortical center for the sense of taste in the tempero-sphenoidal lobe area. Aguesia of the anterior two-thirds of the tongue points to facial nerve per- ipheral or central morbid implication; of the posterior third of the tongue to glossopharyn- geal, or ninth nerve, course or center involvement. When the glossopharyngeal aguesia appears, the soft palate and pillars of the fauces become synchronously involved, If the cause of the trouble is central. As aguesia without peripheral lesion of either the seventh or ninth nerve points to central disease and paraguesia to mouth and stomach perversion, so psychical paraguesia maybe a symptom of hysteria or insanity, the perversion of taste, l.ke anosmia being in the psychic centers and due to cerebral disease. CHAPTER XXX. OUTLINE OF THE CEREBRAL AND SPINAL NERVES AND NERVE CENTERS AND THEIR RELATION TO NERVOUS DISEASES, ETC, CONTINUED. Laying aside this brain and resuming our description of this antero-posterior longitudinal hemi-section of the cer- ebro-spinal axis we have here (Fig. 163) at OI, the first of the spinal nerves or first cervical coming out here under the occiput and VIII is the last or lowest cervical. Bl is the first dorsal or thoracic and DX1I is the lowest and last dorsal. The first sacral nerve begins here at SI; Sv is the fifth; S is the sacral plexus and COI is the coccygeal nerve. The surrounding parts, as you see, belong to the bony encasement of this great nerve center bony canal, made up of the cervical, dorsal and lumbar vertebrae with their bod- ies in front, spinous processes behind and continuous canals in close and marvelous relation for the protection, holding and transmission of the spinal cord between; the basin-shaped pelvis, being, as its name implies, the basin floor of this great nerve center column, the cranial vault resting like a dome or cupola on top. The spinal cord is the flatfish cylindroidal continuation of the medulla oblongata into the vertebral canal, enclosed in the theca vertebralis or vertebral sheath and ex- tending to the level of the lower border of the first lumbar vertebra; here it suddenly narrows to a terminal [352] 353 cone (conus terminalis) which tapers to a slender glisten- ing terminal strand {filiim terminate), in the center of the cauda equina, traceable as far as the third sacral vertebra. From each side of the spinal cord arise the thirty-one pairs of spinal nerves, which leave the vertebral canal through the inter-vertebral foramina.* The female cord more often than the male reaches to the second lumbar vertebra. That woman (with a smaller brain) should have a longer cord than man may be due to the extra pelvic demands upon her cord centers. The levels of escape from the cord of the various spinal nerves vary, as we may see by Gowers' table. The cord contracts at the medulla oblongata, widens from the second cervical to the first dorsal vertebra, again contracts from this point to the eleventh dorsal, where it again dilates, to narrow again at the top of the first lumbar vertebra. The upper is the cervical enlargement, the lower the lumbar enlargement. Its general form is cylindrical. "The spinal nerves are connected to the spinal cord by two roots (Fig. 139) one of which, the efferent or motor, (5), arises from the anterior aspect of the cord; the other, the afferent or sensory (6, Fig. 139) is connected with the posterior surface. After a short, independent course and the development of a ganglion (6, Fig. 139) which is, there- fore, a mixed nerve, containing both afferent and efferent nerves. The nerves distribute themselves by minute rami- fications to the receptive organs and the periphery, each filament remaining distinct in its own course. *The average dimensions of the cord are as follows: Male length, 43 cm.- Volume 34 ccm.; weight, 34 grammes. Female " 40 " " 30 " " 29 Motion of the vertebral column does not appreciably affect the level of the end of the cord. The foetal cord extended originally the whole length of the spinal canal, but the vertebral column begins to outgrow it at the tenth week, and by the time of birth the cord only reaches as far as the second lumbar vertebra. The outgoing nerves which at first passed horizontally outward to their respective metameres, become more and more oblique and retracted within the theca, owing to the inequality of growth. 354 The spinal cord itself consists of central gray matter and white columns or strands. The gray matter has the form of a double crescent with the convex surfaces joined by commissures, in the center of which the central canal of the spinal cord is seen (9), and the horns of the crescents are connected respectively with the anterior and posterior roots of the spinal nerves. The cells of the anterior cornu are large and multi- polar, those of the posterior small, and mingled with what is termed gelatinous substance. The conducting strands form the great divisions or columns, the anterior, the lateral and posterior. (See description of Figs. 139, 146, 147 and 148.) The efferent or motor impulses pass down and from the cord along the motor nerves, chiefly on the sides from which the roots emerge. Hence a tumor pressure disease on one side of the cord or hemi-section, causes paralysis of motion chiefly on the same side of the body, in the parts below the section. The sensory or afferent impressions are received by the cord and conveyed up to the brain chiefly in the opposite half of the cord to that into which the sensory root sinks. Hemi-section of the spinal cord causes loss of sensation on the opposite side of the body in all parts below the sec- tion; increase of sensibility and paralysis on the same side as the lesion. The antero-lateral columns of the cord are the chief motor paths. A certain injury or disease of one side of the spinal cord not involving the brain, causes that form of par- alysis of motion on one side and sensation on the other side known as Brown-Sequard's paralysis, illustrated in this diagram. (See Brissaud's diagram.) The cerebro-spinal axis, at the top of which is the 355 brain, is brought into harmonious touch in health and into inharmonious touch in disease with its environment, within as well as without the body, by means of the twelve cra- nial and thirty-one pairs of spinal nerves whose origins are shown in the illustrations under the head of neuraxis or cerebro-spinal axis. These nerves, as we have seen, are afferent and sen- sory, i. e., conveying impressions to the cerebro-spinal axis, (which includes the brain), and efferent or motor, carrying impressions or expressions outward. This nervous arrangement makes up the sensory and motor nervous systems, as it is combinedly called. The sensory nerves of this system, carrying impulses directly to he brain, by means of the twelve pairs of cranial nerves and directly to the spinal cord and indirectly up to the brain areas of the neuraxis, may be likened to the dendrites and neuraxones of the nervous syslem, as we have said; the cellulipetal influence going to the cell or neurone center or cord center and the cellulifugal nerve influence conducting paths, carrying impressions away from the spinal cord seg- ment or the neurone center. The terms sensory and mo- tor embrace all the action probably belonging to these two means of communication of nerves center with periphery, viz.: feeling or motion, or sensation and impression. Sensory impressions from the place of peripheral destination and motor stimuli from the point of origin of these nerve con- connections and relations, make up the whole of their function, beside the work which is done in the neurones themselves that constitute in aggregate the nerve centers. The work of the central neurones is to receive and send on unchanged, or to change into motor impulse and send out or to elaborate and otherwise transform peripheral impres- sions, as in the reflexes of the spine and medulla or of the 356 eye, nose or ear, or to inhibit or arrest impressions, as in the vagus center, over the movements of the heart and the higher but similar movements of reflection and deliberation in the exalted mind centers of the gray cortex of the brain, that grand grouping of psychic neurones which makes the brain of man the temple of thought and the palace of the soul. FIG. 165. Fibers of the direct pyramidal tract conduct inhibitory influences to the motor neurones of the anterior horns. When they are damaged in paral- ysis, spastic or spasmodic states appear, going out from the cord. Because of the fact that after destruction of considerable areas of the lateral columns, neither motion nor sensation is absolutely paralyzed in any particular part, it has been maintained for the spinal cord, as it has been for the brain, that a vicarious interchange of function exists between dif- ferent parts of the cord. And there is some truth in this, but the variation is not sufficient to invalidate the general law. Above the foramen magnum the spinal cord becomes the medulla oblongata, which we will discuss as a part of 357 the neuraxis in connection with the brain, it being usually described by anatomists as a part thereof. The brain or encephalon, includes all the cerebral mass within the cra- nial walls and above the foramen magnum cranii. The gray matter of the spinal cord is, as you see, cen- tral or internal in relation to the white. The reverse exists in the brain, the gray matter being external. The nerves of the brain and cord are white; conducting nerve tissue is generally white. Nerve matter in gross, that which re- ceives, originates, generates, elaborates, arrests or decides nerve function, is generally gray, so far as we know. The white matter waits upon the gray and carries its messages of sensation or impression to the gray centers and receives from them its commands. The upper and mid-dorsal regions of the cord are the favorite seats of Brown-Sequard paralysis. The leg will be motorially useless on the side of the injury, with increased patellar reflex, (sometimes lost reflex on the same side), cu- taneous hyperesthesia, hyperalgesia; loss of muscular sense with anesthesia and analgesia on the opposite side and the muscular sense on the side of injury intact. If the source of this paralysis is in the cervical region, it causes hemiplegia, that is, paralysis of the leg and arrr. on the same side and anesthesia of the opposite leg and trunk. In a one-sided lesion of the cord, in the sacral re- gion of the cord very low down, sacral paralysis of sensa- tion and motion are on the side of the lesion, because very few sensory fibers belong to the other side, as this illustra- tion of Brissaud shows. (Fig. 166.) Paralytic disease located high up in the brain on one side causes opposite loss of motion with or without loss of sensation on the opposite side, according to its extent or lo- cation. Suspect paralysis of brain origin when you have a 358 sudden loss of consciousness and loss of power of motion on the opposite side of the body, persisting after return of consciousness. Suspect Brown-Sequard paralysis when be- low the neck you have loss of motion on one side and loss of sensation on the other, without history of sudden loss of consciousness. FIG. 166. cvoA&We uxv^oXfcxoV Gcrc& 359 THE RAILWAY NEURAXIS. This psycho-neurosis may result from the shock of rail- way accidents, or from the repeated shocks to the head and cord neurones, received by railway employes long in rail- way service, short of those extreme degrees of injury caused by fractured cranial bones or dislocated vertebrae. The over mental strain of too long hours of an excessively exacting and vigilant service, gives the neurones too little rest and sleep for perfect recuperation in many departments of modern railway work. Too constant psychic neurone service is exacted of the brain, and after a time the central capital of reserve force is exhausted and collapse comes from causes which, in the beginning, would not break the brain. The principal symptoms are an impaired nerve tone, apepsia nervosa, intestinal atony, insomnia and sensory disturbances, cerebral and medullary hyperaesthesia, peri- pheral anaesthesia and other impaired sensory perceptions, facial tics and spasms, mfmory failure and the mental de- bility and timidity of neurasthenia. The power of extract- ing nutrition from the blood to adequately sustain the normal mental spontaneity and neurone vigor of action has become impaired. Metabolism is changed by shock and the apathy, irresolution and morbid apprehensions ofneura- trophia and neurasthenia have settled upon the psychic neurones. The condition appears to be one of cerebro- spinal shock and consequent retrograde change and cere- bral and spinal neurasthenia, in which the nutrition and tone of the neurones of the neuraxis is changed. The modern rapid transit, jerkily moving and often too suddenly stopped street car, and sky-scraper building elevator, may cause the same condition of the brain and spinal cord. 360 NERVOl'S INI ! UENCE IN CAUSING HEMORRHAGE AND NEURAXIS HEAT. Traumatisms and grave shocks of the spinal cord and brain may cause increase of temperature, but so ordinarily does any great violence to the cerebro-spinal axis or to the viscera connected with the neuraxis. Excitation of the motor area for the leg and thigh of one cerebral hemisphere has caused increase of temperature in the limb supplied by the descending decussating fibers to the opposite limb, but the rabbit and dog experiments by brain excitation usually give rise to general elevation of temperatuie. It is not strange, therefore, that various sections of the brain base should cause rise of temperature. Schreiber's section of the medulla where it joins the cord causing increased brain heat. in the pons, is not, therefore, remarkable. H. C. Wood, an eminent American neurologist, conjec- tured the existence of heat centers in the brain many years ago. Isaac Ott, whom 1 have already mentioned, in 1884 located heat centers definitely in the corpora striata of rabbits; in the following year he found heat cen- ters in the optic thalami. Sachs and Aronsohn have confirmed Ott's experimental conclusions, while Richet, a Frenchman, found a heat center in the anterior part of the brain and Tscheschichm, a Russian, found one above the pons. These, as well as Budge, Tussana and Christiana, according to the studies of my lamented friend, Landon Carter Gray, have found the brain to be a source of heat elevation under traumatism. {Vide article Heat Centers, L C. Gray's Nervous and Mental Diseases.) Hemorrhages have been found in the viscera, lungs, stomach, kidneys, etc., after injuries to the basal ganglia, 361 crura cerebri and medulla, and after violent concussion without injury. The experiments quoted show that heat is generated by- nervous influence. Through these thermogenic centers we have a neural as well as chemical heat phenomenon in animal organism. Neither what 1 may tell you nor what your books of today tell you, will give you all you are yet to learn in life concerning neural and extra- neural symp- tomatology and semiology connected with nervous diseases. Some of you are probably destined to make a name and fame for yourselves by further discovery in this direction. 1 wish that the names of all of you may become enrolled high on the keystone of fame's triumphal arch for good work done in this direction. Some railway surgeons, who are often better operators than neurologists, and more accustomed to seeing and treating those sensible injuries patent to the natural eye, where a fractured or dislocated bone or other markedly apparent wound in the anatomy calls for their aid, often display a real or affected skepticism as to the possibility of the neu- raxis being hurt in its neurone center groups, without an appreciable hole or other mark of great violence in the anatomy, to account to them for the nervous disturbance. They are doubting Thomases who must first see the im- print of the nail before believing in the possibility of the symptoms; yet true surgery with all great surgeons who ob- serve and think beyond the mere technique of their art, recognizes concussional and violent straining of the higher nerve centers, even extreme psychic or fright shock, as capable of suspending and damaging central nerve function without sensible external injury. The ready explanation of the smaller- calibered surgeons, for what they can not readily understand among the traumatic neuroses, without a dis- 362 located or fractured back or cracked skull or profound ec- chymosis, especially if the unfortunate victim be a woman, is hysteria. They forget, or ignore, or mayhap have not vet conceded the existence, of those groups of neurones in the gray substance of the cord which constitute centers of trophic influence which affect the motor, sensory, conduct- ing and inhibitory functions of the cord. But 1 cannot here pursue the subject further. You must, at your leisure, consult such books as Erichsen on the one side and Page on the other. Page has made the most of the hysterical view, and hysteria, in those who have the latent hysterical diathesis, is often brought out into full action when it other- wise might have been dormant for life, but for some grave accident or powerfully depressing, neurone depraving, and instability exciting, psychical impression. But in such a case the hysteria itself is the result of the exciting cause, and if this cause be a violent accident, we may justly call it traumatic hysteria, if without the traumatism it would likely have remained dormant. If the hysteria pre-existed in the woman it could not justly be called traumatic hysteria. The sensori-motor tract of the cerebro-spinal axis is con- nected with the various motor displays of prehension, limb, finger, toe, tongue and eye sensation, and with all of the reflexes, spasm and other forms of contracture, normal or abnormal, such as those of morbus Thomsenii, post-hemi- plegic paralysis, chorea, hysteria, convulsions, etc. The tremulous movements of extreme nervous fatigue, of paralysis agitans, of disseminated sclerosis, tic douleureux or tri-facial neuralgia, the jerky movements of chorea, the rhythmical movement and unfixed digital attitudes of athetosis, etc. The sensory nervous system reveals the nerve chan- nel paroxysmally darting pains of sciatic and other neural- gias, and the lightning pains and cincture feeling of loco- 363 motor ataxia. It reveals to us the anaesthesias, the hyper- esthesias, the analgesias, hyperalgesias and parasthesias in various forms of sensory illusion or hallucination and the normal and abnormal distance points, as shown in healthy or diseased states of the peripheral or sensory nervous sys- tem by aesthesiometric measurement. The cutaneously dis- tributed sensory nerves reveal different appreciations of dis- tant points in a straight line at different parts of the skin surface, as we showed you when we presented that instru- ment of precision in sensory diagnosis, the aesthesiometer. DR. E. H. WEBER'S ESTHESIOMETRIC DISTANCE POINT'S TABLE. This table has long been the chief esthesiometric guide and resource of practicing neurologists for the past four decades. It was first incorporated in a neurological work in this country by that eminent pioneer neurologist, now deceased, Dr. Wm. A. Hammond, in his treatise on the Diseases of the Nervous System. [From Milller's Physiology .] Point of the tongue y 2 a line. Palmar surface of the third finger ] Red surface of the lips 2 lines. Palmar surface of second finger 2 " Dorsal surface of third finger 3 " Tip of the nose 3 " The palm over the heads of the metacarpal bones 3 " Dorsum of tongue, one inch from the tip 4 " Part of the lips covered by the skin 4 " Border of the tongue, one inch from the tip 4 " Metacarpal bone of the thumb 4 " Extremity of the great toe 5 " Dorsal surface of the second finger 5 " Palm of the hand 5 " Skin of the cheek 5 " External surface of the eyelids 5 " Mucous membrane of the hard palate 6 " Skin over the anterior surface of the zygoma _ 7 " 364 Plantar surface of the metatarsal extremity of great toe 7 lines. Dorsal surface of the first finger 7 On the dorsum of the hand over the heads of the met- acarpal bones 8 Mucous membrane of the gums 9 Skin over the posterior part of the zygoma 10 Lower part of the forehead 10 Lower part of the occiput 12 Back of the hand 14 Neck under the lower jaw 15 Vertex - 15 Skin over the patella 16 " " sacrum 18 " " acromion — 18 The leg, near the knee and foot 18 Dorsum of the foot, near the toes 18 The skin over the sternum 20 " " five upper vertebra 24 " " spine near the occiput 24 " in the lumbar region 24 " " middle of the neck 30 " over the middle of the back 30 The middle of the arm 30 thigh 30 For convenience of reference in lesthesiometric measure- ments this table, made by Dr. E. H. Weber, will be especially necessary in using Sieveking's, Seguin's, Ham- mond's or any other assthesiometer except my own, and may serve you even in the use of mine. You will find in the museums and text-books and in the excellent casts of Dr. Wm. Fuller and in the descriptive illustrations of Ford Robertson, Bevan Lewis and Morrison and Barker, which 1 have so often shown you in my demonstra- tions on the brain and cord, many elucidatory illustrations to help you to a clean, clear comprehension of the subjects necessary for you to understand. Each text-book on neu- rology possesses some special peculiarity of description or illustration. Here are some further illustrations germane to our present subject in addition to those already shown. 365 FIG. 167. J2*s-. n. li\ poglossal nerve. GP, Glossopharyngeal nerve V. Facial nerve. S, Superior cer> ical ganglion of the sympathetic, gr, Ganglion of the root of the vagus. /. Ganglion of the U unk of the vagus. l. Auricular branch -of the vagus (Arnold's nerve). ■j. Phary ngeal branch. 3, Convergence of nerves to form pharyngeal plexus. 4, Superior laryngeal nerve. 4', Internal branch of superior laryngeal nerve 4", External branch of superior laryngeal nerve. 5, Inferior laryngeal nerve (recurrent). •V, Cardiac branch of inferior laryngeal nerve. G G D, Cardiac branches of the vagus, 7, Convergence of branches of vagus to form cardiac plexuses. 8, Pulmonary branches. 9, (Esophageal branches. 10, Gastric branches. 11, Splenic branches. 12, Hepatic brandies. SA, Spinal accessory nerve. id, Internal division of spinal accessor] . erf, External division of spinal accessory. rc, tIC, HIC, IVC, Cervical nerves. ^_^y 367 MOTOR AND SENSORY AREAS AND TRACTS OF THE INTERNAL CAPSULE. FIG. 169. ES OPEN ES TORN MOUTH OPENS HEAO&EYESTURN HEAD TURNS TONGUE MOUTH RETR, SHOULDER ELBOW WRIST FINGERS, THUMB ' TRUNK HIP ANKLE KNEE HALLUX TOES I C, I C, Internal Capsule. C N, Caudate nucleus. L N, Lenticular nucleus. N C, Nucleus caudatus. O T, Optic thalamus. S, Line of sensory area internal capsule. 368 the Facial nerve and irs connections, within the aqueduct OF FALLOPIUS. FIG. 170. 1, Fifth nerve, with the Gasserian ganglion. 2, Ophthalmic division of the fifth nerve. 3, Superior maxillary division of the fifth nerve. 4, Lingual nerve. 5, Spenopalatine ganglion. 6, Otic ganglion. 7, Submax- illary ganglion. 8, Facial nerve in the aqueduct of Fallopius. 9, Great superficial petrosal nerve. 10, Small superficial petrosal nerve. 11, Stape- dius branch of facial nerve. 12, Branch of communication with pneumogas- tric nerve. 13, Branch of communication with glossopharyngeal nerve. 14. Chorda tympani. (Dalton's Physiologv.) 369 ORIGIN AND CONNECTIONS OF THE GLOSSOPHARYNGEAL, PNEI MO- GASTRIC AND SPINAL ACCESSORY NERVES. FIG. 171. 1, Facial nerve. 2, Glossopharyngeal. 3, Pneumogastric. 4, Spi- nal accessory. 5, Hypoglossal. 6, External (muscular) branch of the spinal accessory. 7, Superior laryngeal branch of the pneumogastric. 8, Pharyngeal plexus. Laryngeal plexus and upper cardiac branches of the pneumogastric. 10, Tympanic plexus, from a branch of the glosso- pharyngeal. (Hirschfield. From Dalton.) CHAPTER XXXI. THE VIRILE OR GENESIAC REFLEX AND ITS SYMPTOMATIC VALUE IN PRACTICE. The pudic nerve branches from the lower portion of the sacral plexus, comes out of the pelvis through the great sacro-ischiatic foramen with the pudic artery, gluteal and sciatic vessels and nerves. It then re-enters the pelvis and gives off the inferior hemorrhoidal nerve and passes along the outer aspect of the ischio-rectal fossa to divide into the perineal and dorsalis penis nerve. The inferior hemorrhoidal nerve sometimes comes directly from the sa- cral plexus and is not then a branch of the pudic. It is distributed to the rectal sphincter muscles and inferior pu- dendal nerves. The largest branch of the pudic nerve, the perineal, dividing it into superficial cutaneous and deeper muscle branches, sends some filaments to the sphincter and levator ani muscles, but it goes chiefly to the perineal in- tegument, the scrotum, penis, labia and anus, communicating with the hemorrhoidal, as already indicated. The muscular branches come usually from the pudic, pass forward and inward beneath the transverse perinei muscle, its terminal filaments going off to the transverse perinei, erector penis, accelerator urinae and sometimes to the bulb of the urethra. The dorsalis penis nerve is a ter- minal filament of the pudic, going between layers of perineal [370] 371 fascia, through the suspensory ligament of the penis and along its dorsum to its glans, branching to the corpus cav- ernosum and integument of the dorsalis penis. Its course is similar in the female. Ranney and Holden, from whom this anatomical description is mainly abbreviated, here in- troduce a note from Hilton to the effect that the integu- ment of the side of the penis is supplied by the perineal branch of the inferior gluteal nerve and from no other source. This probably explains why the virile reflex is so much more rapidly obtained by dorsal than by lateral tap- ping of the organ and by the upward jerk or slow tension of the foreskin. The pudic nerve is a nerve of sensation and motion of the genitals and genital regions of the body, the perineum and integuments, the urethra and clitoris, their mucous walls and linings, the penis and scrotum. It is a sensori- motor nerve of special, as well as pain sense, the nerve of the genesiac sense, in main part at least, notwithstanding the probable associate genesiac function of the inferior gluteal, inferior pudendal and some cutaneous filaments of the small sciatic* 1 believe the pudic is the nerve sui generis of the virile or genesiac reflex, especially in its in- fra-umbilical areas. The pudic nerve and its close perineal relations with the lesser sciatic and some of its branches in its distribution and peripheral reflex sensibilities and re- lations, defines the boundaries of the virile or genesiac re- flex areas. The virile or genesiac reflex phenomenon is a pudic nerve area reflex. It is the diagnostic reflex of the sexual spinal cord sphere in the normally sexual individ- *lt gives motion to the muscles of the perineum and ur»*ra, sensation to the integu- ment of the perineum, scrotum, labium, penis and the mucous covering of the clitoris and the lining of the urethral canal. The friction made upon the cutaneous nerves of the ex- ternal genitals creates a reflex act from periphery to cord, and psychic impression from brain to genito-urinary centers, causes genital congestions, genital and perineal contraction, which expel the seminal and Bartoline secretions, urine, etc., etc. 572 ual, independently of the erectile states of the virile organ or clitorjs.* The pudic nerve, through its reflex function, of which the virile or genesiac reflex is an important part, makes possible erections, twitchings, jerkings, seminal emissions, scrotal retraction, etc. They are brought about through its influence and relations. Anatomists and physiologists have come near to the discovery of the virile reflex before but just missed it, years ago. If you suddenly stretch the foreskin or grasp and pull the glans penis toward the umbilicus of a virile individual, you will discover a sensible downward jerk of the organ, and if you place one or two fingers of the other hand on the dorsum of the member, you will detect, by the sense of touch, the downward retraction, as plainly as you may see the plantar and toe reflexes after stroking your finger tips across the sole of the foot or metatorsal region. Both of these reflexes are normally downward. Or if, while hold- ing the organ slightly tense by grasping the glans around the corona, you jerk or pull the organ up toward the umbilicus and slap the inside of the thigh or sharply stroke upward with the fingertip the inguinal region over Poupart's ligament * and the transversalis abdomis muscle, or if you forcibly pinch up the perineal integument of the perineal scrotum, you will elicit the same downward retraction of the virile organ; appreciable to sight, but more so to touch. Or if you suddenly tap the penis with the same degree of force, the organ being rendered slightly tense, this downward jerk may be felt, even down to the perineal portion of the organ. The compressor urethra seems to contract and the bulbous * Certain fibers of the pudic nerve must be concerned in the production of the virile reflex that are not concerned in the erection or in bulbo-cavernous turgescence. because this reflex can be elicited without necessarily having marked swelling or erection of the organ, though with ureat excitation both erection, vascular tumescence and the twitch of Onanoff appear. 373 urethra may be seen sensibly to enlarge, the dorsal and the muscular branches of the pudic nerve seem to receive and transmit the impression dorsad and return the peripheral im- pression transmitted into motion, in a true reflex manner, in which the compressor urethra and the bulbo-cavernosus portion of the penis participates, when the organ is erectile. Though this retraction may be easily elicited when the organ is not in an erectile condition. Erection is secondary, resulting from more extended penile excitation and not necessary to the display of this reflex sign of virility, though it may be and usually is. This is a true penile reflex, a true penis jerk, a true sign of virile intactness. The jerk is as plainly backward and downward as the knee jerk is upward, with a healthy spinal cord. It is not an erection, but a retraction, like that of the gullet reflex, a downward and backward jerk. There need be no erection accompanying this phenomenon and usually is none, though erection may come on through general pudic nerve excita- tion. It is more active in an erectile state of the organ and may be less active after a normal erection has been physiologically exhausted. It is in no sense a penis erection phenomenon, thought absent when power of erection is absent or lost from genuine organic impotency, and is feeble in some cases or condi- tions of psychic impotence. To determine its value in pure psychic impotence and the genital weakness of sexual neurasthenia, demands more thorough study before abso- lutely positive conclusions can be reached thereon. I have seen it absent and very feeble in persons who subsequent- ly regained power, especially in sexual neurasthenia; in the prostration of typhoid fever convalescence and two of the spurious forms of tabes dorsalis — sexual exhaustion tabes — 374 DESCRIPTION OF FIG. 172 (OPPOSITE PAGE). VL, IS, IIS, IMS, IVS, VS, VIS.— Fifth lumbar, and first, second, thir sacral nerves. LS, Lumbo-sacral cord. c, c, Posterior cutaneous nerves. in, Branches to muscles of back. 1, Branches to pyritormis muscle. 3, Muscular branches to obturator internus. II, llio-inguinal nerve, cutaneous, to inguinal region and scrotum. GC, Genito-crural nerve. G, Genital branch to spermatic cord or round ligament. 2, Muscular branch to cremaster. C, Crural branch, cutaneous, to surface of upper part of front thigh. EC, External cutaneous. P, Posterior branch, cutaneous, to upper and outer part of thigh. A, Anterior branch, cutaneous, to front of thigh. ps, Muscular branches to psoas muscle. AC. Anterior crural nerve. 3, Muscular branches to iliacus. 3', Muscular branches to sartorius. 3", Muscular branches to pectineus. fa, Branch to femoral artery. MC. Middle cutaneous to front of thigh. IC, Internal cutaneous to inner part of thigh. LS, Internal or long saphenous. a, Cutaneous over inner ankle. /, Cutaneous to inner side of foot. 4, Muscular branch to rectus femoris. 4', Muscular branch to vastus externus. 4", Muscular branch to crureus. 4 '. Muscular branch to subcrureus. 4"", Muscular branch to vastus internus. Kj, Branch to knee joint. O, Obturator nerve. ///. Branch to hip-joint. c', Communicating with branches of internal cutaneous and internal saphenous. 5, Muscular branch to pectineus. 5', Muscular branch to obturator externus. 6, Muscular branch to adductor longus. 6 . Muscular branch to gracilis. 6", Muscular branch to adductor brevis. 6'" 6"", Muscular branch to adductor magnus. Kj' , Branch to knee-joint. L. Communicating branch to fifth lumbar nerve. 375 FIG. 172. 376 and malarial toxhaemia. I have also seen the knee jerk absent, and recovered from in post malarial tabes dorsalis. This reflex downward jerk may be elicited by friction - ing the glans for awhile by rubbing it with a piece of pa- pur (Onanoff's method) though I have never succeeded satisfactorily in eliciting it in this way until after the organ got into a state of erectile excitement. Eliciting it in this way not only excites erection, but it shows more as a twitch modification of this true virile reflex, than as the deliberate downward jerk 1 have described as the true virile reflex. This glans reflex friction method and the resultant twitch is the excitation method and the description of M. Onanoff, who made his discovery about the same time I made mine, as 1 learned when I communicated my discovery to M. Brown -Sequard, as I have stated in a former communica- tion on this subject; but you must note that the Onanoff discovery was complicated with erectile co-excitation and is therefore a complex phenomenon, and mine is not, and is not elicited exclusively in Onanoff's way of glans excita- tion, but chiefly and better in a different and less com- plicated manner. Mine is obtained in various ways and by penis upward traction reinforced by tapping or stroking or pinching in any of the genesiac areas of the body below the umbilicus. Onanoff called his discovery a bulbo- cavernous reflex twitch, caused by penile friction with a a paper or feather, while mine is a traction penile reflex, elicited when the foreskin over caput penis is drawn up- ward, as already indicated, if any nerve area of the inguinal, perineal or genital region is excited, as previously described, by either upward penis traction or by traction and tapping combined, or by tickling with a straw or by pinching or pricking certain areas. I have seen it brought out when drawing up the caput 377 penis to introduce the catheter into the meatus or to get into the bladder under the pudic arch. This phenomenon has been in a manner vaguely and indefinitely known to anatomists and physiologists for sev- eral decades before 1 described it, or before Onanoff called attention to his similar phenomenon, but it has not before been separated from other penile phenomena and given the distinctive significance with which 1 invest it. Thus Am- brose Ranney, in 1881, reflecting anatomical observation on this subject up to the time of writing his treatise of that day on applied anatomy of the nervous system, called attention to the fact (Applied Anatomy of the Ner- vous System, 1881, page 469) that "in some cases of frac- ture of the spine, in the dorsal region, where a part of the spina) marrow is left intact below the seat of fracture, you may be able by repeatedly pinching the skin of the scro- tum and penis, to produce spasmodic contraction of the muscles of the perineum and urethra and often to effect turgidity of the genital organ to such a degree as to make it resemble an imperfect erection or priapism." This was an approach to and anticipation of M. Onanoff's bulbo- cavernous reflex discovery. It is not uncommon for vesical, as well as urethral, rec- tal and prostatic disease to produce sympathetic manifesta- tions in the genito-urinary organs in the form of neural- gic pains, involving involuntary emissions, incontinence of urine, etc., etc. Such effects can only be explained by the distribution of the pudic nerve to the integument about the anus and I believe, to the walls of the rectum also, which allows reflex motor impulses to be sent from the spinal cord in response to rectal irritation to the genito-urinary organs and perineal muscles. Now let us again run briefly over the subject of the pudic nerve and its relations for 378 explanation of the modus operandi of this remarkable reflex and its great value, which contributes further to make the pudic nerve in physiological significance, next to that of the wonderful vagus. To recapitulate: The virile reflex is lost, as you see, in impotence, impaired and lost in time by excessive venery and masturbation, this being Nature's inexorable remedy and punishment for prolonged and senseless sexual excesses and the conservation of normal vitality. It is excited in the early stages and lost in the later stages of posterior spinal sclerosis, the opium habit and extreme alcoholism. It wears out in the lascivious and bestial, and with extreme old age. It is excited in erotic hyperaesthesi;i, in some stages of hysteria and in various influences, normal and morbid, coming from the rectum, urethra, testicles or ovaries and by descending influences, normal or abnormal, from the encephalon. 1 admonish you again to maintain the integrity of your virile reflexes, gentlemen, in order that you may go through life a man among men and women and make a manly mark upon your day and generation. Be prodigal of its powers and you will be pigmies in the pathway of the giants you might yourselves be in your day and generation. The world is for the virile and strong. The weak in the pudic nerve and vagus nerve areas of the neuraxis go to the wall or are trodden under by those who better care for, or are better endowed in these vital reflex nerve centers and in their entire neuraxes. CHAPTER XXXII. APHASIA DEFINED AND LOCATED. APHASIA PHYSICALLY AND PSYCHICALLY CONSIDERED. SOME OF ITS MOST ESSENTIAL PHASES DISCUSSED. An important brain disease, often neurovascular or rather vasoneural in origin, but sometimes caused by tumor growths, gummata and other adventitia or by temporal bone frac- ture or concussion, involving a part of the brain in marked disorder, is aphasia or the alalia of Lordat, the asemasia of McLane Hamilton, the amnesia, etc., of other writers. This lo- calized brain disease has many varieties. The form of aphasia first discovered was that of lost power of speech formation and expression. That is the power in the mind to formulate ideas into speech language once possessed, but lost by disease of the speech center of the brain. In this disease there is a paralysis of word ideation power in the neurones of Broca's speech center. Bouillaud, as early as 1825, placed the faculty of artic- ulate speech in the frontal lobes of the brain and so had Gall before him and the elder Dax located the speech fac- ulty in the left side of the frontal lobes, while the junior Dax located the speech center in the left antero- lateral or middle lobe of the brain. It was reserved for Broca to still more definitely cir- cumscribe it in the posterior aspect of the third left frontal [379] 3S0 convolution. .\\. Broca had a patient at BicStre hospital, Paris, named Laborgne, who on admission, appeared intel- ligent, but could not give his name or answer any question save with a gesture and the ejaculation tan tan and an auto- matically familiar oath in French. He had been epileptic from infancy, but had learned the trade of a last maker and followed it till about thirty wars of age, when the loss of the power of speech dis- abled him from continuing his work. Ten years after admis- sion the power of his right side began to fail, and this weak- ness gradually extended to complete right hemiplegia and he became bedridden. There was no facial, tongue or voice paralysis and only the last act of deglutition was difficult. The patient became affected with phlegmonous erysip- elas of the right lower limb which, passing to the head, caused his death in six days. The post mortem revealed the dura and pia thickened, the latter injected, opaque and infiltrated, but not with pus. The greater part of the frontal lobe of the left hemisphere was soft and revealed a cavity the size of a hen's egg fdled with serum in the lower marginal convolution of the temporo-sphenoidal lobe, the convolutions of the island of Reil and the extra-ventricular nucleus of the corpus striatum. In the frontal lobe the inferior part of the trans- verse (ascending) frontal convolution was destroyed and the posterior inferior half of the second and third frontal convolution, the greatest loss being in the third frontal. Broca reasoned from this case that the primary trouble was in the third frontal; that this primary disease extended to the other convolutions gradually and finally to the island of Reil and the extra-ventricular nucleus of the corpus striatum, when hemiplegia was complete. Broca had another patient named Lelong who, after his 381 aphasic seizure, named himself Lelo. Lelong had only a cinque verbe vocabulary consisting of oui for yes; non for no; 'tots' for trots (three) and toujours for always. His fifth word was Lelo, for his name. Lelong was 84 years old. He had a fall on the stairs causing unconsciousness and apoplectic symptoms, but no paralysis. Intelligence re- turned to him with the coming back of consciousness, but not the power of speech beyond what we have noted. He used oui, non and Lelo definitely and intelligently. Tois referred to any number, not specially to three, and toujours for every other word idea. Lelo was an octogenarian, who in I860, while descend- ing a stairway, fell unconscious and was treated for apo- plexy, but in a few days he became convalescent without a sign of limb paralysis, but with the attack he had lost the faculty of speech except in the limited, crippled and bizarre manner above stated. His intelligence appeared intact through the limited vocabulary which he articulated with difficulty, but made clear by an expressive facial mimicry, to those accustomed to be his audience. This case, more than any other in M. Broca's expe- rience, converted him from the skepticism with which he had challenged M. Aubertin to the proof, not long before, of an anterior convolution center for speech lesion, to abso- lute conviction and to the definite area of the third left frontal convolution, which now bears the name of Broca's speech center. Lelong, less than 18 months after his aphasic attack, had the misfortune to fracture the neck of his femur at the age of 84 years, from which death resulted twelve days after the accident. The autopsy of Lelong revealed in the left hemisphere a lesion limited to the posterior third of the second and third frontal convolutions. A small cavity filled 382 with serum was found there. The right hemisphere was sound in the corresponding locality, the pia and dura were found normal, the arachnoid held a considerable quantity of serum; the .right hemisphere, the cerebellum, pons and me- dulla were healthy. Only the left hemisphere showed the lesion limited to the posterior third of the second and third frontal convolution. Remarkable revelation! An old man whose race on earth is run, by a fortuitous accident, reveals in his death a secret which the ages have kept hidden. Broca, a genius of our great profession, a son of France, discovers it by the light of that same necroscopic science shining in another age, which made the great, the sublime Vesalius immortal. These cases were convincing evidences to Broca of a speech center about the island of Reil. The case of Lelong, especially, clinched and confirmed his convictions of the in- sular speech center, which now bears his name. This em- inent and immortal clinician thus summed up the case of Lelong: Lelong understood all that was said to him, he applied with discretion the four words of his vocabulary ; (five words, for his name Lelo was one) ; his intelligence was unimpaired; he understood numbers and had neither lost the general faculty of language nor the power of moving the muscles of speech and sound, but only the faculty of articulate language. Since Broca's discovery, investigators have found and named many varieties of aphasias depending upon con- nection and lesion of other centers in the brain. Amnesia or amnesiac aphasia, such as the loss of the memory of spoken words, agraphia or agraphic aphasia, the loss of memory for written words, sometimes separately, and some- times both together lost. Kussmaul, Tenner and especially Wernicke, at later dates, associated the hearing centers of 383 the temporal convolutions with the speech center of Broca, and the term "word deafness" was born. Ferrier, Hughlings Jackson, Broadbent, Horsely and other later investigators have contributed to extend the aphasia area, the center of its^expression, however, remaining where Broca located it. fig. 173. Charcots QVx%\uo\P'\aar©.xrv.op OroX ar uti tronc comimnr9r - -^"0,'ari0rc paridiali.' ascoodanto. 1, trunk of middle cerebral; 2, artery to orbital lobe; 3, inferior frontal artery to third left frontal or Broca's speech center convolution; 4, ascend- ing frontal convolution arising from 5, a branch from the common trunk of the Sylvian; 6, ascending parietal artery. Other figures show arterial dis- tribution of Sylvian branches to neighboring areas of the brain, including ascending parietal, frontal and temporal convolutions. From Raymond, "Clinique" on "Disease of the Nervous System." Fig. 1, 2, 3, F., first, second and third frontal convolutions; 1,2,3,T., first, second and third temporal; 1 and 2 P; first and second parietal; 1, 2, 3, 0, the three occipital convolutions. Cuisse, thigh; Jambe, leg; Hanche, hip; Tronc, trunk; Epaule, shoulder; Orteils, great toe; Pied, foot; Conde, elbow: Poiguet, wrist; Doigts, fin- gers; Pouce, thumb; Language center, muscles of the face and mastication. 391 FIG. 177. r a. circle o-c \\AMe c\rc\c_) CA — Anterior cerebral, CAA — Anterior communicating cerebral, CM — Middle cerebral. CI — International carotid, COP — Posterior communicating carotid. OPO — Posterior cerebral, CBS — Superior cerebral. CBIA — Anter- ior inferior cerebellar. AUD — Interior auditory, BA-Basillar artery. V — Varolian. CHIP — Posterior inferior cerebellar. SPA — Anterior spinal, SPP P — Posterior spinal. CHAPTER XXXIII. THE MEDICO-LEGAL ASPECTS OF APHASIA. THE CASE OF WM, T. BEVIN. As I have said, aphasics will often be suspected of in- sanity and it may be your professional duty some day, in the line of your observation, to differentiate between the loss of power of speech conception and expression, and the loss of mind. For your further enlightenment on the subject, I here give you briefly a medico-legal case in which this question was asked of me, as a psychological expert, in a St. Louis court. It was the case of Wm. T. Bevin,* an inquiry into the question of aphasia or insanity; a hemiplegic re- recovered with aphasia remaining. Following is the psy- chological expert analysis and opinion rendered on the witness stand in non-technical language and manner of analysis, so far as was practicable, at the October, 1878, term of Circuit Court No. 2. The title of this case on the records is Wm. T. Bevin vs. Powell. On the thirteenth of March, 1873, Air. Wm. T. Bevin, a *The substance of this paper was read before the Association of Medical Superin tendents of Asylums for the Insane, at Washington, D. C , May 17, 187*, and published In the American Journal of Insanity for that year under the title of " Aphasia or Aphasic Insanity, Which ? " [392] 393 builder, a few months after the death of his wife, was stricken with right hemiplegia and aphasia. A cardiac valvular lesion preceded the paralysis and persisted to the time of my last examination, February 7, 1876, and to the time of his death, several years after. His respirations were twenty-one per minute, lungs were healthy, heart and wrist pulsations asynchronous, the latter counting as high as one hundred and eight, and the former sometimes ten to eighteen more, per minute. At this time there was incom- plete paralysis of motion on the right side and general anaesthesia. He was insensible to the pricking of a pin in both hands and feet. The sub-lingual temperature, on either side, was 98° F. He correctly and promptly com- prehended oral signs, but tardily and imperfectly understood written ones. He soon recognized my name and wrote it for me, with his left hand. He likewise wrote his own name and the surname of his attorney (Mr. Rainey), upon my asking them. An H, written by myself, and an imperfectly erased tracing of my surname, were on the card on which he wrote my name. He first attempted to attach "ughes" to the H, I had written, but afterwards changed his mind and made an H of his own, which ac- counts for the somewhat disjointed appearance of the word Hughes, here following: His tongue was clear, but he said he always had a disagreeable taste in his mouth. He either really had, or feigned defective vision. When the thumb was held up 394 before him, looking with one eye, the other being blind - folded, he would say it was two, and when the thumb and little finger were held up, he would say there were three. I intended making an opthalmoscope examination, but be- fore 1 had opportunity the case came to trial, and my tes- timony not being satisfactory to the family, 1 did not offer to examine him further. He had defect of hearing in the left ear, which I thought feigned at the time, but which I later concluded was a fact, as it was in harmony with his aphasia and evidently resulted from the blood pressure disturbance in the neighborhood of the hearing center of the brain, affecting the auditory conducting paths to Broca's center on that side. He signed that he could not hear the ticking of a watch half an inch from his ear, yet he distinctly understood a remark to him by his sister in quite an ordinary tone, at least twelve feet off from him, at the time 1 was testing his hearing with the other ear. None of his family spoke to him in a very high tone, as is customary when one is deaf. He repeated the word uin- nin, accompanied by bowing or a nod of the head, to sig- nify yes and by a turning to left and right to indicate no. When 1 wrote W. T. Bevin and asked if that was his name, he shook his head and taking the pencil wrote Wm. T. Bevin: He had three paralytic strokes, and was seen by his relatives after each attack. He grew steadily better in mind after the first attack, notwithstanding the subse- 395 quent attacks which were slighter and more transient than the first and displayed a singularly exceptional knowledge of the details of his business affairs and signed with his left hand an intelligent and business agreement with regard to some houses he was building jointly with some other par- ties, and in fulfillment of a promise and purpose, made and entertained prior to his attack. He could not write with his left hand before he was stricken. About the same time of, and prior to the signing of this deed of trust, he is said, by some of the members of his family — principally his two sisters and a brother-in-law with whom he lived — to have done some things which they swore they regarded as evi- dence of insanity, such as on one or two occasions (none of the witnesses testifying to more) bowing to pictures in the parlor, when he knew members of the family were present, and with a pleased but silly appearing smile; one side of his face being defective from paralysis. Once he is said to have wiped his nose on his napkin, and one or twice, in the early stage of his paralysis, they say he spat on his plate. Once he unbuttoned his drawers when his sister and another lady were in the room. It was said that once, after his first stroke of paralysis, he defecated in bed. [Once, he is said to have struck his mother with a stick, though one of his brothers, who swore there would have been no suit if he had got his three per cent, commission, as promised, for taking his afflicted brother's interest in the business, said he never saw or heard of such an affair, or of unbecoming conduct of any kind toward her. Some or most of these acts were natural enough to his paralysis, as it was also natural to bow to the crucifixion and other objects when asked to point them out.] At this time he could not, the family say — all but one brother — distinguish letters or tell if they were upside down or not, 396 but readily recognized them if their names were called. As early as the first of May, in 1873, he could sit in a chair and get about the room. In June he appeared to one of his physicians to be silly, "because he smiled peculiarly" and was exceedingly violent and irritable when the battery was applied. To another of his physicians he appeared de- mented, though he was able to go unaccompanied in the following November, a long distance, to this physician's office, correctly select and count his money and pay his med- ical bill, and take and put away carefully a receipt for the same. It was also said that he made grimaces before a glass once or twice, and pulled out his hair, and he ate things when set before him, that he never ate before. He handled his food with his fingers (he could not use a knife and fork), and his manners and tastes at table were changed in some other respects, he having been formerly very fastidious and precise. When he first learned to write his name he would make signs to visitors for a slate, write his name for them, and express his pleasure at the accomplishment by a peculiar smile. After the description of his property, mentioned in the deed of trust, was read to him, he pointed in the di- rection of it and gave an assenting nod, pointing immed- iately after in the direction of other property not alluded to in the document, and indicating his understanding that it was not included, by the usual turning away of the head indicative of dissent. He was attended by different physicians during the first attack. The physician who first saw him at the time of his first seizure found him only partially paralyzed on the right side, with consciousness still remaining, and helped him home. In six hours after this physician saw him, he was hemiplegic and unconscious, and so remained 397 for several days. He commenced to improve in two or three weeks. He was then annoyed by movements about the room and exhibited "not much, but some signs of in- telligence in his countenance." He made signs and efforts to convey ideas, and would mumble unintelligibly in an- swer to questions and had difficulty of deglutition. He never, at any time, had delirium, delusion or hallucination. He recognized Dr. Mudd generally when he visited him. One attending physician thought his mind was impaired, because "there seemed to him to be an absence of power of expression and clear conception of subjects." This was just after the stroke. This mental confusion was a natu- ral concomitant of the great commotio cerebri incident to such a severe, extensive and sudden involvement of a cer- ebral hemisphere in disease, even though that disease were only an embolism of the middle cerebral artery. He might, at this stage even, have been demented, as he was con- sidered to be, later, by one of his physicians but it could not be the real and permanent dementia which results from general degeneration and destruction of the cerebral cortex, as the improvement which soon began to appear and all the sequels — his learning to write with his left hand, rec- ognizing and designating friends, pictures, etc., within four months, conclusively proved. All the symptoms pointed to middle cerebral artery embolic obstruction. When we reflect that his hemiplegia embraced one-half of his face in paralysis, simulating a Bell's palsy, it is not strange that he should have appeared silly and smiled peculiarly in May. He being irritable and violent when the battery was applied at that time, indicates only that the degree of paralysis of sensation has increased since then. It is not strange that he could not distinguish letters or tell if a book or paper was upside down, confusion of vision 398 being the rule rather than the exception, after hemiplegic strokes and cerebral embolism. The length and position of the optic chiasm, tractus opticus, and of the optic nerve within the brain, and the manner in which they are placed and surrounded with blood vessels, expose the apparatus concerned in sight to great disturbance of function from pressure, etc.; for this reason various disturbances of vision are common in morbid condi- tions of the brain. This patient might have been totally blind from pressure consequent upon the cerebra oedema, which generally follows embolic closure of a vessel in other parts of the brain than the spot primarily implicated in the embolism, if we take no account of possible similar, sim- ultaneous closure of other arteries of the brain. In regard to dementia, which only one of his physicians asserted that he had (Dr, Benkendorf), it is difficult for the practiced alienist and neurologist, accustomed to observe the phenomena and progress of this profound form of mental disorder, to conceive how a patient could have really been demented in June, in consequence of a cerebral vascular lesion grave enough to cause hemiplegia, paraplegia, con- fusion of vision and aphasia, and yet, be so recovered by the next following November, as to fully appreciate the services he had received from his physician, and go unac- companied to his office, and settle in an intelligent manner his bill, even though he could not speak. It was singular that of all the acts testified to by Bev- in's brother-in-law and sisters, who were living with him and interested in the success of his suit, none of them should have been observed more than once or twice during the whole time of his affliction. Many of these acts, had they occurred oftener, would have been explicable other- wise than on the theory of insanity, and all of them, as 399 the testimony gives them in this case, are explainable with- out invoking the presumption of insanity. 1 have seen my own little son study the play of his facial muscles in a glass, and when I was a student of anatomy I did the same thing, before a mirror, too. The circumstances connected with the once wiping of his nose on the napkin or table-cloth do not appear. He wiped his nose once or twice. It was not shown that he had a pocket-handkerchief, or that he had ever used his napkin in lieu of a handkerchief before his affliction, or that he did not do it to annoy, rebuke and chagrin those who, should have given him a handkerchief. [In the next lecture we will conclude the record of this subject.] CHAPTER XXXIV. PSYCHOLOGICAL ANALYSIS OF THE BEVIN CASE CONCLUDED. None of these acts indicated mental incapacity on the part of Bevin. Another medical gentleman of large practical experience with the insane, no less eminent in psychiatry be- fore the courts and in my own esteem, concurred with me in the opinion that these acts occurring before the signing of the deed — some of them, as the bowing to pictures, etc., within a month or two — did not indicate sufficient mental impairment to disqualify him for a full appreciation of the nature, quality and purport of the transaction. In this case, 1 think, there was mental impairment only to the extent of a crippled power of speech expression. There •was impairment of executive (not reflective) mental power to such a degree as to incapacitate the individual from profitably engaging in the pursuit of his avocation, after he had fin- ished up the business which occupied him before his affliction. Mr. Bevin seemed himself cognizant of this fact, and conducted himself after his affliction strictly in har- mony with his surroundings, till his death. He learned to write his name with his left hand, attached his signature to an important document, as it was necessary for him to do in order to complete the undertaking he had been en- gaged in, and after that signed no more documents, nor at- tended in person to any business, but relied on the proxy [400] 401 of his next friend. He knew he was disabled for business by his incapacity to properly express himself and use his mind as he should, just as a man with a sprain or broken limb refrains from walking or a business that requires sprinting, and this knowledge and this fact and his actions in conformity thereto, are proofs of his sanity. Let us look at his acts and see how far they tend to establish insanity. In the first place they are limited in number, not a single habitual action appears in his history that is at all singular. He defecated once in bed at the time it is testified by his family physician that he was first paralysed. (This was certainly an accident due to his paralyzed condition at a time when no one was present to assist him, and not the result of mania. This accident was not repeated.) No one was present at the time it occurred. Maniacs have often filthy habits long continued. Accidental occurrences of this kind are seldom, if ever observed. (De- ments often and habitually defecate in bed or in their clothes, unless specially attended to.) The spitting in his plate once or twice before he had learned to so co-ordinate the damaged muscles of oral expulsion, or to adapt his position at the table to the changed circumstances of disease, was due to the facial paralysis rather than insanity. Then as to his irritability. Recovering paralytics and aphasics are often irritable, and not very reasonable at all times when irritated. They can not make their many wants understood, and while they understand themselves well, can not well understand why those about them do not compre- hend their gestures and grimaces more readily. That he should once strike his mother, under such circumstances, does not then appear as an act of insanity. He was at first an irritable, childish paralytic, but gradually improved, and never struck her again. He did not attempt to 402 strike her alter he had sufficiently recovered to write his name with his left hand. He never attempted to strike anyone then. In regard to the bowing to pictures which he had not seen since he was stricken and carried to his bedroom a helpless paralytic, it would have been more singular if he had not, when taken into the parlor, the first time since his affliction, have sought to indicate in some way to his friends that he recognized the objects about him. This act showed an appreciation of his condition not common to in- sane people, and a desire to impress the fact of his mental improvement upon those about him, jusi as he did the frequent calling for paper or slate and pencil, writing his name, and showing them to visitors with manifestations of pleasure on his countenance, even though "his smile looked silly." If he smiled at all it must have been a silly looking smile, by reason of his physical facial disabil- ity. How could a hemiplegic face put on a beautiful or in- telligent looking smile? If, smiling, or in mental repose, his face had even habitually shown the risus sardoriicus, this would not have proven him mad. The making of grimaces before the glass, and pulling out his hair once or twice, does not show an insane motive. A desire to discover to himself the degree of muscular facial paralysis would not have unreasonably led him to view him- self thus in a mirror, and move the muscles of his face, and chagrin at the disagreeable revelations reflected, might lead, without the concurrence of insanity, to the pulling out of some hair. It does not appear that he pulled out much hair, or that he often repeated the operation. I have seen the insane pluck out every hair of the head, and repeat the process, allowing no single hair to remain. It is unusual for an insane person to pull once or twice at his hair and 403 never repeat the operation, whereas, the plucking of the hair to baldness is common. It is not common for an in- sane person to go to the mirror for the purpose of plucking out the hair, and going to a mirror for the purpose of making grimaces is certainly an anomaly among the in- sane. There is too much of rational motive in all of these acts for insanity. Bevin desired to see how he looked. And this was Bevin's motive. He wanted to see how he looked, and what muscles of his face were, still paralyzed. This would be only a rational proceeding on the part of any man con- valescing from a paralytic stroke, which had involved, and still to some extent, implicated his face. It is possible that insane persons, under the dominion of a delusion, might go before a glass and pull at their hair, though not usual, but no delusion appears in this case, in this connection, or in any other during the progress of this case. Laying aside the reasonable presumption made by one of the attorneys, that the testimony to the outrageous and indecorous acts detailed, was the prejudiced evidence of in- terested relatives, enjoying the property placed in jeopardy by the suit, I did not believe this man to be non compos mentis for the transaction in which he was concerned, be- cause: First. The paralysis alone was sufficient to account for most of his acts, his improvement and gradual recovery for the remainder; he now being sound in mind and able to go about with no affliction save the aphasia. Second. Because the lesion was one primarily and finally involving but a portion of one hemisphere of the brain and that mainly the speech area. Atrophy or destruc- tion of a whole hemisphere, especially if gradually brought about, not even necessitating mental disease, the sound hemisphere being capable of vicariously supplementing the 404 one diseased , in the performance of the mental functions. 77//'/;/. The gray matter, even on the affected side, seems not to have been greatly involved at any time, as shown in the absence of incoherence, delirium, delusion, illusion or hallucination, during the whole progress of the ease, and retention of memory, and ability to learn, for a purpose, to write his own name with his left hand, in a few months after the stroke. Fourth. With the absence of incoherence, delirium, etc., there was marked involvement of the face and extrem- ities, absence of muscular twitchings in the limbs, and of rigidity of the neck and of other parts of the body, which usually accompany paralytic lesions involving also more ex- tensive portions of the brain than the Sylvian fissure area. The lesion was mainly an obstruction of the left middle cerebral artery at the base of the brain, as revealed by the aphasia and gradual coming on of the paralytic attack. Fifth. The nature of the lesion with the part of the brain mainly implicated in the case, (the insular and Broca center) extending at first up the Rolandic fissure area, but later subsiding so that he could walk about unaided, is one from which persistent intellectul aberration seldom results. Sixth. I may add since this article originally ap- peared, because of the fact that the primary lesion was a rheumatic embolism. Lastly. For a reason which some may not deem of any weight, namely, because that portion of the brain which has to do, in all probability, with the highest intellection, are the posterior lobes of the cerebrum, and they are not nourished by the artery mainly concerned in the lesion be- fore us; "a conclusion which, however contrary it may be to generally received opinion," to use the language of Charlton Bastian, "has been strengthened by observations 405 made independently in different directions, and by different persons. It seems to agree, moreover, with clinical and pa- thological evidence,"* Dr. Hughlings Jackson and other au- thorities on the subject of brain disease agreeing with him. The above expert opinion and report was, with a few interlineations, marked in brackets, given and made in 1879, while Bevin was still living in the healthy enjoyment of ordinary intellection, all except the oral aphasia. The examination of this case was made, as you will note, over a quarter of a century ago, when 1 had less knowledge of aphasia and its many forms than has been discovered since, or than the world knew. Although clinically it was known to Benjamin Rush and even to Hippocrates, prob- ably, it was only as late as 1861 that those distinguished lights in French medicine, Messieurs Gratiolet, Aubertin and Broca were disputing its location as maintained by Bouil- laud, in the anterior lobes, before the Anthropological Society of Paris, and only a short time before that that the Daxes were contending for a place for it in the fore- brain frontal lobes. This memorable year of 1861, memorable in France for science, in our Own country for war, M. Broca announced his conversion, after a famous autopsy performed by him- self, to the third frontal lobe theory of the younger Dax, and in his conviction further circumscribing the location of aphasia to that portion of the third frontal convolution, that now bears his immortal name. Apropos of our subject, are some observations on cerebral thermometry in aphasia. Before the Paris Academy of Medi- icine, December 30th, 1897, M. Broca** made the following remarks upon local cerebral temperatures: Finally, in cere- bral affections, in aphasia and the paralysis which may be *Bastian on Paralysis, from Brain Disease, p. 239. ** Gazette des Hopitaux, January 3d, 1880. 406 caused either by an embolus in the Sylvian artery or by an acute or chronic encephalitis of the cerebral region which surrounds that artery, the employment of a thermometer permits a diagnosis which the identity of the symptoms would render otherwise almost impossible. In fact, in case of em bol us of the Sylvian artery, the temperature which is found lowered in the temporal region, is found, on the contrary, quite notably increased at the frontal region, and sometimes even also a little at the occipital region. This depends upon the fact, that the re-establishment of the circulation in the region which ceases to be supplied by the Sylvian artery takes place, principally, by the anas- tomoses of this artery with the vessels which nourish the anterior part of the frontal lobe, and, in proportion, much less by the posterior anastomoses of the Sylvian. In the cerebral softening by encephalitis, we observe something analogous. If the encephalitis is acute, the temper- ature is notably increased in all the part affected; if the encephalitis is chronic, the differences are less appreciable, but always of the same kind. Encephalitis is not susceptible generally of being treated by surgical means. There is, however, one case where the surgeon may be called upon to interfere, and with great advantage; it is when following a depression of the cranium, some bony fragments, irritating the cerebral substance, produces sometimes long after the injury, such accidents as symptomatic epilepsy, etc. If then the tre- phine is applied, the epilepsy ceases, once the cause has been removed. In such a case we find that the tempera- ture is elevated at the point where it is best to apply the trephine. M. Broca used an ordinary thermometer in making these researches, covering over the bulb with a sort of hood and waiting till the column became stationary. CHAPTER XXXV. THE NEURAL AND PSYCHO-NEURAL ASPECTS OF SURGICAL PRACTICE. Surgeons have long known the significance of knee pain in hip-joint disease through neural knee-joint connec- tion. The importance of the nervous system in its relation to surgical diagnosis had a forceful exemplification in the case of the lamented President Garfield when that persis- tent pain in his toe and foot, which the distinguished pa- tient complained of, was spoken of daily by him, without due notice being taken thereof by his surgeons, as refer- ring (which it did) to its source of anatomic irritation in the lower lumbo-sacral spine, where a vertebral injury was discovered post-mortem, as having been in the track of the assassin's fatal bullet. (Tarsal branches, anterior tibial; branch of the external popliteal; branch of sciatic, origin of sciatic (great) lumbo-sacral spine, sacral plexus, 1st, 2d, 3d and 4th lumbar; 1st, 2d and 3d sacral) That great operation on the nervous system, trigeminal gangliectomy, for which Spiller and Frazier now propose division of the sensory root within the cranium for tic doloureux, as a substitute for all other operations on the Gasserian ganglion, reminds us also how closely in touch are neurology and surgery, and the latter improved results, according to Krause and Carson's records for Gasserian ganglion excis- ion, show the conjoined benefits of improved surgical technic * L407] 40S and advanced neurotherapy. The screening of the eye alone Joes much more to save the central nervous system than the external eye alone. LUMBAR PUNCTURE AS AN ANAESTHETIC. I have seen this cocain spinal injection substitute aether and chloroform obtunding pain but not consciousness, both in this country and abroad. It is now done from the Atlantic to the Pacific. I saw Winslow Anderson and his able col- league do it in San Francisco, the patient looking on com- placently at her own laparotomy. TUFFIER'S LUMBAR PUNCTURE IN SURGICAL DIAGNOSIS AND PROGNOSIS. Tuffier's remarkable lumbar punctures have developed much more than therapeutic significance. TufFier himself gives the operation diagnostic significance in an article in the Bulletin and Memoirs of the Society of Surgery last year (No. 27), suggesting that subarachnoid effusion of blood mingling with the drawn cerebro-spinal lymph meant internal spinal fracture. Here is a diagnostic procedure of importance in obscure fracture of the vertebrae, with pos- sible greater internal than external damage to the integrity of the spinal canal and the important nervous structures and vital centers of sensation, motion and visceral function which this neural bony conduit encases and protects. Suppose lumbar puncture had been in vogue in sur- gery at the time of President Garfield's fatal wounding and employed in that remarkable case, i. e., provided that President Garfield had had for his medical counsel a really advanced expert surgeon, at the beginning of his wounding, 409 in full rapport with the present wonderful resources of neurology and surgery in diagnosis? As it was, President Garfield had, at the commencement of that fatal case, the counsel of a medical politician, more noted for his political pull than his surgical skill, and famed chiefly as the advo- cate and promoter of the now exploded Condurango cancer cure, that was then working marvels in the daily press, like the oil wells, some of the gold mines and turf ex- changes of the present day, and medical and other fakes advertised in the newspapers of our day. Lumbar puncture for diagnostic purposes is a procedure for the later stages of suspected spinal injury, either of the meninges, the cord proper, or the bony canal, after giv- ing the effused blood, which is likely to be small in quan- tity in the beginning, time to accumulate and stain the cerebro-spinal fluid. In estimating the value of this new lumbar puncture sign the same principles would apply to it as elsewhere, viz., the extent and degree of hemorrhagic dis- coloration. This sign might also prove useful as one ele- ment in the prognosis of the possible after effects to the cord; those sequences of concussion and molecular injury to the cord, which cause so much trouble to corporations and so much real, as well as litiga- tion, distress to victims of spinal injury concussion and cerebro-psychic shock and cause the clashing of victim and company, of neurologist and surgeon in the courts. LUMBAR PUNCTURE AND NEURO- OR CYTO-D1AGNOSIS GENERALLY. The lumbar puncture needle promises to be of as much service to the near and new oncoming neurology and surgery as the ophthalmoscope, microscope or the re- agents of chemistry have been and now are. Neuro- 410 surgical diagnosis and prognosis are even now receiving new impetus from them in main- directions. Recently be- fore the Medical Society of the Paris Hospitals, many wonderful and valuable reports have been made of this method of cyto-diagnosis, beginning in October, 1900, with the reports of Widal and Sicard and Ravaut, his assistants, to whose work the Philadelphia Medical Journal refers editorially with well -deserved commendation. Since the first communication of Widal a flood of reports confirming the value of this method of cyto-diagnosis have appeared in the literature of clinical neurology and general medicine. Monod, as this wide-awake periodical notes, last year, in Paris, examined the' cerebro-spinal fluid of fifty nervous patients, finding leucocytosis in locomotor ataxia and general paralysis, finding nothing significant in alcoholism, hysteria, hemiplegia or neuritis. Chauffard, Boinet, Rabaud, (same source as above, viz., Bulletins and Memoirs of the Medical Society of the Paris Hospitals for last year) confirmed the findings of Widal and his assistants in tabes and general paralysis. Many interesting showings were made by examinations of the fluid too lengthy for detail here, among them Nageottes' finding that in syphilitic meningo-myelitis mononuclear leucocytes predominating in the cerebro-spinal fluid, while in the non-specific cases the majority of the cellular ele- ments are polynuclear. The cerebro-spinal fluid was found normal in hemiplegia, brain tumor, etc. In tubercular meningitis, lumbar puncture showed increasing lymphocytes and low osmic tension, while this cerebro-spinal fluid in- jected into rabbits caused tuberculosis. Here is an important feature in which surgery may assure itself as to the state of the meninges after surgical operations and of the existence or non-existence of tuber- 411 culosis, perhaps of the central nervous system, when spinal puncture is used for anesthesia. The cerebro-spinal fluid after this operation should in- variably be saved and microcytologically examined. The number of leucocytes should be examined and counted. Laubry (same source) reported a case of supposed tu- bercular meningitis disproved by this form of cytodiag- nosis, where autopsy showed cerebellar tumor. This work is still going on actively in France. American surgery should take it up, and keep it up, until the new mine of diagnostic wealth shall have been worked out. In miner's parlance there is undoubtedly ''rich pay dirt here," for clinical surgery as well as for neurology. IDIOTROPHIC AFFINITIES AND REACTIONS OF NEURONES. The central neurones have their special nutritional or idiotrophic affinities appropriating what they need from the blood current for their nutrition, which means their growth, life and function and selecting their own peculiar manner of response to psychic, peripheral and toxic impression as we see in the phenomea of the reflexes of the brain and cord, the pupil reflex and the knee reflex for instance, the psycho -motor movements of a convulsion, the opisthotonos of spinal meningitis and tetanus, the tremors of sclerosis and paralysis agitans, the altered brain workings of convul- sive tic, of trigeminal neuralgia, etc. The physiology of the five or more senses is based on this peculiar reaction of central neurones to peripheral or central impression. They select their own special im- pressions of smell, taste, touch, sound, weight, etc. The knee kicks up, the foot jerks down, the chest expands, the gullet contracts downward, the bronchi and diaphragm con- 412 tract so as to throw air and mucus upward, as in coughing, when their special centers are set into retlex action by per- ipheral excitation, so we also have the phenomena of fecal and urinary expulsion, peristalsis, etc., etc. The irido or iris retlex is a true idio-retlex. There is no other like it. It contracts to light and to certain drugs like eserin, and expands to darkness, atropin, cocain and other mydriatics, ldiotrophic means, strictly speaking, from its derivation (when applied to a neurone or group of neu- rones making a nerve center), a peculiarity of nutrition or selection of its nutrition. But we extend its signification. The selective affinities of certain centers of the brain or cord for anesthetic, motor or sensory impression or what has been called the selective affinities of drugs which are idiotrophies of the neurones, is a subject to thoroughly consider, and their psychic impressibility in surgical practice. Barker, whose book is the bible of modern American neurology, as Nissl, van Gehuchten, Lenhossek, Cajal, and others are abroad, and, in fact, of the mundane neurology of our day, for in it are the sayings of the wisest and best sages and apostles of our faith, concerning the doc- trine of the neurones, following a well- merited defense of Johannes Mueller, who gave to neurologic science the "doctrine of the specific energies of nerves," says "it has been left for the neurone doctrine to explain, if it can, why it is that on stimulation of the retina or of the optic nerve, for example, the response always occurs in one and the same manner; no matter whether the stimulation be by normal methods or by mechanical or electrical means, the sensation of light or of color alone is yielded; or how it happens that when a cold point on the skin is stimu- lated, whether it be with ice, the prick of a sharp tooth pick, an electric current, or a piece of hot wire (cold point 413 paradoxical reaction of von Frey), the sensation of cold always results. The constancy of the quality of the reaction, despite the variability in the form of the external stimulus, is one of the most puzzling of the phenomena with which the neurologist has to deal." To me this does not seem so puzzling in view of the idio- trophic properties of the neurone as 1 here use the term. Though Barker still considers the question as obscure and refers to well-known pathologic cases in which direct irri- tation of certain areas of the cortex "has called forth definite sense perceptions, as evidence that these sense perceptions speak for direct relation of these bodies to the specific energies of the sensory nerves." The explanation is in that wonderful individuality of the neurone, to which 1 have already referred as the crowning cap sheaf cytolo- gical discovery of the nineteenth century making the name of Ramon y Cajal immortal. The idiotrophic property of the neurone unit explains why "odors, images of colored objects, memories of muscular movements, and of sounds have been experienced by individuals suffering from the pressure of cysts and other bodies upon the corresponding cortical sense areas," and why normal sensations reappear in nerve centers when limbs are removed, and why memo- ries of impression, psychic or physical, persist. We need but subject the matter to the test of reason. It appears as an axiomatic truth of the new cytology, that the neurone has this property, as the character and proof of its indi- viduality as distinctive and individual as the selection of its own reconstructive nutrition; which is as distinctive as its chromophile and achromatic properties. CHAPTER XXXVI. THE NUTRITION AND CONSERVATION OF THE NEURONES, OR NEURO- AND PSYCHO-NEUROTHERAPY IN SURGERY. The popular misconception of the surgeon is that he is only a cutter. This misconception extends often to the surgeon himself, and it is not always confined to junior surgeons, who might be excused for knowing no better. In consequence, there sometimes develops in the surgical mind a flippant skeptical treatment of the resources of medicine, especially of the wonderful modern neurotheraphy. The popular misconception about the neurologist is that he is fitted to treat only nervousness and the neuroses of hypochrondria, neurasthenia and the imagination, and to fool with a lot of chronic maladies of the cerebro-spinal axis and peripheral nervous system, requiring more time and patience than the average surgeon has to devote to them. But 1 tell you as a medical man of once extensive surgical practice, that neurology and neuriatry are fundamental in medicine and surgical practice, and they cannot be longer ignored in either clinical medicine nor in the most possibly successful clinical surgery. It is the surgeon who treats the whole patient, neuriatrically and psychiatrically and otherwise therapeutically, up to the advancing modern standard, who will carry the greater trophies of recovery in his warrior belt, as the conqueror of disease. [414] 415 There is a psychic and neural and psycho-neural anti- sepsis, as well as, and no less valuable, as affecting prog- nosis, than the antisepsis of the vascular and absorbent systems, which have made Lister and many of his follow- ers immortal and enabled modern surgery to invade and rescue victims of disease from the very grasp of death. Added to Listerism and the dauntless skill of its world ap- plauded votaries in your illustrious ranks, comes now mod- ern neuro-therapy that enables disease's prostrate and im- prisoned victims to hold out through judicious cytological reinforcement, till the new and conquering surgery accom- plishes its saving work and rebuilds and restores the assaulted central neurones. THE PSYCHIATRIC FACTOR IN SURGERY Consists in conserving the integrity of the psycho-neurones by withholding from the patient and avoiding both during and after the surgical operation, everything that may tend to lower mental or physical vitality. To this end blunt an- nouncement of an operation intended and abrupt statement of possible doubtful prognosis, the needless display of the sur- gical tray and the prelude preparations and discussion of the intended procedure by nurses, except under the specific, de- tailed directions of the surgeon, should be avoided.* The employment of anesthesia in our day has saved patients intended for the operating table much psychic *The little surgeon who pompously displays his tray of instrument before his tremb- ling patient and to his woeful wondering mind decants upon the operation he is about to per- form, and the chances of recovery, or displays a nonchalant unfeeling mien, acts unwisely and does not increase his patient's chances of getting well quickly. And the great surgeon who takes his patient into the operating room and places him while conscious on the table, himself with instruments in hand, while white aproned attend- ants gather around the victim, approaching with sponge and bottle and instruments and ap- pliances of the impending operative procedure, is not so wise a surgeon, and does not so fully consider the effect of depressing psychical influences as he who chloroforms the intend- ed subject of an operation in another room or in the same room without these depressingly suggestive influences.— Alienist and Neurologist, Oct., 1S96. 416 shock they did not escape in the past. If to this should be added the anesthetizing of the patient in a cheerful flower decked, gratefully odored room, without any appear- ances of the coming bloody ordeal, and the patient wheeled into the operating room while anesthetically unconscious, psychic conditions of restive recuperative central nerve tone would be enhanced. PSYCHICAL DEPRESSION AND THE NEUROPATHIC DIA- THESIS. As a sound neuro-surgical aphorism I should say, from the standpoint of a broad experience, avoid all sources of psychic depression and consider well the nervous system of your patient before and after every operation. There are some constitutions so neuropathic and psychopathically pre- disposed that the shock of such an announcement would precipitate a crisis of mental alienation and it were better that the proposed operation should be abandoned than in- sisted upon under such circumstances, or that the patient should be gradually approached and prepared by cautious speech and suitable precursory reconstructive and tranquil - izing neurological treatment. Many of the post- operative insanities and neuroses result from awakening into active life the psycho- neuropathic diatheses and might not result in neurotically well prepared or psycho- neurotically well en- dowed nervous organisms. And these, gentlemen, are the victories of modem sur- gery: A skilled technic never before equaled. Anesthesia, general, peripheral and spinal; antisepsis, cytotherapy. And the honors are even, for anesthesia and cytotherapy are ours. Antisepsis and the new operative technic are yours. Fortunately for mankind these advances are all in one 417 family and that family is one for the weal of a suffering world. POST-OPERATIVE INSANITY. As a suitable addendum to this chapter, let me here quote one of my editorial criticisms from the Alienist and Neurologist of October, 1901: A St. Louis surgeon having performed an enterorrhaphy with acute mania without sepsis as a sequel gives this as a rule which he declares has been adopted by most surgeons, viz: Under no circum- stances ought any insane woman to be operated upon unless for some distinct condition that is compromising life. This is not as a rule based on clinical knowledge, with those who have done their own surgery in a hospital for the insane or have advised surgical procedures on the in- sane. Psychiatry looks at the subject differently. A grave surgical disease preceding insanity or supervening a psychosis may be removed unless the proposal to operate and the preparation and operative procedure are in the line of and tend to aggravate the patient's delusions. Rules of therapeutic procedure medical, moral or surgical in psychia- try are out of the range of the average surgeon's clinical experience and he should defer to psychiatric judgment in the premises and not formulate rules purely from the sur- geon's standpoint. The practical alienist might enlighten surgery in some surgical quarters where surgeons walk in darkness and the darkness comprehendeth not. 1 would like to ask if this is the rule adopted by most surgeons? If so it is not a wise one. Sources of physical drain and irritation should be removed, if practicable, from the insane and nervous as well as the sane and nervously well. JIM 2 2 1928