COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00012700 RC3^I DO mti)pCtlpoflmg0rk College of ^Ijpsidang anb ^urgeonjs ILibvavf G-\pt Op Dr. M.A. S+akR Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/textbookofnervou1904dana NERVOUS DISEASES. DANA. in f,g7 n\ #1 I fc MM t %-2. FIG. 1. GIANT CELL, ANTERIOR CENTRAL. FIG. 2. PYRAMIDAL CELL, 3D LAYER INFERIOR PARIETAL. FIGS. 3, 4, 5. SMALL PYRAMIDAL CELLS, 2D LAYER. FIG. 6. SPINDLE CELL, 4TH LAYER. FIG. 7. NEUROGLIA CELL. TEXT-BOOK OF NERVOUS DISEASES AND PSYCHIATRY For the use of Students and Practitioners of Medicine BY CHARLES L. DANA, A.M., M.D. Professor of Nervous Diseases and (ad interim) of Mental Diseases in Cornell University Medical College ; Visiting Physician to Bellevue Hospital ; Neurologist to the Montefiore Hos- pital ; ex-President of the American Neurological Association ; Corresponding Member of the Socif'te de Neurologic, etc. SIXTH REVISED AND ENLARGED EDITION ILLUSTRATED BY TWO HUNDRED AND FORTY-FOUR ENGRAVINGS AND THREE PLATES IN BLACK AND COLORS NEW YORK WILLIAM WOOD AND COMPANY MDCCCCIV Copyright, 1904, by William Wood and Company PREFACE. It is the object of the author in this treatise to present the sci- ence of neurology in a concise yet as far as possible complete form. Each subject has been taken, all the available facts regarding it have been ascertained, the writer's own experience has been col- lated, and with the data thus gathered the chapters have been writ- ten. The labor involved in such a task has been very great, but I am encouraged to believe that the result will be a useful one ; for the work does not compare or compete with the large treatises which are already in the field nor with the smaller introductory text- books. I have tried to furnish a book which will be suitable for the student and practitioner and not valueless to the specialist. The extreme importance of a knowledge of anatomy has led me to pay especial attention to furnishing in a condensed form the most recent accessions to our knowledge of this subject. Starting with the facts that can be gained in ordinary anatomical works, the stu- dent can, I believe, acquire a good idea of modern neuro-anatomy with the help of the anatomical chapters given here. In the classification of nervous diseases and the description of their pathology, I have tried to apply the modern knowledge of general pathology as modified by bacteriology. This I have ilone conservatively, yet not less than in my opinion is absolutely de- manded. A good deal of havoc will be wrought eventually in our conception of the nature of nervous diseases by the newer patho- logical doctrines; I have made as little change as was consonant with undeniable facts. The limits placed upon me have made it imj)ossil)le to fiiniisli a bibliography or to give due credit to every original investigator. Full references to literature are to be found in the works of Hirt, Erb, Seeligmllller, Ross, and Gowers. In many toi)ics I have been nnich licljjed by valuable mono- IV PREFACE. graphs of my American colleagues. While a part of these are credited to their jDroper source in the text, I feel that I ought to refer here to some of the articles that have been of special service to me. They include monographs on Spinal and Brain Tumors by Mills and Lloyd; on Cerebral Palsies of Children by B. Sachs; on Muscular Dystrophies and "Writer's Cramp, by G. W. Jacoby and by M. Lewis ; on Aphasia, Cerebral and S})inal Localizations by M. Allen Starr; on Cranial Temperatures and on Neurasthenia by L. C. Gray; on Degenerative Neuritis, by W. H. Leszynsky; on Po- liomyelitis, by Wharton Sinkler ; on Craniometry and Cranial De- formities, by F. Peterson and by E. D. Fisher; on Angioneurotic CEdema, by Jos. Collins; on Brain Tumors, by P. C. Knapp, and on Sclerosis of the Cord, by J. J. Putnam. I am indebted to Tourette's recent treatise on hysteria, to that of Fere on epilepsy, and to the annual volumes of Bourueville on these subjects. The masterly lectures of Charcot and the treatises of Ross, Gowers, Hammond, Hamilton, and Putzel have necessarily been freely used. In the anatomical part 1 have used the works of Edinger, to Avhose courtesy I am particularly indebted, the treatise of Ober- steiner, and many monographs by Golgi, jVlarchi, Cajal, His, Wal- deyer, and others. My own work in teaching anatomy and pathol- ogy has enabled me to do more than present a compilation. I must finally express my thanks to my publisher, Mr. W. H. S. Wood, for his patience and helpful generosity in my efforts to make my work a production that would be creditable to American neurology. To the Student. As a special text-book the present work will be used by two classes of readers, one consisting of those who simply consult it for reference in connection with their cases, the other composed of stu- dents who desire to ground themselves systematically in a knowl- edge of neurology. To this latter class I venture some advice as •to the method they should pursue. Neurology is a difficult branch of medicine to master, nor is there any royal road to it. Still, it can be made comparatively easy if its study is undertaken in a pro])er and systematic way. In using the present work, the student should first refresh his PREFACE. V general knowledge of nervous anatomy as furnished in ordinary text-books. He should then go carefully over the anatomical de- scriptions here given of the general structure of the nervous system, and of that of the nerves, spinal cord, and brain. A thorough knowledge of anatomy and physiology makes clinical neurology comparatively easy, and in fact reduces much of it simply to a mat- ter of logical deduction. The student shoi;ld next master the general facts of nervous pathology, symptomatology' , and etiology, for he will tind common laws underlying apparently the most varying phenomena. Finally, he must begin to study the special diseases. The number of these is very great; in the present work I have described 17G. Many of these are rare, and it would be wrong for the student to burden his memory with the details about them. He need know only of their existence and general physiognomy. There are, however, accord- ing to my enumeration, about 65 nervous diseases which are either very common or extremely important, and it is these that the stu- dent should master and make part of his working knowledge. Since the distribution and names of the common and rare diseases may be a useful guide, I append here a table and a list : Peripheral. Spinal Cord. Brain. Functional. Totals. Common and important nervous diseases Kare 31 56 13 27 12 16 10 11 65 111 87 40 28 21 176 The common or im])ortant nervous diseases are : General. — Neuritis, multij)le neuritis, degeneration, neuralgia, parsesthesia (5). Cranial Nercrs. — Anosmia, optic neuritis, optic atrophy, ]»tosis, ophthalmoplegia, abducens i)alsy, headache, migraine, trigeminal neuralgia, facial si)asm, facial ]ialsy, tinnitus, vertigo, ageusia, wryneck (Ifi). Spinal Arrmv.— Cervical neuralgia, liiccougli, biadiial jtalsies, single and combined, brachial neuralgia, intercostal neuralgia, herpes zoster, lumbar neuralgia, sciatica, leg jialsies (10). Spinal C'o/y/.— Spina bifida, hemorrliage, i)achymeningitis, lep- Tl PREFACE. tomeningitis, poliomyelitis, transverse myelitis, acute and chronic, secondary degenerations, locomotor ataxia, the progressive muscu- lar atrophies, bulbar palsy, muscular dystrophies, spinal irritation (13). Brain. — Malformations, hypersemia, pachymeningitis, leptomen- ingitis, simple, tuberculous, and epidemic, abscess, hemorrhage, embolism, thrombosis, children's palsies, syphilis (12). Functional. — Epilepsy, hysteria, the tics, chorea, tetanus, neu- rasthenia, spermatorrhoia, exophthalmic goitre, occupation neuro- ses, paralysis agitans (10). PREFACE TO THE SIXTH EDITIOX The present edition contains a description of the i)rint'i])al types of insanity, in which I have followed in general the modern scheme of classification as set forth especially by Kraepelin. While adopt- ing provisionally the term dementia prsecox, it seems probable that the symptom groups now included under this name will have to undergo some modifications. The author's view of melancholia and mania is based on a personal study of a large number of non-asylum as well as asylum cases, and while it differs somewhat from the current scheme, it is not essentially out of harmony with it. I have thought it of especial importance to insist on a distinction between nmjor and minor psychoses, and to emphasize the fact tliat one may have a psychosis and yet not be in any sense insane. In fact I am in sympathy with the view that makes as few people in- sane as possible, of narrowing the conception of major psychoses and enlarging that of the minor. The addition of a cliapter on psychological terms seemed a necessity to an understanding of men- tal symi)toms. The chapters on nervous diseases have been very little changed. Some new cuts have been added and slight corrections in the text made. Perhaps the most important practical addition to iieuroh)gy added since my last edition is that of cyto-diagnosis, and on this I have made some comments. A good deal of tluit which was urigi- nally written under the head of special therapeutics has now become part of general medicine. It has been cut out, and by this means the book has not been much enlarged by the chapters on psychiatry. The writer tpiite appreciates the defects and limitations inci- dent to attempting to present such a subject as psychiatry in a small compass. I have received much help and useful .suggestion from Dr. Flavins I'acker and Dr. (iregory of the psychopathic wards of Belle vue IIos|)ital. New Youk. .hily Hth, U>(U. TABLE OF C0XTE:N'TS. PART I. CHAPTER I. PAGE General Ax atomy, PnYSiOLocy, and Chemistry. General Histol- ogy — Neuronic Architecture of the Kervous System, ... 1 CHAPTER II. The Causes of Nervous Diseases, ... ... 23 CHAPTER III. General Pathology, . .... . . 27 CHAPTER IV. General Symptoms, . . . „ .... 81 CHAPTER V. Diagnosis and 3Ietiiods of Examination. Degeneration — Skull Measurements — Disorders of jNIotility, of Sensation, ... 39 CHAPTER VI. Hygiene, Pkophylaxis, Treatment. Diet — Exercise — Ilydrotlicrapy — ^Massage — Climate — Eleotro-Therapy, 60 CHAPTER VII. General Diseases of the Pekiphkral Nerves. Anatomy — Pathol- ogy — Symptoms — ^lultiple Neuritis — Tumors, .... 78 CHAPTER VIII. Motor Neuroses of Cranial Neuves. Cranial Nerves— The Ocular Nerves — Anatomy — Sym|)toms — Tlie Oplitlialmoplegias — The Spasms— The Fifth Nerve— The Facial Nerve— The Glossopharyn- geal Nerve — The Vagus— The Spinal Accessory — The llypoglossus, 08 CHAPTER IX. Motor Neuroses of the Spinal Nerves. The Upper Cervical— The Lower Cervical and Brachial— The Thoracic— The Lumbar— The Sacral 131 X. CONTEXTS. CHAPTER X. PAGE Sensory Neuroses oi' the Cerebro-Spinal Nerves. Paraesthesia — Neuralgia — Neuroses of the Nerves of Special Seuse — Headache — Tinnitus — Vertigo — Neuroses of the Sensory Spinal Nerves — Vaso- motor and Trophic Neuroses, 153 CHAPTER XI. Diseases of the Spinal Cord. Anatomy and Physiology, , . 208 CHAPTER XII. Diseases of the Spinal Cord. Malformations — Spinal Hemorrhage — The Caisson Disease — Hyperajmia — Anaemia — Meningitis, . . 334 CHAPTER XIII. Myelitis, 249 CHAPTER XIV. Degenerative Diseases. Locomotor Ataxia — Spastic Spinal Paralysis — Combined Scleroses, 270 CHAPTER XV. Progressive Muscular Atrophies, Muscular Dystrophies. Amyo- trophic Lateral Sclerosis — Asthenic Paralysis, .... 308 CHAPTER XVI. Tumors and Cavities of the Spinal Cord. The Recognition of Diseases of the Cauda Equina, 330 CHAPTER XVII. Anatomy ajsv Piiysiology of the Brain, . . . . . • 343 CHAPTER XVIII. Diseases of the Brain. General Symptoms — Irritation — Compression — Hemiplegia — Aphasia — Malformations — Anaemia — Hyperaemia— Meningitis, 385 CHAPTER XIX. Diseases of the Brain. Inflammations — Multiple Sclerosis— The Apoplexies— Infantile Cerebral Palsies, 405 CHAPTER XX. Tumors of the Brain. Syphilis, 445 CONTENTS. Xi CHAPTER XXI. PAGK Functional Nervous Diseases. Epilepsy, 474 CHAPTER XXII. Hysteria. The Tics— 3Iyoc;lonus — Tlionisen's Disease, . . . 487 CHAPTER XXHI. The Acquired Neuroses. Ciiorca — Tetany, 507 CHAPTER XXIV. Neurasthenia. Sexual Neuroses — Traumatic Neuroses — Exophthal- mic Goitre, 519 CHAPTER XXV. The Occupation Neuroses, 551 CHAPTER XXVI. Paralysis Aoitans, 561 CHAPTER XXVII. Trophic and Vasomotor Disorders. Hemiatrophy — Acromegaly — Myxoedema — Cretmism — Angio-neurotic (Pklema 568 CHAPTER XXVIII. The Disorders of Sleep. Insomnia — Hypnotism — Morljid Sonmo- lence — Catalepsy — Trance — Lethargy — The Sleeping Sickness, . 577 CHAPTER XXIX. Cranio-Cerebral Topography, 593 CHAPTER XXX. Neurological Therapeutics, 597 PART ir. CHAPTER I. Definitions, Classification, General ETi<)L<)1 CH.M'IKli n. Genhkal Psychology, ... t'OT XU CONTENTS. CHAPTER III. PAGE General Symptoms and Symptom Groups, 613 CHAPTER IV. Methods of Examination" and Diagnosis, 623 CHAPTER V. General Prognosis and Treatment, 636 CHAPTER VI. The Minor Psychoses and Psycho-Xecroses. Plirenasthcnia, Hys- teria, Hypochondriasis, Hysteria, 638 CHAPTER VII. Dementia Pr.ecox, 636 CHAPTER VIII. Melancholia and Mania, 641 CHAPTER IX. Paranoia 649 CHAPTER X. CoNFusiONAL INSANITY. Plxliaustion, Iiifections, and Toxic Psy- choses, 652 CHAPTER XI. The Organic Psychoses; Gereral Paresis, 657 CHAPTER XII. The Psychoses of Senility. Psychoses of Epilepsy, of Gross Or- ganic Brain Disease, and of Trauma 664 PART I. DISEASES OF THE NERVOUS SYSTEM. CHAPTER I. GENERAL ANATOMY, PHYSIOLOGY. AND CHEMISTRY. Ix studying the phenomena of life in the human Dody, we as physicians first learn about its normal structure and functions. We then note the new phenomena which develop when disease comes on, the causes which produce them, and the anatomical changes lying back of them; we group our facts and give the disease a name. Lastly we apply the methods by which the disorder can be expelled and future attacks prevented. In fine, we investigate our subject just as we do that of any branch of natural history. Our study divides itself, therefore, into Normal anatomy and physiology. Etiology, a study of the causes. Symptomatology, a study of the morbid phenomena. Pathology, under which we include a study of the morbid anat- omy and physiology. Diagnosis, or the method of recognizing and separating out the iifferent groups of diseases. Prognosis, a forecast of the future course of the malady. Treatment and prophylaxis. Again, althov-^h nervous diseases show many phases and have many different morbid clumges behind them, there are certain fea- tures common to all. It simplifies their study, therefore, to learn lirst what these general features are, just as a person can better sur- vey and plot out country in detail if he knows certain general facts about its boundaries and topograi)hy. Ilenct; I shall first present in a general way an outline of the fundamental facts that touch more or less on all forms of nervous disease. My first chapters will DISEASES OF THE XEKVOUS SYSTEM. be devoted to a geueral descriptiou of the anatomy and physiology, and then ol the etiology, symptomatology, pathology, diagnosis, prognosis, and treatment. GENERAL ANATOMY. The nervous system is derived from the epiblastic laj'er of the developing ovum, and its constituents are modifications of epithelial cells. These cells in the embryo are of two kinds : neuroblasts, which develop into nerve cells and fibres ; and spongioblasts, which develop into a supporting structure called neuroglia (His). The nervous system is composed of: (a) Neurons, which form the nervous tissue proper, and are made up of nerve cells, of their processes, one of which becomes a nerve fibre; and nenroglia. (h) Non -nervous tissue, consisting of connective tissue, blood-vessels, lymphatics, and epithelium. These tissues are united together to form a cen- tral nervous system, consisting of the brain, spinal cord, and the peripheral nervous system. This latter is composed of nerve fibres, and structures attached to the terminations of the nerves, called and finally the ganglionic or sympathetic nervous Fig. 1 end-organs, system. The An'angement of the Nercoiis System. — The subdivisions of these parts, and their descriptions in detail, belong to gen- eral anatomy. But there have been so many special subdivisions, and particular names given to them in recent years, that I deem it FiG. 2. necessary, in order to prevent confusion, to describe briefly the subdivisions accepted by modern anatomists. The names here used GENERAL AXATOMY, PHYSIOLOGY, AND CHEMISTRY. are those adopted by the committee on anatomical nomenclature of the German Anatomical Society, and they have also been adoptea by a large number of writers ou neuro-anatora} . Beginning with the brain, we find that its particular subdivisions are based upon the embryological development of this organ. As will be shown in more detail later, the brain is developed out of three vesicles, known as the anterior, middle, and posterior vesicles (Fig. 1). The most anterior of these vesicles is the ^:>?'ost'«ce/^/taZo« or anterior brain ; the middle vesicle becomes the weseneephahni or inid-hrain, and the posterior vesicle develops into thQ rltombencejjha- Ion ov piosterior brain. Brain. fProsenceplialon ! (anterior brain). I' and I- Mesencephalon (middle brain). II Rhombencephalon (posterior brain). Ill and IV ^ 1. Telencephalon. ( 2. Diencepbalon. ■{ 3. Mesencephalon 4. Isthmus. 5. Metencephalon, 6. Myelencephalon. The anterior vesicle develops two secondary vesicles: the an terior portion of these, including the corpora striata, olfactory lobes, and the cerebral hemispheres, forms the telencep]ialon,V while the hinder portion of this vesicle, which includes the thalamus and mammary bodies, ioima the die ncf^p/talon (1'). The middle vesicle i.>; the nie.sena-jjhulon, and it includes the corpora quadrigemiua and cerebral peduncles (II). The posterior vesicle is divided, from before backward, into three different parts: (1) the isthmus, which in- cludes the superior cerebellar peduncles and valve of Vieussens, and jjart of the cerebral peduncles; (2) the metenceplialon or /rind-brain. which includes the cerebrum and ]K)ns Varolii; and (o) the myelen. i-cphalon or after-brain, which includes the medulla oblongata. These different parts can be understood better by means of the .i.companying figure (Fig. 2), which represents in a schematic way the brain of a mammal (Edinger). They are intimately connected by strands of nerve fibres, and are connected closely also with the next portion of the nervous system, the spinal cord. The brain and spinal cord are spoki'u of as a cerebro-spinal axis, and this is in close relation with the p«n'ii)heral nervous system. This peripheral nervous system is composed of two portions — first, the cerebrij-spinal mixed nerves, whose origin, distribution, and relations are comitaratively easy to follow; and s('coniissl or chromo- Madri.i, ison. p. 121. fkt. 37.) pliilic granules. These form the cliromatic svibstance of the cell. W'liile most nerve cells have these granules, some, such as the granule cells of the cere- bellum, do not. Tlie nerve cells which do stain and have the chromophilic granules an^ called sonuitochronies, the others are *Tln"s view is now (Iciiicd by ccrtaiii suillinrilics, and liicrc is no doultt that ill some of tiic lower aiiinials liliriis from tiic eii(l-l)nisiies of one neuron pass into the dendrites of anotlier ami Ihenee tliroui^h tiie body of tiie<-ell into its iieuraxon. But tlioiiirii tlw-re may l)e this analoniieal unity, the ge- netic and pliysiological independence of tlie neurons still continues to be a fact. DISEASES OF THE NERVOUS SYSTEM. Fig. 6a.— Examples of a Variety of Nerve-Cell Nuclei. (After Ram6n y Cajal, S., " Textura del sistema nervioso," Madrid, 1899, p. 134, Fig. 4:!.) called karyocliromes (ISTissl). The chromophilic granules are ar- ranged differently in cells of different function. They are be- lieved to represent the nutrient substance of the cell, while the fibrilke form the conducting and functioning part (Fig. 5 and plate). The cell body usually contains a little pigment (Fig. 6). The nucleus of the cell is a small s})herieal body, which is also made up of a reticulated structure known as the ch romat in network, because of its taking up dyes and staining very intensely (Fig, (Ja). Besides this net- y\ /^J>fr^ work, however, there is a finer network, which J >v;x_p>r \;j^'/k^ ^^ similar to that rj j) £ in the body of the cell, and which is known as the linin net- work. The chro- matin is practically identical with nuclein. Within the nucleus is a smaller body, known as the nucleolus, which stains still more in- tensely. Nerve cells are surrounded by a i)ericellular space, but are not inclosed in capsules, excepting those of the posterior spinal and vertebral ganglia. Central Nerve Cells. — There are three kinds of central nerve cells, that is, cells lying in the brain and cord, and they are classi- fied in accordance with the peculiarities of the axis cylinders (neu- raxoiis) into : 1. Cells of the first type, or cells of Deiter. These are the kind just described above, and they form the great mass of nerve cells. The neuraxou is continued as a nerve fibre (Fig. o). 2. Cells of the second type, or cells of Golgi. In these the axis cylinder soon gives off numerous collaterals and quickly splits into a number of fine branches. Kone of these branches ends in be- coming a nerve fibre and none travels far from the cell body (Fig. 4). 3. Cells of the third type, cells of Cajal. In these there are two or more neuraxoiis. They are found in the superficial layer of the cerebral cortex. Peripheral Nerve Cells. — The cells of the peripheral nervous system resemble fundamentally the central nerve cells, but undergo some changes in order to adapt themselves to their peculiar func- tions. Thus the cells of the posterior spinal ganglia have quite peculiar anatomical characters. They are rather large in size, being from 29 to 60 ,a {-^^^-^ to -^-^ inch). They are spheroidal in shape and GENERAL ANATOMY, PHYSIOLOGY, AND CHEMISTRY, 9 have one process, which speedily divides in two, in a T-shaped fashion. Tliey are surrounded by an endothelial sheath, which is analogous to the myelin sheatli of the nerve hbre. The cells have one large nucleus with a nucleolus. The body is composed of short granular fibres, which are arranged in a somewhat concentric layer.* Tlie nerve cells of the sympathetic or vertebral ganglia are veij' like the central nerve cells in the anterior horns. They are multi- polar in shape and have dendrites and a neuraxon. The neuraxon goes to other neighboring cells, or it passes on and becomes a fibre of Kemak. The cell is surrounded by a connective-tissue capsule lined with endothelium, like those of the posterior spinal ganglia. The peripheral or terminal sympathetic nerve cells l^'ing in the viscera resemble those of the vertebral ganglia. The cells of the special sense organs have many peculiarities of shape and structure, Fio. 7. — From a Tkansverse Section through thk Sciatic Nervk. ep, Eplneurium ; p, perineurium; n. nerve fibres constituting a nerve bundle or fasciculus iu cross-sectiou; /, fat tissue surrounding the nerve (Klein). but they are all developments of the same model. In the retina and olfactory bulb there are cells without axis cylinders (spongio- blasts of Cajal and granules of olfactory bulb). Nerve cells are classified in accordance with their shape and number of processes. The multipolar cell is the common type and is found throughout the brain, cord, and sympathetic ganglia. Hi- polar cells are foimd chiefly in the column of Clark of the spinal cord; and unipolar cells in the posterior spinal ganglia. Small nuclear cells and flask-sliaped or Purkinje's cells are found in the cerebellum. Besides these there are described in the brain cortex angular, granular, pyramidal, globose, and spindle cells. * III the centre of this, in invertebrates and the lower vertchrntes at least, is a body which is called a centrosoinu (Fig. 5), which has probably little im- portance. 10 DISEASES OF THE NERVOUS SYSTEM. The nerve fihkes of the nerve centres are found chiefly in the white tissue or white matter. In the periphery they form the nerve proper of gross anatomy. The per- ipheral nerve is composed of bundles of nerve hbres called nerve fasciculi (Fig. 7). It is surrounded by a con- nective-tissue sheath called the sheath of Henle, or epineurium. From this sheath, connective-tissue fibres pass in and surround the fasciculi. The sheath of the fasciculus is called the perineu- rium. From the perineurium, strands of connective tissue run in among the ultimate nerve fibres, forming the endo- neurium (Fig. 8). Lympliatic spaces lined with endothelium exist in the lay- ers of the peri- and endo-sheaths. In the nerve centres, the iierve fibres have no such sheaths, but are supported by a connective-tissue and neuroglia framework. Tlie nerve fibre is a long fine strand of tissue varying in diameter. Fig. 8.— a Simple FcxicrLis More HKiHLv Magnified. The apparent small nueleated cells are sections of the nerve fibres anil their axis cylinders, a. Axis cylinder; n\ white substance of Schwann or medullary substance : 71. neurilemma; c. endoneurium ; p, perineurium ; h, connective-tis- sue cells of the same. (Piersol.) Fig. 9. Fig. 10. Fig. 11. Fig. 9.— Medullated Nerve Fibre, a. Axis cylinder; n, nuoleus; m, medullary sheath; c, node of Ranvier. Fig. 10.— Medullated Nerve Fibre, showing axis cylinder, nuclei of medullary sheath nodes, and oblique incisures of Schmidt. Fig. U.— Medullated Nerve Fibre, showing mod* of division. GEXERAL AXATOifY, I'FYSIOLOGY, AND CHEMISTRY. 11 It may be white or gray, according to its structure. It is composed from within out of (1) an axis cylinder, (2) a myelin sheath, and (3) a neurilemma. (1) The axis cyHnder is the essential part of the nerve. It is the prolongation of the neuraxon of a nerve cell and consists of protoplasm. It is itself made up of tine fibrillae (primitive fibrillae) which run longitudinally. By means of re- agents, a transverse striation can be seen also. {2) The raijelin sJn^ath, medullar ij sheath, or sheath of Schwann, surrounds the axis cylinder. It is composed of a semifluid, fatty substance, which chemically consists of lecithin, neurin, and some cholesterin. It varies much in thickness, and this is the principal cause of the different sizes of nerves. The myelin sheath is interrupted at reg- ular intervals b}' constrictions called the " nodes of Ranvier. " These constrictions involve the myelin sheath alone. The axis cylinder passes through and the outer sheath (neurilemma) passes over it. There is a little granular matter at the point, called intercellular cement. The nerve fibres, if they divide, always do so at a node (Fig. 11). The part between two nodes is called a nerve segment. In each segment there is an oval nucleus embedded in the myelin sheath. The nodes are about 1 mm. apart. The myelin sheath is probably developed, like the axis cylinder, from the epiblast, and is closely related nutritionally to the axis cylinder, which it protects and isolates.* (3) The nevrilemma or primitive sheath is a delicate homogeneous covering forming the outermost sheath of the nerve. It is of connective-tissue origin. The sheath is absent in the fibres of the central nervous system and in some fibres of the periphery. Variations in the Tupes of Fibres. — In accordance with the ar- rangement of the sheaths of the nerve fibres, several kinds are described. The principal types are the medullated and non-medul- la ted. Medullated nerve fibres make up the bulk of the white matter of the brain and cord and cercbro-spinal nerves. They consist of a myelin sheath and axis cylinder, and may or may not have a neu- rih'mma. Fibres with myelin sheath, but without a neurilemma, make up the white matter of the central nervous system. Snn-medidhited fibres, or fibres of Remak, occur principally in the sympathetic system, but they are also found in the cerebro- * Uciwccii it Mild tlie axis cylinder ^laiitliner describes a membranous slicuth (axis-cylindrr slieath). Another sheath is said to be between it and tlic neiirih'iiinia (incdiillary sheath) . By means of certain reagents, oblique lines (incisures of Schmidt) or a rcticuhir appearance may be developed (net- work of Gedveist). These appearances are, perhaps, artificial. 12 DISEASES OF THE XERVOUS SYSTEM. spinal nerves. They are grayish and faintly striated, and consist of axis cylinders, with a thin, homogeneous, nucleated sheath lying directly upon them. This sheath, however, cannot often be demon- strated (Schaefer). Naked axis cylinders are found in the peripheral terminations of nerves as well as in the braiti and cord. Size. — The nerve fibres are of two kinds as regards size. The Fig. 13. Fig. 12.— NoN-MEDULLATED Nerve Fibre, n. Nucleus; b, striations. Fig. 18. — Diagram showing the Neuron and Mode op Connection between Nkrvb Units throughout the Nervous System. 1, Nerve cell; 2, nervous process; 8, col- lateral; 4, end brush; 5, nerve cell. small fibres are about 2// or y gtg,, inch in diameter, the large 20/i or Y^ViT i'lch. The small fibres are connected with smaller cella, and either run a shorter course or are distributed to the involuntary muscular fibres of the blood-vessels and viscera. The motor fibres are larger than the sensory. The peripheral nerve fibres, except the optic, have no neuroglia; GENERAL ANATOMY, PHYSIOLOGY, AND CHEMISTRY, 13 they terminate in fine fibrillee among epithelial cells, or in special end organs. The central nervous fibres make up the white matter of the brain and cord. They are, like the peripheral nerves, the prolongations of the neuraxons. They are composed of an axis-cylinder process and myelin sheath, but have no neurilemma, and probably no nodes. At frequent intervals each fibre gives off branches at right angles forming the "collaterals." Connections of Nerve Cells and Ner^e Fibres. — One nerve cell is never connected directly with another, so far as anatomical investi- gation can show. One nerve process becomes an axis cylinder, re- ceives a myelin sheath, gives off collaterals, and finally breaks up into a fibrillaiy "^nd brush" surrounding a cell, but not passing into it. There is physiological, but no apparent anatomical continuity (Fig. 13). The Neuroglia. — The supporting tissue of the peripheral nerves is connective tissue only ; that of the central nervous system is con- FIO. 14.— GLIA CKI.LS as iMPRErjNATKn IN SILVKR-CIIKOMATE I'KEPAKATIONS. ( Aftf r UlltlK'in y Cajal, H., "Textura (it-l si.sU'inii iicrvlostj," Madrid, IH'.MI, p. 175, Fljr. 4K.) nective tissue and, in addition, a pccnliar substance called ntMi;og]ia. The neuroglia or supporting tissue of the nervous centres is derived from the epiblast. It is coni))osed of cells with very numerous and finely ramified processes, which make a supporting network about the nerve cells and fibres (Fig. 14). The neuroglia cells are sonu'- 14 DISEASES OF THE NERVOUS SYSTEM. times known as "spider cells." They differ somewhat in size and shape, but not in general characteristics. The cell body is composed of granular j)rotopiasm, lying in Avhich is a large nucleus, within which is the nucleolus. The body of the cell is small in amount in proportion to the nucleus. The fibrillary processes form a felt-like network, and in regions where there is much neuroglia tissue this looks like a homogeneous matrix. It is, liowever, made up of the fine fibrils. These connect with the walls of the blood-vessels. Fig. 15. Fk;. Iti. Fig. 1.5.— arteries of Sciatic Nerve (Quexc and Lejars). Fig. 16.— arteries of the Medi.vn Xerte. A A, Branches to tbe uerves; B, bracbiai artery: JX, median nerve (Quenu and Lejars). Weigert has shown that the processes become changed in their chemical and physical character, so that they take a different stain from that of the cell body itself, and thus form a really separate -struc- ture (Plate I., Fig. 7). In inflammatory conditions the cells miilti- ply, swell up, and assist in carrying off irritating products (scaven- ger cells of Lewis). Neuroglia tissue is richly deposited about the centra] canal of the spinal cord, beneath the ependyma of the ven- tricles, and beneath the pia mater of the brain and cord. The epi- GESTERAL AX ATOMY, PHYSIOLOGY, AXD CHEMISTRY 15 tlielial cells of tlie central canal and ependyma of the ventricles send down fine processes which form a minor part of the support- ing framework. The iSTox-XERVOUs Tissues — Tlip Blonrl-vesfiph. — The peri- pheral nerves are richly supplied with blood. Each nerve receives arterial supply from many differ- ent branches, but always from the same general source. The artery passes to the nerve sheath obliquely, then divides dichoto- mously and sends branches a long distance up and down on the sheath. It may pierce the sheath, however, first, and then divide, as above described. The dichoto- mous branches send off arterioles and capillaries, which form plex- uses about the nerve fascicles. These are "the interfascicular arcades." The arteries subdivide in such a "way as to prevent sud- den impact of a large blood stream into the tissue of the nerve, in this resjject the nerve circulation resembles that of the brain and cord. The veins subdivide di- chotomously, like the arteries. They freely anastomose with the muscular veins, so that muscular action helps nerve circulation. The veins of the superficial nerves connect with those of the deep nerves (See Figs. 15, IG, 17). The blood-vessels of the spinal cord and brain will be described later. Lymphatic vessels and spaces are found in the epineurium and lierineurium. There are no dis- tinct lymphatics in the fas- ciculi, but lymph spaces probably exist. I'll). 1". — iNTKIlFASCULM.Art Ul.^TUlUUTli-i.V OF Aktkhies cyc£.NU AMo Lkjak») 16 DISEASES OF THE NERVOCS SYSTEM. The Neuroxic ARrt(il ill function. The other process is the neuraxon proper and it is n-J- lufiKifil, carrying impulses away from the ganglion cell into the cord. The next neuron begins as a cell in the posterior horn, or in like parts. It sends a neuraxon up the spinal cord, a collateral branch passes to the cerebellar cortex, while the direct fibre surrounds a cell in the optic thalamus. This forms the second sensory neuron. The cell in the thalamus gives off a neuraxon which passes to the gray matter of the 'jevebral cortex, and here it either directly affects 2 18 DISEASES OF THE XERVOUS SYSTEM. the cells m this region or does it through the medium of anothei shorter neuron, which is called " associative. " Thus each sensory impulse from the periphery reaches the con- scious centres of the brain by passing along three or four neurons. The primary neuron in all cases lies mainly outside the central Pig. 18.— Diagram showing the Akrangkmknt of the Neurons or Nerve Units in »HB Architecture of the Nervous System. M. Neurons I. and 77., Motor neurons; S. NeuronH I . II., 777., sensory neurons; A. NeurQ,n, associative or commissural neuron. nervous system and forms a sensory nerve. The sensory nerves do not therefore arise in the cord or medulla, but have their terminal nuclei there. The neurons of the brain cortex cannot yet be distinctly classi- fied, and 1 shall not attempt it here at all. The matter will be brought one more fully in connection with the anatomy of the brain. It is sufficient to say that nerve units connect together the cere- bellum and cerebrum with the basal ganglia, the frontal lobes and the cerebellum, the two hemispheres of the cerebrum, and different areas of the cerebral cortex. Leaving out of consideration these neurons, which are largely psychic in function, we start with the large motor cells in the central convolutions of the brain. These GENERAL AXATOMY, PHYSIOLOGY, AXU CHEMISTRY. 19 send down neuraxons, which pass into the spinal cord and surround the cells of the anterior horns. They form the primary or central motor neurons. The anterior-horn cells send off neui-axons, which pass out through the anterior roots and thence to the voluntary muscles. These are the secondary or peripheral motor neurons. Besides this there are groups of cells in the lateral horns and cen« tral parts of the spinal cord which send off neuraxons that also pass through the anterior roots, but they leave the cerebro-spinal nerves and enter the vertebral sympathetic ganglia. Here they in part surround the cells of these ganglia and have their terminals there. These sympathetic ganglion cells in tiu'n send neuraxons, which pass in the sympathetic nerves to the peripheral ganglia, where they meet a third group of neurons. They also connect with the other ganglia of their own class and send neuraxons through the posterior spinal roots to the cord. It is not known with what neurons higher up in the nerve centres the lateral-horn cells are connected, but probably with cells in che thalamus. Such in outline is the neuronic architecture of the nervous sys- tem. I do not attempt here to work out the neurons of the special senses, nor to introduce the spinal-oerebellar neuron. This will be done later. It is sufficient to say that the studies in this direction show a marvellous harmony as well as beauty in nature's scheme. The neuronic architecture is shown in the accompanying dia- gram \Fig. 16). GEXERAL PHYSIOLOGY. T/ir Perijiheral Neurovs. — The nerves wliich run between nerve centres and end organs cany impulses each way. They are, there- fore, divided into the (ifferi'nt, centripetal or in-going, and efferent, centrifugal or out-going. The old division into motor and sensory nerves will not answer, for there are many out-going nerves which arc nut motor. The afferent nerves are: 1. The sensory, including: Nerves of general j Pain nerves or patliic nerves, lioal and cold or thermic sensations. { nerves. ( Contact, Tactile, inrhiding ■ Pre.ssurc, ( Locality. Nerves of muscular and arliculur sense. Nerves of special sense of smell, sight, taste, hearing and space. 2. Excito-reflex nerves. Nerves of special sensation. 20 DISEASES OF THE NERVOUS SYSTEM. The efferent nerves are : 1. Motor nerves, going to voluntary or striped muscles, heart muscle, smooth muscle, including the vaso-constrictor and dilator nerves. 2. The secretory. These act upon glands. Impulses to the blood- vessels (vasomotor) generally accompany the secretory impulses. 3. The trophic. 4. The inhibitory. These nerves control muscular movements, i.-6Cretion, perhaps also nutrition. We must admit that afferent and efferent impulses take place also between end organs and certain (so-called) sympathetic ganglia. In other words, the cerebro-spinal axis is not always the centre. But these subordinate and peripheral centres are normally in con- nection with the spinal cord and may be influenced by it or by higher parts. The Central Neurons. — There are intercentral or commissural neurons, which connect different parts of the cerebro-spinal system together. Some of these connect symmetrical parts on each side together. They have co-ordinating function. Others connect higher with lower centres. These latter are made up of ascending and descending fibres. Higher centres send down impulses by the latter, wdiich may stimulate or inhibit lower centres. In the pe- ripheral nervous system we have also end organs. These are deli- cate and in some cases complex arrangements of the nervous and other tissue at the periphery of the nerves. Their object is to allow the nerves to be irritated by special stimuli which would not other- wise affect them, e.g., light or sound. Their object is also the proper utilization of efferent impulses upon other tissues. There are end organs, therefore, for both sensory or afferent and for effer- ent nerves. The end organs of the afferent nerves are — eye, ear, taste buds, corpuscles in the Schneiderian membrane, various tactile cells and bodies, the space-sense organ. For the efferent nerves — neuro-muscular corpuscles in the volun- tary muscles, local ganglia about the arteries, local ganglia in the glands. Trophic end organs are not known. In many cases the end organ is nothing but the terminal fibre of the nerve. This loses both medullary sheath and neurilemma, leaving only the axillary cylinder. It then splits up into a terminal plexus, or else without splitting passes between and around the cells which it is to affect. The nerves, centres, and end organs thus described may be ar- ranged in mechanisms, each mechanism subserving a special func- tion. These form the mechanisms of the nervous system pi'operj and those of the other organs of the body. GENERAL AXATOMY, PHYSIOLOGY, AND CHEMISTRY. 21 They may be classified somewhat as follows: I' I. The psychical mechanism. II. The automatic mechanisms or the mechanism of inher- Cerebro- J ited and acquired aptitudes, spinal. I III. The sensory mechanism. IV. The voluntary motor mechanism. V. The reflex mechanism. (The secretory mechanism. The trophic mechanism. ujcv.uaijiotLi.T). I Tlie thermic mechanism. I The vasomotor mechanism. Various of the simpler mechanisms are combined to form those more complex. Thus the automatic and psychical mechanisms embrace in their activity other mechanisms of lower grade. In the same way mechanisms are combined for the regulation of visceral functions. Thus we have the cardiac, respiratory, and other visceral mechanisms. The Cell-hody of the Neuron. — In the working of these mechan- isms the nerve-cell body is the agent which generates the energy of all nerve force, by which impulses are started, controlled, and dis- tributed. The larger the nucleus of the cell in proportion to its protoplasmic body, the more stable or less sensitive the cell. The larger the amount of protoplasm relative to the nucleus, the more active the discharging power of the cell. The nucleus is the part of the cell body which is essential to constructive metabolism. By means of it the cell builds up its protoplasmic substance. AVhen the nucleus dies, the cell may live or function for a time, but it lives only on what has been stored up ; it can build no more. Nerve c^Us with few exceptions (spinal ganglia) have no centrosomes; they cannot divide and multiply. Once dead they cannot be re- stored. The nerve fibres conduct impulses generated by nerve cells. These impulses travel at the rate of about 100 to 120 feet per sec- ond. It IS less in visceral nerves (25 to 30 feet per second). There are no electrical cm rents in normal living nerves (Landois) except when an im])ulse travels along them. Then an electrical current travels along with tlie im])ul.se. It is called the current of negative variation. The irritability or excitability of a nerve is the power it has of resjionding to a stimulus. When a constant electrical cur- rent is passed along a nerve its irritability is modified. This modi- fied condition is called elertrotnnus. When a nerve impulse passes U)) an afferent nerve ajid is then reflected along an afferent nerve, it is called a rcjicx action. The time required for this process is 22 DISEASES OF THE NERVOUS SYSTEM. called the reaction time. This averages from 0.125 to 0.2 of a second. CHEMISTRY. The specific gravity of nervous tissue is about 3.036; that of the brain is 1.038; of the spinal cord and nerves, 1.034 (Bischoif, Krause). The reaction is alkaline, but this is lessened by activity, owing to the development chiefly of lactic acid. The gray matter is less alkaline than the white. The nervous system has the following composition (Bauni- stark, quoted by Hammarsten) : White Matter. Gray Matter. Water in 1,000 parts 695.35 769.97 Solids 304.65 230.08 Protogon ] ^^^ ^^^^^^^ \ 25.11 10.08 lusoluble albumin and connective tissue, .. . 50.02 60.79 Cholesteriu , 45.12 23.81 Nucleiu 2.94 1.99 Neurokeratin 18.93 10.43 Inorganic salts 5. 23 5. 62 Water makes up nearly three-fourths of nervous tissue, there being more in the gray than in the white matter and least in the sympathetic nerves. The inorganic salts amount to about .5 per cent. The largest single constituent is phosphorus (Breed) com- bined with potassium, sodium, magnesium, calcium, and iron, form- ing phosphate salts. Of other constituents chloride of potassium is the most important. Protogon is a very complex substance of a fatty character, con- taining nitrogen and united with glycerin-phosphoric acid instead of glycerin. It is said by some to be made up of tAvo bodies, cerebrin and lecethin, the latter containing an ammonia compound called neurin. Protogon is especially found in the white matter. The gray matter contains nuclein, a very important substance in cell metabolism. Kuclein (C„3H^gN,jP,p^„, Miescher) is composed of nucleic acid, a substance rich in phosphorus and a variable amount of albumin. The gray matter, i.e., the nerve cells, contains also various albuminous substances. The nuclein and the allied sub- stance nucleo-albumin are called albuminoids (Halliburton). They both contain phosphorus and are found chiefly in the nucleus. The albuminous substances, called also pro'teids by Halliburton, have little or no phosphorus, and make up the most of the cell bodj or cytoplasm. CHAPTER 11. THE CAUSES OF NEEVOUS DISEASES. Nervous diseases are produced iu part by predisposing influences wliich may be likened to a fecund soil; in part they are due to exciting causes, which are like the seeds dropped upon the soil in the accidents of life. Heredltij is the most serious and important of these predisposing causes, in particular of those neuroses that are constitutional and are not the results of bodily accidents. A nervous disease, how- ever, is rarely directly inherited. Parents do not pass down special maladies, but only a general tendency to nerve disease, which is not developed into any distinct trouble unless some disturbing cause arises. Nervous parents may have children who have unstable, over-irritable, and inadequate nervous systems. Such persons have what is called a neuropathic constitution or diathesis. This diathe- sis may be transmitted when the parents, though not especially neurotic, suffer from syphilis, alcoholism, and diseases of mal- nutrition, like tuberculosis. So far as the offices of parentage go, [lersons of great talent in affairs, or great artistic genius in any direction, may be counted as neurotic and are very likely to have children of neuropathic constitution. This is less apt to bo the case when one parent is of stable and lymphatic type. If persons having not simply a nervous constitution but distinct nervoiis or mental disease marry, their children are hable to serioiis nervous or mental disease. The intermarriage of blood relations such as first cousins does not lead to neurotic children if the parents are not both of that class, or are of robust health and dissimilar temperaments. In- juries or even severe shock to the mother during the early months of pregnancy sometimes leads to nervousness in the offspring. Tlie mother transmits neuroses more often than the father. There are certain rare nervous diseases which appear in different branches and members of a family, such as an uncle, cousin, nephew, and son. These diseases ma}' pass also by direct inheritance from jiarent to child, or may skiji a gcmeration. They are called " family diseases," and are of the nature of congenital defects, like webbed fingers or elul)foot. Morbid traits that have become fixed m a family reappear at 24 DISEASES OF THE NERVOUS SYSTEM. about the same age in the descendants. If these traits or tendencies are disappearing from the family, however, they appear later in life with each successive generation in the descendants. It they are becoming more intensified, they develop at an earlier age in the suc- cessive descendants. Thus migrainous attacks which have existed in a family usually appear between twelve and fifteen. If now they do not develop till the age of thirty it shows that the mi- grainous taint is dying out. When a nervous disease develops in a grandchild, having skipped a generation, it is called a manifestation of atavism. Atavism is a very slight factor in nervous diseases, and rarely goes back more than two generations. Degeneration is the name given to a condition in which there is a morbid deviation from the normal average. It is almost always an inherited state, and the word degenerate is often used to indicate a person who has a hereditary neuropathic constitution. Degen- eracy in a moderate degree often accompanies great mental powers, especially of the artistic kind, and it is almost invariably associated with genius. It is quite compatible with mental soundness and a fair degree of physical health. Those who have unusual mental gifts and degenerate characteristics are called superior degenerates. The criminal and the insane and erratic and eccentric persons of weak judgment have also the neurotic constitution, and are called inferior degenerates. The weak minded, imbecile, and idiots form the lowest class of degenerates, and are called the debiles. The degenerate tends to sterility, and if two degenerates marry, and have children, their children are likely to be more abnormal than the parents. Degenerate families tend to die out. But this ten- dency can be avoided by the infusion of sound blood. A(je. — In infancy and early childhood, nervous diseases are rather frequent on account of the accidents at birth, the liability to infectious fevers, and malnutrition, and the high degree of sen- sitiveness of the yet immature nervous system. Still, a carefully watched infant is relatively safe. Motor disorders, such as paraly- ses, convulsions, and chorea, are mucii the more common troubles. At the time of puberty sensory disorders, such as headache and migraine appear, and often epilepsy, hysteria, and disorders of sleep. Hereditary tendencies to nervous disease also begin to develop at this time or a little later. At the period of adolescence, the mal- adies already mentioned also may be brought out; but in addition neurasthenic, morbid sexual, hypochondriacal, and insane tenden- cies are seen. From maturity to the time when degenerative changes begin, forty to forty-five, the individual suffers from those THE CAUSES OF NERVOUS DISEASES. 25 nervous disorders brought on by accidents, injuries, prostrating attacks of sickness, overstrain, infections, indulgence in alcohol and narcotics, and the abuse of the bodily functions. At and after the climacteric, one sees oftenest such maladies as result from vas- cular disease, apoplexies, softening, severe forms of neuralgia, and spasm. Sex. — Sensory and functional disorders are more frequent in women ; motor and organic disorders more frequent in men Condition and Occupation. — No general facts will be laid dowQ here. Celibates, however, ib may be said, suffer more from ner- vous disorders than married people. It will be shown later that certain occupations entail special nervous disorders and that in- door life promotes functional nervous diseases. The influence of education in the development of nervous diseases is very great, but it can be best considered in connection with special diseases. Habits. — Excessive indulgence in alcohol is a most prolific cause of nervous disease, chiefly by the action of this substance on the blood-vessels and the stomach. Excesses in eating, in tea-drinking, irregularity in sleeping, and bad habits of working predispose to nervous disease. Sexual excesses are usually the result rather than the cause of nervous disorders. They are the evidence of mental more than of nervous weakness. Climate and Civilization. — Nervous diseases are most frequent in temperate climates, and in those which are dry and elevated. They increase with the progress of civilization and the gi eater strain, complexity, and luxury of modern social life. Those or- ganic nervous diseases which are largely dependent on vascular dis- ease are frequent in the poorer classes, among whom syphilis, alcoholism, and bad feeding prevail. Functional and degenerative disorders are frequent in the higher classes. Nervous diseases, if we except those of the degenerative type, prevail more in urban populations. DlatJu'sls. — The rheumatic and gouty diatheses predispose to nervous troubles, more especially those which are of a peripheral and functional nature. Litheemia, a condition in which the prod- ucts of tissue waste are not properly oxidized and eliminated, has a similar iuHuence. Traunia and Shock. — Exhausting hemorrhages and trauma may be tlio direct cause of or may jjiedispose to nervous disease. Trauma and sliock may cause functional diseases such as neurasthenia, or may lead to the development of insanity or indirectly to degenera- tive organic disease. ^Mental shock, and especially a fright, oftenei 26 DISEASES OF THE XERVOUS SYSTEM. than severe bodily injury, leads to the development of functional neuroses. Infections. — In comparison with their frequency, the infective fevers are not great factors in producing nervous disease, but prac- tically they often play an important part. Scarlet fever is the most dangerous disorder in this respect. Measles perhaps ranks next; then follow influenza, diphtheria, typhoid fever, and pertussis. Among chronic infections syphilis ranks first; malaria, the pellagra, and beriberi are also to be mentioned. Poisons. — Alcohol, tea, coffee, and lead, mercury, copper, and arsenic, are to be placed among the frequent causes of nervous dis- ease. Alcohol in excess is justly credited with exerting the most sinister influence on the nervous system, even leading to an acquired state of degeneration. Reflex Causes. — Among other causes are local disease of viscera, such as renal, uterine, and ovarian diseases, dyspeptic and liver disorders, visual and auditory troubles. Keflex irritations are dis- tinctively exciting causes, and with few exceptions they cannot cause a nervous disease unless there is a predisposition to it. They may, however, cause many distressing nervous symptoms, such as pain, spasm, and even convulsion. CHAPTER m. GENEEAL PATHOLOGY. The nervous system is composed of nerve cells and nerve fibres, forming neurons, comiective tissue, the neuroglia, blood-vessels, and lymphatics. Its disorders involve one or more of the above tissues. The following is a list of the forms of disease which affect the nervous system : 1. Malformations; incomplete development, or agenesis ; defec- tive development, or dysgenesis. 2. Hyperaemia, anaemia, hemorrhage, oedema, and arterial and venous diseases. .3. Degeneration and atrophy, softening, sclerosis, classed as regressive processes. 4. Inflammations. ."). Tuberculosis and syphilis. (5. Tumors and parasites; o, 4, 5, and 6 being classed as pro- gressive processes. 7. Nutritive and functional disorders, inchiding disorders asso- ciated with metabolic and glandular defect, sucli as acromegaly and exoplithaliuic goitre. Inflammation. — The pathology of most of the above types of diseases will be given elsewhere, and does not call for discussion here. It is, however, of tlie utmost importance that the student, have a clear understanding of the nature of inflammation and degeneration as they aft'ect the nervous tissue. Inflammation is a iiiorl)id process which has to deal primarily with l)lood-vessels, lyni[iliatics, and connective tissue. Inflauiniation, teleologically, is the reaction of tlie organism to an irritant. Wlierever tliere is iuflaniniation, there is irritation. The irritant in inflammation is practically always the product of microbic action or some irritating product of tissue change. Witliout some microbic or tissue irri- tant tliere can be no inflaniniaticMi. \N'e make this exception only: tliat certain elu'uiical substances, such as alcohol, arsenic, and lead, may al times excite a form of inflammation, which is, however, i)ro!)ably, primarily a degenerative or destructive i)roc- ess. Inflamnuition, when the irritant is removed, tends to subside. I^caving these facts in mind, it will he found that inflammations 28 DISEASES OF THE NERYOUS SYSTEM. of the nervous tissues never or very rarely occur without the pres- ence of some microbe or some destructive process whose irritant products excite inflammatory reaction. Inflammations may be divided into the (1) exudative and the (2) productive forms (Delatield). The exudative inflammations may be simple ; without necrosis, with necrosis ; purulent ; purulent and necrotic. (3) Degenerative or parenchymatous. 1. Simple exudative injiammution is accompanied with conges- tion, stasis, emigration of white corpuscles, and perhaps diapedesis of red cells, transudation of blood serum, and formation of flbrin, the total result being an exudate containing white blood cells, now called pus cells, and fibrin in varying proportions. When there is little exudate or proliferation of cells and the tissue cells are chiefly affected, some authors call it o, ijarenchymatous inflammation. In iniTulent inflammation there is a great accumulation of pus cells and less relatively of fibrin. If the tissue is destroyed, it i^ a ]turulent and necrotic inflam- mation. In some exudative inflammations there is increase of connective tissue from the start, and the process continues till the inflamma- tion subsides. Most exudative inflammations are acute or subacute. Inflammatory tedema is a form of exudative inflammation. 2. Productive or proliferative inflammation is a process in which there are little congestion and exudation, while new connective tis- sue is slowly formed. Productive inflammation is usually chronic; tuberculous and syphilitic processes are varieties of productive in- flammation. The principal poisons which may cause chronic productive in- flammations are alcohol, lead, and arsenic. Certain irritating auto- toxsemic agents, such as occur in gout, rheumatism, diabetes, and states of inanition, appear able at times to cause productive inflam- mations. Classification op Inflammations. Simple exudative, with or without necrosis. Purulent, with or without necrosis. Productive or proliferative . Cause. Microbic or toxic. Microbic Microbic Microbic or toxic. Example. Meningitis. Poliomyelitis. ]Meningitis and encephalitis. Acute purulent myelitis. Chronic meningitis. Leprous neuritis. Degexeratiox and Sclerosis. — By degeneration is meant in patliology a gradual death of the nerve cells and fibres, or in other GENERAL PATHOLOGY. 29 woi-ds of the parenchyma of the organ. The cells swell up, be- come granular and fatty, and then either break up and become absorbed or enter into a condition of a dead coagulum (coagulation- necrosis). Degenerations may be acute or chronic, primary or sec- ondary. Acute degeneration causes a condition known as softening or necrosis. It is due to cutting olf of vascular supply, direct injury, and to necrotic and inflammator}- poisons. Acute degeneration may be follov»'ed b}^ a reparative process, which is called a reparative or reactive inflammation, and which ends perhaps in producing a cicatrix or sclerosis. Chronic degeneration is accompanied and followed by a prolif- erative process which results in the production of connective tissue and sclerosis. Degeneration may in some cases be classed as a degenerative or parenchymatous inflammation. Sclerosis is a process of connective-tissue proliferation, as a result of which the normal or injured parenchyma is supplanted by fibrous tissue. The word sclerosis is usually employed in describ- ing degenerative diseases, though it indicates the result rather than the primary nature of the process. In the nervous system there is often an increase or proliferation of neuroglia tissue in the proc- esses of degeneration. Exactly how large a factor this is cannot yet be said. A jmmai'y degeneration is one in which the process is due to inherent defect in nutrition or to some poison acting directly on the cell or fibre. A secondary degeneration is one that is due to a cutting off of nerve fibre or cell from its trophic centre, or to an injury or shutting off of its vascular supply. Ordinarily, in speaking of secondary degenerations one refers to those due to the first-mentioned class. Practically, primary and secondary degenerations often occur in the same disease. Degenerations. Forms. Examples. f Primary (Myelomalacia. •' I i'rogressivc inuscular atropliy 1 Secondary and mixed ] S„t ^iSi sclcn^ls. Acute and Chronic Degenerations are caused by certain poisons, such as arsenic, phosphorus, lead, and the poisons of infectious disease. Degenera- tions also result from obliterating arteritis, such as occurs in old age or frran humoral poisons. Degenerations sometimes are due ap- parently to an inherent defect in the cell nutrition — a premature death of it; also to causes yet unknown. The question as to 30 DISEASES OF THE NERVOUS RYSTEAI. whether certain scleroses are forms of productive inflammation or of chronic degeneration is one that has been much debated in the past. It is quite certain now that the so-called chronic inflammations of the nervous centres are really degenerative processes, and that the primary trouble is in the parenchyma, and not in the connective tissue. Gliosis. — It is contended by some French pathologists (Chaslin, Dejerine) that some of the chronic degenerative diseases are the result of a proliferation of neuroglia, not of connective tissue. This process is called gliosis. Nutritive and Functional Dlsnrdcfs. — Under this head are in- cluded defects due to disorders of the blood and blood glands, to defects in metabolism, to poisons, extrinsic and autochthonous, and to local diseases. In conclusion some fundamental iieeuliarities of the nervous tissue may be noted here. Nerve cells once destroyed never develop again. The same is true, though not so absolutely, for the nerve fibres running in the central nervous system. Peripheral nerves may grow again when cut or destroyed. They grow usually from the trophic centre, but may develop out of the cells of the neurilemma. Nerve tissue in brain, cord, or periphery can never be sutured so that it will functionally unite by direct union. There are a few apparent exceptions. A further peculiarity of nervous tissue is that it is dependent for its integrity upon two things, blood supply and trophic influ- ences. The nerve cell is solely dependent on a proper suppl}' of blood, and dies when this is Avithdrawn. But the neuraxon is more dependent on the trophic influence of the neurilemma and of the cell of which it is a prolongation. It dies when cut off from its cell, but it can get along for a time with but little direct blood sup- ply. On the other hand, if the neuraxon is injured it reacts on the cell, leading to a partial but curable degeneration of the cell body. CHAPTER IV. GEXERAL SYMPTOMS. When' the nervous system is disordered it produces various symptoms, which are classified aud receive names according to tlie parts affected aud the kind of change present. The general name given to any kind of morbid nervous state is neurosis and the gen- eral name for any morbid mental state is p^ijchosis. "When the neurosis affects the motor sphere, whether in the brain or cord or nerves, it is a motor neurosis, or, more technically, a kinesio-neuro- sis; when the sensory parts are disordered we have a sensory neu- rosis, or sesthesio-neurosis. In the same way we have trophic, thermic, vasomotor, and secretory neuroses. The symptoms of nervous disease are further divided in accor- dance with the kind of disturbances present. Now a function can only be disordered in three ways. It may be exaggerated, lessened, to the point perhaps of entire loss of function, or it may be perverted. In order to indicate this certain Greek prefixes are used. They are " hyper, " which means excess ; " liypo, " meaning diminution ; " a" or " an, " indicating entire loss; and "para," meaning perverted. Thus we have, for example, hyperaesthesia, or excessive sensibility; anaesthesia, or loss of sensibility ; and pareesthesia, which means per- verted sensibility. Finally, nervous symptoms are often spoken of as objective or subjective. The former are those symptoms which can be seen or directly noted by the physician without depending on the patient's statements. The subjective symptoms are those which are felt by the patient, but give no outward sign. Thus headache is a subjec- tive symptom, paralysis is an objective one. So far we have been grouping together only like kiiuls of symp- toms; but it happens that many nervous diseases may have quite different kinds, some being motor, some trophic or sensory. Thus nt'i-vous diseases practically are to a considerable extent classified simply on the basis of the part of the nervous system diseaseii; and we have spinal-cord and brain diseases, gastric and sexual }ieuro- ses, and so on. Nervous symptoms, however, are always grouped together in 32 DISEASES OF THE NERVOUS SYSTEM. accordance with tlie physiological function disturbed. So that we have the following tabulation (see also Fig. 19) : 1. Mental and cerebral, forming psychoses. 2. Motor and reflex, forming kinesio-neuroses. 3. Sensory, forming ffisthesio-neuroses. 4. Trophic, forming tropho-neuroses. 5. Vasomotor and thermic, forming augio-neuroses and thermo- neuroses. 6. Secretory, forming secretory neuroses. Combinations of these groups of symptoms may affect various organs. They are called mixed neuroses. Combinations of mental and nervous symptoms form psychoneuroses. The particular symptoms which nervous diseases cause will be described and recorded under the several heads given above. 1. The mental symptoms include all those found m insanity, idiocy, and imbecility, and will not be given in detail here. The common symptoms met with by the neurologist are mental irrita- bility, depression, emotional excitement, morbid fears, volitional weakness and lack of self-control, persistent or fixed ideas, weak- ness of memory and of power of concentration, and a tendency to hypnotic and somnambulistic states. Certain symptoms due to disturbance of brain function are often called cerebral, as distinguished from mental. They are : vertigo, disorders of equilibrium, insomnia, somnolence, stupor, coma. Headache, head pressure, and similar feelings are also often de- scribed under the head of cerebral symptoms, 2. Motor Symptoms. — The symptoms of disordered motility are as follows : A. Symptoms of exaggerated motility, or hyperkineses. a, fibrillary: Tremor: T intentional, h, tremor proper : \ passive, ( constant. i tonic. Convulsions : \ clonic, ( co-ordinate. Choreic and choreiform movements, athetosis. Muscular tension (hypertonia) and contracture. Forced and associated movements. Exaggerated reflexes and clonus. B. Symptoms of lessened motility. Paralysis and paresis, amyasthenia. Loss of reflexes, superficial and deep. Hypotonia or lessened muscular tonus. GEXERAL SYMPTOMS. 33 The particular characteristics of these different symptoms "will be best shown in the description of the special diseases, but a biief account will be given here. Tvemor is the result of a disorder in the tonic innervation of muscles. Muscles are kept normally in a state of slight tension by rhythmical impulses passing down at the rate of about twelve per second. When the rhythm and force of these normal impulses are interfered with we have tremor. The simplest form of tremor is one in which the normal tonic impulses have an apparently exagger- ated force. This causes a line tremor of eight to twelve vibrations per second. When there is an interruption to some of the impulses we have a coarse tremor. Here the vibrations are five to eight per second. It is caused by a partial or complete dropping out of the alternate impulse. Various technical names are used in describing the tremors. We have the fine and coarse, as described. \;\n Psycho ^^Kinesioneu roses Assthi Secretory &fropKio \'aso- motor Fig. 19.— Diagram illcstratino the Principle op the Classification cf Nkbvous Symptoms. Intention tremor is one that occurs on voluntary movement, and is opposite in kind to the p'tssinc. tremor or tremor of rest, whicli decreases or ceases on voluntary effort. Tremor is sometimes of a coarse, jerky, and inco-ordinate character, and these words are then used to indicate it. F'lhrillorij tremor is a fine twitching of the individual strands or parts of muscles, and occurs usually when they are wasting from lack of neuro-trophic influence. Convulsions consist of abnormal and exaggerated muscular con- tractions occurring in ra.pid succession. Couvulsions may be clonic, i.e., the muscles rapidly and alternately contract and relax in an exaggerated and irregular way; or they may be tonic, i.e., con- tracted steadily and continuously. When a tonic muscular contrac- tion is painful it is called cramjy. Couvulsions may be co-ordinate. In this case the patient moves the limbs and body in a more or less purposeful way. lie throws liimself about the bed, jumps, kicks, 3 34 DISEASES OF THE NERVOUS SYSTEM. strikes, tears tlie clothes, etc. Convulsions are usually accompanied with loss of consciousness. ChoreiQ movements are sudden jerking, twitching movements of different groups of muscles. The movements are purposeless and are not under control of the will. Convidslve tic is a form of choreic movement confined to certain groups of muscles Avhich work together for a common purpose, like those of the face, or eyes, or larynx. The movements in the " tics" are more definite in character and are limited to muscles physiologically grouped for a definite function. Thus we have tics of the muscles of expression, or of respiration, or speech, or locomotion. Athetosis is a name given by Hammond to a peculiar form of movement characterized by slow, successive flexion, extension, pro- nation, and supination of the fingers and hand and arm, or of anal- ogous movement of the toes and feet. The motion rarely ceases in Fig. 20.— The Hand in Athetosis (StrUmpell). ■waking hours except for a short time. The contractions are forci- ble, steady, and even, and sometimes painful. The hand assumes characteristic positions (Fig. 20). A contracture is a tonic muscular spasm of long duration, i.e., days or months. A contracture may be functional or organic ; and in order to test this, one must find whether it ceases during sleep or under an anaesthetic ; if so, it is functional (see Hysteria). In forced movements the patient suddenly and involuntarily is thrown forward, sideways, or whirled about in various ways. Associated movements are those which occur involuntarily in a limb or muscle at rest when the corresponding limb or muscle is moved on the opposite side. Thus in hemiplegia the movement of the normal arm may excite a movement ni tlie one paralyzed. The patient is given a piece of chalk in each hand, and each hand is placed upon a blackboard lying on the table ; attempts at drawing lines with the sound arm cause movements of a similar kind, but less perfect, on the paralyzed side. GENERAL SYMPTOMS. 35 Parahjsls or akinesis is a loss of motor power. Monoplegia is a condition in which one limb is paralyzed; hemiplegia one in which one-half the body is paralyzed; and paraplegia one in which the two lower limbs are affected. Sometimes a double hemiplegia or diplegia occurs. The term paralysis is sometimes used to indicate loss of any kind of function, as paralysis of sensation or secretion. Faresis is a term used to indicate a partial paralysis. It is not to be confounded with the term general paresis, which is a form of insanitv. Fio. 21 .— Rhowin'o the CornsE op thk iMpn^sE ix a Simple Reflex Action. IVie liejlcxcs;. — When an impulse started in an afferent nerve reaches the spinal cord or medulla and is thence reflected upon au efferent nerve, the result is called a simple rcjh:c arfioii (Fig. 21). The process is an involuntary one. It ordinarily occupies one-tenth to one-twelfth of a second. The afferent nerve may be au ordinary cutaneous simsory nerve, or it may be a special nerve whose func- tion is to excite rcfl(>x action. These latter nerves are called excito- reflex. This kind is inincipally supplied to the viscera. In neurology Ave iiave to do with four kinds of reflexes. The skin or superiieiul reflexes. The tendonous or deep reflexes. The visceral reflexes. Idiopatliic or diixnit muscle rcHex. All these may bo exaggerated, lessened, or absent. Further de- scription of these reflexes will be given under the head of diagnosis. 36 DISEASES OF THE KERYOUS SYSTEM. 3. Sensonj Sijmjitoms. — Tlie sensory functions include all thoss. belonging to the nerves of general and special sensation. Sensory nerves have a part in reflex action and in the inhibition of motor and other functions. The nerves of special sense when deranged show \arious phenomena, which will be described in more detail later. In general there may be depression or loss, increase or per- version cf their function. In accordance with this we have : Ancestheskt which is a loss of tactile sensibility. Analgesia, a loss of sensibility to pain. Thermo-anoisthesla, a loss of sensibility to temperature. There may be loss of cold-sense or of heat-sense, or, as is usually the case, of both senses. The term anaesthesia is often used with a general meaning to indicate loss of all forms of sensibility. Anaesthesia in this sense is a s^'mptom referred to the skin, bones, mucous membranes, spe- cial senses, or viscera. The muscles have two kinds of sensibility, a sensibility to pain and a special muscle sense. Anaesthesia of the pain sense of muscle is called loss of muscular sensibility or muscu- lar analgesia. Anaesthesia of the special muscle sense is one of the factors in causing a symptom known as ataxia. Ataxia is a symptom due to loss of the special sensibility of the muscles, articular surfaces, and tendons. This special sense is sometimes called the " deep sensibility.'' It informs the individual of the degree and strength of muscular movements, and by it deti- nite and co-ordinated movements are made possiljle. The weight of objects and position of the limbs are also determined by it. In static ataxia tliere is loss of the power to preserve j)erfectly the equilibrium Avhen stauding. It is due to the form of anaesthesia just referred to. In locotJiotorov motor ataxia theve is loss of power to co-ordinate the limbs properly in motion. In these conditions there is also usually a loss of power to appreciate weights or the position of the limbs. Tlie term muscular amrsthesia , however, is often used to indicate these latter symptoms. Cerebellar ataxia is a form of inco-ordination due to disease of the central organ of equilibration, viz., the cerebellum. Astereor/nosis is a symptom indicating a loss of ability to appre- ciate the form or shape of objects felt. It is due generally to loss of deep sensibility, but may be caused by a loss of tactile sensibility. Hyper'cesthesia is an excessive sensibility to touch, contact, and other stimuli. Iluiierah/esia is excessive sensibility to pain, and is nearly iden- tical with tenderness. Dysoisthesia is an abnormal sensation, such as a " thrill " or feel- GENERAL SYMPTOMS. 37 ing of (lis(!Oinfort produced by ordiuaiy tactile or jtainfnl iiniires- sioii.s. Parcesthesia is a term applied to all the morbid general sensa- tions except pain. The paresthesias include such feelings as numb- ness, prickling, formication, flushing, bui-ning, itching, coldness, tickling, feelings of Aveariness, exhaustion, various peculiar visceial sensations. Ordinarily in speaking of parsestliesice, however, we refer to such feelings as numbness, prickling, and creeping. Delai/i'd sensation is a symptom in which an appreciable time exists, usually one or more seconds, between the time of applying a stimulus and its appreciation m consciousness. Normally a tactOe sensation can be felt and responded to in less than one-tentn of a second. Transferred or referred or reflex sensations are those in which the irritation is made at one point and felt at another. Thus an irritation in the stomach causes a pain felt in the forehead. The whole class of so-called reflex pains are really transferred sensations, since in reality there is no reflex action in the process, as will be seen later. Allocliiria is a peculiar form of transferred sensation, in which an irritation applied on one side of the body is referred to a corresponding point on the opposite side, 4. Troplilc Disorders. — These are called tropho-neuroses. They consist, so far as relates to neurology, chiefly of hypertrophy and atrophy of nerves, muscle, cutaneous and mucous tissues, joint de- generations, and various skin eruptions. The tropho-neuroses, if they affect joints, are called arthropathies; if muscles, atrophies, hypertrophies, and dystrophies; or if with atrophy there is a great substitution of fat the condition is known as lipomatosis. When nerves are affected there results degeneration. Tropho-neuroses of the skin produce various syniptonis, such as herpes, pemphigus, and other eruptions, pigmentation, leucoderma, alopecia, and bedsores. 5. Vasomotor and Secretori/ Symptoms. — The nerves supplymg tlie blood-vessels and secreting glands work together and are usually disordered together. Separate disturbances of the vessels and glands, however, occur. Anglo-nenrosis is the term given to dis- orders of the vasomotor centre and nerves. Anr/io-spasni is a con- dition in which there is increase of vasomotor tone and spasmodic contraction of the muscular coats of the arteries. Anf/!o-/)((rati/si's represents the opposite condition. Such disorders affecting the skin are shown by ))all;)r and coolness or by flushing and heat. Av;/io' (ita.itii is a condition of variability and irregularity in the tonus of the blood-vessels. 0. The scrvi-tor;/ vrnrosfs affect the functions of the skin, mucous membranes, and special glaiuls. J/i//it'ridrosis is an excessive sweat- 3S DISEASES OF THE NEKVOl'S SYSTEM. ing. Ani(I)'(is!,s is excessive dryness. J'dr'ulrosis is a perversion of secretion in which peculiar odors or colors are noted. Bcemi- drosis is the term applied to bloody sweating. The secretions of the internal organs are controlled by nervous influences, and their special disturbances often form part of the symptoms of nervous diseases. Thus we have waterj* diarrhoea in Basedow's disease, and a peculiar membranous discharge from the bowel in asthenic states. The blood glands, and particularly the thyroid and pituitary gland, have perversions of function Avhich lead to serious nervous symptoms, which will be described under the head of exophthalmic goitre and acromegaly. I CHAPTER Y. DIAGNOSIS AND METHODS OF EXAMINATION. The diagnosis of a nervous disease may be simply a clinical one; that is to say, one may recognize it as belonging to a certain known and definite group of symptoms. Thus in recognizing the phenom- ena of epilepsy, one makes a clinical diagnosis. In other cases, and especially in all organic nervous diseases, the physician must make in addition a local, and then a pathological diagnosis. That is, we must determine the seat and nature of the disease. A diagnosis is made by first getting all the obtainable facts in the patient's past history, then by learning from him all his subjec- tive symptoms, and finally by making an examination according to the technical methods to be here described. In examining a patient, it is imperative that a careful search for diseases outside the nervous system first be undertaken. Then the morbid nervous phenomena should be investigated. The physician should make it an invariable rule to make this examination in a certain fixed and systematic manner. The best method is first to get the family and personal history, and then to go over the mental, cerebral, and special ner- vous functions serially in the Avay indicated under the description of general symptoms, thus: Examine — 1. Physiognomj', general condition of nutrition, complexion, physical defects (stigmata of degeneration), gait, station, posture, speech. 2. ]\[cntal and cerebral symptoms. 3. Motor and muscular symptoms, including muscular and joint atrophies, electrical reactions, and the reflexes. 4. Sensory symptoms, general and special. 5. Vasomotor, trophic, and secretory. 6. Visceral centres. In investigating the family history-, it is often necessary to make very direct and probing intpiiries, for patients are, as a rule, inclined to forget or ignore the existence of nervous and mental disease among relatives. The existence of consumption and inebriety, epi- lepsy and syphilis, in the direct line are very important facts; so also are those concerning birth. The patient shoidd be questioned closely as to his previous diseases, especially syphilis; also as to his 40 DISEASES OF THE NERVOUS SYSTEM. habits in relation to sexual indulgence, indulgence in alcohol, and smoking. In women, the tea habit should be inquired into. The patient may be allowed to tell his own story first. Proper queries should be put to supplement this, and finally the patient should be asked to state those symptoms which to his mind are main and dominant. We will now go over the above points in detail. 1. The physiognomy, complexion, and general nutrition are first noted. Many nervous disorders are compatible with a very healthy appearance, and patients often make the introductory apology, " I don't look like a sick person." An anxious look, restless manner, and excited or diffident speech, however, often show something wrong. The nervous trouble is usually serious in reverse proportion to the voluble anxiety of the patient to make his condition exactly understood. The character of the gait may reveal at once the nature of the malady. The dropped foot and flaccid swing of the leg in poliomyelitis and neuritis, the stiff shuffling march of para- plegia from myelitis, the waddling movements of juvenile muscular dystrophy, and the bent head and careful stamp of locomotor ataxia are almost of themselves diagnostic: Ji^t vet'us i)icessu j[)atuit morbus. The speech also often betrays the malady. The physician soon gets to recognize not only the striking symptoms of aphasia, but also the weak piping of paralysis agitans, the stumbling enunciation of paresis, and the peculiar dysarthrias of multiple sclerosis and bul- bar palsy. As a rule, the occurrence of speech difiiculties in adults is significant of organic and often serious disease. I regard it of much importance that in the chronic and constitu- tional nervous maladies careful note be made of the marks of degen- eration. The nature of this condition has already been described under the head of hereditary causes of nervous disease. As already stated, degeneration ineans a marked and morbid deviation from the normal standard of the race. The existence of degeneration implies an imperfect or an unbalanced development of the body. The con- dition is usually shown in some nervous or mental defect in the individual, and degeneracy, as ordinarily understood, implies a neu- ropathic or psychopathic state. But degeneracy may also mean only a lessened vital resistance to certain forms of infection or injury, as, for example, in persons of a tuberculous tendency, who often have marks of degeneracy. However, in ordinary use of the term it applies to those who have inherited nervous and mental weaknesses. The degenerate shows certain marks which are called the stig- mata of degeneration. These are of three kinds: anatomical, DIAGNOSIS AND METHODS OF EXAMINATIONS'. 41 physiological, and mental. I have space to give ouly the more important. Anatomical stigmata : Cranial anomalies, e.g. Asymmetry of cranium. Microcephalus. Peculiar shape of skull, trigonal, scapho-ceplialic, plagio- cephalic. Facial asymmetry, and excessive prognathism. Large jaws. Deformities of the palate and uvula, inchiding high narrow arch and the torus palatinus. Anomalies of the teeth, tongue, and lips. Anomalies of the eyes : narrow palpebral fissure, muscular insufficiency, excessive astigmatism, nystagmus. Anomalies of the ears: badly placed, ugly shapes, asym- metry, adherent or lobeless ears, markedly conchoidal ears. Anomalies of the limbs, genital organs, and body generally. Anomalies of the skin, excessive hairiness, or absence of hair. PJii/slologirdl Stigmata. — Tremor, tics, nystagmus, and hered- itary defects in the muscular system leading to atrophies. Exces- sive or defective sensibility of the cutaneous and special senses, defects in speech, perversions of the sexual and other instincts are to be classed here. A diminished resistance to nervous and emo- tional strain is a most frequent physiological mark of degeneracy. Jleiital Stigmata. — These include all those factors that make up the erratic, luibalanced, and inorbidly emotional individual. The specially morbid note in these persons, as Peterson says, is an ex- cessive egotism, an intense self-consciousness, often with peculiar disturbances of the sense of personality. IMental degeneracy is often associated with great special aptitudes, even genius, and is quite compatible with sanity and a fair degree of health. Of the foregoing the most important of the anatomical stigmata are deviations in the symmetry and shape of the skull, defects iu the palate and under jaws, badly shaped ears, badly set teeth, and a generally weak and badly developed body. Stress is laid n[)(m the skull because its development corresponds with that of the brain. Tlie palatal stignuita are in general those which make the cavity of the mouth smaller, it being the fact that the mouth cavity increases in size as we ascend the vertebrate series (Peterson). Ab- normal palates are found in about ten per cent, of normal peojile (Charon) and in from forty-six to eighty per cent, of degenerates. The high narrow ]ialate is one oftenest seen by myself. The torus ItMlatinus or longitudinal ridge on tjie hard palate is significant if it 42 DISEASES OF THE NERVOUS SYSTEM. is well marked. The importance of defective ears is based iipori comparative observations. They are found in from twenty to sixty- four per cent, of degenerate persons. While many of the stigmata have no significance in themselves, yet a combination such as impresses the observer with its prepon- derance is of great importance, for neuroses or psychoses developed among this class have a much more unfavorable prognosis. It is especially among neurasthenics, epileptics, severe forms of hysteria, and in the insanities that these signs are to be looked for and stud- ied. Among normal men about two or three anatomical stigmata are often found ; among lunatics, criminals, abortive types of para- noia, and primary forms of neurasthenia, the number is much greater. The accompanying table will be of help in making the investiga- tions relating to the cranium (page 43) . To understand it, it is necessary to describe the skull landmarks, and to give briefly the classification and terms used, by anthropolo- gists and alienists in describing the dimensions and shape of the skull. DiMEXsioxs AND Shape OF Skull — General Classification. — Anthropologists make a general classification of skulls into : Fig. 19.— ilf, /3, T, The Triang-.e for Ascertaining the Empirical Greatest Height (lieUMlict). The dolichocephalic, in which the antero-posterior diameter is to the transverse as 100 is to 75 or less; the brachycephalic, in which the length is to the breadth as 100 is to 80 or more; the mesocephalic, in which the length is to the breadth as 100 is to 75 to 80. The physiological limits of variation in the ratio of length to breadth are from 100 to 70 to 100 to 90. The dimensions and shape of the skull vary Avith age, sex, individual, race, and with certain pathological conditions and artificial deformities. In gen- eral, however, the. variations in the sliape and size of the skulls of DIAGNOSIS AND 3IETH0DS OF EXAMINATION. 43 6 55 1^ • i 1 -^ • 1 ■^ ^ <-. S • • ?> »=i "'' I '. " ! ! u ~ !- >> C< t; 1- 6 •y: ? : 000 >> ^' £j ^-i ?522 w T-« • • »:; q m T-T : : ^ ^ >T ij 2^.1 ,~ • • '- d : : — • i— . ;i; — ^ ■ :;<-'"• r ^ ^ q '- q l; « ci fj ■" i( k=; % : ■5 . _ p o-r • 1. 1 c: c; C-. S • CJ ^ -T- L- -^ =C -; t^ ^-, « — TT "3 2 ■A s c e '. B 2 t^B 22BSS '/ s ^§5 -3''' ~T ;5 c- *"• 8 => - - CI •= a: : « m ^ ^ ^ *— 7» — i- ■ i^ ;^ y : jj *^ cc .1 CC — — ' t- j5 ^ q q q iT i.-^ = t- ci-n « fi ■ ii "^ S^3^ SS I'O v-« T7 r^r-* 1 • u : ; U, . ^ .1 • . ^ • \ 11:1 ; ^ ' 2 •" • • S ■ 1 3 ^■Xl> •/J ■ 'il ii- 3 i ^~ i~ 57" a =~'r 5.? 'J ^ t* V^x.s:- 3 3 •^'irio'c • 00 o» e i2 <= 1- u = 1 £ 3 a. cs r 9 en 1; =- a —J ;j s .c 4:4 DISEASES OF THE XERVOUS SYSTEM. healthy adults of European and American races are fairly uni* form. Variations Dependent vpon Age. — -The proportions of the skull change most considerably in the first year, aud continue to change up to the fourth year. After that, modifications are slight in auiount and appear more slowly. By tlie end of the seventh year the skull has nearly reached its full size (see table), more nearly in girls than in boys. The chief measurements during childhood are given in the table. The protuberances and ridges are less marked in children. The female skull is larger posteriorly, is broader, lower, with higher orbital diameter; often it has no glabella, no super-glabellar depression, an 1 is less well marked as to its ridges, prominences, and sutures. Variations as Regards Tutee. — The length-breadth index and other cranial h dices and the volume are the only racial differences so far extensively studied. Even these are too indefinite factors to be of any practical value. In general, we may say that the doli- chocephalic or long-headed are : the English, Irish, Scandinavians, negroes, 73; Arabs, 74; Chinese, 7G. The brachycephalic or broad- headed are: the Germans, 81; Russians, Turks, 81. The meso- cephalic or medium-shaped heads are : the American Indians, 79 ; Hollanders, Parisians, 79. Tlie Variations Dependent vpou Artijieial Deformities, Accidents, Perversions of Groirth and Development, and upon Disease. — There are certain more or less pathological variations in the shape of the skull, due to a premature ossification of a suture, or arrest of devel- opment in a centre of ossification, or to a hyperplasia or aplasia of a part of the skull or of its contents. When one part is shut off from its natural expansion, other parts, as a rule, undergo compen- satory development. This principle underlies the pathology of cra- nial deformities. Those deformities which it would be w^ell to look for are : The triangular or trigono-cephalic skull; the keel-shaped or scapho-cephalic skull; the acrocephalic or pointed skull; the oxy- cephalic or steeple-shaped skull; the flat-headed skull; the plagio- cephalic or obliquely deformed skull. Variations in the Neuropathic anil Psychopathic Classes. — Varia- tion from the regular type is oftener found in these classes than in the normal, but definite variations corresponding with a special type of disease are not yet made out. For all ordinary purposes the only instruments needed in exam- ining the cranium are a tape, a strip of lead to use as a conforma- tor, and a pelvimeter. 2. IXVESTIGATIOX OF SYMPTOMS OF DISORDERED MOTILITY. — ■ In studying the attitude, expression, gait, and speech, some notion of the condition of the motor functions has been obtained. Special DIAGJfOSIS AXD METHODS OF EXAMIXATIOX, rlisturbances of the various parts must then be investigated. The patient is made to extend the arms and move them in all possible ways; the face, trunk, and lower limbs are put through all their changes. The degree of paralysis in some groups of muscles can be measured by dynamometers. The ordinary hand dynamometer of Mathieu measures the degree of paralysis in the flexors. It should be graduated accurately in pounds or kilograms. The average power of pressure on the Mathieu d^'namometer is, for an adult, forty to fifty kilograms for the right hand, and three to five kilograms less for the left. A woman has about two-thirds of the power of a man. I have had constructed an apparatus by which the strength of the leg push, Li"., 6f the ex- tensors of the leg and foot, and the extensors of the thigh is tested. Dr. W. Kraus has devised a simpler instrument. The anterior tibial and calf muscles can also be tested by means of an instru- ment called the pedodynamometer devised by the late Dr. William K. Uirdsall. Fio. 23.— Leo Dynajiosieter. Fig. 24.— Foot Dynamometer. A good idea of the degree of paralysis can be got by making the patient take the i)liysician's two hands with his own and squeeze each at the sanie time. A malingerer or hysteric will often in this way unconsciously press much harder than he is aware. Th i)hy- siciun's own ingenuity will suggest various ways of testing the strength of the leg and thigh muscles, snch as making the patient rise on one toe, climb upon a chair, push against an object with his foot, etc. Tn-iiiof is tested by making the patient hold out the hands and arms at full length, spreading out the fingers at the same time. To determine whether the tremor increases on volitional movement, give the patient a full glass of water, let him hold it out for a mo- ment, then bring it to his mouth slowly. If the tremor increases witli this movement it is called "intention." As a general rule, the tremor of organic disease is increased by volitional movement, 4G DISEASES OF THE NERVOUS SYSTEM. and ceases diiring rest of the extremity. Fuiietional tremors are usually continuous. In most forms of tremor tLe liand and arm shake as a whole. In other forms the tremor involves only the fingers or hand or forearm and hand. Such tremor is called seg- mental. It is especially aeen in paralysis agitans. As I liave abeady l'^t!±yKi^i!''''^-'i^'''Hl[i,i''X''W^^^^ Fig. 25.— Diagram op a FmK Vibratory Tremor. Ten of the divisions on the lower line equal a second. said, tremor may be fine or coarse, i.e., four to six or eight to twelve per second. To determine this accurately a special apparatus is needed ; but one can with a little experience determine this fairly well by observation alone. Or we can use a sphygmograph, as shown by Dr. F. Peterson. This instrument is fixed firmly on the table, and the tremulous forefinger held lightly against the lever. Coarse tremor is usually a sign of organic disease or of paralysis agitans, but it occurs also in hysteria and grave conditions of alcoholism. Tremor that is hardly observable by the eye can be felt by placing one's hand against the extended fingers of the patient. Tremor of the tongue and lips and facial muscles must be carefully looked for. It is tested by making the patient close the eyes tightly and show the teeth or protrude the tongue. Facial tremor if very marked usually indicates a serious condition of nervous exhaustion, alco- holic poison, or perhaps oftenest of paresis. Tremor of the whole head due to the neck muscles must be distinguished from secondary shaking of the head due to a tremor of the trunk. Fibrillary tremor, which involves only certain fibres of the mus- cle, is seen oftenest in the tongue and face and muscles of the extremities. It indicates wasting or exhausted muscles. Choreic viovevients, tics, associated and forced movements, and the other forms of motor disturbance can be recognized by simple observation. Mijoidema is a tonic spasm of a part of a muscle near its tendon- ous attachment. It is produced by a sharp blow upon the muscle near its tendonous insertion. This causes the muscular fibres to bunch up into a small tumor for several seconds. Its presence may indicate rapid muscular wasting from exhausting disease. Idiopathic muscular spasm is a phenomenon of a similar nature. When the belly of a muscle is struck with a dull instrument, a DIAGNOSIS AXD METHODS OF EXAMIXATIOX. 4? welt of cciitracted muscle appears and lasts several seconds. It indicates an exaggerated muscular irritability. The ExAMixATiox of the Reflexes. — These, as already stated, are of four kinds : (1) the superficial or skin, (2) the deep or ten- donous, (3) the visceral, and (4) the muscle reflexes or responses. 1. A skill or superficial nfii'X is produced by scratching, tick- ling, pinching, or irritating the skin with hot, cold, or chemical irritants. The result is a contraction of the muscles supplying the parts near the irritation. The skin reflexes which can be ordinarily brought out are the plantar, cremasteric, epigastric, abdominal, erec- tor spinal, interscapular, palmar, scapulo-humeral, and certain cra- nial reflexes. The plantar reflex is produced by tickling or scratching the soles ot the feet. This causes usually, when carefully done, a slight flex- ion of the toes. In many cases there is, however, no response. In irritable persons and children there is a sudden dorsal flexion of the foot, and often a contraction of the inner hamstring muscles. In pathological conditions involving the pyramidal tracts of the cord or even the motor centres and tracts in the brain there is a dorsal flexion of the toe. This is called the fiexov response or the sif/n of Babinski. The cremasteric reflex is brought out by scratching the inner side of the thigh or the skin over Scarpa's triangle. It causes a drawing up of the testicle, not of the scrotum alone, on the same side. The abdominal reflex consists of a contraction of the abdominal recti muscles, caused by irritating the side of the abdomen. Tlie epigastric reflex consists of a contraction of the upper fibres of the rectus, caused by irritating the skin of the lower part and side of the thorax. The erector-spinal reflex consists of a contraction of some of the fibres of the erector spinse, caused by irritating the skin along its outer edge. The scapular reflex consists of a contraction of some of the scap- ular muscles, caused by irritating the skin over them. The palmar reflex is produced by irritating the palms of the hands. The cranial reflexes are the lid reflex, caused by irritations of the conjunctiva or of the retina; the pupillary-skin reflex, which consists of a dilatation of the pupil caused by scraching the skin of the check or chin. The palmar reflex is rarely present in healthy people except during sleep, and in children. The superficial reflexes depend upon the integrity of the reflex spinal arc, and to a less extent upon the 48 DISEASES OF THE NERVOUS SYSTEM. degree of cerebral iiihil)ition. 'When present, they show that the spinal cord at the level through which the impulses travel is healthy. "When absent, they do not necessarily indicate much of anything, for they vary in amount in different persons and at different ages. In cerebral hemiplegia during and for a time after the acute attack, they are generally lessened or absent on the affected side. Later they may be exaggerated. - The levels of the spinal cord through which the impulse travels are indicated in the accompanying table : Spinal Nerve. Deep and Super- ficial Reflex. £51 6 1 2 3 4 15 |6 Spinal Nerve. 10 11 12 Deep and Super- ficial Reflex. Abdominal }■ Elhoiojerh I J Scapular J s Epigastric ^ 3J 1 i 3i 4 5 ■ Knee jerk Gluteal Ankle jerk and clonus Plantar Spinal Cord Levels of the Superficial and Deep Eeflexes. The deep reflexes are sometimes called tendon reflexes^ though this is not a strictly correct name, since they can be called out by striking periosteum or muscle as well as tendons. The deep reflex in all these cases is not a true spinal reflex, but is due to the direct effect of the concussion or sudden stretching upon the muscle itself (Gowers), which is in a condition of slight tonus. Those who ac- cept this view speak of the deep reflex as indicating the myotatic irritability or muscular tonus. The deep reflex implies the integ- rity of a reflex arc. The deep reflexes are very numerous. The important are : The patella-tendon reflex or knee jerk. The ankle reflex or DIAGNOSIS AXD METHODS OF EXAMINATION, 49 ankle jerk and clonus. The wrist reflex. The triceps-tendon reflex or elbow jerk. The jaw reflex or chin jerk. The light (or pupillary) and accommodation (or ciliary) reflexes. The patella reflex or knee jerk consists of a sudden contraction of the quadriceps femoris, vastus internus, and subcriireus caused by striking the patella tendon when the leg hangs loosely at right Fio. 20.— Oetti.nu tub Kneic Jf.hk uy Kk-enforcement. 50 DISEASES OF THE NERVOUS SYSTEM. angles with the thigh. This reflex may also often be ])roduced by striking the lower part of the muscle itself. The activity of this reflex is increased if, at the same time that the blow is struck, a voluntary contraction of some other muscles is made by the patient. Usually the patient is told to pull on his clasped fingers, or tightly shvit the hands. This process is called the re- enforce meat of the knee jerk (see Pig. 26). Such re-enforcement can be caused by irritating the skin and by various sensory or psychic stimuli. The nerve roots involved are those, in man, of the second and third lum- bar segments. The peripheral nerve is the anterior crural. The most essential muscles are the vastus internus (Sherrington) and Fig. 27. — Getting the Elbow Jerk. the quadriceps. The wrist reflex is brought out by striking the wrist tendons while the forearm is supinated and held limply on tlie hand of the physician. The triceps reflex or elboAV jerk is brought out by striking the triceps tendon while the arm is supported and the forearm alloAved to hang down loosely at right angles to the arm (Fig. 27). These reflexes occur in normal individuals. The jaw reflex or jaw jerk is brought out by having the })atient open the mouth and leave the jaw relaxed. A flat instrument like a paper DIAGNOSIS AND METHODS OF EXAMINATION. 51 cutter is then laid on the teeth of the lower jaw, and if this is struck smartly the elevators of the jaw contract. The light reflex is caused by throwing a bright light into the eye, and the ciliary or accommo- dation reflex by making the patient look at a distant and then at a near object. The pupil normally dilates in the former case and con- tracts in the latter. ^Mien the light reflex is lost while the accom- modation reflex remains, the condition is called the ArgijJl-Iiohertson Ankle clonus is caused by having the seated patient extend the limb and hold it rather lirnily in a semiflexed condition. The physician takes the foot by the toe and heel and quickly flexes the toot on the leg. He thus suddenly stretches the calf muscles, and they undergo rhythmical contraction. This phenomenon does not occur in healthy peo- ple. It is found in transverse and compres- sion myelitis and in degeneration of the lateral columns of the cord, and it usually in- dicates organic disease of the cord. A pseu- do-clonus sometimes occurs in which there Fig. 28.— Getti.no Ankle Clonts. are a few rhytlimical contractions on sudden dorsal flexion of the foot, but the contractions soon subside. This is seen in neurasthenia and hysteria. The deep reflexes, and in particular the knee jerk, for that is the one most easily and often tested, are practically always jiresent in ht-alth. They may be decreased, delayed, absent, or exaggerated. Their exaggeration is common and not of special clinical signifi- cance. The absence of the knee jerk is of great significance, indi- cating in persons who have no paralysis of the crural inusdes, locomotor ataxia, neuritis, or some toxiemia, such as follows diph- theria or exists in diabetes. The "paradoxical contraction" is a name given to tlie tDuic con- 52 DISEASES OF THE NERVOUS SYSTEM. traction of the anterior tibial muscles caused by the physician's suddenly flexing the foot on the leg, thus shortening these muscles. This is a rare phenomenon, never found in health, and usually as- sociated with excessive spasticity of the legs. Tlte Electrical Conditions in IHsturhunces of Hot Hit ij. — These cannot be imder stood without some description of the methods of using electricity, and hence the technique of electrical examinations for purposes of diagnosis will be described under the head of treat- ment. ExAMixATiox OF THE DisoRUEKs OF Sexsatiox. — The objcct of examining the sensory functions is to see if they are exaggerated, perverted, or lost, and to locate the extent of the disturbance. Patients differ greatly in their intelligence and power of description, so that great care must be taken in drawing conclusions as to sen- sory disturbances. In examining the skin and muscle senses, the patient's eyes should be closed and he should be carefully told to answer promptly whenever he feels the stimulus. It is best to in- FiG. 2'.). — Instrvmkxt for Testing Tendun Rkflexics. sist that he always reply in the same way, e.g., using the word "now" the moment the sensation is felt. Many ingenious instru- ments have been devised, and I have described some of them, but for ordinary purposes a camel's-hair pencil and a pin answer very well. Sensations are of two kinds, general or common and special. A common sensation is one which is referred to the body, and it is subjective in character. A special sensation is one which is referred to the external world, and in particular to the object which causes the stimulus. The pain from a knife cut is referred to the body, and is a common sensation. The coldness felt when a knife blade is laid on the skin is referred to the knife, and is a special sensation. Special senses give us very often objective symptoms, i.e., such as can be noted directly by the physician. The sensory functions to be examined are : The cutaneous. The muscular, articular, and tendonous. The visual, auditory, olfactory, gustatory, and space senses. Visceral and general bodily sensations. DIAGNOSIS AXD METHODS OF EXAMINATION. 53 The cutaneous sensations are: (1) The tactile sense, which in- cludes pressm-e and contact ; (2) the teniperatme sense, which in- cludes the heat sense and cold sense j (3j the pain sense. The first two are special senses, the last is a general sense.* To test the tactile sense, blindfold the patient and use the sesthe- siometer. This is an instrument with two rather blunt points, which can be separated or approximated. A hairpin or two ordi- nary pins can be used in its stead. Its use depends upon the fact that the power to appreciate the contact of two points on the skin gradually approximated varies with the tactile sensibility of the patient. The tongue, finger tips, and lips are the most sensitive points. The back, arms, and thighs the least sensitive. The following table shows the average distance at which two points are appreciated as such by an intelligent adult: Tip of tongue 1 mm. (J- in. ). Tip of toes, cheeks, eyelids . . 13 mm. Tip of fingers 2 " Temple 13 " Lips 3 " Back of hands 30" Dorsal surface of Neck 35 " fingers 6 " Forearm, leg, back of foot. , 40 " Tip of nose 8 " Back 60-80 " Forearm 9 " Arm and thigh 80 " The figures vary somewhat with the thickness or softness of the skin and with the dulness or keenness of the nervous organization. If the distances are double those given above, it may be considered in most cases abnormal, t The sense of contact, Avhich is a form of tactile sense, is tested by drawing a pencil or a bit of cotton lightly over the skin. The sense of locality or power to localize a point on the skin that has been touched varies with the tactile sense and with the muscular sense. It is tested by placing the finger lightly on a given spot and * Psycliologists deny tiie independence of the pain sense, and assert that it is only a quality or modification of otlier senses. f The tactile sense may also be tested by the svriling-methotl (Rvmipf). Figures or letters are written upon tlie skin witii a hard-pointed instrument, and the patient is askerackett).* *Tliis is not always the case. DIAONOSIS AND METHODS OF EXAMIXATION. 59 Ataxia of motion is tested by the gait. The patient cannot walk a straiglit line and cannot walk without watching the floor with the eyes. The arms cannot be moved in a co-ordinate way. "With the eyes closed, the patient cannot place the finger on the tip of the nose, or lobe of the ear, or any indicated spot. Ataxia of motion involves especially the articular and tendonous sensations, but not these exclusively. It may be measured by noting how close in walking the patient keeps upon a given line ten feet long; how near he can place the finger upon the centre of a board marked like a target. The patient is placed ten feet away, and made to walk directly at it and place the finger in the centre. To sum up the foregoing, we have: Due to Tested by Ataxia Muscular aiutsthesia Articular and tendouous antesthesia. Combiued forms, e.g., static ataxia. Weights, etc. Positiou of limbs. Co-ordinate movements. Locomotor ataxia I Station and gait. Vision. — The special modes of examination are given under the head of Diseases of the Optic Nerve and Ocular Muscles. The special points which the neurologist must investigate are visual acuity, astigmatism, errors of refraction, limitation of the visual field, exophthalmia, retraction of the bulb, color blindness, the state of the pupil and its reflexes. Jfrarlnij. — The special methods of examination are given else- where. The points chicfl}' to be investigated are acuity, range, bone conduction, aerial conduction, electrical reactions. 8e7is6 of Smell and Sense of Taste. — See cranial nerves. CHAPTER VI. HYGIENE, PKOPHYLAXIS, TREATMENT. In the treatment of nervous disease, the physician attempts to relieve distressing symptoms, to secure radical cure, and to prevent return. Tliis calls for various measures, which may be classed under the heads of general hygiene, diet, exercise, climate, hydrotherapy, massage in various forms, electricity, drugs, external applications, and surgical intervention. Gexekal Hygiene. — To secure and keep steady nerves, and to prevent the supervention of organic nervous disease, would require a considerable reconstruction of the present social system. I can only give some hints as to the kind of advice physicians should give to help along the desired end, this being meant more especially for the neuropath. Thus two people of very nervous tempera- ment should not marry. Blood relations of the same temperament should not marry, and families with a psychopathic taint should not intermarry. Children should be brought up to eat slowly a mixed diet, to sleep early and long, to play in the open air, to learn self-control and obedience. Their parents should keep from them all infective fevers. Systematic study and work are good for all children. It is the strain due to defective vision, poor light and ventilation, and unsuitable tasks that hurts the neurotic. Educa- tion and occupation are the best kind of builders up of healthy nerves. There are children, however, who cannot follow the ordi- nary educational lines and who must be specially trained in conse- quence. The queer and eccentric children with some twist, or pre- cocious talent, need especial care. They usually must be brought up to follow lives on a low mental plane. Too many good farmers and artisans are spoiled by being made poor professional men, or being set up in responsible business positions. Adults need to keep in mind only — moderation, exercise, and the avoidance of a luetic infection. With these they need not fear the use of alcohol, to- bacco, tea, coffee, or even occasional irregularities in sleeping and eating. Physical and mental shocks, infective fevers, and poisons are prolific promoters of nervous disease. Syjihilis stands out as the most important single factor in producing organic nervous diseases. If it could be removed v/e would have little if any loco- motor ataxia, paresis, or myelitis, and far fewer cases of apoplexy. HYGIENE, PROPHYLAXIS, TREATMENT. 61 Alcohol is a less important factor, but does iiiucli to produce mental disease, vascular disease, and hereditary degeneration. iJkt. — For the neuropathic in general, the best diet is a nitro- genous one, but it should contain some fat. Water should be drunk plentifully except by the obese, while the total amount of food should be less than when severe muscular exercise is taken. The best foods are meats, especially fowl ; fish, eggs, milk, buttermilk, cocoa, green vegetables, and stale bread with plenty of butter. If there is a tendency to constipation, farinaceous foods and green vegetables may be made the prominent articles of diet in one of the daily meals, and stewed fruit and some alkaline water added. Milk is not a very good food for adults or the aged, except in mod- erate amount. The drinks of brain workers should be mainly plain and alkaline waters. Alcohol can be taken in moderation by some brain workers without harmful results. It may even secure an in- creased capacity for Avork, but this is rarely the case in the Ameri- can climate. In persons of an especially irritable nervous system those who are classed popularly as "nervous," neurasthenic, or hysterical, the above rules apjily as to a nitrogenous diet, plus as much fat as can be digested. There is a class of nervous jjersons who of themselves find that they cannot take anything sweet without producing head- aches, rheumatic pains, and dysjieptic symptoms. These persons should live on meats, fish with butter, oysters, cream and milk, cod- li\t'r oil, and fat pork. Beef tea with the white of an egg or some peptonoids forms a very nutritious dish. It has been the canon of medicine for many years that animal food must be the soul of the neurotic's diet. Most nervous j^ersons find in addition that green vegetables like spinach agree very well with them. Stale bread can be taken twice a day freely, ]>lenty of butter being used upon it. The dietetic breads from which the starch has been removed are some- times useful, but are, as a rule, unpalatable, and soon cause disgust. Wlien a rigid diet is to be laid down, there is no better list for nervous invalids than the following: fowl; beef; mutton and lauil); fish, l)oiled or broiled; oysters; milk; butter; eggs, raw or soft- boiled; cocoa; graham bread and gluten bread; s])inach; Brussels sprouts; string beans ; stewed fruits. Sonu' iieuroticr jjcrsons seem to need a great deal of food, but as a iiilr harm comes from full dit'ts, and one cannot get strong by stuffing. Tlic frankly ncrvcjus and especially tlic liystcrical ])atient3 should not u.se alcohol at all. Tea and coffee can be taken in very snuiU amount, and best without sugar. The various alkaline juin- eral waters may be used temperately with im})unity, but none of 62 DISEASES OF THE NERVOUS SYSTEM. them have much specific effect in relieving nervousness or curing the nervous temperament. Water should be drunk between or before meals and a moderate amount at meals. At least three pints of liquid should be taken daily. American neurotics do not drink water enough. They have half-desiccateidly inti'irupted and alteruated currents of extremely DISEASES OF THE XERVOUS SYSTEM. high voltage are passed through tlie body and cause increase in iiietabolisiu and lowering of blood pressure (D'Arsonvalization). Galoanlc Batteries. — There are two kinds of these in practical use. The one includes the cells which act as soon as the circuit is closed ; the other includes those which act only when the elements composing the battery {e.g., zinc, carbon, platinum, capper, etc.) are dropped in the exciting liuiil. The former class (known as two- fluid cells) are not touched except to renew water or add some chemical. In the latter (the single-fluid cells), one of the elements is always taken from the fluid when the current is not in use. The first class of cells has a much Aveaker chemical action and evolves less electricity in a given time. It includes the Daniell cell, the gravity cell, the Leclanche cell, and the silver-chloride cell. Among the second class or single-fluid cells, the zinc-carbon cell, known as the Grenet or Stohrer's cell, already referred to, is most used. The best portable batteries are made of the zinc-carbon ceU or the dry chloride of silver cells. Stationary or office bat- teries are Itest made with the Leclanche cell or some modification of it; or the dry silver-chloride cell may be used. The electric-light current can be utilized to supply continuous and in- terrupted currents and for ])urposes of the cautery. It is expensive. Tlie ordinary accessories to the faradic and galvanic batteries are electrodes, rheostat, and milliam|>ere- nieter. The electrodes needed for ordinary purposes are: An indifferent electrode measurhig 5 cm. by 15 cm. A normal electrode, 10 sq. cm. A unit electrode, 1 sq. cm. A soft wire brush. Three handles: one 10 cm. and one 40 cm. long, one short handle with an interrupter. A milliampere- meter. A rheostat. (See Fig. 35.) Jlethods of Jjjjjlicatiov. — Static electricity is applied for fifteen or twenty minutes daily or tri-weekly. For general tonic or seda- tive effects, sparks are drawn from all parts of tlie body except the face. In paralysis or spasm or pain, sparks are applied to the affected area. For headaches and cerebral ])arsesthesise, the elec- trical breeze is very useful, but it must be strong. Author's Electrode Set. HYGIENE, PROPHYLAXIS, TREATMENT. 73 The faradic and galvanic omrents are used for about tlie same time and intervals as the static. In some cases, howev^er, the gal- vanic current should be given daily or even two or three times a day. As a rule, a course of electrical treatment should be continued for six to eight weeks, and then discontinued for a time. The special methods used in applying tliese currents are : 1. General galvanization and faradization or general electrization. 2. Local electrization by galvanization of the brain, of the neck, of the spine, of the special senses, limbs, and viscera. Or by fara- dization of the neck, spine, limbs, and viscera. 3. The combined faradic and galvanic currents. These are given by means of the De Watteville switch. General and local electrization can be given in this way. 4. The polar method. This is employed chiefl}' in using the galvanic current. The indifferent electrode is placed on the sternum or back, and the other electrode applied wherever indicated. 5. Cataphoric electrization by means of Peterson's electrode. 6. Electrolytic applications are used in enlarging strictures and affecting inflammatory deposits and neoplasms. In general electrization, whetlier galvanic or faradic, the indif- ferent electrode is jjlaced on the sternum, IVc^t, or back, and the other pole is carried over the lindjs, trunk, neck, and, if indicated, the head. In some cases, however, the two electr(.)des are applied together upon the different muscles of the body. In local electriza- tion, the large electrode may be applied on an indifferent spot, and the other applied to the affected limb or limbs, or the two electrodes may be used together on the same segment of muscles. There are special points at which the muscular contraction is most easily brought out. These are called the motor points. See Figs. 3(\ to 41. In the ordinary practice of applying electricity for spinal-cord dis- ease, witli galvanic currents, a very minute ar.iount of electricity reaches the cord. "With large electrodes, however, and currents of no to ] 10 )iiilli;imiicres the cord is reached with a current of -\ to 1,^ nia. sti-ength. In locomotur ataxia one (positive) electrode, six by twelve inches, is placed on the upper i»art of the ])ack, and a sec- ond electrode of the same or larger size placed on the al)(k)men, the lowest part of the back, the legs, and the perineum. The current should bo increased very gradually and should bo kept on for only a minute in each place. Tlu^ nu'tlmd must be varied somewhat according to the size and sensitiveness of the patient. The detail!? for galvanizing the brain, special senses, ami viscera must be ob- taineil from special text-books. When an electrode is held stea means greater than ; <, less than. Thus AnCC> CaCC means anode closure contraction is greater than cathode closure contraction. Degenerations in nerve do not occur except in lesions of the nerve or spinal cord, and in very late stages of primary atrophy of muscles. Hence when one finds degenerative reac- tions, he can almost ab- solutely exclude disease of the brain, functional dis- ease, and primary disease of the muscle. The fol- lowing rules may be formu- lated for testing for degen- eration reactions : Use the faradic current Hi'st. Fig. 42. The Fdradic Current. — Use a secondary induction coil of Avire. .225 mm. in diameter and 800 metres long. Tlie distance over which the coil moves is divided into a hundred parts. The strength of current is indicated by percentage or millimetres. In many scales it takes 30 to 40 mm. of CD or coil distance to cause a muscular contraction. Record the minimum necessary for muscular contrac- tion, using the same electrodes and in the same way as in testing with galvanism. The Galcunic Current. — 1, Place the indifferent pole over the sternum, and a 10 sq. cm. electrode over the muscle. 2. Pass the current for one minute. 3. Then find the minimum strength needed for a cathode closure contraction. 4. Then for an anode closure contraction. Eepeat this test three times. 5. With a given cur- rent, note whether the cathode closure contraction is stronger than AnCC, or otherwise. Test this three times. 6. Note the character of the contraction, if sharp or sluggish. 7. Test nerve in same v/ay. The qualitative changes may be expressed by a formula like AnCG = or > CaCC, i.e., the positive-pole closure contraction is equal to or greater than the negative-pole closure contraction. Or, better, the minimum strength of current required to cause a con- traction in the muscle is recorded for the positive poie and for the negative. Thus : HYGIENE, PROPHYLAXIS, TREATMENT. AnCG 5 ma. or 8 cells. CaCG 4 nia. or G cells. The followiug table (modified from De Watteville) and diagram (Fig. 42) show the diseases in which degeneration reactions may be expected : Table Suowlxg the Lesion, its Results, the ^Naxies of the Dis- eases, AND THE Electrical Reactions. Lesion of — Result. Disease. Electrical Reaction as to Qualitative. 1 to 214. Paralysis, c o u - Hemiplegia from hemor- Nerve : normal. Cortex to cord. iraotures. rhage. Embolism, tumors, lat- eral sclerosis. Muscle: normal. 3, 4, aud 5. Paralysis, degen- Acute and chronic ante- Nerve : DeR. Corijiia. erative atropliy of nerve and mascle. rior poliomyelitis. Muscle: DeR. 2 to 21^. Paralysis, c o n - Amyotrophic lateral scle- Nerve : normal 1 t^„t> Muscle : partial I "^"• 3 to 5. tiactures. rosis. Lat. cols, and D eg en era tire ant. corn. atrophy of mus- cle. Degenerative 5 to 6. Progressive muscular Nerve : normal. Trophic cord atrophy of luus atrophy (spinal formj, Muscle : or i>arti'il DeR. centres. cle. Paralysis from wasting of mus- cle. Later, degenera- tion of nerve. bulbar i^aralysis ('i). When disease is advanced. Nerve Paralysis; degen- erative atrophy Neuiiti.s; from wounds, to.x'aemia, or pressure. Muscle: DeR. Nerve: DeR. o f nerve and nmscle. Muscle Wasting, paresis. Simple atrophy; primary or idiopathic myositis. Nerve and muscle norma? until late in the disease. Juvenile form of i)r<)gres sive imiscular atrophy ; pset.do-nmscularhyper- tropliy ; other types of T>rimary myopathies. Nerve and tniis- Paresis and atro- Rheumatic ntrojihy and No DeR. unless severe. cle. phy. paresis. It should be said, finally, that it is the slugf/ish contraction which is the most important element in showing degeneration: also that it is the muscle which should be tested most carefully, as only over it does one get the qualitative changes. Therapnutirs. — Electricity is used as a counter-irritant and as a general mechanical tonic in slates of muscular and nervous weak- ness. It is used in i^aialysis, spasm, and pain, and for its supposed specific action in certain functional and organic diseases. The f'aradic and stati(^ currents have a counter-irritating, stimu- lating, and e.xcito-ivfiex effect. The galvanic current has a sedative and antispasmodic effect. Electrolytic, cauterizing, and cataphoric effects are al.so pro- duced, but are rarely needed by the neurologist. A considerable portion of the effects of electricity are psychical, but they are not tlie less real or valuable. CHAPTER VII. GEKERAL DISEASES OF THE PEEIPHEEAL NEEVES. Intkoductiox — Anatomical. — The peripheral nervous system consists of twelve pair of cranial and thirty-one pair of spinal nerves with their root ganglia and terminal sense-organs, and the sympa- thetic nervous system. The sympathetic system is composed of the intervertebral and the cranial ganglia, and the peripheral gan- glia. The latter arise during embryonal life from ganglionic cells of the same class as those of the spinal root ganglia, and migrate to their adult position in the sympathetic (Minot). The peripheral nervous system, therefore, to use the language of modern anatomy, is composed of peripheral motor neurons, peripheral sensory neu- rons, and peripheral ganglionic neurons (Minot). The Origin of Nerves. — The recent discoveries of the true nature of the nerve cell and its relation to the nerve fibre have made a great difference in our conception of the nervous centres. We assume that the peripheral nerves are essentially the prolon- gations of the axis-cylinder processes of the nerve cells, with certain anatomical additions which nature has made in order to isolate and support them. The peripheral nerve fibres are only a part of certain neurons. The motor nerve fibres come from the motor nerve cells, and form the peripheral part of the peripheral motor neurons. The sensory fibres are derived from the sensory nerve cells, and are only a part of the sensory neurons. All periph- eral nerve fibres of motor nerves have, in the spinal cord or brain, certain cells of origin, which are known as the nuclei of origin of these nerves. These motor miclei lie in the anterior and lateral horns of the spinal cord, and in the corresponding parts of the medulla and pons. It has been customary to refer the sensory nerve fibres also to nuclei of origin in these same parts. This, however, according to modern views, is not correct. All sensory nerve fibres take their origin from nerve cells in the posterior nerve ganglia, or in corresponding cranial ganglia, such as the petrous and the jugular, lying upon the roots of the cranial nerves. The nerve cells in these ganglia send off a single process which divides in a T-shaped fashion, the peripheral branch going out to form the sensory fibre, the central branch passing into the cord or brain, to end in a terminal arborization which surrounds groups GENEKAL DISEASES OF THE PERIPHEKAL XERVES. 79 of sensory nerve cells. These sensory nerve cells in the cord are, therefore, not really nuclei of origin, but are terminal nuclei. There are no nuclei of origin for sensory nerves in the central ner- vous system. This changed point of view is of especial importance in our consideration of the anatoni}- of the cranial nerves (Fig. 43). General Pathology. Hyperemia axd Ax-emia. — -Under the head of hyperaemia and anaemia there occur types of nerve irritation, leading to different forms of neuralgia, paresthesia, and motor weakness or irritation. Hyperaemia and anaemia are, however, secondary conditions and are rarely recognized clinically. It cannot always be determined Fig. 43.— Showing the Cells op Origin op the Motor Nerves in the Anterior Horns of the Spinal Cord, and the Cells op Origin op the Sensory Xerves in the Posterior Spinal Ganglia (Van Gehuchten). whether an irritated nerve is congested or anjemic, or whether the central part of the nervous system is not mainly at fault. Ixklammatiox ok Nkrvks — Xeukftls. — There are two forms of neuritis: 1. Interstitial neuritis and perineuritis. 2. Diffuse neuritis with parenchymatous degeneraticm. The first form may be acute or chronic. In the first type there is hyperaemia, with sometimes extrav- asation of blood. An exudation occurs into the fibrous framework of the nerve, with migration of leucocytes. The inflammation may become sui)[)urativo or gangrenous. If severe, it destroys the nerve fibres; but oftenest the axis cylinders are not destroyed, and re- covery takes place. Chronic interstitial neuritis and perineuritis are accompanied with hyperplasia of the connective tissue, com])res- sion and more or less destruction of the nerve (Fig. 44). It may 80 DISEASES OF THE JS'ERVOUS SYSTEM. ascend or descend, and it is called, accordingl}-, ascending, descend' inrj, or migrating neuritis. It may affect only certain segments of the nerve, when it is called segmental neuritis or disseminated neu- ritis. Tuberculous and syphilitic neuritis are of the chronic inter- stitial or diffuse type. These latter forms rarely involve peripheral nerves, but rather the intracranial parts of the cranial nerves and the spinal nerve roots in meningeal tuberculosis or syphilis. A syphilitic peripheral multiple neuritis is, however, thought to occur sometimes. Leprous neuritis is a very typical form of proliferating Fig. 44.— AfLTE Infectious Neuritis, showing hemorrhage, connective-tissue prolifera- tion, diseased nerve fibres, and obliterated vessel (Rosenheim). chronic perineuritis. Cancerous neuritis sometimes occurs, and it IS of the diffuse tj'pe, though sometimes an actual cancerous process invades the nerve. The second tj-pe is called degenerative neuritis and this process of degeneration is the dominant one, so that the changes can be best described imder the head of degeneration of nerves: DEfJEXEKATiox OF Kerves. — Tliis is a process in which the nerve fibres gradually die; the myelin sheath and axis cylinder disappear, leaving only a strand of connective tissue. yerre Degeneration. — There are three forms of nerve degenera- tion : 1. Primary; 2. Secondary; o. Neuritic or toxic. GENERAL DISEASES OF THE PERIPHERAL NERVES. 81 1. The primary form is rare, slight in extent, and of little clinical siguiticauce. In it there is simply a gradual Avasting and disappearance of the axis cylinder and myelin sheath. It occurs in old age, wasting diseases, and as part of locomotor ataxia (Fig. 45). 2. Secondary degeneration or Wallerian degeneration. This form occurs when the nerve is cut across, or compressed, or de- stroyed by inflammation, neoplasms, or injuries. The essential part of the nerve fibre, the axis cylinder, is simply a prolongation of the process of a nerve cell. Its next essential part is the myelin sheath. This is of epiblastic origin and consists of a hollow cylinder inclosed in a thin membrane and containing a fatty substance. In degenerative processes of peripheral nerves the medullary sheath is first affected, then the axis cylinder, least and .(&.- Fig. 45.— Simple Atrophy ok Nerve in ^fARASMi-s. last the neurilemma. The myelin becomes turbid, splits up into fragments and droplets. The £xis cylinder also breaks up into fragments or swells up and becomes liquefied. Extravasated leu- cocytes pick up the products of disintegration and form fat-granule cells. The neurilemma and its luiclei usually remain intact. The nerve during this time shrinks in volume and looks grayish and translucent, or grayish-red. The nerve finally become only a fibrous cord. Changes can be seen in the nerve within forty-eight hours, and by this time its irritability, which was first slightly increased, is lost. Ip. about two weeks the disintegration of the myelin sheath and axis is practically complete (Fig. 4(1) . The peripheral end of the cut nerve shows a loss of nearly but not quite all the fibres as far as its terminatictn. In the central end, the degeneration ascends at first onl}- to the first or second node of llanvier. Very soon, how- ever, a change occurs in the cell from wlucli the fibre springs. This change is called the rcacfton at a ilistance, or degeneration of 82 DISEASES OF THE XERVOUS SYSTEM. Nissl. Thus when the iieuraxou is injured the whole neuron suf- fers, but the peripheral end far the most. When a section is made between the spinal ganglia and the cord, the fibres all degenerate toward the cord, and even within it, but the peripheral fibres do not degenerate. Hence the spinal gan- glia are the trophic centres of the sensory nerves (see Fig. 47). Degeneration occurs in the motor nerves, also, when the cells of the anterior horns are destroyed. Hence these cells are the trophic centres for all motor nerves. The process of degeneration takes place at about the same time throughout the whole length of the nerve. The motor end plates in the muscles are affected a little the earliest. About the cut end, little bulbous tumors may de- FiG. 40. — Showing Different Stages in the Process of Nerve Degeneration on Sec- ond, Third, Sixth, and Ninetikth Days after Sec:tion (Ranvier). velop, which contain numerous nerve fibrils and connective tissue. The general law is that nerves degenerate in the direction in which they cany impulses, but this is not the whole case, as has been just described. If the injury to the nerve is permanent, a slow decay affects the whole neuron. Supposing for example a motor nerve is injured or inflamed at the point D. Immediately a degenera- tion takes place along the parts below to T, and in a few days a slight degeneration takes place in the cell body G (see Fig. 48). Snmmarij : Feripliercd nerve fibres degenerate when cut off from their trophic cells. The degeneration begins at once throughout the length of the nerve. Loss of function occurs in forty-eight hours. The degeneration is practically complete within two or three weeks. The myelin sheath and its nuclei are affected first, the axis cylinder next. The degeneration takes place most quickly and markedly in the direction in which the nerve impulse runs, except in peripheral afferent nerves. The central end of the nerve GENERAL DISEASES OF THE PERIPHERAL NERVES. 83 and its cells of origin undergo a slower and milder degeneration. The final stage is one of nerve atrophy or of nerve degeneration. Within tlie, central itercoua sijsteiti degeneration also occurs mainly in the direction of the nerve impulse. The axis cylinder is first affected. There is sometimes a preliminary swelling or hypertrophy of this axis cylinder. Degeneration with calcification of the nerve MR. S.G, Fig. 47.— Showing Effects op Section of Mixed Xerves and Sensor-? Root. PMX., Sec- tion through mixed nerve ; J/ff., motor root; .S.i?., sensory root; .S'. 6'., spinal ganglion. fibres sometimes occurs. In associative or commissural fibres the degeneration extends only part of the length of the nerve. 3. Neuritic or toxic nerve degeneration. This form occurs iu connection with neuritis, and will be described under that head. Its chief characteristics are that the degeneration attacks the nerve in segments, that the axis cylinders are not so much affected, and the myelin breaks up into small fatty droplets instead of into large masses. The same general laws apply to it as to Wallerian degen- eration. Degenerative processes in the non-medullated nervous fibres have been observed in the fine fibres of the cornea and in the submucous and myenteric plexuses of the alimentary tract. liegeneratioii of nerves is a process that usually follows degen- eration. It occurs only in peripheral nerves — very little, if at all, Fio. 48. in the nerves of the central nervous system of mammals. It is an unique process, in that the nerve is the only specialized tissue that can grow again after being destroyed. Regeneration occurs when- ever tlie tr()j)hic centres are healthy, when the mechanical obstacles to a union of the divided fibre are not too great, and when the peripheral nerve is not too completely atrophied. It occurs most quickly, therefore, when the cut ends are carefully apposed and when the separation has not lasted for a long time, i.f.y for yeara 84 DISEASES OF THE NERVOUS SYSTEM. It progresses always from tlie cent ml end toward tlie periphery. The fibres of the central stump grow out into the degenerated peri- pheral fibre. Union by Jirst intention or second intention never occurs. Human nerves cannot be made to unite physiologically, but only anatomically. * Eegeneration may be complete in a few months in short nerves. In the sciatic it may take one or two years. When regeneration takes place, the axis cylinders of the central stump swell and divide into a number of new cylinders which pierce or creep around the intervening tissue, enter in bundles the peripheral nerve, and be- come inclosed in new myelin sheaths and neurilemma. General Symptoms. One of the commonest forms of symptoms occurring in the distribution of the peripheral nerves is paralysis and atrophy of muscles in a greater or less degree. But since the motor nerve carries with it some vasomotor and secretory fibres, there may Fig. 40. also be congestion, oedema, sweating, etc. When the motor neuron is damaged only to a moderate extent or is irritated by any agent, twitchings and spasmodic movements of the muscle may occur. Spasmodic symptoms in the distribution of peripheral nerves may also be due to disturbances acting upon the central motor cell. The seat of the trouble is either in the sensory neuron, as m reflex spasmodic troubles, or in higher motor neurons. Thus, in a spas- modic disorder affecting the motor nerve A, the irritation may be in the cell body C, but is more often reflex, starting in the sensory neuron S or in a higher motor neuron whose neuraxon is repre- sented at P (Fig. 49). A symptom that is also very common in disease of the peripheral nerves is neuralgia, or the milder degree of nerve irritation called pareesthesia. AVe have besides this various forms of anaesthesia, which is due to cutting off the sensory fibre wholly. Neuralgia in its sim2:)ler and commoner j^athological forms is due to some irrita- tion of the peripheral sensory neuron, especially its ganglionic ■•^Tliis is not entirely true. Some regeneration occurs through tiie influ- ence of the neurilemma. GENERAL DISEASES OF THE PERIPHERAL NERVES. 85 centre. The particular nerve ati'ected tells the location of the irri- tation. But the peripheral sensory neuron is in close relation -with the central neurons that carry the painful impressions to the brain. Hence the whole sensory path may become disordered, and this is particularly the case in young and neurotic patients. As a conse- quence we find that neuralgias and pains are more diffuse and less sharply localized at this period of life. Besides this, it sometimes happens that the central sensory neurons in the brain are themselves the seat of injury or irritation, and we have at times, therefore, central neuralgias. However, there can be no doubt that the central sensory neurons are not easily irritated to the point of exciting pain referred to a peripheral nerve, and this is because the ascending sensory tract is a widely diffused one and not massed in a single compact fasciculus. It will be seen from the foregoing that the nervous diseases affecting the functions of the peripheral nerves will fall into three classes : first, those affecting a large part of the spinal nerves, at the same time causing general symptoms of paralysis, pain, etc. ; next, diseases involving especially certain nerves of motion ; and finally, those affecting especially nerves of sensation. So I shall describe general neuroses involving the functions of many and mixed nerves, then neuroses in the limits of the motor, and those in the distribu- tion of sensory nerves. MULTIPLE XEURITIS— POLYNEURITIS. Originally multiple neuritis was described as though it were al- wavs the same disease. Later investigations show that this is not a true view to take of it because nerves are inflamed in very differ- ent ways and degrees, and because the causes of the inflammation affect the general system so differently. A diagnosis of multiple neuritis alone is, therefore, not sufficient. The chief recognizable forms of multiple neuritis are: 1. The motor form, or paralytic neuritis. 2. The sensory or ataxic form of neuritis (pseudotabes). 3. Endemic neuritis (beriberi). 4. Acute pernicious neuritis (Lan- dry's paralysis).* TiiK Motor Tyi'K of ^Mlltitlk Neuritis {Alcohollo r/itht'rltic Faralijsis). — This is the common form of the disease, making up fully ninety percent of all * Among 71 cases of multiple neuritis of vliicli I liave analyzed the notes there were of tlie eonmion motor form, 62 ; sensory or pseudotahetie, 4 ; endemic (beriberi), .3; acute pernirious, 2. Over half of the motor type were eonfessedly alcoholic, '.\\. Of the others, there were : Post-diphtheritic, 8 ; measles, 1 ; grippe, 2 ; erysipelas, 1 ; sepsis, 86 DISEASES OF THE NEKYOUS SYSTEM. cases seen in this country. Wliile sensory and other symptoms al- ways accompany this type, it is the paralysis and atrophy of mus- cles which are the leading and chronic conditions. It is a malady coming on acutely, running a subacute or chronic course, rarely fatal, and characterized by weakness or paralysis of all four ex- tremities associated with atrophy, pain, tenderness, and various vasomotor, secretory, and trophic disturbances. It is a disease pre-eminently due to poisons and infections, alcohol being far the commonest factor. It occurs oftener in the female, owing to the fact that alcohol poisons the nerves of women more than of men, and perhaps because of the predisposing influence of tea-drinking. Multiple neuritis is essentially a disease of early adult life. Al- most all cases occur between adolescence and the period of degenera- tive changes, twenty to forty-five. Young children are very rarely subject to it, but cases have been reported occurring in children at the age of seven, nine, ten, and fourteen, and G. M. Hammond has reported several cases occurring in infants. A few cases have oc- curred m persons over sixty ; but they are only a little less suscep- tible than children. The sporadic forms of polyneuritis from alcohol and various poisons and infections occur without much reference to a seasonal influence. Probably more cases occur in spring and fall, owing to sudden changes in temperature. Epidemic influences like that causing cerebro-spinal meningitis may increase the number of cases of multiple neuritis. Practically, in this country, the question of drink settles the question of the distribution of polyneuritis. It is rare in the temperate rural districts and smaller toAvns, and much rarer in native Americans than in foreigners. Sexual excesses, exposure to cold and wet, insufficient diet, ex- cessive tea-drinking, the presence of tuberculosis, predispose to the disease. The same neuropathic tendency leading persons to excesses in alcohol, tea, and to suicidal indulgence in arsenic is of some moment in leading to the development of neuritis. The list of the special and exciting causes is long and includes nearly all infectious fevers, many chemical and autochthonous poisons. The common infections are diphtheria, puerperal and 1; puerperium, 4; diabetes, 3 ; metallic poison (lead), 2; ptomaine poison- ing, 1. The sex of 44 was male, 27 female, but in the alcoholic cases the sex was female in the proportion of 10 to 1. The age ranged from under 10 (diphtheritic cases) to 67. Most cases oc- curred between 31 and 40 (25 cases), next between 21 and 30 (18), and next between 41 and 50 (15). GENERAL DISEASES OF THE PERIPHERAL NERVES. 87 other septic fevers, and endemic infections of unknown origin. Nearly every infectious fever and malaria may be added to the list. Of chemical poisons alcohol heads the list, causing over two- thirds of the adult cases. Next come arsenic, lead and phosphorus, and copper. Among the autochthonous poisons, rheumatismj dia- betes, and the metabolic products , . .. ■ — resulting from starvation and ca- chexia lead to multiple neuritis.* Among the foregoing causes, arsenic and diabetes produce more often decided sensory symptoms. Prodromuta. — The disease often begins with prodromatu lasting several weeks. The pa- tient suffers from numbness, slight pain.s, and weakness affect- ing especially the loAver extrem- ities. Sometimes a peculiar condition of mental confusion and weakness precedes the attack. Usually the symptoms come on rather suddenly. The patient suffers from pains and tenderness in the legs and feet, and is obliged to go to bed. There may be a fever for a day or two, the temperature rising to 102^ or even 104'' F., but this is not the rule. The pains and weakness increase. The muscles and nerves are very tender. The fin- gers, hands, and arms are often similarly but less affected. At the same time the skin becomes reddened or slightly ccdematous. The muscles of the legs grow weak, and in a day or two the patient is unable to stand. In a week or two there may be a complete loss of power in the anterior tibial muscles and a lesser degree of paraly- sis ill the extensors of the hand (Fig. 60^. Nearly all of the leg and forearm muscles become eventually involved. Atiopliy sets in at the same time and very severe pains are i)resent. The- motor cranial nerves are in rare cases affected, and paralysis of the facial or of the third, fourth, or sixtli nerve li;is been seen. When the disease is fully developed, which is within a fortnight, there is paraplegia *Tiioiiiil is to he addi'fl to tlu' list of dniirs which iiiav (•aiisc neuritis. ':/ V Fig. 50.— Alcoholic Paralysis, with Foot Drop and Whist Drop. 88 DISEASES OF THE XERYOUS SYSTEM. with foot drop, some degree of wrist drop, miisc-ular atrophy, and slight oedema, especially of the feet. The skin reflexes are often, the knee jerk and elbow jerk always lost. There is some tactile an- aesthesia, often with hyperalgesia. Temperatnre and pain sense are also lessened and slowed in transmission. The anaesthesia occurs in patches or diffusely. ]\Iuscie and articular sense are lost in the sensory or pseudo-tabetic form, and are usually somewhat involved in the ordinary paralytic form. l*aiu and sensitiveness continue. The nerves lose their irritability and the muscles show degenera- tion reaction, partial or complete, the characteristic being a great variability of reaction over different groups of nerves and at different stages of the disease, and an early loss of faradic and lessening of galvanic irritability. There is sometimes retinal hyperaemia and even optic neuritis. Of the visceral nerves, the vagus seems often- est to show signs of involvement, in rapid pulse and disturbances of respiration. The sphincters are rarely involved and tliea only for a few days. In such cases there is, perhaps, involvement of the cord or of the abdominal and pelvic splanchnics. In alcoholic and occa- sionally in other forms of neuritis, mental symptoms, such as a low, muttering delirium, are very often present, and occasionally a well- marked confusional insanity develops. The disease usually reaches its height in a Aveek or two and then starts on a chronic course; but it sometimes happens that exacerba- tions occur, or that a paralysis and atrophy progress for several weeks before regression begins. In alcoholic cases there is often great general prostration ; the patients lie for several weeks in a delirious condition, and finally develop pneumonia ami die. In dipJifherifi'c neuritis some of the eye and throat muscles are involved, while the extremities are usually but slightly or tempo- rarily affected and the sensory symptoms are few. Some further details should be added. Jlotor Si/mptoins. — The characteristic paralysis of multijile neu- ritis is a quadruplegia, all four extremities being involved. The special characteristic is the foot drop, which is indicative of alcoholic neuritis, just as wrist drop is of lead jialsy. The paraly- sis is typically a x)eripheral one. It affects the feet and legs, hands and forearms. It usually involves the anterior tibial muscles more than the calf muscles, bu.t sometimes the reverse occurs. The muscles become wasted and flabby. They soon lose in bad cases all reaction to faradism, and they require a strong galvanic ciirrent to produce a contraction. In anterior poliomyelitis, on the other hand, the diminution in galvanic irritability comes on only after weeks or months. Hence an early loss of galvanic as well as faradic GENERAL DISEASES OF THE PERIPHERAL XERVES. SO reaction is an important sign of neuritis. As tlie nerve and muscle recuperate, the galvanic irritability increases. After a time, if the paralysis is great, contractures occur. The feet are extended, the legs are flexed on the thighs, and are almost immovable, and the patient's condition is most pitiable. Sensory SymptGins. — Numbness, hyperaesthesia, severe pains (dull and sharp), burning sensations, great tenderness, all occur, and are very marked symptoms. They are felt mostly in the feet, legs, and hands. Hyperaesthesia is usually followed by anaesthesia to touch and somewhat to pain and temperature. The transmission of these latter two sensations is delayed. The anaesthesia some- times occcurs in patches, at other times diitusely over foot, leg, and hand. Muscular and articular aucesthesia are common, and in the sensory form are the dominant symptom, causing an ataxia of gait and station. The other special senses are not affected except in rare cases in which there is optic neuritis. Vasomotor and Trophic Symptoms. — There is often oedema, some- times redness of the skin; occasionally the epidermis of the soles and palms peels off. Glossy skin and profuse perspiration are rare. Eruptions and ulcers do not occur. Mental Symptoms. — The most common mental disturbance is that so often seen in acute alcoholism, viz., a muttering delirium. This is associated with great general vital depression. If a true insanity develops, it also resembles, as a rule, alcoholic insanity or acute confusional insanity. The characteristic symptoms are a curious degree of forgetfulness, together with many and varying delusions rapidly succeeding each other. These often relate to the pains and paraisthesia from which the subjects suffer. They think that there are gloves on their hands or that something is on tlieir feet. They often think that they have been out walking or riding. Tliey are talkative, incoherent, and sleepless. Orffunlc Centres. — The bladder is occasionally affected for a short time, the other centres not at all. This freedom from involve- ment of the sphincters is an important characteristic of the disease in distinguishing it from myelitis. Froux the foregoing it will be seen tliat the dominant symptoms are parujsthesia, pains (burning, lancinating, and dull), muscular tenderness, some anaesthesia, paralysis affecting especially the lower extremities and causing foot drop, muscular wasting, with degenera- tio!i reactions; with no involvement of the sphincters; sometimes peculiar mental disturbances. TiiK sK\s(»i;v (>u I'SKiitit-TAiJKTic typo of multiple neuritis is causeil less often l)y aleolud and more often relatively by diabetes 90 DISEASES OF THE NERVOUS SYSTEM. and the metallic and infectious poisons. Arsenic given medicinally in doses of one-sixth of a grain or more may cause such a neuritis. Multiple neuritis from lead is not often seen in painteis, but usually when the poison is taken in larger doses, as in snuff takers. The general course of sensory neuritis is much like that of the paralytic form, but there is less paralysis, and on the other hand there are more of the burning, tearing pains, a greater degree of anaesthesia, with a very decided muscular anaesthesia causing symptoms of a subacute locomotor ataxia. The paresis, muscular wastmg, trophic changes, such as shedding of the ei:)idermis and electrical reactions, serve to distinguish the disease. A double facial paralysis some- times complicates this type. Endemic and Epidemic Types (Bevlbevl or Kakke, Igni' jyedites, Acrodi/nia, 31alarial Mtdtiple Neuritis). — Beriberi or en- demic multiple neuritis is seen in this country rarely, and only by accident. Beriberi is the Indian name ; kakke, meaning " the leg disease," is its Japanese name. Ignipedites is a name given by Indian physicians to probably the same disease. French physicians gave the name of " acrodynia" to an epidemic disease which pre- vailed in France and the Crimea in the early part of this century. It was probably multiple neuritis. There are various types of this disease, in some of which the neuritic symptoms seem subordinate to those of other organs. The forms described by Scheube and Taylor are : The acute pernicious, the acute or subacute benign, the atrophic or dry, and the dropsical or wet. The symptoms generally resemble those of multiple neuritis, as already described, plus oedema, extensive serous effusions, and gastro-intestinal disorders. The paralysis affects especially the lower extremities, but in beriberi there seems to be an especial ten- dency also to involvement of vasomotor and visceral nerves.* Acute Pkrxicious Multiple Neukitis. — There is a form of multiple neuritis which comes on suddenly, progresses rapidly, and *MALAKrAL Multiple Neuritis. — Jamaica seems to be the only place in which the malarial poison produces an endemic neuritic paralysis (Strachan), and the causation in these cases is not yet demonstrated. Dr. Strachau's description of the symptoms of what lie terms malarial peripheral neuritis shows it to be quite extensive, often involving trunk and cranial nerves, and accompanied by much pain and wasting. Cramps and skin eruptions are often noted, complications that do not occur in the ordinary types. Th(!re are sporadic forms of multiple neuritis occasionally seen in this country, but it is yet to be proved that the malarial plasmodium can alone cause neuritis. It is more likely that it acts only m conjunction with some other toxic condition. GENERAL DISEASES OF THE PERIPHERAL XERVES. 91 causes death in a few days or weeks. These cases usually show the ordinary symptoms of neuritic paralysis, with final involvement of the cardiac and respiratory nerves, causing death. The agent in these cases is apparently of the nature of sepsis. The neuritis is interstitial and hemorrhagic. Other cases of acute pernicious mul- tiple neuritis take the form of acute ascending or Landry's paraly- sis. Here there are few sensory symptoms, no electrical changes or atrophy. The disease is due to an infectious poison which over- ''':i'4o Fio. 51 . — DiPHTHKRiTio Neitritis, Chiefly INTERSTITIAL. CSiemerling); with secondary degeneration. whelms the system before it has time to set up any inflammation or organic change. In these cases the anterior-horn cells of the spinal cord are also involved and the disease is one tliat attacks the whole peripheral motor neuron. I'uiholo'ji/. — In multiple neuritis the disease affects the periphery of the nerves most, and extends up, very rarely reaching the roots. Tlie anterior tibial and musculo-spiral nerves on the two sides are oltenest and most diseased. The process when mild in grade re- sembles a secondary degeneration following section of the nerve. In severer cases there is evidence of interstitial inflammation as well 9'^ DISEASES OF THE XERVOUS SYSTEM. as degeneration (Fig. 51). This process, liovvever, varies in degree at different points of the nerve's conrse. Hence it has been called segmental or disseminated neuritis. In some of these cases and in all acute pernicious cases there is still more interstitial inflamma- tory change; small hemorrhages occur, exudation takes place, and collections of leucocytes about the vessel walls and among the nerve fibres are seen (Fig. 52). The muscles supplied by the dis- eased nerves undergo atrophy. This is usually simple and non-in- flammatory. But sometimes there is an interstitial myositis with exudation compressing the fibres (Senator). If the disease progresses, the nerve fibres degenerate and their Fig. 52.— Longitudinal Section of a Nerve in Multiple Neuritis, showing rich prolifer- ation of nuclei (Leydeu). The process here is inflammatory as well as degenerative. place is taken by connective tissue, and the same process occurs in the muscles. The spinal cord when examined by the help of Nissl and Marchi stains shows some involvement. The anterior-horn cells undergo the same degeneration as that which occurs when the nerve is cut across, and slight areas of degeneration are found in the posterior and lateral columns. The changes are very slight compared with those in the nerves and in the writer's opinion are secondary. It will be seen, therefore, that in multiple neuritis there may be: (1) Simple degeneration; (2) degeneration with some evidences of interstitial neuritis (degenerative neuritis) ; (3) decided intersti- tial neuritis with degeneration of nerve fibres. GENERAL DISEASES OF THE PERIPHERAL NERVES. 93 Diagnosis. — Multiple neuritis must be diagnosticated from diffuse or transverse mj-elitis, anterior poliomyelitis, locomotor ataxia, spinal meningitis, and hemorrhage and Landry's paral3-sis. Practically, diffuse myelitis is the disorder from which it has often- est to be distinguished. From this it is recognized, first, by investi- gating the cause and onset. Xeuritis begins more slowly and with sensory prodromata; it affects the legs and feet, especially the ex- tensors, and if it ascends it skips the hip)S and trunk and attacks the forearms. There is more muscular atrophy than in myelitis; the knee jerks are absent. It progresses more slowly, and after four or eight weeks gradually regresses. Electrical degeneration reactions are more varied and decided. There are tenderness over the muscles and nerves and peculiar burning, darting pains. The cutaneous anesthesia, if present, is not so extensive and complete, as a rule, Avhile muscular anaesthesia is more decidedly marked. There is very rarely involvement of the sphincters or bedsores. There may be belt-like constrictions felt round the extremities, but not around the waist. The gradual improvement of the paralysis and atrophy and eventual recovery confirm the diagnosis of neuritis. The presence of neuritis of the cranial nerves would strengthen the theory of a general neuritis. From poliomyelitis it is distinguished by the presence of pain and other sensor}' symptoms, the earh* fall in galvanic irritability, the age of the patient, and the etiology. From locomotor ataxia, neuritis is distinguished by its more rapid onset, the presence of paralysis and atrophy of muscles, paresis, with degeneration reactions, and the absence of involvement of the organic centres and pupils. Spinal hemorrhage usually leads soon to a secondary diffuse myelitis easily distinguishable from neuritis by the characters above given. Here there is also usually pain in the back. Spinal menin- gitis is associated with characteristic i)ain, tenderness, and stiffness along the back. Acute ascending paralysis in its typical form shows but very slight sensory disorders, and no wasting or change in elec- trical irritability. The complication of multiple neuritis and myelitis or posterior sclerosis is possible, but is very rare. In the former case the ordi- nary symptoms of myelitis are added to those of neuritis. In loco- motor ataxia there is often some nerve degeneration and occasionally neuritis. The nerve degeneration probably causes only slow atro})hio changes and paresis; the neuritis causes pains, anaesthesia, skin eruptions, and local troi)hic disorders. I'j-o'jiiosis. — Alcoholic multii)le neuritis is a serious disease, be 94 DISEASES OF THE NERVOUS SYSTEM. cause of its associated conditions. uSTearly one-half of my patients have died, mainly because they continued the use of alcohol after paralysis appeared. They do not die of neuritis, but of alcoholism or of phthisis. Other forms of neuritis rarely cause death. The great majority recover almost completely. It may be from six months to two years before all symptoms disappear. The average time is about a year. Treatment. — The patient needs, first of all, rest in bed. The limbs are often extremely tender and the patient's pains excruciat- ing. To relieve these the legs may be painted with menthol and enveloped in cotton batting. In other cases flannels wrung out in hot water and renewed every two hours give relief. Internally phenacetin, antipyrin, or other coal-tar products may be given for the pains. Fluid extract of ergot in doses of 3 i. to 3 ii. repeated in three hours sometimes relieves pain. In the early stages, salicylate of soda in doses of gr. xx. every two or three hours is recommended. If there is a great deal of depression from alcoholic poisoning, strychnine, gr. -gV q. 3 h., and aromatic spirits of ammonia, 3 ss. q. 3 h., should be used. There is no drug which really cuts short the process. The best measures for this purpose are rest, thorough cleansing of the alimen- tary tract, abstinence from alcohol, and a nourishing diet. After the acute stage is passed the labile galvanic current occa- sionally interrupted may be applied, 5 to 10 ma. for ten minutes three times weekly. Later, by the sixth week, the faradic current, mas- sage, and careful exercise should be given. At this time or earlier (third week), strychnine, iodide of potassium, arsenic in small doses, and tonics may be given. In old cases in which a great deal of paralysis and contracture have occurred, forcible extension of the limbs, the use of splints and rubber muscles, are needed. With patience and perseverance the worst cases can eventually be brought to a complete recovery. COMPLICATIJTG PoRMS OF NeURITIS AND NeUKITIO DEGENERA- TION. — Neuritis and neuritic degeneration complicate many dis- eases, but they especially mark and modify subacute and chronic rheumatism, locomotor ataxia, diabetes, ])aralysis agitans, wasting diseases, and old age. A neuritic degeneration almost always affects the nerves in the neighborhood of an old rheumatic joint. The chief result of this is to produce wasting and some paresis of the muscles inoving the joint (Pitres and Vaillard). The process is a reflex atrophy (see Arthritic Muscular Atrophy). In locomotor ataxia, parenchymatous nerve degeneration is very GENERAL DISEASES OF THE PERIPHERAL NERVES. 95 often present. It does not produce the cardinal SA'iuptoms of tliis disease. It does, however, cause some of the anaesthesia, partes- thesia, muscular atrophy, skin dystrophies, and visceral crises. Ill diabetes, the neuritis takes the form of the sensory type of multiple neuritis, and causes symptoms like those of locomotor ataxia. The patient has sciatic pains, burning or numb feet, loss of tendon reflex, ataxia. The upper extremities are rarely affected. 1)1 Wastlnrf Diseases and Old Age. — ^In various wasting diseases, such as phthisis, cancerous cachexia, long-continued fevers, maras- mus, and in senility, a simple parenchymatous degeneration of nerves, with atrophy, occurs (Arthaud, Koster, Jappa). The symp- toms caused by these changes are very slight. They contribute to the weakness and wasting. In old age, the atrophy of the nerves is one cause of the lessened sensibility and activity of the skin and its underlying muscles. TUMORS OF NERVE. These consist of: 1. Nerve hyperplasia. „ ^ ^ ^. , \ Benign. 2. True neuromata. ( Smgle. -^ Malignant. 3. False neuromata. \ ^i^.j^iple. J, Benign. 1. Jlijijei-plasia or hypertrophy of nerve trunks is very rare. Generally the increase in size is, in fact, due to increase of the in- terstitial connective tissue. Sometimes there is an increase in the number of fibres and thickening of the myelin sheath. 2. True neuromata are also very rare, and occur almost exclu- sively on spinal nerves. In some there is an increase in medullary fibres; in others only an increase of non-medullated fibres, /.'-., only the axis cylinders and neurilemma increase. They occur either singly or multiply. Miiltijde neuromata are generally of a neuro-fibromatous character. Neuro-fibromata when multiple may affect the subcutaneous nerves and form growths known najihroma vtoUuscum. Nerve fibres united in a nuiss by hyperplastic connective tissue form what are called jjlrxiform neuro-Jibrojnata. Multiple neuro- mata may be true neuromatous growths. True neuromata are usually small, ranging from 1 cm. (two- fifths of an inch) to 6 cm. in diameter. They may be much smaller or larger. Neuromata are usually few in number, or at least there is only a local multiplicity of tumors. Multiple (true) neuromata may, however, be very numerous. Gowers estimates in one case that as 9G DISEASES OF THE XERYOUS SYSTEM. luanj- as one thousand were present. Even larger nnmbers liavs been observed. 3. False JSeuroriiata. — This term is applied to the various uerve tumors in which a fibroma, myxoma, glioma, sarcoma, carcinoxx^a, or syphiloma grows upon or in the nerve. Fibro-ueuroma is tne most common formj glio-neuroma has been observed on the auditory nerve. Syphiloma occurs only on the intracranial or intraspnial nerves. Carcinoma of nerves may be primary, but is generally secondary, and is of scirrhous or medullary type, rarely the colloid. Leprous neuritis sometimes forms neuro-fibromatous swellings. Ttihercula dolorosa are simply small false neuromata situated subcutaneously on the ends of the sensory nerves. They vary much i)i histological structure. Malignant Neuromata.- — A few cases, about thirty in all, have beeen observed of multiple malignant neuromata. Trauma and hereditary influence are the etiological factors. The great nerve trunks are oftenest affected, the median, sciatic, and crural ranking first. The tumors start from the perineurium; they are at first spindle shaped, and may grow very large. Sarcomatous cells are oftenest found in thein ; but they may be myxomatous, fibromatous, or mixed. EfhiliKiij. — Three general causes exist for the production of neu- romata, viz. : 1. A hereditary or a neuropathic predisposition; this tends to cause the true, the multiple, and the plexiform neuromata. 2. Injuries, surgical operations; these cause especially the fibro- neuromata of which the amputation neuroma is an example. 3. Diathetic, e.nfjitiidiN((l ImndJc. The fibres of the third and fourth nerves pass to their nuclei on the same side, then decvissate and pass up in the inner part of the Fig. 54.— Showing Distribution of Third and Sixth Chanial Nerves. erusta to the frontal part of the central convolutions of the cortex, A. few fibres decussate and enter the nuclei of the opposite side. They are connected with the internal rectus nucleus. The fibres of the fourth nerve almost entirely decussate, running forward a long distance before they finally reach their nuclei. Thus it appears that the fourth is the only cranial nerve except the optic which largel}- decussates before reaching its nucleus. However, those fibres of the third Avhich supply the internal rectus also de- cussate, as already stated. The arrangement of the nuclei is believed to be as follows, the upper on the list being anterior : Median line, r Sphincter iridis, Ciliariiis. III. X. Levator palp. , Eect, int. Rectus superior, Rect. inf. Obliquus inferior. rV. N. \ Obliquus superior. VI. X. ] External rectus. MOTOR DISOllOEP.S OF SI'FXIAL XEKVES. 101 In order to understand the peculiarities of eye palsies, to be de- scribed later, the relations of the sixth to that micleiis o± the third nerve which innervates the internal rectus must be understood. In turning the eyes to one side, these two nuclei and their nerves act together, causing the external rectus of one eye and the internal rectus of the other to contract at the same time. The impulse from the brain which does this decussates and acts first upon the sixth, and through this npon the external-rectus n\udeus of the same side. The impulse from this nucleus then goes to the third-nerve fibres of jV. suprotroch ON. tVfptr y. nupraorb. Red. aup. Leirator^ p.- nua max. But. inf. ' N. supramax. Fir;. 5."). — Tiiii .\itaciimext op thk Eye ?Iuscles to the (iLOBE (Merkel). the same side and thence to the internal rectus. This can be better understood by the diagram, i'ig. 57. Thus lesions in the brain at (ji) cause paralysis of the sixth nerve of the opposite side and internal rectus of the same side. The eyes turn toward the side of the lesion. Lesions in the pons at (h) cause paralysis of the sixth on the same side and internal-rectus nucleus of the opposite side The eyes tiuu away from the side of the lesion. The eye musides move the eyeball in the following way: The superior rectus elevates the eyeball. The iuferior obli(pie rotates out and up. The inferior rectus depresses the eyeball. The superior obiiipu; rotates out and down. The superior and inferior oblicpu', acting together, rotate inward. The external rectus rotates outward. The internal rectus rotates inward. The rectus internus, rectus superior, ol)li«pius iuferior, rotate upward and inward. 102 DISEASES OF THE NERVOUS SYSTEM. The rectus iutei-uus, rectus inferior, obliquus superior, rotate downward and inward. The rectus externus, rectus superior, obliquus inferior, rotate out and up. The rectus externus, rectus inferior, obliquus superior, rotate out and down. The movements of the eyeball are made by the simultaneous ac- tion of several muscles. Most of them act as their names indicate. But the oblique muscles help to depress and elevate, and then help to rotate in or out according as the internal or external rectus is acting. oVIN Fig. 56. Fig. 5r. Fig. oC. — Diagram showing the Arrangement of the Nuclei of the Motor Nerves OF the Eye, and the Decu.s.sations of the P'ourth and Internal Rectus Branch of THE Third Nerve. Fig. 57. — Diagram showing the Probable Relations of the Nuclei of the Sixth AND OF the Internal Rectu-s Branch of the Third to the Brain. P.L.B., Posterior longitudiual bundle. The cortical centres for the eye muscles are not positively known. Lesions in the inferior parietal lobule sometimes cause paralysis of the third nerve. Lesions of the posterior part of the prefrontal lobes also sometimes cause eye palsies, especially conjugate devia- tion, and the dominant are in the prefrontal lobe at the base of the upper and middle frontal convolutions. As the optic nerve is the special sensory nerve of the eye, so the third, fourth, sixth, and part of the seventh nerves are the motor nerves. By means of the optic nerve and its receptive and re.frac- tive apparatus, the form, color, movement, and, to some extent, re- lations and distance of objects are determined. The motor neives adjust the eye to near and distant objects, inform us as to size and distance, and enable us to follow moving objects and to shift the gaze readily. They also assist m protecting the eye against injury. MOTOR DISORDERS OF SPECIAL XERVES. 103 Genkkal Symptoms. — It is impossible always to disassociate di.se;is«'!5 of tlie Ofulo-motov nerves from those involving their nuclei. Hence we must study here really the affections of the whole neu- roji8. These are: 1. Paralyses or ophthalmoplegias, which may be acute, chronic, or progressive. 2. Pareses or amyosthenic states, called ordinarily muscular asthenopias. o. Spasms, such as strabismus, nystagmus, and blepharospasm. There are uiany special terms which are used to indicate the peculiar effects of various paralyses and spasms of the ocular mviscles and nerves, and some of thes(^ I will define here : Erroneous projeition is a condition in which the patient is unable to judge exactly of the relation of external objects to the body; for this relation is determined by the movements of the ocular muscles, and, these being weak, wrong sensations are conveyed to the brain. Vertigo may result from this disturbance of muscular sensation. l)ilil(>/iiii or double vision is a condition due tu the erroneous sen- sation resulting from eye-muscle palsy, and to the fact that the images of the object fall upoii non-correspond.ing retinal fields. Diplopia is simple or homonymous when the false image is seen on tlie same side as the affected eye. When a red glass is placed over this eye two images are seen, the red one being on the side of the eye involved. r)iploi)ia is heteronymous or crossed when the false image is on the side opposite to the sound eye. ( 'oitjuf/fite (/friafioii of the eyes is a condition in which both eyes turn strongly to one or the other side. It nmy be paralytic or spas- modic. The mechanism is a complicated one and not perfectly un- •ler.stood. In general, destructive lesions of the brain cause a ])ara- lytio deviation toward the side of the lesion, and irritative or compressing lesions the opposite effect. Destructive lesions in the )>ons cause a deviation away from the side of the lesions. The palsy then involves the sixth cranial nerve and the branch to the internal rectus from the third. The sixth-nerve nucleus is the domi- nant one, and im])ulses from the brain go to it first (see Fig. 57). In diseases of the motor nerves of the eye it is found that the jjaralyses occur in various ways, which may be best groujied as follows : Oiihthalmoplegias . 1. Paralyses of the third nerve. i Acute. 2. Paralyses of the fourth and sixth nerves. \ Chronic. ."). Progressive paralysis of all or part of these nerves. 104 DISEASES OF THE NERVOUS SYSTEM. The Ophthalmoplegias. I. Paralysis of the Oculo-Motokius or Third Nerve — J£tivlo(jj. — The commonest causes are exposure to cold, and syphilis. Other causes are basal meningitis, intracranial tumors, injuries, compression from orbital tumors, the diphtheritic poison, and ex- cessive exposure to light; excessive use of tobacco, and alcohol, morphine, or other poisons may be a cause. Temporary palsy some- times occurs in migraine, or it may take the place of an attack of migraine. A palsy of some of the muscles supplied by the third is sometimes caused by cerebral lesions involving the inferior parietal lobule. Partial palsies also occur in locomotor ataxia and in certain primary muscular atrophies. The common causes, liowever, are, as stated, rheumatic in- fluences and syphilis. There occurs, in rare cases, an acute in- flammatory degeneration of the nuclei of the ocular-muscle nerves similar to acute anterior poliomyelitis. This condition has been called " polio-encephalitis superior" or upper bulbar /'^' -V palsy. 4 Sijnqjtoms. — When all the muscles sup- no. 58. -Double Ptosis, pli^d by the third HcrvB are paralyzed, there is dropping of the lid (ptosis, Fig. 58); the eye can be moved only outward and downward and inward; there is therefore divergent strabismus and double vision (diplopia). The pupil is somewhat dilated and does not contract to light, owing to paralysis of the constrictors of the iris ; and there is loss of power of accommodation, so that the patient cannot read print close to him. The patient suffers much annoyance from the lid drop and the double vision, and there are sometimes vertigo and photophobia. Only one nerve is involved at a time as a rule. The various eye muscles supplied by the third are rarely all attacked. The levator may escape almost entirely ; the ciliary muscle and iris may also be but slightly involved; but these latter nniscles are never involved alone in ordinary types of the disease. The affection usually runs a subacute course, lasting but a few weeks. Functional palsies last but a few days; syphilitic palsies are usually temporary (one to three Aveeks), but may relapse or be- come extremely obstinate. Periodical palsies occur every year or six months or even oftener; they last a few days or weeks and are accompanied at first by some pain. They continue to recur for years. They may be associated with attacks of migraine. MOTOR DISORDERS OF SPEPTAL XERVES. 105 In diphtheritic eye palsies the first three or four nuclei of the eeries making up the origin of the third nerve are oftenest affected, causing paralysis of accommodation, paralysis of the iris and of the internal rectus, the three muscles concerned in accommodating the eye to near objects. Fatholofjij. — In the rheumatic jxilsies there is a low grade of peripheral neuritis, and the same is true of most diphtheritic and other palsies of infectious origin. In syphilitic and tabetic palsies Fio. 59.— Sht'tter for Testing Pi'pil Reki.ex. Tlie appiii-iitus ailinits of usingcolored kIbkhcs for testing,' liystt-ria atul inaliiigering-; also of the use of a !\IaclUox prism for testing I lie eye Tiiiiscles. there is usually a specific basilar meningitis involving the nerve roots. The meningitis may be sliglit or may amount to gummatous dt'l)Osit. In fuTictional and some periodical palsies there is a vaso- motor disturbance causing congestion or anaemia or jx-rhaps simply iiiliil)ition of the nuclear centres. Some periodical palsies have been found to be due to small tumors involving the nerve root. In rare cases there is ])rimary nuiscular atrophy of the eyeball nerves, or ])rimary degeneration of the nuclear centres, or a cerebral lesion. The nuclear inflammation forming " polio-encephalitis su]»erior" is a disease jn-obaVjly inl'ectious and (jiiito similar to anterior polio- myelitis. 106 DISEASES OF THE NERVOUS SYSTEM. Diagnosis. — One must first determine how extensively the muscles supplied by the third are involved. If only the levator palpebrte, there is simply falling of the lid. If the eyeball muscles are involved, we get the following symptoms. They are : Limitation of movement of the globe. Strabismus and secondary deviation. Erroneous projection. Double vision or diplopia, which is either simple or crossed. Paralysis of the iris or iridoplegia and of the ciliary muscle or cycloplegia. Concentric limitation of the visual field. All these points must be tested, but the detailed knowledge of them is best gained by consulting ophthalmological works. The extent of involvement of eye muscles can generally be suffi- ciently tested by making the patient move the affected eye in various directions, and by testing for accommodation and for the pupillary reaction to light. Paralysis of the ikis, ok iimdoplegia, and of the ciliary muscle — cycloplegia. The motor fibres of the third nerve to the iris supply the sphincter, and when paralyzed there are dilatation and immobility of the pupil, a condition known as mijdriasis. Fibres from the same nucleus innervate the ciliary muscle, and the iris and this mxiscle are usually paralyzed together. Paralysis of the ciliary muscle is called ciidojilegia. In this latter condition there is loss of power of accommodation. Iridoplegia and cycloplegia are usually due to local disease of the eye or to the use of mydriatic drugs. Occasionally they are observed after diphtheria or in multiple sclerosis. It may occur in locomotor ataxia, and in disease of the lower cervical cord involving the cilio-spinal centre, which when destroyed causes a myosis. Paralysis of the levator iialijehra;, causing jAos'is, is sometimes seen alone, but usually other branches of the third nerve are in- volved. A functional palsy of the lids sometimes occurs in anemic and nervous people at the time of waking. It is a temporary inoni- ing or u-aking 2>tosis. Paralysis of the sympathetic fibres of the eye causes con- traction of the pupil (myosis) from the unopposed action of the third nerve. There is also a slight prominence of the eye and slight ptosis from an involvement of the nerves that supply Mllller's muscle. The pupil does not dilate when the skin of the cheek or neck is irritated. This is a condition known as loss of skin reflex. In locomotor ataxia there is often a rigidity of the constricting fibres MOTOR DISORDERS OF SPECIAL NERVES. 107 of the iris, while the ciliary muscle continues to act. The i)upil is then small and does not respond to light, while it does respond to accommodation. This is known as the Arg[/U-Eohertson pupil . II. Pakalysis of the Fourth Nkrat:. — This is a rare affec- tion and not always easily detected. The causes are much the same as those of palsy of the third nerve. The symptoms are slight convergent strabismus when the eye is moved downward and diplopia on looking down. There is defect in the movements of the eye doAs'nward and outward. Paralysis of the sixth nerve (abducens) is the most fre- quent of eye palsies, and occurs especially often in syphilis and in locomotor ataxia. It causes convergent strabismus and double vision. III. pROGRESsivi: Ophthalmoplegia {Fro'jressli-e TJpper Buh hill' J'o/s//). — Besides the palsies already described, there occur cer- tain forms which have a peculiar origin and course. They begin slowly, as a rule, and steadily progress. In some cases only do they reach a certain stage and then remain chronic. The term '' progres- sive" applies fairly well to them. They often affect the third, fourth, and sixth nerves together. In accordance with the muscles invaded, these palsies are called external, inteinud, paiiial, and tolal. Thus if tliose branches of the third nerve supplying the iris and cfinitt(>ii. — Progressive ophthalmoplegia is a degenerative dis- ease of the nuclei of the motor nerves of the eye. It is in most cases the same disorder as of bulbar paralysis and ])rogressive mus- cular atrophy. J'jttnlixjij. — It develops between the ages of fifteen and forty, but may occur later. The sexes are equally affected. Lead, diphtheria, traumatism, syphilis, appear sometimes to be the cause. It may complicate locomotor ataxia; more often it forms part of progressive muscular atroj)hy. The si/iiijjfmtis are often not noticed until tiie disease is far ad- viinced. The vision is not disordered, and there is only a gradual limitation of mobility of the eyeliall. A slight droopingof the lids, cinising a sleepy look, or a slight squint, usually divergent, is noticfd. 'I'hen uj)ou examination it is found that the eye cannot follow tht! finger, except to a slight extent. This peculiar physi- ognomy is known as the "Jfutchinson face" (see Pig. GO). The iris reacts to accommodation and light usually. Double vision may he present. Usually the patient accustoms himself to monocular vision. The disease lasts a long time, and it may become station- ary. If complicated with progressive nniscular atrophy, however, 108 DISEASES OF THE XEKVOIS SYSTEM. the course is relatively rupid, death occiu'ring from the latter dis- ease in two or three years. Fatlwlogical Anatomij.- — In all progressive cases there is a de- generative atrophy of the nuclear cells. In a few rare cases no lesion has been found, and in a few stationary cases the anatomical change is that of neuritis. The treatment is that for the disease which it complicates or the condition which causes it. That is to say, it is the treatment for locomotor ataxia, progressive muscular atrophy, syphilis, or lead Fig. CO.— Sho-wing "HtrrcHiNsoN Face." poisoning. Iodide of potassium, strychnine, arsenic, nitrate of silver, and phosphorus may be given. Electricity is of very doubt- ful value, and only the galvanic current would be indicated. Gen- eral tonic measures and rest to the eyes should be employed. Muscular Asthenopia axd Muscular Insufficiencies.* — This is a term employed to indicate a lack of equilibrium of the muscles of the eye, as a result of which the visual axes cannot be kept parallel without an effort. This effort is often unconscious, and shows itself only by a ready tiring of the eye on attempting to read, or by the production of headaches and cerebral parsesthesise. Examination of the eye by. means of prisms reveals the special character of the trouble. When the eye muscles act normally the condition is called one * Partial njilitlialinopicgia occurs also in myasthenic paralysis. MOTOR DISOKDEHS OF SPECIAL NEUVES. 109 of ovthoijhovia. "When some of the muscles are Aveak it is called lieteivplioria. There are various forms of heterophoria, viz. : eso- phoria, a teudiug of the visual lines inward, from weakness of the extern! ; exophoria, a tending of visual lines outward; hyperphoria, a tending of the visual line of one eye above its fellow. The condition is tested in various ways. The simplest is this: Kefractive errors having been corrected, a series of prisms is placed over the eye, at first with the base inward, while the patient looks at a candle twenty feet distant. The prisms are increased in strength until the patient can no longer coalesce tho images. The degree of prism is noted, and this indicates the strength of abduction or of the externi. The same process is gone through with for the in- terni, the base of the prism being out. The externi should over- come a prism of about 8"^, the interni one of 23'' to 25'^ or more. There are great individual variations, and there is also considerable variation in individuals. The above tests measure the amount of abduction and adduction. To test the presence of heterophoria, the writer uses the Maddox double prism held in a frame. The line where the bases of the two prisms unite is brought directly over one eye, and is held there in a perfectly horizontal position while the patient looks at a candle twenty feet away. A red glass is at the same time held over the other eye. "With the eye covered by the double prism the patient sees double, one flame being above the other; with the other eye he sees a red flame lying just between the two white ones. If the red flame is directly in a vertical line, there is orthophoria; but if it lies to one side or the otiier there is exophoria or esophoria according as the red flame was on the side opposite to the eye covered with red glass or on the same side. If heterophoria is found, prisms are placed over the eye until the three lights are in a vertical line. The number of the jirism required to correct the heterophoria indicates its extent in degrees. By changing the double prism so that its common base line is vertical, the test for hyperphoria can be made.* Mi/snt/iir (isf/ifti()jt!n is said to cause a disturbance of vision, vertigo, migraine, cerebral para.'sthesia, and pains in the head, more particularly in the occipital and cervical region. It is believed to be a possible factor in producing choreic twitchings in the face. In neurasthenics persons it may eaus(! a wider range of nervous symp- toms. It is said to lie an essential factor in causing epilepsy, chorea, and hysteria. The author cannot accejjt this latter view, and believes that the importance Df muscular asthenopia in causing * Merc cl!il)tjratc uiul exact metliods have hccii devised by Dr. Stevens ant' are empmyed 1)y ophtlialniologists. 110 DISEASES OF THE NERVOUS SYSTEM. general nervous symptoms is not great. Mucli of it, if not all, maj be relieved hy correcting refractive errors and by helping the gen- eral health of the patient. The treatment of it, after all myopia, or hypermetropia, or astigmatism, if present, is relieved, consists in building up the gen- eral health, the systematic use of prisms for training the muscles, the wearing of proper glasses. Some advise graduated or complete tenotomies according to the method of Stevens. Spasmodic Diseases of the Ocular Muscles. These are: (1) Conjugate deviation from spasm; (2) irregular and associated spasms from convulsive and irritative brain disorder; (3) nystagmus. Spasmodic conjugate deviation occurs from an irritating lesion of the ocular nuclei or of the brain in its cortical motor areas and tracts. Irregular spasmodic movements occur in meningitis, hydrocephalus, and in lesions involving the semicircular canals. Peculiar asso- ciated spasms occur in hysterical attacks. Various spasmodic move- ments and contractions of individual eye muscles occur from ocular disease, errors of refraction, muscular weakness, and paralysis of certain eye muscles. ' llhytltriiical siiasni or nystagnius occurs as the result of hereditary visual weaknesses and refractive errors of various kinds, in albinoes, and in chronic hydrocephalus. It is found usually in neurotic cases associated with ocular defects, in multiple sclerosis, and sometimes in epilepsy, chorea, hysteria, neurasthenia, and insanity. It occurs in certain degenerative nervous disorders such as disseminated sclero- sis, hereditary ataxia, tumors, especially of the cerebellum, and other focal lesions, and in meningitis. It occurs in miners, and is called miners' nystagmus. It may be a reflex symptom from a remote irritation. Tn nystagmus the oscillation of the eyeballs is usually lateral. It may be brought out when slight in degree by causing the patient to look steadily to one side. Vertical and a kind of rotating nys- tagmus sometimes occur, and are due to much the same causes as those of lateral nystagmus. Spasm oftJie Itiinitor imlpehrai is sometimes seen and is usually tonic. The above troubles are usually syinptomatie, and their treat- ment depends upon correction of some local disease or cerebral neurosis. MOTOR DISORDERS OF SPECIAL ^-ERVES. 111 The Motor Branch of thk Fifth Cranial Nerve. The anatomy of this nerve is described under the head ot the neuralgias of the trigeminus. The diseases of tlie motor branch of the trigeminus are rare, and generally symptomatic of some more general disorder. Trismus (lockjaav) is the only important independent affec- tion of this motor nerve. It is a tonic spasm of the muscles of mastication. Etiolorimary origin in a single nucleus deeply situateil in the lower part of the pons (Fig. 01). It belongs to the same series of nuclei as the motor nuclei of the vagus, glosso-pharyngeal, and of the spinal aee<'Ssory; in other wortls, it is a prolongation of the lateral Jioru of the spinal cord. It has not a nucleus common to it with the sixth, as is usually stated. Those fibres of the nerve which go to the orbicularis, liowever, appear to come from a nucleus in the third-nerve series and to reach the knee of the facial by the posterior longitudinal bundle (Mendel). The deep fibres of the facial take a tortuous course, ])assing inward, dors:illy, then curving down and out around the nucleus of thesixth nerve (Fig. 02). The cortical origin of the seventh is in the lower part of tlui central convolutions, es])ocially tlu? precentral. The fibres pass down through the knee of the internal cai)sule and enter 112 DISEASES OF THE NERVOUS SYSTEM. the ci'usta at the inner side of the pyramidal or motor tract. They decussate and reach tlie nucleus. The nerve has its exit at the posterior edge of the pons, external to tlie sixth nerve. It then has to take a long course through a bony canal, during which it receives taste fibres from the second or third branch of the trigeminus (or the glosso-pharyngeal). These fibres leave the nerve at the chorda tympani, and join the lingual branch of the fifth nerve to supply taste to the anterior two-thirds of the tongue. The facial nerve supplies motion to all the muscles of the face; to the stapedius, stylo-hyoid, buccinator, and platysma myoid. It B. VII Fig. 01.— Showing the Position op thk Ckanial Nuclei in the Medulla. also contains trophic and secretory fibres. It does not supply, how- ever, the muscles of mastication. The taste fibres of the facial nerve come in most cases from the second branch of the fifth via Meckel's ganglion, the large superior petrosal nerve, and geniculate ganglion. In other cases they come from the glosso-pharj^ngeal nerve via the ganglion petro- sum, Jacobson's nerve, tympanic plexus, and geniculate ganglion (Fig. 63). Some think that the intermediary nerve of ^^'risberg, which arises in the upper part of the glosso-phyaryngeal nucleus and connects with the geniculate ganglion, carries taste fibres to the facial. The facial nerve being motor, its diseases are spasmodic and paralytic. The two common types are facial tic and facial palsy, but there are other minor forms. The spasmodic disorders are (1) diffuse facial spasm or mimic tic and (2) spasm of single branches, including (a) blej)hai'Ospasm and (Ij) nictitating spasm. MOTOR DISORDERS OF SPECIAL NERVES, 113 Facial Spasm (Mimic Tic). — This is a disease characterized by intermitteiit, involuntary twitchiugs of the facial nniscles. It is always chronic and generally unilateral. Etloloijij. — It is a disease of middle and later life, and occurs 1 / wS^m^^m^mm^ nff s ^ ^ Flo. 62.— Showing the Relative Position op the Nuclei op the Motor Cranial NEKVE3 (Van Gehuchten). oftener in women; there is usually a neuropathic constitution; it is not hereditaiy. The exciting causes are anxiety, shock, injury, and exposures. It often has a reflex cause, usually from irritation of some branch oi the trigeminus or the cervico-brachial nerves j rai-ely n moix Inf n irtju.nitauy' nopkVialm. /'-~\_^'^ ^ b€ivt ftUreujc. iUDcrf.- n JycUcLd n cUjxt ■n d m, cl leJtritl' cU, Jo-cobsoit, UiixpuraJ ^ufitrf. r c^tt cClo & citx Atulo- Kuoict I6r tcmporo fgnale. Fio. 68.— Shovino the Coursk or the Tastk Fibrks in- the Seventh and Fiptb Xkhves I Kraiise), from eye strain. It is sometimes associated with tic douloureux. Organic diseases, such as tumors and softening, affecting the nerve nucleus in the pons or the cerebral centres, cxuse a symptomatic tic, but not the true disease. Thus we may have a post-hemipiegic tic 8 114 DISEASES OF THE NERVOUS SYSTEM. or a tic due to cortical lesion and associated witli epilepsy. True facial tic may also be caused by irritation or disease of the nerve or its nucleus. Symptoms. — The disease usually begins slowly and the orbicu- laris muscle and zygomatici are earliest affected. It rarely goes above the eyebrows, i.e., to the corrugator supercilii and frontalis. The lower branch of the facial is little affected. The spasm is a clonic one ; the muscles of the face are affected by a series of light- ning-like twitches, with intervals of rest. Sometimes, however, the contraction becomes tonic and lasts several seconds or more. There is no pain. The spasm is increased by emotions, nervous excite- ment, conversation, exposure to light and cold, and is at its worst when the patient himself is most depressed. It is a very good gauge of the general nervous stability of the patient. There is no paraly- sis or atrophy, and there are no secretory or trophic symptoms. The taste fibres are rarely involved, though occasional subjective sensations of taste have been felt. The electrical irritability is either unchanged or slightly increased. Associated movements of the eyes, of the jaw muscles and cheek muscles are sometimes seen. Pressure over the motor points of the nerve will sometimes arrest the movements for a time. The disease is a unilateral one. It lasts for years and even for the lifetime. PatJiolofjij. — There is no known anatomical change in idiopathic cases. The disease is allied in character to wryneck and other chronic tics, and is a motor correlativ(3 to the severe neuralgias like tic douloureux. In these cases it is probably the expression of some local cortical degeneration of light grade. The disease is sometimes a pure reflex neurosis from ocular or dental irritations. Diagnosis. — Idiopathic facial spasm is chronic, imilateral, unac- companied by pain or paralysis. It is distinguished from facial spasms of organic origin by the fact that the latter always have some other symptoms. Thus facial habit chorea is bilateral ; spasm from cortical disease is attended by disturbance of consciousness and comes on in paroxysms: the spasm occurring after hemiplegia is usually tonic, and so is hysterical facial spasm. Profjnosis. — The disease is m most cases incurable, especially after it has lasted some time. If a reflex cause exist, the prognosis is better. Life is, however, never endangered by it. TreatTrvint. — The most important thing is attention to the general health, removal of ail depressing influences, rest, and freedom from excitement. Among specific remedies arsenic, the bromides, can- nabis indica, gelsemium, conium, hyoscyamus, strychnine, codeine, and morphine are recommended. Morphine is useful, but must be MOTOR DISORDERS OF SPECIAL NERVES. 115 tried carefully and in small doses. Coniuin lessens the spasm, tut this drug has to be given in large doses and is not entirely free from danger. Hyoscine and gelsemium sometimes do good. Careful examination of the teeth, eyes, nose, stomach, and uterus for reflex irritation is imperative. Galvanism, if carefully and persistently applied, almost always helps. It should be given daily. Various methods are described. The best way is to place the negative pole on the sternum or back of the neck, and the positive pole over each motor point of the nerve for one to two minutes, then over the occiput and over the facial cortical area for the same time. Currents of from two to five milliam- peres should be used, i'l'eurectomy of the supraorbital, continuous pressure on the motor points, stretching the nerve itself, are all measures which may be considered valueless. Freezing the skin over the nerve with chloride of methyl has been recommended by Mitchell. lUistering and cauterization are needless inflictions. The ansesthetization of the conjunctiva with cocaine is often help- ful, both in diagnosis and treatment. Blepharospasm is the name given to a spasm of the orbicularis palpebrarum. It is generally caused by diseases of the eye, and its nature and treatment are matters belonging to ophthalmolog}'. It is a rare symptom of hysteria. NiCTiTATixG or wixKixG SPASM is a clomc spasm of the orbicu- laris, and usually forms part of habit chorea or is a symptom of hysteria. Tonic faclal spasm is sometimes seen in major hysteria. Facial Palsies. The paralyses of the facial nerve may be due to lesions that are central, nuclear, meningeal, or peripheral. Facial palsy of centnd o7-!;/tii is almost invariably an accompani- ment of hemiplegia and is due to hemorrhage, softening, inflamma- tion, or tumor of the brain. The lower two branches of the facial are chiefly involved. Facial palsy of miclcat- or'ujhi is very rare and is an accompani- ment of glosso-labial palsy, of diphtheritic palsy, or of gi-oss lesions of the pons. Facial palsy of vieninr/ixd orU/'m is due to tumors, meningitis, or fracture of the base of the brain, and is accompanied by lesion of other cranial nerves. Syphilis is the most important factor here. All those forms are simply part nt other diseases. Pkripiikual facial palsy (Bell's palsy) is the common type of facial paralysis. 116 DISEASES OK THE XEKVOUS SYSTEM. Etiologij. — The typical cases of this disease are clue to exposure, infection, and so-called rheumatic influences. Males are oftener affected, and the common age is between twenty and forty. It is more frequent in the Avintcr and in temperate climates. It is not hereditary. A neuropathic tendency predisposes to it. Syphilis rarely causes an isolated facial palsy ; in fact, it is apt to leave this nerve alone (Hutchinson). Facial palsy may occur in multiple neuritis, when it is often bilateral, and in locomotor ataxia. Non- typical and accidental cases of peripheral facial palsy are due to in- juries, fracture of the petrous bone, or ear disease. Forceps pres- sure in difficult labor causes some cases, and a very few have been congenital. Symjdoms. — The disease comes on rather suddenly, and reaches its heighfwithin a few hours, or, at most, two or three days. Pre- ceding and accompanying the onset there may be some pain about the ears and a little swelling is sometimes seen. The patient feels a subjective discomfort on the paralyzed side of the face. He linds that he cannot completely shut the eye; if he tries to chew on the affected side, food gets between the teeth and cheek. He cannot pucker the lips, and his speech is a little muffled. The axjpearance of the face is most characteristic. On the affected side the wrinkles are smoothed out, the angle of the mouth is lower, the mouth is drawn at first to the sound side, and owing to this distortion the tongue appears not to be protruded straight. In laughing or other emotional movements of the face, the trouble is most clearly brought out. But the most characterized appearance is produced by telling the patient to shut the eyes tightly and draw out the angles of the mouth so as to shoAV the teeth (Fig. 64). The eye on the palsied side is not closed, and the eye- ball turns up, showing the white of the eye. This test of the palsy is better than any examination of the wrinkles and folds of the face, for in children and in the young and plump these differences in the two sides of the face are not very marked, especially in the slighter cases. The nostril on the affected side does not expand on forced inspiration ; the eye is apt to bo watery and the conjunc- tiva somewhat injected. If the disease extend well up into the Fallopian canal, so as to involve the nerve to the stapedius, that muscle is paralyzed, the tensor tympani acts unopposed, the drum is tightened, and unusual sensitiveness to sounds results. This is rare, however; most of the ear symjitoms in facial palsy being due to a concomitant disorder of the tympanum or the acoustic nerve. If the disease involve the nerve between the geniculate ganglion MOTOTl DISORDERS OF SPECIAL NERVES. ii7 and the point where the chorda tympani is given off (see Fig. 63), some loss of taste follows, and this is a frequent symptom, but not one of long duration. If the disease is located more centrally than the geniculate ganglion or more peripherally than the chorda nerve, taste is not involved. Usually, when there is no taste involvement, it is because the lesion is peripheral. By an examination of the Fio. C4 — Pati?:nt with Lkft Kaciai^ ]^\I.^Y A i-ri .mi'tin(; to Ti.ose Roth Eves axd Snow THE Teeth. taste sense and oC the htMring, th(» location of the trouble can be accurately made out. After a few weeks sunie Avasting of tln' facf, niay be noted, but this is never very great. The electrical reactions are THE Accessory Part OK THE SJ'IXAL ACCESSORY. AxATo^iY. — The pneu- mogastric or vagus nerve has two nuclei of origin, a motor and a sensory. 1. The motor nucleus or nucleus ambiguus, Avhich is a prolongation of the lateral liorn of the spinal cord, lies deep in tlie medulla and is a nucleus common to the vagus and glosso-])haryngeal (Fig. 65). 2. The sensory fibres arise chiefly from two ganglia that lie on the root of tlie nerve, the jugular and plexiform. These bodies resemble s})inal ganglia. Tlie cells arc uni- l)olar and send oft" a neuraxon which bifurcates. The periph- eral fibre passes along the nerve aiul supplies it with its sensory fibres. The central part passes up to the gray matter of the floor of the fourtli ventricle and ends in the so-called sensor}' nucleus (Fig. 65). Fll! -The Vagus and Rpisai^ ArcK.->: Nkkvk (Young). 122 DISEASES OF THE NERVOUS SYSTEM. This nucleus, however, is not the real nucleus of origin, but, as in the case of the ninth it contains cells which send their axis cylinders or nem-axons brainward and form secondary sensory neurons. Fi- bres also go to the ascending sensory root common to this nerve and the ninth. It is probable that some of the cells of the terminal sensory nuclei of the ninth and tenth are efferent visceral cells, like those of the columns of Clark, and send out visceral fibres. Both motor and sensory fibres are chiefly visceral in distribution and function. The SPINAL, ACCESSORY ncrvc is purely motor in fimctiou (Van Gehuchten) . The accessory part rises from the cells of the nucleus ambiguus and passes into the trunk of the vagus. The spinal part of the spinal accessory arises from the lateral horn and outer part of the anterior horn of the spinal cord. Its fibres of origin reach from the first to the third or fourth cervical nerves as far as the fourth or fifth cervical roots. The fibres imite in the cranium and pass out through the posterior lacerated foramen Fig. C7. — Longitudinal Section showing the Relative Position of the Cranial Nerve Nuclei (Ediiiger). in the same sheath as the vagus. After their exit from the skull, they divide into an internal and external part. It is the external branch which contains the fibres of spinal origin. The internal part contains the fibres from the medulla and unites with the vagus. The nerve receives some sensory fibres from the first and sometimes from the second cervical nerve. The terminal branches receive motor fibres from several cervical nerves. The spinal accessory contains large and small or visceral fibres. The spinal part contains only the large fibres. The spinal accessory supplies the sterno-cleido-mastoid almost exclusively, but only the upper part of the trapezius ; the rest of this muscle is supplied by the cervical and dorsal nerves. The sterno-cleido-mastoid, when innervated, draws the chin np and over toward the opposite side. The upper fibres of the trapezius draw the head back slightly and down toward the same side. Physio- logically the spinal part of the accessory nerve is one of the motor cervical nerves; the accessory or medullary portion is part of the vagus, and has visceral and sensory as well as inotor functions.* * Dees thinks that tlie spiual origin of the eleventh is continuous above 310T0R DISORDERS OF SPECIAL XERVES. 123 The Tagus and accessory part of the eleventh together have an extraordinary wide distribution antl diversity of function. 1. First they contain motor, iidiihitory, and vasomotor fibres. These fibres go to the pharynx, hirynx, trachea, and bronchi; to the CESophagus, stomacli, small intestines, and s])leen. 2. Sensory fibres, which go to the occipital and transverse sinuses and dura mater of the posterior fossa, to the external audi- tory meatus in part, to the pharynx, larynx, and trachea, and to the oesophagus. 3. Excito-reflex fibres, which go to the lungs and heart, stomach, and to other organs mentioned as supplied by the vagus with sensa- tion. These reflex fibres stimulate or inhibit the vasomotor centre, the respiratory rhythm, and the cardiac rhythm. They also excite re- flexly deglutition and respiratory movements. The secretory fibres go to the respiratory tract, oesophagus, stomach, and pancreas and small intestines. Cardio-inhibitory fibres go to the heart, while reflex accelerating fibres and inhibiting fibres go to the lungs. The accessory nucleus supplies the laryngeal adductors and the cardio-inhibitory fibres. Diseases ok the Pxeumogastkic !Nekve and of the Bulbab poktiox of the sl'ixan accessory. These nerves are essentially visceral in character. Their dis- eases call for a study of laryngeal, pulmonary, cardiac, and ab- dominal neuroses, which would bring us into the domain of laryn- gology and general medicine. Hence, despite their great importance, I have thought it best not to try and present them here. Some of the symptoms are described in connection with locomotor ataxia, progressive musctdar atrophy, exophthalmic goitre, and angina pectoris, Neuroses of the Spixal 1'aj;t ok the Accessorius. This is a purely motor nerve, and its disorders are therefore spasni and paralysis. Torticollis (Wryneck, Caput OnsTiruM). — Torticollis is a disease characterized by clonic or tonic spasm of the muscles sup- plied by the spfnal accessory and often of other muscles of the neck. There are several forms of wryneck, which must be distin- guished from each other. They are: 1, congenital wryneck; 2, with the twclftli, not with tlio aiitt'rior nucleus of the tenth. lie denies that the niedulhiry nucleus sends fibres to tlie larynx. The internal branch of the eleventh sends motor fibres lo tlie rectus posti cus (E. Reinali). 124 DISEASES OF THE NERVOUS SYSTEM. symptoniatic 'vvryneck; 3, spurious wryneck, from spinal disease; 4, true spasmodic wryneck. 1. Congenital ivryneck is clue to some intra-uteriiie atrop>liy or obstetrical injury of the sterno-cleido-mastoid. It occurs oftenest after breech or foot presentations. The riglit side is usually aifected. There is no spasm at all, but the neck is fixed to one side by the shortness of the muscle, and also rotated to the opposite side. The deformity becomes more noticeable as the child grows older, because the parts atrophy. The atrophy affects not only the shortened muscles, but the face on the affected side (Fig. 68). 2. Bymptomat'iG wryneck is usually due to a rheumatic myositis, and occui'S chiefly in children. It may be due also to tumors, Fig. 68.— Conoknital AVryneck of the Right Side. adenitis, abscesses, and local syphilitic disease. In these cases there are always pain and tenderness associated with the deformity, 3. Spv.rious v-rijncrh is an apparent or real spasm of the neck muscles due to caries of the spine. Treatment. — Congenital wryneck, if taken earl}-, can be cured by tenotomy of the sterno-mastoid and subsequent fixation of the neck for a time. When osseous changes have occurred perfect relief is impossible. Symptomatic rheumatic wryneck is a trivial and temporary affection, which needs only to be palliated b}^ hot appli- cations and saline purges until cure takes place. Spurious wryneck requires suitable orthopaedic measures, such as the plaster jacket and jurymast. 4. Spcistnodic Wri/neeh. — This is a purely nervous disease characterized by spasm of the muscles supplied by the spinal acces- sory and often of those supplied by the upper cervical nerves also. Etiolofjy. — Women are much oftener affected than men. It MOTOR DISORDERS OF SPECIAL NERVES. 125 occurs in early adult and middle life, never in children or old peo- ple. A neuropathic constitution and heredity often exist. The excitincr causes are occupations which put the lateral muscles of the neck en a strain, depressing emotions, physical shocks and blows, rheumatic influences, and perhaps malaria. Sometimes no cause can oe detected. Reflex irritations, perhaps, exist in some cases, but it is difficult to find them. Sijinptoins. — The disease begins with slightly painful sensations in the neck, which are soon accompanied by spasm. The spasm is at first clonic and intermittent. The sterno-mastoid is oftenest in- volved of single muscles; but the rule is that the upper fibres of the trapezius are also affected. The patient's head is inclined toward ^^^/^:^rv. y \ Pia. 60.— Typical WBYNtrK Ixvolviko the Spinal Acessohy on the Rich-: Side C^Valion). the affected side by the trapezius, the chin is raised, and the head rotated to the opposite side by the sterno-mastoid and trapezius, and this is the typical position in the disease (Fig. 69). If both trapezii are affected the head is pulled back, but this is a rare form. It is called retro-collio spasm. The complexus and obliquus superior are the only other neck muscles which can rotate the head to the opposite side. Tliey are supplied by the iqiper cervical nerves and are sometimes involved in wiyuerk. In torticollis the muscles affected with spasm have a similar jjliysiulogical function. Hence while the sterno-mastuid, trapezius, complexus, and snnerior oblique on one side are attacked by the spasms, nuiscles on the other side may be at the same time im])licated. The opposite muscle com- monly affected is the s]tlenius, which inclines the head laterally and rotates it to the same side. Probably the deep muscles, recti capitis 126 DISEASES OF TKE NEEVOUS SYSTEM. postici, major and minor, and the inferior oblique, which draAv the head back and rotate to tlie same side, are also at times affected. The list of muscles that may be involved and their nerve supply are as follows : Muscles usually involved. Muscles rarely involved. Turning Head to Opposite Turning or Inclining Head to Si(l<^. Same Side. Nei-ve Supply. Steruo-cleido-mastoid. . . Upper tibres of trapezius Superior obliquus. Coniplexus Recti capitis postici, niaj., min., infer. obliq., spleuius. Eleventh. Eleventh. Cervical. Cervical. Extreme rotation without much retraction of the head would in- dicate involvement of the sterno-cleido-mastoid and opposite splenius. Retraction of the head indicates involvement of both trapezii. The disease may start in one muscle and gradually extend to others, even inrolving the facial, masticatory, and brachial nerves. As it progresses the spasm becomes more constant, and finally it may be tonic, never yielding except to artificial means or during sleep. The pain associated with the disease gradually decreases. The affected muscles hyj)ertrophy, the muscles thrown into disuse atrophy. There is some deformity, in time, of the neck and shoulders, but facial asymmetry does not occur in this form unless it begins, as is very rarely the case, before maturity. The disease may be complicated with or alternate with other neuroses. I have known epilepsy to be associated with it. Fathology. — The disease is a neurosis involving the bulbar and cerebral centres. The neuro-mechanism controlling the move- ments of the neck is unstable and out of control. Consequently it sends out intermittent and irregular discharges of nerve force. The seat of the typical disease is never in the nerve alone, probably the cortical centre controlling the mechanism of the head movements is at fault. The disease is a degenerative one, and indicates the premature decay of centres never perhaps originally perfect. The diagnosis has to be made from the other forms of wryneck mentioned. The age, history, and fixed character of the spasm serve to distinguish congenital wryneck. The history, the pain and tenderness, and the temporary duration differentiate the rheumatic forms. The increased rigidity on passive motion, the pain, deformity, and other signs of cervical caries are sufficient to diagnosticate ver- tebral disease. Prognosis. — The disease is not fatal. It generally reaches a MOTOR DISORDERS OF SPECIAL NERVES. 127 certain stage and then remains chrojiic. In rare cases it is cured; in many others it can be much ameliorated. Cases occurring in young people, in the hysterical, and in those without a decided neurotic history are the most favorable. Ti'cjitment. — The drugs wliich are efficient are opium, atropine or hyoscyamine, conium, gelsemium, valerianate of zinc, asafoetida, chloral, bromides, arsenic, and cocaine. Of these, opium, atropine, gelsemium, and zinc are generally the most efficacious. Opium must be given with great caution. Atropine should be given hypo- dermically in increasing doses up to intoxication (gr. -^^^ (Leszyn- sky). The galvanic and faradic currents are useful adjuvants in helping to relax the spasm and keep up the nutrition of the muscles; but alone they are not curative. Massage and stretching the neck in a Sayre apparatus, together with systematic exercise of the neck muscles, often help; neck stretching will even sometimes cure. The only surgical measures to be advised are nerve resection, and possibly the partial cutting of the sterno-mastoid miiscle. A very few cures and many failures have followed surgical interference. Splints and mechanical-hxation apparatus do no good as a rule. Resection of the posterior branches of the upper three or four cervical nerves, as suggested by Keen, has done great good in a few cases (Powers). Prolonged rest for eight to twelve months with massage and exercises is on the whole the most satisfactory remedy Spasmus Nutaxs {eclampsia nutans, nodding spasm, salaam spasm, osrillatlnfj spasm). — This is a disorder occurring chiefly in children and characterized by rhythmical nodding or oscillating movements of the head. Etiiilnf/^/.- — The disease occurs in young children who are aiuemic and badly nourished. Dentition, digestive disorders, basilar men- ingitis, gross disease of the brain, are causes. Sometimes it is only a kind of hal)it chorea, and occasionally this habit continues during life. Si/niptoms. — The disease may come on suddenly; njore rarely it develops slowly. The patient has j)ar()xysms usually of a rather violent character, lasting for minutes or hours, or even continuing nearl}' all the time except during sleep. The head moves thirty to sixty times a minute usually, but the motion may be slower or faster. Movements of the eyes and facial muscles often complicate the affection. The paroxysm may end in an epileptic attack. The diagnosis is easily made by tlie symptoms. The jn-ognosis and irrntuicnt depend upon tlie etiology. I have found useful bromide of potassium, hyoscine, and syrup of iodide of iron. Paralysis oi-' tjik Si-inai. Vxmv ok tiik Accessory — Etl- vlogg.- -Tho causes arc injuries, caries of vertebra, jjrogressive mus- 128 DISEASES OF THE NERVOUS SYSTEM. cular atrophy, and all forms of spinal disease reaching high up in the cervical cord. tSi/nij)toms. — When one nerve is paralyzed the head anay still be held straight, bnt there is inability to rotate it perfectly. The prominence of the sterno-mastoid is absent — atrophy takes place. No spasm of the other muscle occurs, and there is no such thing as paralytic torticollis (Gowers). The involvement of the trapezius causes a depression in the contour of the neck, especially noticeable on deep inspiration. There is some trouble in raising the arm, the scapula is drawn away from the spine, and the lower angle is rotated inward. When both nerves are paralyzed there is great difficulty in rotating the head or raising the chin. Paralysis of both sterno=mastoids causes the chin to drop backward, while paralysis of both trapezii in their upper parts causes the head to drop for- ward. Atrophy of the muscles attends the paralysis of the nerve; and degenerative reactions may be noted. The cervical nerves ap- pear sometimes to supply the sterno-mastoid and upper part of the trapezius so much that in disease of the accessories decided paralytic symptoms are absent. When both parts of the spinal accessory are involved, dropping of the palate, dysphonia, and rapid pulse are added symptoms. The (Vmrjuusls depends upon a thorough examination of the motility of the parts. The treatment is based on a knowledge of the cause of the dis- ease. The Hvpoglossus — XII. AxATOMY. — The hypoglossal nerve arises from a long and large nucleus lying in the lower part of the floor of the medulla near the median line and to the outer and ventral side of the central canal. The nucleus is a continuation upward of the anterior horns of the spinal cord and is homologous with the sixth, fourth, and third nerve nuclei higher up (see Fig. 67) . It reaches below as far as the decussation of the pyramids and above as far as the glosso-pharyn- geal nucleus. A second small-celled nucleus lies just beneath the nucleus proper. Its cortical representation is in the lower end of the central convolutions, to which it is connected by fibres that pass into the raphe and thence to the anterior pyramids. Its fibres pass out between the olivary body and the anterior pyramid. At its origin it is a purely motor nerve; it receives a few sensory fibres from the cervical nerves and the vagus. It supplies the following muscles : Intrinsic muscles of the tongue: superior and inferior longi- tudinal and transverse. The extrinsic muscles of the tongue : hy- oglossus, genio-hyoglossus, and styloglossus. (The palato-glossus and Unguals are supplied by the fifth and seventh cranial nerves MOTOR DISORDERS OF SPECIAL NERVES. 129 respectively). The depressors of thehyoid: the thyro-hyoid and, with the cervical nerves, the sterno-hyoid and sterno-thyroid. The elevator of the hyoid : genio-hyoid. It is also thought to send fibres to the oral muscles (Tooth). The hypoglossal nerve is concerned in the movements of the tongue and in fixing or depressing the hyoid in mastication and deglutition. When diseased, therefore, speech and deglutition are affected. The small nucleus of the nerve is thought to control the finer lingual movements of articulation. Motor Neuroses of the Hypoglossal Kerve. The diseases of this nerve consist of lingual spasms, lingual palsy, and lingual hemiatrophy. LiXGUAL SPASMS take part in the disorders of articulation, help- ing to cause stuttering and speech cramps. Such troubles are often developmental in origin and belong to the habit choreas or convulsive tics. Stuttering is a spasmodic disorder in which the tongue muscles are involved, preventing the proper enunciation of words and sentences. Stammering is an imperfect articulation due sometimes to dis- ease or defect in the hypoglossal nerve and its muscles. It is not a spasm. The letters that are oftenest badly pronounced are R, L, and S. Lisping is a form of stuttering. Stammerers are sometimes called the "RLS people." Aphthongla is the name given to a form of spasm occurring in speakers and similar in nature to writer's cramp. Clonic lingual spasm occurs in chorea, hysteria, and during the attacks of epile[)sy. Unique cases of this spasm also occur from reflex irritation or central nervous disease. Tonic lingual .spasm occurs in hysteria, and sometimes as an in- dependent affection duo to unknown causes, generally those of a debilitating and nervously depressing character. Reficx irritation may be a cause. LiN'GUAL PARALYSIS (glossoplegia) is usually one of the symp- toms of glosso-labio-laryngcal jtalsy. It may be caused by a bilateral or even a single lesion in the cerebral hemispheres. The condition is then known as pseudo-bulbar jiaralysis. Di-seases of the medulla and of the nerve itself may cause the luiralysis. The i)aralysis may be either unilateral or bilateral. 'I'lie .symp- toms are an imi)airnient of speeeli and of swallowing. Fuller de- tails will be given under the head of liulbar Tal.sy. 9 130 DISEASES OF THE NEKYOUS SYSTEM. Progressive Lingual Hemiatrophy. — A progressive hemi' atrophy of the tongue sometimes occurs. It is analogous in all re- spects to facial hemiatrophy, with which it is sometimes associated. It is probably due to a low grade of degenerative neuritis of the nerve. It is very rare. LOCATION OF THE SEGMENT FOR MoTn>rrT. Muscles Sphincter of the lrl» ciliary lultrrnal rectus, levator palpebre superior!* rectus, inferior aud superior 'Inferior oblique .Superior oblique Masseter, temporal, pterygoids [(upper facial) External rectus, frontalis, orbiciihiria of ej» Mimetic face muscles (lower facial) Mouth and throat mucclea i^ Laryngeal muscles . Tongue muscles Sterno-cleido mastoid Deep neck musclea Trapezius, Serratus antlcu Deltoid, biceps, pectoralls (clavicular part) Brachialis anticus, supinator lon^i Triceps, jatissimusrtorsi, pectoralis (costal por- Eitensors of the lingers and phalanges 1 ''"") Flexors of the fingers and phalanges ( ^^'^'^ Jnterossel and lumbricafes e-a Thenar, hypothenar Intercostal muscle* Back muscles AbJomlna' masclea Thigh [tUod Leg _ -Peronel Fiexors) extensors of font and tOC* Gluteal „ , , , ••J*erlneal 1 ■ bladder V Musculature Kectunv I ExpiJLNATioN OF THK ABBRKviATioN8.-, for th.> respiratory re- flex (.r.). for the cremaster reflex icr.), patellar reflex (pot.), and the Achilles reflex (.t). The centres f..r tlie bladder an.l rectum in the sacral cord are represente.l by circles; likewise the centres for er.-ction and ejacu- latir.n. The centre for contraction of the uterus is probably liliewise in this vicinity (Jakob). NERVOUS DISEASES. | Dana. - Oi'il/o//>oforiits ~~^^^ j ^ ' ""°^ " "i"^- niovemen o e oyc u s upwo . inwar , nn oivtiwor . a. iWusclea of ransticutioa ; mdssdter. tempnral, iiterrKoid, milo-hyoid— ant. digoa /^tlCllsttCUS "Jl tlf t'ho eiirs, Htu|iedius,' poarerior digaatric, etc, 'Nasol BecretionH." Te yy,' .aloSSOph ari^npfllS '_2ZL . !'ri""'""t"'"u-rculntnro ico t ' to l i o-th ■ "d f o of n trio "ui -occipiinl inaffih ihoAcict ari f Kcrrntua nnticiH major iIonG thorncic nerve j fi«a the shoulder blndo nnd draws the b LOCATION OF THE SEGMENT (r. oi/= olfactory tract; c.g.l.=. , represent approximately the lo- cation of the reflex ceutrej; the pupillarj- reflex Cp). for the respiratory re- flex tn). for the cremaster reflex (cr.), patellar reflex Cpaf.), and the Achilles reflex (.4. ). The centres for the bladder and rectum In the sacral cord are represented by circles; likewise the centres for erection and ejficu- lation. The centre for contraction of the uterus is probably likewise in this vicinity (Jakob). CHAPTER IX NEUROSES OF THE MOTOR SPINAL NERVES. Anatomij and Physlologij. — The spinal nerves arise from the spinal cord by two roots, anterior and posterior. These roots unite outside the spinal canal to form mixed nerves. The mixed nerves divide and go to their various destinations. There are thirty-three pair of spinal nerves, viz. : Cervical 8 Dorsal 13 Lumbar 5 Sacral 5 Coccygeal 3 (all rudimentary). 33 The last two coccygeal nerves are microscopic in size, and the first pair is very small, so that practically there are but thirty sets of spinal nerves. The posterior roots are closely connected with ganglia lying in the intervertebral canal, and called intervertebral ganglia, or ganglia of the posterior roots. These ganglia are the real origin of the great majority of the fibres of these roots. The mixed nerve is connected, by fibres that come chiefly from the anterior root, with the sympa- thetic or praevertebral ganglia. The distribution of the spinal nerves is also shown in Fig. 70. For the purpose of conveniently studying the diseases of the spinal nerves, we divide them into six different groups, each having a somewhat definite work to do. These groups are shown in the accompanying table. strands of Spinal Nerves. Distribution. Associated Ganglia of Sympathetic. (i oiip I. Ulip'T friiir cervical. < iccipilal iej,'ii.ii, iifclv. First cervical. 11. Iviwer four cervical and first dorsiil. UpiKjr e.xtrtiuities .Second and third cer- vical, first dorsal. *• III. Upper six dorsal. Thoracic wall. First to sixtli dorsal. - IV. Utwar six dorsal except last. .\bd(iniiiial wall, upper lum- bar, upper lateral thigh surface. Fifth to twelftli dorsal. V. Twelfth dorsal, four lum- bar. Lumbur repinn, upper rIu- teal. anterior and iiuier tliiKh and knee. First to fourth lumbar. " VI. Fifth luiiihiir and five Lower Kluteal, posterior First to fifth sacral. sacral. thlKh, leg. Group I. Tiik Ui-i-ku Ckrvical includes the first four of the spinal nerves. These divide into an- terior and posterior branches. The posterior branches sup^dy the 132 DISEASES OF THE NERVOUS SYSTEM, muscles and skin of the back of the neck and the occiput. The principal nerves are the suboccipital and the great occipital. The anterior branches form the cervical plexus. Its principal branches are the auricularis magnus, occipitalis minor, and phrenic. The FiQ. 71. — Showing the Formation ov the Mixed Nerves and the Mode of Ortgin' of THE Motor and Sensory Parts. special distribution of the nerves is shown in the table facing Pig. 70. The upper cervical nerves supply motion to the muscles which rotate the head and draw it back and sideways. One branch, the phrenic, supplies the diaphragm ; other muscles assist in fixing the thorax in forced inspiration. They innervate some of the hyoid and thyroid muscles, but have no influence on phonation or deglutition. This group of nerves is in close connec- tion centrally with the trigeminal nerve, whose descending root reaches down into the cervical cord. The fibres to the scalp and face also anastomose with the trigeminus in their peripheral distri- bution to the scalp and chin. The diseases of the upper cervical group are spasms, paralyses, and neuralgias. Spasmodic Diseases. — Torticollis may be limited to the cer- vical nerves, as has been shown. Toxic spasm causing a rigid neck is a frequent symptom of meningitis, and forms part of epileptic and other convulsions. NEUROSES OF THE MOTOR SPINAL NERVES. 133 In oscillatory and rotatory sjjasnis the cervical nerves are in- volved. In some forms of stutterixo the phrenic nerve is involved in a clonic or tonic spasm. Hiccough is a clonic spasmodic disorder of the j)hrenic nerve. It is usually due to gastric disturbance, with flatulent distention of the stomach. When chronic, it is caused by hysteria, neuritis, diaphragmatic pleurisy, or some pressure upon the nerve in its course. I have seen cases in which it was probably a pure spasmodic neurosis. Ordinarily, hiccough can be stopped by simple carminatives like spirits of chloroform or lavender. In obstinate cases in which no known cause can be found, pilocarpine, hyoscine, and bromides are useful. Counter-irritation along the neck helps some cases. A most effective measure is to lay the patient supine over a thick bolster so that the head hangs back and the thorax arches up. An injection of morphine and atropine promptly stops some cases. Paralyses and Atrophy. — The cervical muscles are paralyzed in progressive muscular atrophy, in pachymeningitis hypertrophica, and occasionally in vertebral and pheripheral disease or injury. Some deformities and weakness in head movements result, but the most serious consequence is involvement of respiration through palsy of the phrenic. Paralysis op the Phrenic Nerve — Etlologij. — Such pa- ralysis may be due to disease or injury of the cervical corcl and also to ])eripheral disease, to which the nerve is somewhat liable owing to its long course through the anterior mediastinum. Pleurisy, peritonitis, mediastinal tumors, rheumatic and toxio influences, and hysteria are among the special causes of phrenic paralysis. Spinal-cord disease, such as tabes, acute ascending l)aralysis, and surgical injuries are, however, the commonest eti- ological factors. Siji)ij)t(niis. — In dia])hragmatic ])ara]ysis, if bilateral, as is usually the case, there is cither no movement of the abdomen or the epigas- trium and liypochondrium are drawn in. On slight exertion there are dyspnoea and increase of respiration. Dia/jnosls. — If no other muscles than the diaphragm are involved, the cause is probably in the trunk of the nerve. Inflammatory disease of the dia])hragm may cause a paralysis which is recognized by its painful character and the febrile reaction. 'frmtmcnt. — This is to be guided by the cause. It need oidy be said that there is a motor point in the neck where by careful elec- trization one can get a contraction of the diaphragm (see I'ig. o(Sy JJ). In paralysis of the phrenic this fact should be borne in mind. 134 DISEASES OF THE NERVOUS SYSTEM. Group II. The Lower Cervical Nerves and Brachial Plexus. Anatomy and Physiology. — The anterior brauches of the lower four cervical nerves and first dorsal nerve unite to form the brachial Fig. 72.— Showing the Distributio.v of the Sensory Nerves of the Skin. IfEUROSES OF THE MOTOR SPINAL NERVES. 135 plexus. This gives off sliort nerves to tlie shoulder and trunk and lonr/ nerves to the arm. The mode of formation of the brachial plexus is shown in the diagram (Fig. 73). It is in accordance with the descriptions of Walsh and Allen. The short or upper branches supply the shoulder and intercostal muscles. The lowj or lower branches supply the arm and hand. The neiu'ologist needs to know : (1) the muscular distribution of each nerve and the function of the muscle; (2) the cutaneous sensory distribution; and (3) the level of origin of the nerves. Tlie previous figure, Fig. 70, and table give these points, and will be found useful for study and reference. They are based upon the investigations of Ferrier and Yeo, Thorbum, and also on Abbe's and my own experiments. The Arrnnrjement of tlie Brachial Plexus. — It is made up of three nerve trunks, which in turn make up three cords, these cords giving off various branches, thus : 1. Trunk from sixth and ) forms outer cord, which i fj^^^gX^^^^^^^^^ seventh cervical roots f gives off ^ ^^^^^ ^^^_^^^ ^^^^^j^^^_ f Inner head median. ) forms inner cord, wliich ^ };j"''c;,tan. I Int. ant. tliorac. 1^ Intercost. -hum. Tnmk from fifth, sixth, ) ^^^ „ .,„„*.„„;„„ „^^a ^a.w.\. I Subscanuhir, ., 1 • 1 ii f tonus posterior cord, whicli i /-,• '4. seventh, and eightli cer- - ^. ', ^ ' -I Circumrtex. vical and first dorsal ) S^^^^ ^ ^lusculo-spiral. Trunk from eiglith cervi- cal and first dorsal roots f gives off 3. The following table shows the origin, muscular distribution, and effect of paralysis on the motor but not on the sensory nerves. This latter is indicated in Figs. 72 and 32. Nerves and Roots of Origin. Muscular Distributiou. Function as Shown by Effect of Paralysis. Posterior thoracic. Fifth and sixth cervical. Circumflex. Fifth, sixth, seventh and eijflith cervical. Suprascapular. Subscapular, Bhort. Fifth and sixth cervical. Subscapular, long. Fifth, sixth, seventh, and eighth ct*rvical. Anterior thoracic. Musculo-cutaneous. Fourth and fifth ct-rvical. Mu.sculo-spiral. Serratus magnus. Deltoid. Teres minor. Supraspinatus. Infraspin a t u s and teres minor. Subscapulares. Teres major. Latiss. dorsl. Pectoralis major. Bicejis and brachialis anticus. Triceps. Posterior edge of scapula is rotated out when arm is raised antl carried forward. WealF«*C5THESIA « llArm. Fig. 73. — Illustrating the Formatiom of the Brachial Plkxi's; also the I>-vclvkmk.nt OF THE Plexus is Degenerative Neuritis (Leszynsky). tional palsies, from overwork ami hysteria; in rare cases, spinal- cord and brai)i disease. The sijrnjifoiny. vary with the severity and extent of the lesion. With regard to severity, there are three degrees. In the first there is simjily a transient palsy, due to lying too long on the arm. The arm feels heavy, numb, and "asleep." In a few minutes or hours this palsy disappears. In tlie second degree the nerves are so much compressed as to be mechanically injured. If the patient has been drinking hard, even moderate pressure may set up an in- flammatory or destructive process that leads to quite a serious palsy. In the third degree the nerves are actually cut or torn across, or so compressed as to lose their anatomical integrity. The resulting symptoms are those common to all nerve injuries, viz., paralysis, wasting, changes in electrical reaction of the muscles. Pain, tenderness, anaesthesia, trophic, secretory, and vasomotor dis- turbajices are also j»resent in varying degree. The distribution of the paralysis, atrophy, and sensory disturb- 138 DISEASES OF THE XERYOUS SYSTEM. ance depends, of coursej upon the arm nerves chiefly inYolved. The c-uts and table "will enable one to see in any ease where the trouble is localized. There are three common sYmptoms, however, of which it is often very important to anal^-ze the cause. These are the loss of power for elevation of the arm and for flexion and extension of the forearm. Fle:clon of the forearm is performed by the biceps and brachialis anticus, and is helped by the supinator longus. These muscles are Fig. 74.— Upper-Arm Palsy of Left Side, supplied by the musculo-cutaneous nerve, except the supinator, which is supplied by the musculo-spiral. Hence when a person cannot flex the forearm, the musculo-cutaneous is chiefly affected. Extension of the arm. is done by the triceps, which is supplied by the mu.sculo-spiral. Elevation of the Aiin Outward. — Inability to raise the arm is the common and striking symptom in combined brachial palsies. The arm is raised by a number of muscles. The deltoid acts first and most, but it can raise the arm only to a right angle. It is supplied by the circumflex nerve from the posterior cord of the plexus, ^ter the arm is raised to a right angle, it is further elevated by XEUE0SE3 OF THE MOTOR SPIXAL XERYES. 139 rotating the scapula, and this is done chiefly by the middle part of the trapezius (lower cervical and upper dorsal nerves) and by the serratus niagnus, supplied by the posterior thoracic nerve. A number of other muscles combine to strengthen elevation of the shoulder, but this action can be abolished only by paralysis of the deltoid or trapezius and serratus mangus. The (lifMjnosls of these cases involves, first, the consideration of the seat of the lesion and the special nerves involved; next, that of the nature of the lesion. A recognition of the seat of the lesion and of the special nerves involved depends entirely upon the study FlO. 75.— Lower-Arm Palsy dfe to Mn,TiPr.K Nettritis. of the distribution of the palsy and of the atrophy and sensory dis- turbance. It is important to determine whether one is dealing with a total-arm palsy, an upper-arm type (Erb's palsy) or a lower-arm type. In JCrh's i>(ihii there is involvement of the deltoid, biceps, bra- chialis anticus, and supinator longus, with at times paralysis of the supinator brevis, and even of all the muscles supplied by the median nerve. The lesion is either in tlie cord formed by tbe fifth and sixth cervical nerves or a little lower in the brachial plexus, Avhere the fibres supplying the musculo-spiral, circumflex, and musculo- cutaneous lie close together. At all events, the lesion involves the central parts and upper cords of the jjIoxus. Tlie arm hangs by the side and the forearm cannot be flexed (Fig. 74). In the loiccr-unn tijim the triceps, tlie flexors of the wiist, the 140 DISEASES OF THE NERVOUS SYSTEM. pronators, tlie flexors and extensors of tlie fingers, and the hand muscles are involved. The arm can be raised and tiie forearm flexed and supinated, but the hand is useless and the extension of the forearm is impossible. The lesion here involves chiefly the nerves from the seventh and eighth cervical and first dorsal roots (Fig. 75). If the lesion is in the nerve there will be atrophy, changes in electrical reaction, sensory disturbances, and often, if there is neu- ritis, pain over the nerves. The reflexes will be lessened or absent. If the lesion is in the spinal cord, symptoms in other parts of the body will be present, or, if not, there will be no sensory disturbance, as in an arm palsy from anterior poliomyelitis. In rare cases arm palsies may be caused by spinal tumors or a local meningitis, in which case diagnosis is difficult. The iippcr-arm tupa and hnrer-arm ti/pe palsies are caused by much the same factors as the combined palsies; their symptoms have been indicated above. The upper-arm type is especially fre- quent in infants and constitutes one of the obstetrical paralyses. It may in son^e cases be due to injury or hemorrhage in the cord. The prof/nosis is usually good. Nearly all these cases get well, the duration of the incapacity being from two or three months to a year. Even in the severest cases recovery is possible after one or two years. If, however, the nerves are torn across and the ends widely separated, recovery is doubtful unless an operation is l^romptly done. The treatment consists in electrical applications, mechanical sup- port, with potassium iodide internally and abstinence from alcohol. Local injections of nitrate of strychnine are useful, and massage should be used if it can be applied caref;illy. In brachial palsies due to severe injuries, dislocations, frac- tures, etc., in which there is evidence, from the extreme atrophy and absence of electrical reaction, that the nerve is entirely cut across and that the ends are not in apposition, a surgical operation is stringently needed. The nerves should be exposed and the ends brought as near together as possible. Decalcified-bone tubes or sterilized macaroni may be used to give a passage for the central end to grow into the peripheral. In these cases, however, it must be remembered that the two ends do nob imite; but the central end grows down in the tract of the old degenerated peripheral stem. A peculiar form of combined nerve palsy sometimes occurs, due apparently to ajji-imari/ brachial oin/ritis. It begins in the ])lexus and involves first the nerves of the ujtper cervical roots. It may extend down and involve the ulnar, median, or musculo-spiral. XEUKOSES OF THE MOTOK SPIXAL XERVES. 141 It occurs in adult men generally and in those exposed to rheu- matic influences. Perhaps lead-poisoning may exist. It begins gradually with slight pains and weakness in the shoulder and arm muscles. Atrophy and anaesthesia follow, and degeneration reactions are present. There is not a great deal of pain (Fig. 74). The disease is usually confined to one side. It lasts several months, and nearly complete recovery finally takes place. Eelapses may occur. It is differentiated from progressive muscular atrophy by the pain, auffisthesia, and electrical reactions, and from arthritic atrophy by the absence of any history of arthritis and the presence of de- generation reactions and antesthetic areas. Paralyses ok Single Kerves — Paralysis of the Pos- terior Thoracic Kerve — Et'wJoijy. — This rare trouble usually occurs in male adults and is due to injury or sudden strains. Its paralysis may be part of a progressive muscular atrophy. The nerve goes to the serratus magnus. Symptoms. — When paralyzed, there is difficulty in raising the arm above the horizontal position and the movements of the shoulder are weakened. When the arm hangs by the side the lower angle of the scapula is drawn a little nearer the vertebral column and pro- trudes slightly. When the arm is held out horizontally the inner edge of the scapula jirotrudes and is drawn toward the middle line. "Wlien the raised arm is brought forward there is a deep groove formed between the inner border of the scapula and the thoracic wall (Fig. 76.) The disease often runs a long course and is accompanied by pain. Paralysis of the Circumflex Nerve. — The nerve goes to the deltoid, teres minor, third head of the triceps, and shoulder- joint. It gives sensation to the skin of the shoulder. It is very often paralyzed. The commonest causes are a fall or injury, dislo- cation, aiul rheumatic inflammation of the joint. The arm cannot be elevated or rotated outward. There are atrophy, amesthesia, and sometimes pain. Paralysis of the Slii'Rascai'Ular Xekve. — The nerve goes to the spinati muscles, teres minor, and shoulder-joint. Disease of this nerve alone is rare. The supras})inatus rotates the shoulder in, the infraspinatus and teres minor rotate it out. When paralyzed, there is an impairment of rotation and some iiu])airment of elevation of the shoulder. Paralysis ok the ^MrscrLO-Si'iR.VL Nekve (irn'sfdm/t, Laid Pafsi/, Compression Paralysis). — The distribution of this nerve is 142 DISEASES OF THE XERYOUS SYSTEM. given in the table and cut. Its function is to extend and suiiinate tlie forearm, to extend the wrist and fingers, and to adduct and abduct the fingers slightly. It extends directly only the last or un- FiG. 76. — Paralysis op Serratus Magnus op Left Side (Leszynsky). gual phalanges, the first and second phalanges being extended by the ulnar nerve. Etiolofji). — The musculo-spiral, owing partly to its course, is the most frequently affected by paralysis of all the arm nerves. Pres- sure on the nerve during sleep, especially when the patient is intoxi- XEUROSES OF THE MOTOR SPINAL XEEVES. 143 cated, crutch pressure, fractures, Avounds, tumors, lead poisoning, arsenical, alcoholic, and other forms of multiple neuritis are the causes of its disordered function. Si/7)iptoms. — The symptoms of this paralysis are "wristdrop," due to an inability to extend the wrist or fingers. The first and second phalanges can be extended somewhat by the interossei and hxmbricales, but the last phalanges cannot be extended at all. The first finger is least affected. The fingers can be only slightly ab- ducted, supination is generally lessened or lost; if the lesion is high up, the triceps is involved and the power of extending the forearm Fio. 77.— Paralysis ok- MrscrLoSpiRAL Nerve and Wkistdrop weakened. There may l)e atrophy of the inuscles and degeneration reaction. A swelling over the tendons of the wrist-joint may occur. Some numbness and tingling exist, and occasionally there is anaes- thesia in the distribution of the radial nerve on the hand. The dis- ease lasts but a few weeks if due to compression; for months if due to neuritis, lead poisoning, or severe injury of the nerve. Even- tually recovery takes jdace. When the disease is due to lenil j)oisoninf/ there are some pecu- liarities in its course. Thus the supinator longus usually escapes j the palsy begins gradually and usually involves both arms; it may extend to tlie upper arm. Partial degeneration reactions are pres- ent. There is rarely any aniesthesia and but little pain. Often there is a lead line on the gum and a history of constipation and colic. ■ In alcoholic and otlier forms of multiple neuritis there are pain and panestliesia, both arms arc involved, and the flexors and other forearm muscles are somewhat implicated. There are marked sensory disturbances. The legs are also affected. In cotnjiression puis// tlie supinators and often the triceps are involved. When the lesion of the nerve is high uj), as in crutch ixwuljslSf 144 DISEASES OF THE NERVOUS SYSTEM. there is but little anaesthesia, and that is found on the anterior surface of the forearm, in the distribution of tlie external and in- ternal cutaneous nerves. Lesion of the nerve lower down may give rise to some anaesthesia along the radial border of the forearm and back of hand; but the anaesthetic area varies a great deal. The d'uKjnosls of the paralysis is easily made. The most impor- tant point is to find out the cause. The different characteristics of lead palsy, neuritic palsy, and compression palsy have been indi- cated in the description of the symptoms. One must be sure to exclude also progressive muscular atrophy. The treatnicnt consists of inechanical measures such as elec- tricity, massage, the application of rubber muscles, and in bad cases the fixation of the forearm and hand in hyperextension by means of a splint and plaster-of-Paris bandage (Gibney). Internally in the early stage it is best to administer iodide of potassium and sulphate of magnesium (in lead palsy), the salicylates or nitrate of silver in neuritis; later, hypodermic injections of strychnine may be given. Static sparks, galvanism, and other forms of electricity unquestion- ably do good in some cases, as I have had opportunity to prove. Paralysis of the median nerve is rare as an isolated trouble, and is almost always due to injury or neighboring lesions. Embo- lism of the axillary artery after labor has produced it. Fir. 78.— Area ov Anesthesia in Paralysis of the Median Nerve. When paralysis occurs the grip is weakened. Flexion and ab- duction of the thumb and flexion of the first and second fingers are impaired. Atrophy of the thenar eminence may occur. The anaes- thetic area varies, but is well shown in the accompanying cut (Fig. 78). Paralysis of the Ulnar ISTkrvk — Etwlogij. — The ulnar nerve is rather commonly affected by paralysis, the occurrence rank- NEUROSES OF THE 3I0T0R SPIXAL XERVES. 145 ing next in frequency to musculo-spiral i^alsy. It is rarely affected in lead poisoning, but is usually early involved in progressive mus- cular atrophy. It is sometimes attacked by a primary degenerative neuritis. Injuries are the common cause. The symptoms are shown by the table (p. 227). Tlie hand cannot be closed tightly, the little and ring fingers being especially weak. The first phalanges are drawn back and the second and third pha- langes flexed; when the interossei and lumbricales atrophy, the re- sult is the '' griffin claw" or vialn en griffe. The fingers cannot be adducted or abducted except feebly. P^cs. 79. — Rhowixo Area op Anesthesia in Ulnar-N'erve Palsy (Bowlby). There is anaesthesia over the area of distribution of the ulnar (Fig. 70) ; there may be pain and tenderness. SYMMKTuicATi SPONTANEOUS Ulxah Neuritis. — A form of neuritis of tlie ulnar nerve sometimes 0(;curs wliicli has certain peculiar cliaracters. It develo^JS slowly in persons with a neuro- patliic history, and without known exciting cause. There are first some pain and paresthesia in the region of the ulnar nerve of one hand; tliis is followed by weakness and atrophy of the mucles sup- plied by the ulnar nerve, and characteristic deformity appears. Anuisthesia develops coincidently. The other hand soon becomes afft'cted. The disease is very chronic, and complete recovery is rare. It is jirobabl}' a form of degenerative neuritis, and is due to some infection. jM iff r[ammalian Retina. A^ Layer of rods and cones; B, bodies of visual cells (external granular}; C, external molecular layer; E, layer of bi- polar cells (internal granularj; F, internal molecular layer; G, layer of ganglionic cells; H. layer of optic-nerve fibres; «, rod; b, cone; c, b(jlar cells; z, point of contact between the cones and their bipolar cells; s, centrifugal nerve fibre (Cajal). The optic nerves each contain about ;')00,000 fibres. They pass to the optic chiasm, where al)()ut one-tliirtl of the fibres cross, in man. In lower animals the decussation is greater. Th(}se fibres wlii(;h do not cross come from the outer or temporal third of the retina; those which do cross come from the internal or nasal two- thirds. A few fibres pass from one ojjtic centre in the brain along tlie posterior border of the ojitie cliiasm to the centre on the opposite side (commissure of Guthleii).* After leaving the eliiasm, the fibres form the t)j)fi'r frarf. The tract curves up and back around the crus cerebri, and divides into a lateral and mesial root. * There is still very higli iiiitliority for dfuying the partial crossing of the optic nerve (Michel, KOlliker). 164 DISEASES OF THE XERYOUS SYSTEM. These roots connect with the external geniculate body, the an- terior tubercles of the corpora quadrigemina, and the posterior gan- glion of the thalamus or the pulvinar. These ganglia are called the primary optic centres. Through the anterior tubercles of the corpora quadrigemina, and by other means, the optic nerve is con- nected with the oculomotor nerve, and thus reflex movements of the pupils, lids, and eyeballs are brought about. From these primary optic centres, libres enter the posterior part of the internal capsule, curve np and back toward the occipital lobes, forming the optic radiations of Gratiolet. They are finally distributed to the cortex of the occipital lobe, and in man chiefly to the cimeus and the parts about the calcarine fissure. It will be seen that eacli retina is connected with the occipital lobe of both hemispheres ; further, that the outer or temporal half of each retina is connected with the occipital lobe of the same hemi- sphere, and the inner or nasal half of each retina with the occipital lobe of the opposite side. The upper part of each retina seems to be connected with the lower part of the cuneus, and vice versa (Fig. 86). Other connections exist by which the optic centres on the two sides are connected with each other and with other cranial nerves in the medulla. The optic nerve is a nerve of special sense of vision and has no other function except that of an excito-reflex character. Diseiises oftLe Oj)fia JS^erve. The optic nerve ma}' be affected by nearly all forms of patho- logical change. For the neurologist, however, the especially im- portant conditions are inflammations, degenerations, injuries, and functional disorders. Inflammation of the nerve, or optic neuritis, may occur as a papillitis or inflammation of the head of the nerve, a neuro-retinitis or descending neuritis, a perineuritis, or a retro- bulbar neuritis. Perineuritis is rare. Keuro-retinitis and papil- litis are closely associated clinically and pathologicall}^ (Noyes), so that practically only two forms of neuritis need be discussed sepa- rately. Papillitis axd Neuro-ketinitis — Etiologij. — This condition is seen by neurologists in connection with brain tumors, brain ab- scess, meningitis, and occasionally multiple neuritis. The other causes are nephritis, diabetes, infectious fevers, lead, and severe hemorrhages. The disease occurs at all ages and in both sexes. In brain tumors it occurs in two-thirds of the cases, and especially often in cerebellar tumors. It occurs in eighty per cent of cases of tuberculous meningitis. SEXSORT NEUROSES OF THE CEREBRO -SPINAL NERVES. IGo Stjmptoms. — Subjective symptoms are often not present. The vision may remain good for a long time. In other cases there are concentric limitation of the visual field, loss of color sense, and scotomata. For a description of ophthalmoscopic changes, the reader is referred to special text-books. It is in this condition that " choked disc, " which is a papillitis with much serous infiltra- tion, occurs. The changes are less striking in neuro-retinitis. The disease may affect one or both nerves. In brain disease both nerves are usually involved. Pathology and Pathological Anatomy. — The process is usually Fig. tC.— Thk Optic Nbrvb axd its Ckxtral Coxxbctions (modified from Obor- 8teiu«r>. A'. Retina, dark oa the side connect«-d witli left heiiiispJiere; So, opiic ner%e; CA, cliiasm; Tro, opiic tract: CM, Mej-nert's commissure: CG, Guddens ommissure; Tho, tiialanius; Cgl, c»>rpu3 prenic. est. : ^i, corpor. qiiad. : S», optic radiations; Co, occip- ital cortex; Lm, mesial lemniscus. ^The shading of the retina and visual field should just reach the vertical lines. ) subacute or chronic. Congestion, exudation, small hemorrhages, and collections of leucocyt**s occur. The sheath of tlie nerve just back of the globe is often distended with a serous exudate. Alter a time the nerve fibres atrophy, connective tissue proliferates and takes their place, and we have a s»x>ondary optic atrophy. 166 DISEASES OF THE NERVOUS SYSTEM. The process is essentially peripheral, but it extends back with lessening intensity into the trunk of the nerve. The purely me- chanical theory of neuritis, that it is due to compression, cannot be accepted in the light of modern pathology. It is probable that the neuritis results from an irritating serous fluid which extends down the sheath of the nerve, this sheath being a prolongation of the arachnoid cavity. Mechanical causes lead to constriction, accumulation of the fluid, and compression of the nerve at its periphery, and hence to inflammation. Sometimes, at least, the irritating fluid contains microbes or microbic poisons. Fig. 87.— Neuro- retinitis (Jaeger). Eetrobulbar Neuritis. — In this disease the lesion lies chiefly behind the globe. Its causes are especially toxaemia from alcohol and tobacco. It is also due to rheumatic influences, syphilis, lead, and diabetes. In the acute cases there is usually rather rapid loss of sight, with some pain and tenderness. The ophthalmoscopic changes are relatively slight. In chronic cases, which are usually toxic in origin and due to alcohol or tobacco, or oftenest to both, there are color scotomata or absolute scotomata and amblyopia. There is no pain. The condition is known as tobacco or alcoholic amblyopia. The ijrognosis of neuritis varies with the cause. If this is re- movable, as in the toxaemias, recovery is the rule. This is a proof that in neuritis the connective tissue is the part chiefly involved, SENSORY NEUROSES OF THE CEREBRO-SPIXAL NERVES. 167 for a destroyed or atrophied optic nerve does not recover. In many cases, however, atrophy follows the neuritis. The treatment is based on the cause. In acute cases one may use cups, salicylates, the iodides, and mercury; later, the iodides and strychnine. Perfect rest to the eyes should be enjoined. F:g. 88.— Papillitis, "Choked Disc," in a Case of Cerebral Tumor. Degexeratiox of th?: Optic Kkkve, ok Optic Atrophy. — This condition may be primary or secondary. Secondary atrophy is usually the result of a neuritis. I shall describe here ^'^'imary optic atrophy. Etloloyy. — It occurs oftener in men than in woman (three to one). It occurs as part of locomotor ataxia in less than half the cases; other degenerative diseases of the cord, like multiple sclerosis, may accompany it. Next to the spinal cord, it occurs ofteuest with degenerative diseases of tlie brain, such as multiple sclerosis and general paresis. Hemorrhages, alcoholism, and lead may be causes. It may occur without known cause. The ST/mpfoms are those of gradual decrease of acuity of vision, concentric limitation of the visual field, loss of color sense, dilata- tion and immobility of the pupil. The sense of sight may remain good for a long time. Oplitiialmoscopically, the nerve disc is opaque, grayish, or dirty looking, and often has a cup-shaped or " cupped-disc" appearance. The vessels are smaller and fi'W in number. 168 DISEASES OF THE NERVOUS SYSTEM. '^\\^Q Ijatholofjij 2iXLi\. potliolorjictil anafoiinj are tliat of a parenchy- matous degeneration with loss of nerve fibres, "which are replaced by connective tissue. The ijror/nosis is almost uniformly bad. The treatment is that usually of the cerebral or spinal disease. Mercury, iodides, strychnine, phosphorus, and iron are given. Warm baths and salicylate of soda sometimes have a temporarily good effect. Strychnine in physiological doses gives, however, the best symptomatic results. Electricity is not of any use. Stretching the nerve does no good. Eserine, pilocarpine, and santonin, or nitrate of silver may be tried. The optic nerves and their primary and cortical centres are sub- ject to various other diseases. So far as these are organic, they will be described in detail under the head of brain diseases. But there are certain symptoms often of functional origin which are best described here. These are: (1) Amblyopia and amaurosis; (2) retinal hyperaesthesia and dysaesthesia ; (3) hemianopsia. Amblyopia and Amaurosis. — Amblyopia is a partial loss or dimness of vision, there being no observable lesion of the eye, or its nerves. Amaurosis is a total loss of vision, also Avithout ob- servable cause. Etvdoijy. — The causes are injuries and shocks, hysteria, migraine, concussion of the brain, lightning stroke, and severe hemorrhages. There are also certain toxic causes, chiefly alcohol and tobacco, quinine, and salicylic acid. Other causes are glycosuria, uraemia, and reflex irritations, especially of the trigeminal nerve. Night blindness and snow blindness are forms of functional amblyopia. The sijrnptoiiis are diminution or loss of vision, usually sudden, temporary, and involving both eyes. Amblyopia in hysteria is usually greater in one eye and associated Avith concentric limitation of the visual field and disturbance of color sense. Underlying amblyopia there may be minute hemorrhages in the brain, causing temporary pressure, or a vascular spasm, causing anaemia. ^\i^ jiToynosh is usually good. The treatment is purely a causal one. In most cases one must examine for drug poison, uraemia, diabetes, migraine, or a hemor- rhage. Retixal ok ocuLAJi iiYPEKiESTHESiA is a Condition in which the eye is abnormally sensitive to light. It may be diie to expo- sure to extreme light or to seclusion in a dark room. The neu- rologist sees it oftenest as a symptom of hysteria {vide Hysteria) and neurasthenia and perhaps in hypnotic states. It occurs in my- SENSORY NEUROSES OF THE CEREBRO-SPINAL NERVES. 169 diiasis and albinism. It is not to be confounded with photophobia due to irritation of the conjunctiva. Xyctalopia, or the condition of seeing better in a dim light, is a form of the disease. Hemiaxopsia, or half-sightedness, or hemianopia, a condition in which there is a blindness of one-half the visual field, may be due to a functional or organic disorder of the nerve or its centres. It is a symptom of many lesions and conditions, and can be de- scribed only generally here. Fig. 80.— Showing Lateral Homonymous Hemianopsia. This is not quite complete, there hfing a space on the bhnd side where the patient can see (Xoyes). EfloliKiif. — Its principal functional causes are migraine, lithae- mia, goat. Its organic causes are tumors, inflammations, soften- ings, or hemorrhages involving j)art of the optic nerve or its central connections. Symptoms. — Various descriptive terms are used to indicate the character of the hemianopsia. In lateral hemianopsia a vertical half of the field is involved. In lateral homonymous hemianopsia there is lialf-blindness on the left or right side of each eye, as the case may be (Fig. 89). In temporal hemianopsia the outer halves of the eyes, and in nasal the inner halves, ari' involved. Tlie upju-r or lower segments, or irregular segments of the visual field may be involved. These various forms nf liemianupsia depend upon the location of the Itision which cuts into and destroys the optic fibres in their course from the eye to the visual centre in the occipital cortex. The mechanism will be understood when it is remembered that each occipital lobe is supplied by nerve fibres from one-half of the retina of ea(;h eye. A cut shows this better than any descri})tion ( Fig. 8(!). In temporal hemiano])sia the lesion mu.st be at Ch, in front of the chiasm. In Itihitcral nasal lieniianopsia it must be doulde 170 DISEASES OF THE NERVOUS SYSTEM. and at JV and iV'. In lateral hemianopsia the lesion must lie farther back than the chiasm, in the tract, the primary centres, the optic radiations, or occipital lobes. In hemianopsia from disease of the nerve as far back as and in- cluding the j)rimary centres in the optic thalamus and corpora quadrigemina there is a loss of light reflex when a ray of light is thrown upon the blind side of the retina, but the pupil still con- tracts when light is thrown on the sensitive side of the retina. This phenomenon is called "Wernicke's hemiopic pupillary reac- tion." If in hemianopsia the light reflex is preserved, the lesion is back of the primary centres and involves the optic radiations or cortex. A test for the condition of hemianopsia in its early stage, and one that is useful in stupid or partially comatose patients, is the following : "When the finger is suddenly brought in front of the eye on the sound side, there is a wink ; if brought in front from the blind side, the orbicularis does not contract. Hemianopsia is almost always the sign of organic disease. It is not found in hysteria, but does occur in migraine and lithaemia. It is best made out and recorded by means of the perimeter. Its course and treatment depend upon the cause. Sensory Neuroses of the Trigeminal Nerve. Anatomy. — The trigeminus or fifth nerve is one of the most ex- tensively distributed and most delicately sensitive nerves of the body. Its sensory branches represent the atrophied and lost sensory roots of the third, fourth, sixth, seventh, and twelfth cranial nerves (Gaskill). The trigeminal nerve is a mixed nerve. It has two nuclei of origin: a central nucleus for the motor part, and a perijiheral nucleus for the sensory part. The motor nucleus has two parts: a chief nucleus lying deeply in the substance of the pons Varolii, and an accessory nucleus, which consists of a long tract of gray matter, known as the descending root and lying in the upper part of the dorsal portion of the pons. It passes down along the side of the aqueduct of Sylvius. There has been much discus- sion as to the exact function of this root or nucleus, but the most recent studies have shown quite conclusively that it is motor in function (Kolliker, Cajal). The sensory root of the trigeminal has its origin in the Gasserian ganglion, which is composed of unipolar cells, like those of the spinal ganglia. The axis-cylinder processes of these cells bifurcate; the external branches pass outward and become part of the peripheral sensory root; the internal branches pass into the substance of the pons, and there give off ascending and descending branches. The ascending branches are short, and pass to a terminal nucleus, known heretofore as the sensory nucleus SENSORY NEUROSES OF THE CEREBRO-SPINAL NERVES. 171 of the trigeminal. The descending branches pass down to the pons and medulla, as far as the cervical part of the spinal cord. In their coarse they give off terminal filaments, which come in rela- tion with sensory nerve cells, and the whole forms a column of matter, known as the ascending root of the trigeminus. Fio. 90. — Snowrs-G thk Mode of ORicrN' of the TRir.EsnxAL Nerve, and the Relations of the Motor and Sensory Roots, rac. cer. is the cerebral or motor root anil its fibres go to tlie inferior maxillary branch; rac. spin, is the spinal or ascendin)^ root. Tlie" cut shows the Gasserian ganglion giving origin to the sensory fibres (Van Gehuchten). The nuclei of the trigeminus reach the whole length of the pons and medulla, and are coextensive with the origin of all the other cranial nerves (Fig. 91). Hence the frequency with Avhich its dis- orders are complicated with those of these nerves. Its cortical origin is probably in the lower part of the pre- and post-central con- volutions. Tlie trigeminus su])]dies sensation to the face, conjunctiva;, nose, the frontal and maxillary sinuses, tlie teeth, the palate, tongue, and ]>art of the upper pharynx; also to tlie scalp as far back as the vertex, and to the external auditory meatus (Fig. 93). The distri- bution is not always the same and is lielped by fibres from the cer- vical nerves. Entire removal of the Gasserian ganglion in man may give, for exami)le, aniesthesia only over the areas shown in Fig. 91', ill wliich antesthesia i.s not comjjlete in areas /'or a. It gives sen.sa- tion also to the anterior tliree-fourtlis of tlie dura mater, the falx, ami probalily the tentorium. The pia and arachnoid are not sensitive. 172 DISEASES OF THE XEKVOUS SYSTEM, The posterior fossa and the occipital pai-t of the dura mater are sup- plied by the vagus. The trigeminus also supplies the above-named parts with trophic, vasomotor, and secretory fibres. The vasomotor fibres are brought to it, in part, from the medulla and cervical spinal Fk;. 91.— Showing the Origin of the Cranial Nerves and the Extent of the origin OF THE Trigemints (Edinger). cord via the sympathetic ; tlie secretory fibres have the same origin. An exception is to be made of the lacrynial secretory fibres which are brought by the motor nerves of the eyeball. The opinion, based largely on physiological experiment, that the trigeminus sends Fig. 02.— showing Area ok Anesthesia after Removal of Gasserian Ganglion 'Kraiise). trophic fibres to the conjunctivae and cornea, is denied by Krause, who reports many successful cases of entire extirpation of the Gas- serian ganglion witliout any intiammation of the eye following. The trigeminus supplies motion to the muscles of mastication, viz. , the two ])terygoids, the temporal, masseter, mylo-hyoid, and anterior belly of the digastric. The sensory neuroses of this nerve are neuralgia, parsesthesia, and anaesthesia. SENSORY NEUROSES OF THE CEREBRO-SPIXAL NERVES. 173 Neuralgias of the Trigeminus. — The trigeminal nerve is sub- ject to two types of neuralgia, viz. : 1. The syraptomatic form. 2. Tic douloureux. 1. The syynjdomatic neuralgias are by far the most frequent. They are called supra-orbital, infra-orbital or supramaxillary, inf rainaxillary or dental, and mixed forms. The most common type is the supra-orbital ; next, the mixed form. Etiolofjy. — The female sex is oftenest affected; most cases are seen in the first half of life; most attacks occur in the winter and spring. The left side is oftener affected. The second and third branches of the fifth nerve are most susceptible to rheumatic influ- Fio. 93. —Showing thk Dirtribitttom op the Sensory Nerves op the Face. I, 77, 777, First, second, niid tliinl branches of tlio flftlj. The shaded i>art is siij)plit:'d by the cervical nerves; 2 C.a.hr., second cervical anterior branch; 2 C.p.br., second cervical jKJsterior brancli. ences, the first branch to malarial and septic poisons. Dental dis- orders naturally are frerpient factors in neuralgia of the second and tliird branches. Anaiinia, exposure, child-bearing, and other de- pressing inrtuences are factors in causing these neuralgias. Ocular and nasal disease may cause pain in the supra-orbital nerve. Gout, diaV)etes, syphilis, malaria, hysteria, epilepsy, trauma, rheumatism, all may be factors in causing trigeminal neuralgias. Si/mptoms. — The pains of trigeminal neuralgia are sharp and in- tense, with exacerbations and remissions. The i)ain often lasts for days witliout entirely ceasing. It then goes away and may not return 174 DISEASES OF THE NERVOUS SYSTEM. for a long time. The characteristic of neuralgia is that it stays till its cause is removed. In supra-orbital neuralgia there is sometimes great oedema of the lids and the parts about, together with suffusion of the eyes. There are tender points over the course of the nerves. The tender points in supra-orbital neuralgia are supra-orbital, pal- pebral, and nasal ; in infra-orbital neuralgia, nasal, malar, and gingival; in infra-maxillary neuralgia, inferior dental and tem- poral. In the mixed forms we find various combinations of the above. There is often also a tender point over the parietal emi- nence and vertex. The pain may radiate to the ear or occiput, or it may be located in the orbit. Dental irritation may also cause an otalgia or a neuralgia in tlie upper branches of the fifth. There is sometimes a dilatation of the pupil, and in severe cases a reflex facial spasm occurs. Tic Douloureux [Prosopalgia, FothergUVs Neuralgia, Ejnlepti- form Neuralgia). — Tic douloureux is a special form of trigeminal neuralgia occurring in middle or advanced life, unusually severe in its symptoms and obstinate in its course. It ought to be distin- guished sharply from the ordinary forms of trigeminal neuralgia. These latter are symptomatic pains almost altogether; while tic douloureux is a special disorder, dependent upon changes in the nerve itself. Etiology. — It occurs, as a rule, in persons who are over forty, and is seen in the very aged. It is, indeed, almost the only neu- ralgia which old people have. It is brought on by exposure, over- work, and depressing influences; sometimes, perhaps, by local dis- eases of the teeth and jaws. It occurs in men and women in about- equal frequency, in my experience. Other observers find it oftener in women. Si/mptonis. — It is characterized by intense darting pains, which usually start in the upper lip and by the side of the nose. From here they radiate through the teeth or into the eye and over the temple, brow, and head. They are confined to one side of the head. During a paroxysm the face usually flushes, the eyes water, the nose runs, and the patient assumes an expression of the greatest agony. The attack lasts for a few minutes, then becomes somewhat less, but the pain rarely ceases entirely. A breath of cold air, speak- ing, eating, putting out the tongue — all bring on paroxysms. The pains are worse in winter and often become less or cease during summer. Occasionally they come on for a few months every year, usually during the spring. The pains are always limited to one- side of the face and are centred chiefly in one branch of the nerve,. SEKSOBY NEUROSES OF THE CEREBRO-SPINAL NERVES. 175 ofteuest in the supramaxillary and next in the inframaxillary. They may spread so as to involve the whole of one side of the face and tongue. Spasmodic movements of the face, tongue, or jaws may be associated with the pain. Examination rarely reveals any objective trouble, but in a few cases some anaesthesia may be noted. Fatliolofjy. — The disease is usually a degenerative one, and probably is due to irritative and atrophic processes occurring in the nerve and its ganglion, A low grade of neuritis, perhaps from alveolar disease, has been found sometimes, but as a rule the nerve does not appear much changed. The arteries supplying the nerve, however, often undergo the changes of endarteritis, their calibre is much lessened, and the nerve cannot get its proper supply of blood. Thus an obliterative arteritis underlies some cases of the disease. Traatment. — In cases which occur in old people, the use of nitro- glycerin given in doses of gr. ji-jj- q. 2 h. sometimes has a happy effect. A very good remedy is crystalline aconitia given in doses of gr. ^J-jj- until its physiological effect is obtained. Besides these measures, galvanism daily, iodide of potassium in large doses, gelsemium, croton chloral, codeine, external applications of menthol, freezing with chloride of methyl, and heat — all may be found use- ful. The common practice of pulling out all the teeth is almost always unsuccessful, and ought not to be undertaken without specially good reason. Tonics containing iron, phosphorus, quinine, or arsenic are generally helpful, and should always be given after a course of specifics. In younger patients the remedies recommended under the head of Migraine and Headache may be given. Change to a warm, equable climate may be tried; it is not a certain resource. I have found that in cases not of over four or five years' duration, rest in bed with massive doses of strychnine sometimes effects striking cures. The drug should be given hypodermically in doses of gr. -^ once daily, gradually increased until gr. i or \ is reached. This is repeated four days and then the amount gradually reduced. The patient must be ke^it rigidly quiet and the full course persisted in. After a month iodide of potassium and iron are given. The treatment may have to be repeated with lessened rigor. The treatment by large doses of opium, gr. iii. to vi. daily, is uncertain and often dan- gerous. Finally, surgical interference may be necessary. The removal of the nerve at as deep a point as possible is the only operation to be seriously entertained. This sometimes causes cure, but, as a rule, the pain comes back in six or twelve months. Even such a 176 DISEASES OF THE NEKYOUS SYSTEM. respite, however, is often gladly seized upon. Eemoval of the Gasserian ganglion has been attempted with success. Ligature of the common carotid has been tried also, but of late years the opera- tion has been generally abandond. Simple drilling out of the infra- orbital nerve with a dental probe made of piano wire has given long relief. There are numerous methods of operating upon the different branches of the trigeminus. For buccal neuralgia, Zuckerkandl has devised a method. For superior maxillary neuralgia, the method of Carnochan, modified by Abbe, is, in my opinion, the best. Others favor Langenbeck's method. Ullmann, Mikulicz, Obalinski, and many others have devised special methods. Hartley, of New York, has devised an operation by which he enters the middle fossa through an opening in the temporal bone, thus reaching the root of the nerve. Rose, Krause, and others have reported many successes following this rather serious operation. Trigemikal Par.esthesia. — Sometimes persons suffer from peculiar numbness, thrilling, or formication in the course of the trigeminus. The sensation may be nearly constant and excessively annoying. It never amounts to actual pain. It occurs in autemic, nervous, and hysterical persons. It is to be regarded as an abortive form of neuralgia, and so treated. Trigeminal Anaesthesia. — This occurs from various patho- logical lesions in the coarse of the nerve or in its nuclei. The most common organic cause is syphilitic disease of the membranes at the base of the brain. Trigeminal anaesthesia occurs together with an- aesthesia of other areas in hysteria and in organic disease of the nerve centres. It is sometimes noted in tic douloureux and facial hemiatrophy. Heijjes, flushing, pallor, lacrymation, salivation, are all symp- toms of disturbance of the trophic, vasomotor, and secretory fibres running in the trigeminal nerve. They are usually, if pathological, only concomitant symptoms of other diseases. Headache (Cephalalgia). Headache is the name given to attacks of diffuse pain affect- ing different parts of the head and not confined to the tract of a particular nerve. It usually comes on in paroxysms at various intervals, but may be continuous. Etiology. — Headache is the most common of nervous symptoms. Ten to fifteen per cent of school children, twenty-five per cent of men, and over fifty per cent of women are subject to it more or less, SENSORY NEUROSES OF THE CEREBRO-SPINAL NERVES. 177 though this proi)ortioii would be mnch reduced if migraine were exchided frojii statistics. The headache ages are from ten to twenty-five and thirty-five to forty-five ; most cases occur between the ages of eight and twenty- five, es^Decially in females. The number of headaches increases gradually from the period five to ten years up to the period fifteen FlO. fl4.-SH0WIN(; TllK MOTOK AM) SK.NSOKY N'KKVKS (»K THE FACE (MlTkel). to twenty, then falls till tlie thirty-fitth year, and rises again till about the age of forty. Early childhood and declining age are practically exemi)t from chronic functional headaches. Women suffer from it more than men in the proportion of about three to one. It is more frequent in city populations and among the wealthier classes. Headaches are more common in the spring and fall and in temperate climates. Headaches may be classed, in accordance witli tlicir causes, as follows: 1. Ha-mic or autotoxic causes, in which impoverislu'd or dis- ordered blood is brought to the brain, as in (//) anaemia and conges- tion; (//) diathetic states: gout, rheumatism, diabetes, ura-iuia; ('•) infections: malaria, fevers. 2. Toxic causes : lead, alcohol, tobacco, etc. 3. Neuropathic states : epilepsy, iK'urasthenia, hysteria, neuritis. 4. lleflex causes: ocular, nasopharyngeal, auditory, dyspeptic, sexual. 12 178 DISEASES OF THE NERVOUS SYSTEM. 5. Organic disease, including arterio-sclerosis, syphilis, tumors, meningitis, and diseases of the cranial bones. Very frequently several causes act together. The anaemic, dyspeptic, ocular, and neurasthenic are the common forms of chronic and recurrent head- ache. Edinger thinks that a large percentage of chronic headaches are due to the presence of certain nodules situated near the origin of the muscles of the back of the head. The location of these is in- dicated in Fig. 95. Massage by removing these relieves the head- Fig. 95.— Location of Headache Nodules According to Edinger. ache. I have not found these often, and doubt if they have so much importance, but their existence and possible influence should be borne in mmd, especially in gouty subjects. Symptomatolofjy. — Headaches may be classed in accordance Avith their location and the character of the pain. We have accordingly : 1, frontal headaches; 2, occipital headaches; 3, parietal and tem- poral headaches; 4, vertical headaches; 5, diffuse headaches and various combinations of the above. The most common form of headache is the frontal, next the fronto-occipital or diffuse, next the vertical, and then the occipital. The kind of pain differs with different persons and with differ- ent causes. We have: 1, pulsating, throbbing headache; 2, dull, SENSORY NEUROSES OF THE CEREBRO-SPINAL NERVES. 179 heavy headache ; 3, constrictive, squeezing, pressing headache ; 4, hot, burning, sore sensations ; 5, sharp, boring pains. The first form characterizes headaches with vasomotor disturb- ances, and usually indicates migraine. The second is usually of a toxic or dyspeptic type. The third is found in the neurotic and neurasthenic. The fourth in rheu- matic and anaemic cases. The fifth in hysterical, neurotic, and epileptic cases. The accompanying diagram shows some of the relations of localized pain to the cause. A large experience both in my own practice and in that of others shows it to be approximately correct. Headaches may continue for a day or maj'- last for weeks or months. Some persons have headaches only when constipated or Constipation. \ Caries of incisor. \ Error of eye-refraction.,^ ">) P - ^ --/x"-'''' Decayed teefh. Fig. 90. — Showing the Location of the Pain in Headaches from Different Cacses. bilious, or when thej' have an attack of indigestion. Others suffer from a little pain nearly all the time, exacerbations occurring at various periods. Neurasthenic and ocular headaches are generally of this type. "When headaches are per-sistent, examination should be made of the eyes, of the nose and sinuses ; the patient should be questioned as to syphilis, the continuous use of tobacco, and chronic dyspepsia. The possibility of brain tumor, of pachymeningitis from blows, or sunstroke or chronic alcoholism should be considered. The persistent headaches not relieved by ordinary treatment are due to eye trouble, antfimia, neurasthenia or spinal irritation, rheu- matic nodules, syjjhilis, or pachymeningitis. Eye strain may cause true migraine or ordinary headache. Eye-strain lieadache is usu- ally associated with sonu^ weakness of eyesight ami pains ami dis- comfort about the globe, besides severer i)ains at times in the brow or occij)ut. The cause of the eye strain is usually astigmatism and hyp('nnetro))ia. Occasionally it is due to weakness or lack of bal- ance of the eye muscles. Headaches may occur regularly every morning on awaking. 'I'hcy are called iminii/i;/ /triKinr/irs, and are a symi)tom of neuras- thenia and litluemia. They occur oftenest in niidille life. ]80 DISEASES OF THE NERVOUS SYSTEM. Symjifoms Associated vi'dlu JleadacJiP. — The symptoms oftenest associated with chronic and recurrent headaches are vertigo, som- nolence, sensations of heat and pressure (cerebral parsesthesias), and nausea. Vertigo goes oftenest with headaches of dyspeptic origin; some of the so-called bilious headaches of early life develop later into attacks of vertigo; this symptom often occurs with frontal headaches. Somnolence occurs oftenest Avith anaemic and malarial headaches ; it may develop also with syphilitic head pains. Nausea I have found oftenest with occipital headaches. Pathology. — Headaches are to be distinguished from neuralgias and from a special and common form of head pain known as migraine. Headaches are diffused pains caused, as a rule, by irritations located in or referred to the peripheral ends of the fifth nerve. Their seat is usually within the skull. Neiu'algias, on the other hand, are caused by irritations of the ganglia or trunks of these nerves. The pains are local and confined to the single branches of the nerve. Migraine is a periodical neurosis in which there is a discharge of nerve force, not only affecting the trigeminus, but often other cranial nerves as well as sympathetic fibres. It is a general disease of which the headache is only one symptom. The nerves of the dura mater are those most involved in head- ache. Headaches, when occipital, involve the sensory fibres of the vagus and the upper four cervical nerves. There is no anatomical change in the nerves except in organic headaches. But in many cases the membranes of the brain and their sensory nerves are congested or anaemic. JJia(jnosis. — No symptom requires more careful investigation a? to its cause than that of headache. The diagnosis is always to be made, not of this symptom, but of its cause. Most of the foregoing description accordingly refers to etiology. It may be quite posi- tively affirmed that headaches which persist for months, are worse in the day, and leave the patient able to sleep at night, to recur on waking, are exhaustion pains and are due to a neurasthenic state. Chronic headaches, worse at night, are usually of specific or organic origin. It is important, however, to decide whether the case is one of migraine, or neuralgia, or headache. Headache is usually diffuse and bilateral. It is more or less persistent. Migraine comes on paroxysmally, lasts a short time, and then leaves the patient feeling perfectly well or even better than ever. Migraine is often accom- panied with nausea, flashes of light, strong pulsations of the head, SENSORY XEUROSES OF THE CEREBRO-SPINAL NERVES. 181 vertigo, pallor, or, more rarely, eongestiou of the face. Neuralgic pains are sharp and shooting; they run along the tract of the nerve, and often are associated with suffusion of the eye and oedema. Tender points are felt. Treatment. — The constitutional treatment is based upon the etiolog}'. Regulation of diet and digestion, securing a regular movement of the bowels, attention to ocidar troubles, abstention from tobacco and alcohol and overwork are the important points requiring attention. Kest is the important point to attend to, as in almost all painful neuroses. The symptomatic treatment consists in giving antipj-rin, anti- febrin, phenacetin, salicylate of sodium, caffeine, muriate of ammo- nia, and sometimes morphine or codeine, and bromide of ammonium. Antipyrin can be given in doses of gr. v. every twenty minutes till three or four doses are taken. Phenacetin often needs to be given in large doses of ten or even twenty grains. Antifebrin is less trustworthy and must be given in small doses. Exalgin is not a very good or safe remedy. It may be tried in doses of gr. iij. to gr. v. Muriate of ammonia is an excellent remedy given in very large doses, 3 ss. to 3 i., well diluted. Menthol in doses of gr. v. to gr. X. in hot water sometimes stops headaches. In headaches from ana;mia, caffeine and ammonium muriate are best. In head- ache from nervous exhaustion, similar stimulating anodynes are usually most efficacious. Combinations of caffeine citrate and salicy- late of sodiuiu or benzoate of sodium are often better than the single drug. Caifeine iu any case must be given in larger doses than is or- dinarily done, i.e., gr. iv. or v. Local applications of a twenty- per-cent solution of menthol, the ice bag, cloths wrung out in hot water, or a piece of sheet lint soaked in chloroform liniment two parts and tincture of aconite one part are efficacious measures. A cathartic, rest iu a darkened room, light diet — all these are measures which many patients themselves learn to adopt. Finally, in headaches from organic disease we have often to resort to iodide of potassium, mercury, and the use of some prepa- ration of opium. As will bo seen, each case of headache requires special treat- ment and a certain amount of exiierimentatiou in order to learn the idiosyncrasy of the patient. MiGiiAixE, Sick-Hkadache, IIemicuaxta. — Migraine is a con- stitutional neurosis characterized by periodical attacks of pain chieily m the course of tlie fifth nerve. The pain is often associated with nausea or vomiting, mental depression, vasomotor disturbances such as flushing or pallor of the face, by flashes of light, vertigo, tinnitus 182 DISEASES OF THE NERVOUS SYSTEM. aurium, and in rare cases by partial paralysis of one oculomotor nerve. It will tliiis be seen that migraine is more than ordinary head- ache and unlike an ordinary neuralgia. Etiology. — The disease is very common in civilized countries and is frequent in America. Ifc occurs oftenest in women in the propor- tion of about three to one, and it begins in most cases at or a little before the age of puberty. It may begin as early as the fifth or even the second year. It occurs in neurotic families, and there is very often a history of direct inheritance. Other neuralgic trou- bles, epilepsy, and gout may be found in the family history. The attacks occur oftenest in the winter in our climate. The cases that begin in childhood and early life are sometimes started by overwork at school, but "usually no especial cause can be found. When they begin after maturity, a history of excesses in work, injury, shock, or exhausting disease is found. Migrainous patients visually have some refractive disorder of the eye or a weakness of eye muscles, and this condition is one factor in bringing on or keeping up the headaches. Autotoxsemia from uric acid and poisons developed in the intestinal tract is considered an important factor in migraine by some. Sijinjjtoms. — The patient for several days may feel a sense of malaise and depression ; usually, however, the prodromal stage lasts only a few hours or a day. The attack often comes on in the morn- ing and gradually increases in intensity until the victim has to give up work and lie down. Sometimes the pain comes on with almost epileptic suddenness and violence, waking a person from sleep or compelling him at once to lie down. Fuhjm-ating migraine is the term applied to this type. The pain starts in one side of the head, usually in the forehead, but often in the occiput. It increases and finally may involve the whole head. The pain is of a tense, throb- bing, blinding character, increased by jars, light, and noises. It is accompanied by dimness of vision, often by flashes of light or dark or light spots variously colored floating before the eyes. Re- striction of the visual field, sometimes in the form of hemianopsia, may occur. Vertigo, tinnitus aurium, confusion of ideas, feeling of stupor, disturbances of memory, are not uncommon; nausea and even vomiting are the rule. The vomited matter is at first chiefly mucus, but it may later become yellow and bitter from the presence of bile. Hence the term " bilious headache, " which is an improper one, because the bile is only the result of retrostaltic action from the vomiting. Migraine is not the result of gastric or liver dis- order. The patient's face usually is pale and gives the evidence of acute SENSORY NEUROSES OF THE CEREBRO-SPINAL NERVES. 183 suffering. The flushed face is very rare; the distinction between angiospastic or pallid migraine and angioparalytic or congestive migraine is not of clinical value. The pulse is small and hard, and may be lessened in rapidity. The temperature in children often rises. The attack lasts from six to twelve or twenty-four hours, occa- sionally even two or three days. As the intensity of the pain lessens FIG. 97.— SCLNTILLATING AND ZIG-ZaG LIGHTS SEEN IN MIGRAINOUS ATTACKS (Bablnskl). the patient sinks to sleep, and awakens next morning feeling re- freshed and better tlian before the attack. The attacks occur at varying periods, fortnightly or monthly, and even weekly. In women they often occur during menstruation. Some women are entirely free from them during pregnancy. At about tlui time of the menopause in women, and at about the same time of life in men, the disease lessens in severity and as a rule dis- appears. Some form of neuralgia or some neurosis in rare eases takes its place. 184 DISEASES OF THE NERVOUS SYSTEM. Conviylicatiti;/ >S//iiipf()i/i.s. — Partial oculomotor paralysis, teui- poraiy aphasia, slight hemiplegia, hemmumbuess, peculiar odors or tastes, convulsive movements of the body almost resembling epileptic attacks, occur. Cases presenting these symptoms are rare. When they occur in one case, however, they always occur in each attack unless it is modihed by treatment. Vicarious Attacks. — Migraine is sometimes associated with epi- lepsy, locomotor ataxia, or insanity ; that is to say, persons in early life have had migraine and later developed the diseases mentioned. The relation between these diseases, however, is not so close as some writers would lead us to infer. The attack of migraine can be sometimes replaced by an attack of gout, or visual disorders, or other sensory symptoms, or even by an oculomotor paralysis. Sometimes, instead of a fully developed attack, the patient has a sense of mental depression, with confusion of ideas. Cases have been reported in which acute mania took the place of the headache. Types. — Writers have described the angioparalytic and angio- spastic types; also the typical, subtypical, and supratypical ; and finally the ordinary type and the ophthalmic type. Practically we find two classes : (1) The typical, associated with visual disorders and having most of the symptom described above. (2) The irregular or mixed type, in which with many symptoms of ordinary migraine there is a history of rheumatic influences and often of anaemia or dyspepsia. These are eases of a true migrain- ous affection complicated with some form of symptomatic head- ache, such as has been already described. The mixed or irregular migraines are important to recognize, for they call for special treatment. They occur almost altogether in women; the attacks are often associated with weather changes and may be of a neu- ralgic character. Many women have their sick-headaches and their neuralgic headaches, so called, and have to distinguish be- tween them. In mixed attacks the face is usually also pale, the eyes are not suffused, nor is there any visual or aural disturb- ance, as in migraine. Sometimes the pain remains in the occipital nerves, and I have met with one patient who localizes her pain there entirely, and who always vomits during the attack. Pathology. — The seat of the disease is chiefly in the intracranial branches of the fifth nerve and of the i)neumogastric ; the upper cervical nerves, however, are often involved. There are no morbid anatomical changes known. The most plausible theory of the dis- ease is that it is a fulgurating neurosis, in which there are periodical discharges of nerve force, or nerve storms. The seat of the dis- SENSORY NEUROSES OK THE CEREBRO-SPINAL NERVES. 185 charge is jjerhaps in the ceiebral cortex, or jjossibly in the pri- mary sensory centres, i.e., the root ganglia of the fifth and vagus nerves. The disease is certainly not in the sympathetic system, as was once taught. The presence of excess of uric acid or of some other autochthonous poison as a factor in the disease may be re- garded as probable. Diagnosis. — The diagnosis is based upon the hereditary history, the periodicity and seat of the attacks, the nausea, the complicating visual and other sensory symptoms. It should not be forgotten that the same patient may have migraine and other neuralgias, or may have also an organic brain or renal disease. Treatiiient — rro^ylnjlaxis. — Childi-en of families in which this neurosis exists should be carefully watched during the ages between five and twenty. The eyes and nose should be examined. They should not be subjected to excessive mental or visual strain, and if attacks develop they should be promptly treated. The application of glasses should be considered, but not hastily adopted. As regards constitutional treatment, the best measures for curing a case of migraine consist in correcting any visual or nasal defect, such diet and exercise as secure tone to the nerves, and the continu- ous use internally of bromide of potassium, nitroglycerin, cannabis indica, or arsenic. The diet should be very simple and non-fermen- tative. It should be mainly of meats and green vegetables and cooked fr\iits. The meats should be moderate in amount, and some- times only iish and poultry should be allowed. Of the drugs, salicylate of sodium and cannabis indica, either with or without arsenic, are the most trustworthy, while the bromides are tlie least. The hemp should be given in large doses and for a long time, gr. -J to gr. i., ter in die. Tlio salicylates may be com- bined with an alkaline laxative like Kochelle salts, a dose being taken night and morning. Much stress is laid by some upon ocular muscular insufficiencies, and I believe that such conditions should be remedied, but place little confidence in them alone. On the other hand, the correction of snuiU or large degrees of astigmatism and hypermetropia sometimes produces surprisingly good results. The reported cure of numerous cases of migraine by treatment of nasal hypertrophies and catarrh should not excite too much confidence in such measures. In fact, since migraine is a constitutional neurosis, one cannot ex^tect permanent results from removing reflex irritants alone. The daily use of a strong galvanic current four to eight mil- liamperes (eight to ten cells) for ten minules is useful. For tJie rdlff of the attack the following drugs may be given: Salicylate of soass to the brain and by direct action on the nervous centres cause vcitigo. This is probably the explanation of the vertigo of biliousness and constipation. It is a paroxysmal vertigo, noted most in the morn- ing, not very severe, and often accompanied by nausea. yeurntic Vertigo. — The symptoms of epileptic vertigo will be described under that head. Neurasthenic vertigo is a not uncommon symptom. The attacks are short, generally sulijertive, not s»'vere or accompanied by nausea or syncope, but they often cause much alarm. Underlying them are 10"2 DISEASES OF THE NERVOUS SYSTEM. exhausted and irritable nerve centres, with ocular, gastric, and hu- moral irritations. A neurotic vertigo occurs sometimes in the form of attacks almost exactly resembling seasickness. There are intense vertigo, nausea, and faintness lasting for hours, coming on suddenly without known cause except overwork or excitement. The attacks occur in neurotic subjects and are analogous to other nervous crises. It is a periodical neurosis of the space-sense nerve. A form of vertigo which is psychical in character occurs in neur- asthenics. It consists in a sudden sensation of insecurity, an ap- prehension of falling, of an approaching loss of consciousness. There is no true vertigo, either subjective or objective, and the patients really never stagger or fall. It is a psychosis rather than a nervous condition. In some nervous subjects there occurs a sudden giving way of the legs. There is no conscious vertigo, yet such probably exists. The symptom is noted in exophthalmic goitre. It is a '* stumbling vertigo." Ocular Vertigo is a rare symptom, but is, when present, chronic and annoying. It is caused by refractive errors and unequal action of the ocular muscles. The ineclianlccd vertigoes such as seasickness, car sickness, etc., are produced by swinging, or whirling, the movements of the ship, steam ear, and elevators. Railway mail clerks, elevator boys, often suffer from chronic disturbances of a vertiginous character. Ocular and auditory nerve sensations enter mainty into the causation of the troubles. Arteriosclerotic Vertigo, Se7iile Vertigo. — This occurs in persons who have arterio-sclerotic changes in the brain vessels, either from disease or senility. The symptom is caused by impaired brain nu- trition with consequent anaemia. Senile vertigo may also be due to a weak and fatty heart. Patliologg. — The consciousness of the proper equilibrium of the body and of its relations to the external world depends upon the con- tinuous inflow of nervous impulses from the eye and its muscles, from the nerves of the muscles, joints, and viscera, and from the ear. Anything which suddenly disorders this even inflow may cause a disturbance of consciousness and sensations of vertigo. The aural impulses come from the semicircular canals and ampullae; they are the most important. These impulses are not felt in consciousness normally, but go to certain lower centres chiefly in the vermis of the cerebellum. Prom this point they influence the acts concerned in holding the body in equilibrium. SENSORY XEUROSES OF THE CEREBRO-SPINAL NERVES. 193 ^^^len impulses from, the eye and its adjusting mechanism do not flow in ncjimally, there may be disturbance of consciousness and a fneling of vertigo. Probably visceral impulses can ju-oduce a similar disturbance. Everything which suddenl}- interferes with the nutri- tion of the cortex of the brain, such as anaemia and poisons, may lead to giddiness by lowering the level of consciousness and confus- ing the sensory inflow. Diagnosis. — In investigating vertigo the physician should find (1) whether it is subjective or objective, (2) paroxysmal or chronic, (3) accompanied by ear symptom, nausea, tinnitus, and loss of consciousness. He should then direct himself to finding the special cause and seat, remembering that the auditory, gastric, toxic, and neurasthenic are the common forms. In elderly persons the arteries should be carefully examined. In young persons the possibility of epilepsy must be remembered. The in-ofjnosis depends upon the cause. Epileptic vertigo and vertigo from organic disease are most serious. Labyrinthine ver- tigo usually ceases when complete deafness occurs. The other forms of vertigo are usually susceptible of relief. Treat III I'lit. — The attack is treated by rest in the horizontal position and the administration of a volatile stimulant. The dis- order must then be treated in accordance with the cause. In ^leniere's vertigo the use of quinine by Charcot's method is said to be useful. Quinine is given in doses which are gradually increased until cinchonism results; then the drug is stopped. ^Mitchell advises the addition of hydrobromic acid; Gowers advises the use of salicylate of sodium in five-grain doses instead of quinine. Ilirt recommends ten drops of a two-per-cent solution of pilocarpine injected hypodermically every other day. Neurasthenic vertigo is cured by rest and attention to diet, laxa- tives and mineral acids being used. Hydrobrcmiic acid with pepsin and glycerin are often very helpful here. Gastric vertigo is to be treateil with saline laxatives and simple bitters before meals. In the vertigo of " biliousness" and litha-mia there is often a neurasthenic element, and a similar attention to diet and to the digestive organs is indicated. In arterio-sclerotic and senile vertigo small doses of nitroglycerin and iodide of potassium, with or with- out digitalis, should be given. Ke.st and warmth of the extremities are indicated. In all forms of vertigo bromide of potassium is help- ful and will relieve the symptoms for a time. It is tlie best symp- tomatic remedy. Counter-irritation to the neck or mastoid region by the cautery does good occasionally. 13 194 DISEASES OF THE NERVOUS SYSTEM. There are two peculiar forms of disease to which the name vertigo has been attached which may be described here. Laryngeal Svxcope (Laryngeal Vertigo, L, Epilepsy). — This is a rare form of disorder characterized by attacks of paraes- thesia of the throat, with coughing, followed by sudden syncope, and. sometimes by slight convulsive movements. The disease occurs chiefly in males at about the age of fifty, though the range of age is from thirty-five to seventy. xsTeurotic constitution is often present. Tliere may be a history of injury and the use of stimulants. Laryngitis, bronchitis, apical phthisis, and asthma may be present. At the onset of the attacks a burning or tickling sensation is felt in the larynx or trachea; there is a spasmodic cough, perhaps some asthmatic or dyspuoeic symptoms, when the patient suddenly falls unconscious for a short time. The attacks maj' occur daily or only once in a few weeks. Most cases are curable, yet the disease is not without danger. It is probably a reflex neurosis, not a true epilepsy. The treatment should be directed to relieving any local con- dition or pulmonary trouble. Bromide of potassium should also be given. Pakalyzinc^ Vertigo (Gerlier's Disease). — This is a disease occurring only on the farms in southern France and Switzerland. The symptoms consist of sadden attacks of ptosis, vertigo, paresis of arms and legs, and cervico-occipital pain. The disease is most prevalent in the summertime. It attacks chiefly males. Single attacks last not over ten minutes, but may occur frequently. The cause is sujiposed to be a special microbe developed in the stables during the heat of summer. We are not aware of its occurrence in America, though Seguin calls attention to the close similarity of the symptoms to those of poisoning by conium maculatum. Hyperacusis (Auditory Hyper.esthesia). — When there is undue keenness of the sense of hearing, the condition is called hyperacusis. It occurs in hysteria and hypnotic states. Some persons have naturally an extraordinary keenness of hearing. In facial paralysis there is sometimes hyperacusis due to paralysis of the stapedius. When ordinary sounds cause painful feelings, the condition is called dysacusis. This occurs in the neurasthenic and hysterical, in persons of enfeebled vitality, in the brain congestion of fevers, and in meningitis; also in local ear troubles of an inflammatory character. Sensory jSTeuroses of the Glosso-Pharyngeal Nerve. The anatomy of this mixed nerve is described under the head of motor neuroses. The sensory fibres may be affected in hysteria, causing the symptom called globus, and also the pharyngeal times- thesia found in the same disease. SENSORY NEUROSES OF THE CEREBRO-SPINAL NERVES. 195 The special fibres of taste may be affected, causing ageusia or loss of taste. Ageusia (loss of the sense of taste) is an affection in which the power to discriminate the tastes of bitter, sweet, salt, acid, and alkaline substances is lost. Etiolo(jij. — It occurs oftenest in an incomplete form in facial ])a]sy and in hysteria. Injuries of the trigeminus and glosso- jiharyngeal nerves, catarrhal diseases of the mucous membrane of tlic mouth and nose, are frequent causes. It is not caused by cortical brain disease so far as known. Some ageusia is present in the imbecile, and the sense of taste is less keen in the lowly organized and criminal classes. Si/mptovis. — The symptoms are subjective and may not be noticed at first by the patient. In hemiageusia from facial palsy and hys- teria it has to be looked for, as the patient does not complain. The tests are made with solutions of salt, sugar, vinegar, and quinine. A single solution of sugar usually answers. But the different parts of the tongue differ in sensibility to different substances (see Fig. 97). Care must be taken to exclude the nose as a factor in taste. Patholofjij. — Ageusia occurs as the result of disease of the roots of tlie trigeminus, especially of the second, or, as Krause claims, the third; also from disease of the facial when the chorda tympani is implicated and from disease of the glosso-pharyngeal root. Disease of the trii,'eminus and facial usually causes ageusia on the anterior two-thirds of the tongue, Avith loss of taste, especially for sour and bitter substances. Sometimes, however, disease of the tiigeininus or disease of the tympanum involving the tympanic jilexns and chorda tympani causes ageusia of the whole tongue on the affected side. Ageusia from disease of the glossu-pharyngeal alone is very rare, and then causes loss of taste ou the posterior third of the tongue, soft palate, and jiilhirs of the fauces, with loss of taste to sweets and acids. A few cases have been reported in which paraly- sis of the glosso-pharyngeal caused complete ageusia on the affected side. It must be inferred, therefore, that taste fibres run some- times wlxjlly iu the fifth, more rarely wholly in the ninth nerves, au'l usually in both. The tridtmriif. dejiends on the cause. Locally, cleansing and stii lulatiiig mouth washes and electricit}^ nuiy be used. l*ARAain grad- ually subsides, and the disease itself runs its course in a few weeks. Trriitnii-nt. — In the early stage the galvanic current is efficacious. Local anodynes and ]irotective ointments may be ajjplied. Anti- rheumatics and analgesics are to be administered internally. 200 DISEASES OF THE NERVOUS SYSTEM. Sen'sory Neuroses of the Lumbar Nerves. The upper two lumbar nerves are almost entirely sensory. Neuralgias of these nerves are called lumbo-abdominal. They occur oftener in women and usually after the thirtieth year. To the ordinary causes of neuralgia Ave add straining, con- stipation, and pelvic disease. True essential neuralgia is rare ; but myalgic and reflex pains from uterine disease are very common. Si/nqitoms. — There is pain in the loins, back, and buttocks, ex- tending down to the hypogastrium or genitals on one side. The pain in the back, however, is often bilateral. Painful points may be found after a time, as in intercostal neuralgia. Sometimes the pain is located in the side of the penis (penile neuralgia). Neural- gia of the long lumbar branches is called femoral or cnu'al. A common form of this constitutes what is called jjniuful thigh. When these nerves are subject to a lesser irritation, causing sensa- tions of numbness and pricking along the thigh, the condition is called merah/ia. In true neuralgia, the patient complains of pain in the front of the knee and the anterior and outer parts of the thigh, but has no pain posteriorly and none below the knee. The internal branches of the anterior crural nerve do not seem to be affected, while the middle and external cutaneous branches and the genito-crural nerve are involved. Disease of the hip or of the sacro-iliac joint or vertebrae may cause a reflex pain in the obturator nerve, localized especially in the knee and back of this joint. The fa3tal head sometimes compresses these branches, causing a symptomatic neuralgia. Diseases of the internal genital organs are especially liable to cause reflex pain in the lumbar nerves. Diseases of the external genitals and bladder more often reflect pains upon the sacral nerves. In biliary colic pains are felt in the ilio-inguinal and hypogastric nerves. Local disease of the psoas muscle or iliacus, in the neighborhood of Pou- l^art's ligament, causes pains in the lumbar nerves. Lumbar neu- ralgias generally run a favoral)le and not very long course. Diagnosis.— lj\\mhdL\ neuralgia is distinguished from lumbago by the unilateral position, the distribution and paroxysmal charac- ter of the pain, and the lack of severe suffering on motion and press- ure ; the tender points and the absence of any organic disease. Lumbago comes on suddenly, with a history of exposure, is bilateral and confined to a single group of muscles, which are tender on deep pressure. In lumbar sprain the onset is also sudden, with a history of injury, great local tenderness, and evidences of trauma. The treatment is the same as that for neuralgia in general. The SENSORY NEUROSES OF THE CEREBRO-SPINAL NERVES. 201 frequent presence of pelvic disease aiid of antemia and a rheumatic history must be borne in mind. Sciatica (Xeukalgia of the Sciatic Xerve, Sciatic Xeu- RiTis). — This is a form of neuralgia occurring in middle life and characterized by intense pain in the course of the sciatic nerve. A large proportion of the cases is due to a neuritis. Etiolocjij. — The disease occurs three times as often in men as in women, and is the only neuralgia of which this can be said. Most cases in this country occur between the ages of forty and fifty ; next betAveen thirty and forty.* The gouty and arthritic diathesis, and occupations which lead to exposure and strain, predispose to the disease. It is not rare, therefore, among laboring men. In younger persons a neurotic constitution predisposes to the disease, and in this class the trouble is more truly of a neuralgic character and less of a neuritis. ^lost cases occur in the autumn and winter. The exciting causes are constipation, pressure from hard seats, exposure, muscular strain from heavy Avork, and pelvic disorders. Symptomatic sciatica may be caused by the pressure of pelvic tumors, injury to the nerves, inflammation, vertebral and spinal disease; sciatica occurs in diabetes and in phthisis. In elderly persons of a rheumatic con- stitution inflammatory processes about the hip-joint complicate or cause the neuralgia. Symptoms. — The disease begins rather suddenly. Pain is felt in the back of the thigh, running down the leg in the course of the nerve. Generally it is most marked in the thigh, extending up often into the lumbar region. Sometimes the disease begins like a lumbago ; more rarely pain is first felt iu the calf or foot. The pain is increased by motion, and the patient holds himself in a con- strained i)osition. Tlu* pelvis is tilted up toward the sound side and the trunk inclined over to the diseased side. After a time this leads 111 some cases to a characteristic deformity (sciatic scoliosis) in which the convexity ot the curve of the vertebral si)ines is directed toward the diseased side. The pain is almost continuous, with jiaroxysms of great severity, which often occur at night. Puring these paroxysms the pain is sharp, burning, and lancinating. In the interval it is dull. Besides the pains the patient suft'ers from feelings of numbness, tingling, and a sense of coldness and weight in the affected limb. There are almost always tender points over the course of the nerve. These may be fouiul at the sciatic notch, * Personal statistics (102 cases) and those of Dr. L. Putzel (■'iS cases) give: Males. Ill ; females, 44. Ages: 10-20. 4; 21-30, 30; 31-40, 43; 41- 50. 44; 51-60. IS; 61-70. 12; 71-80. 4. 20^2 DISEASES OF THE NERVOUS SYSTEM. at the middle of the hip, behind the knee, just below the head of the fibula iu the middle of the calf, behind the external malleolus, and on the back of the foot (Fig. 99). A pain running up the back of the thigh may be caused by pres- sure over the back of the knee when the leg is extended at a little more than a right angle. This is diagnostic (Gowers). If the pa- tient lies on his back and the leg is kept extended, and then the whole limb brought slowly up until it is at an acute angle with the trunk, a sharp pain in the sciatic notch is felt; this too is diagnostic. Anaesthesia over the course of the nerves occurs very rarely. When present, it indicates a severe neuritis or injury to the nerve. Mus- cular wasting and weakness occur after a time, and in old and severe Fig. 90.— Showing the Tender Points in Sciatica. Fig. 100.— Plantar Form of Sciatica; Plantar Neuritis, showing: area of pain CMitchell). cases partial electrical degeneration reactions may be observed. Herpetic eruptions over the course of the nerve occur in rare cases. The affected limb usually feels colder and shows evidence of en- feebled vasomotor supply. The disease usually lasts two or three months; not rarely it lasts six months or even a year or inore. It has been known to extend slowly upward and involve the sacral plexus or even the spinal cord. FotJiohiijij. — The trouble is, as already stated, a chronic peri- neuritis in the majority of cases. iJ'uuj Hosts. — Sciatica has to be distinguished from hip-joint dis- ease, organic disease of the eauda equina or cord, muscular pains in the hip and leg, and from pains caused by tumors. Pure sciatic neuralgia ought also to be distinguished from sciatic neuritis. A SENSORY NEUROSES OF THE CEREBRO-SPINAL NERVES. 203 consideration of the facts already given ought to make the diag- nosis not difficult. Pure sciatic neuralgia occurs in early life and is not accompanied by much local tenderness. There is no paralysis or wasting of the limb. Double sciatica is most always symptomatic of diabetes or organic disease. True sciatica is rarely double. rnMiiiosis. — Almost all cases get well in from three to six months. Severe attacks in people over forty are the most intrac- table. Eelapses occur, but not as a rule. Treatment. — In all cases which are seen early, the most impor- tant indication is rest. The patient should be put to bed, and the whole lower extremity secured in a Thomas splint extending from ankle to axilla. Ice bags or linseed poultices or leeches should then be applied over the course of the nerve. A blue pill (gr. v.) may be given twice daily at first. In less severe or older cases large l)listers should be applied over the nerve in the thigh, and the ap- plication repeated in a week. If there is a rheumatic history, potassium salicylate or iodide should be given in full doses. The bowels must be freely opened. Hypodermic injections of morphine or cocaine (gr. ^) may be needed for a few days, the cocaine being repeated if necessary. When the disease has become more chronic a strong galvanic current may be given daily with large electrodes, one over the lumbar region or sciatic notch, the other, which should be the positive pole, over the leg and foot. As so-called specific remedies we have oil of turpentine in doses of fifteen drops t. i. d , and this may be advantageously combined with oil of gaultheria. Massive doses of antifebrin or antipyrin sometimes stop the pains (gr. x., q. 2 h.). There are a great many local remedies which at tiujes prove useful. Among these mustard plasters, menthol, chloroform liniment^ setgns, acupuncture, cups, and the actual cautery and chloride of methyl can be icconimended. Bandaging the Jimb in sulphur to which a little menthol is added is often very efHcacious. Kneading the neive with a glass rod and an anodyne oiiitu'.ent is sometimes benelicial. Very little can be expected from nerve-stretching, but it may be tried as a last re.sort. If tried, liowever, great caution should be exercised in pulling on the nerve. Not over thirty to forty pounds i)ull sliould be used. The operation oi cutt'iig down on the nerve and dissecting oft" the shrnth for a space of several inches may be tried. ri.ANTAit Kkukalcwa. — III rare cases the ])ain of sciatic neu- ralgia is limited to tlie plantar neives. and is accompanieil by par- a-sthesia and even aiKcsthesia of this region. The condition here is l)iobably a neuritis conihined sometimes with arthritic changes. Erytlironu'lalgia may be ifgar % point of exit of the nerves from the cord a 6^ slight constriction is formed. *" Till' Root Ganrjlia. — On each posterior root, outside the dura, is a posterior spinal ganglion. The ganglia lie in the inter- vertebral canals, except those on the sacral nerves. Fissu)-es. — Throughout the w hole length of the cord there are two median ^2 Conus medullaris Filum tenniuule. Fid. 10-J.— Rhowin(» THK Rki.a- Fui. Hm. -r. Spinous process; 1", boily of vertebra: TivK SizK OF THE DiFFKRKNT 1. lit^iinieiit ; ~. vessels ; U, duni iimler wltli tlic iinieliiiold Parts of the Cord (After Iviim directly iM-neatli It; 4, anterior root; 5. posterior Allen). root ; t>. spinal i:an>rlion; 7, ll>fuinent. Hssurt's, caUed tlie anterior and posterior. Columns. — Tlw'sp fissures and the lines formed by the exit of tlie roots divi(h' tlic cord into four cohnnns — anterior, postri'ior, and two lateral. Till' (''luijiDsIfi'i))) nf till' Cord. — The cord is composed of white and gray matter. The white nmtter lies outside aiul is compo.seil 14 210 DISEASES OF THE XERVOUS SYSTEM. mainly of nerve fibres, the gray matter mainly of nerve cells. Each has also neuroglia, connective tissue, and blood-vessels. In the gray matter in a central canal lined with epithelial cells. Format reti'r.ul. First Cervical. Second Cervical. T/7ter/ne.cL Ce//^ ^asc CuneaX\. ■Fane. graciZ/s Clork'.s Col. Suhst. gelatin. \ ^''%%^c. ■ col. post. \ ^>Oir~> . 'ntermecf. Cells Tost. root. ""^^^i^H.! Cent.canaJ Commis. cbIIs Med. motor cells Lat._ motor cells Sixth CervicaL 3^ ^/&sura dot. Co/nwiss. cell^ -J^otor < CfarKs col. 1/ >- f-aot fin t. col. Eighth Dorsal. First Lumbar. Claries col. Third Sacral. Com miSS.cel/i ' . ,„,/, Median cells First Sacral. Flo. KM ^ — Sll()WI.\(S .\HRANOKMENT OF OraY AND WhITK Ma-ITKH AT IllKKKHK-N'T LETKU OP THE t'oKD (.VfttT Merli«l;. called th<' gray commissure. Between the two i.s the central canal, and surroiinding it is the vt-ntral (jrUtthinutt siihstdiii-i'^ compust'd of nt'uniglia. Tlie posterior liurns reacli to the perijihery. Tljcy are divided, beginning from witliout, into the rim zone or Lissauer's column. 212 DISEASES OF THE NERVOUS SYSTEM. tlie spongy zone, and the gelatinous substance of Rolando. The rim zone is composed of very fine nerve fibres ; the spongy zone and gelatinous substance are composed of very small nerve cells, some having continuous neuraxons (cells of Deiter) and some having rapidly branching neuraxons (cells of Golgi). The substance of Rolando is extremely rich in nerve cells and is not made up of neuroglia, as was once supposed. To sum up, we have the gray matter — Arranged in : Composed of : ( anterior, a. A ground substance of neuroglia and con- 1. Horns -] lateral, uective tissue forming the substantia ( posterior. spongiosa. 2. Intermediate gray. b. Cell groups : internal, anterior, etc. c. Plexuses of fine nerve fibres, e.g., in the rim zone. d. Masses of neuroglia : (1) The central gelatinous substance. (3) The jieriphery of the cord and the spongy zone. e. Blood-vessels and connective tissue. Now, taking up some of these factors in detail, we find that : («) The ground substance of the gray matter is made up of a fine meshwork of fibres which are the processes of neuroglia cells and of nerve cells. Besides this, there is some connective tissue, and there are prolongations from the base of the epithelial cells lining the central canal (Fig. 105). (b) The nerve cells are, in part, arranged in groups with the long axis parallel to that of the cord. The cells are surrounded by a rich plexus of dendrites and end brushes, as well as by the sup- porting neuroglia matrix, a little connective tissue, and many small blood-vessels. The cell groups are named in accordance with their position — internal, antero-lateral, lateral, median, posterior or sen- sory cells, and the cells of Clark's column (Fig. 104). This nomenclature answers for ordinary anatomical descriptions. Histologically we find two kinds of cells, the root cells and column cells (Strangzellen). The former are those cells whose neuraxons pass out to form the anterior roots. They form the great part of the anterior horns. Deep in the anterior horns are a few root cells, whose neuraxons pass into the posterior roots and thence to the ganglionic system. The column cells are found in the posterior horns, intermediate gray, and to some extent in the anterior horns. Their neuraxons pass to the white matter of the same or opposite side, and furnish commissural, associative, and even long column fibres. The anterior-horn root cells are arranged in groups which over- lap each other. Each group has the special duty of presiding over certain sets of muscles or other organs which have a common func- tion. These cells are large in size, 35 to 100/x (yj-jr to ^-l-^- in.); they are multipolar, having five or six processes, one of which is an axis-C3'linder process, which, in lower animals at least, gives off DISEASES OF THE SPIXAL CORD. 213 a collateral before it leaves the cord. The cells in the central parts of the horn are the smaller; the cells in the lumbar swelling are largest, because they are connected with long nerves. The cells of the cervical swelling are next in size. The cells of the posterior horn are small and multipolar. The cells of Clark's column are bipolar, 30 to GOv. (^-J-y- to ^i^ in.) iu diameter, and are arranged Fio. 10"). — Showing THE Nkcrooi.ia GRi)r.\i)\vf>RK in an KMnrivoNic Cokd. witli their h:)ng diamft<'r i)arallel to tlic axis of tho cord. Thev are groujjed together iu a ki:'.d of nest at tlie inner and central jiart of the posterior horn (see Fig. 104). Clark's cohimn is most distinct from tlie eighth dorsal to the second lumbar nerves, but extends \ip as far as tlie last cervical. An analogous group of cells is found at the level of the seeond and third sacral nerves. A small group of spindle-shaped cells lies in the intermediate gray matter at the base of the posterior horns. There are other minor groups of cells which it is not necessary to describe here. The white mtitter of the cord is composed mainl}' of neuraxons and the collaterals of these running in a su^jporting network ot neuroglia, connective tissue, and blood-vessels. Surrounding it. and lying just beneath the pia mater, is a thin layer of neuroglia 5 to o)> I. (-ji - to -j>,; in ) thick. The neuraxons are medullated, but have no neurilemma, and Init few, if any, nodes of Kanvier. There are two kinds: the large (Si to 20;,) and the small (2 to 3," m 214 DISEASES OF THE NERVOUS SYSTEM. diameter). The small fibres make up the postero-internal (Goll's) column entirely, and are numerous in the deep part of the lateral columns, but they are found in all regions. The fibres run up and down for the most part, but constantly send off branches to the gray mattero They are arranged in columns, the division being based j)artly on anatomical, partly on physiological, and partly on embr3'ological grounds. Anatomically there is a simple and natural division, which we have already given, into the anterior, lateral, and posterior columns, the divisions being made by the median fissures and the roots of the nerves. On physiological and embryological grounds the columns are further subdivided as follows ; The anterior columns ( Direct pyramidal tract. are divided into ] Anterior fundamental column. Lateral fundamental columns. Lateral limiting layers. Crossed pyramidal tracts. Direct cerebellar tracts. Antero-lateral ascending and descending tracts, or Gowers' column. The lateral columns are - divided into The posterior Postero-internal colunm, or column of GoU. f Burdach's column is divided Postero-external columns, J into _ or column of BurdacJi. | Middle root zone, coluiiius "are ■{ I Posterior root rone. divided into ] The ventral zone. The comma. The oval zone. I The triangular column. I Rim zone, or column of Lissauer. The fibres which make up these columns are of two kinds — lo?if/ or projective, short or associative. The lon[/ fibres connect the different levels of the cord with the brain, and the posterior spinal ganglia with nuclei in the upper part of the cord. The short or associative fibres connect different levels of the cord Avith each other, and also connect the two halves of the cord at the same levels. The names of the long-fibre tracts are the direct and crossed pyramidal, the direct cerebellar, the antero-lateral ascending, and the postero-internal or column of Goll. The direct 2»jramidal tract lies along the anterior median fissure and extends down as far as the lower part of the dorsal cord. Its fibres cross over in the anterior commissure at various levels and connect with the cells of the anterior horns. The crossed 2>^''<'>»'idal tract extends down the wiiole length of the lateral column of the cord and sends its fibres to the anterior horns of the same side. DISEASES OF THE SPINAL CORD. 215 'Tnf/^tj. ,.j^ji:^(x?^ ■x:^^jj,^^ - \ /MilJoL- First Lumbar. Sixth Cervical .^i-KineuL. o/rw. 'i,jr.:^of. hy^'^m First DorsaL ■lnr.Jl>jB2-: fi Fourth SacraL i/ /^oof' TfljtTii'or. • 1 /.:,//■■ . • Eighth Dorsal. First Sucral. biQ. 106.— Showino thk AnRAKOBMKXT OP THK Orav and thk Whttk Mattkk at DiFFERE.ST Lkvkls OP TiiK Cdkd, also tliecolumiis and ci'II ifroiij)s. 216 DISEASES OF THE NERVOUS SYSTEM. Both of the above tracts are continuations of the anterior pyra- mids or motor tracts of the medulla. These ])yramids divide at the lower end of the medulla, about ninety per cent of fibres crossing over to form the crossed pj^ramidal tract and ten per cent contin- uing on the same side. Some of the fibres of the crossed pyramid redecnssate (in lower animals) and enter the pyramidal tract of the side on which they started. The direct cerehellai' tract begins at the level of the first lumbar nerves. Its fibres originate in the vesicular column of Clark. They pass up to the cerebellum and go chiefly to the vermis. Most of them then cross over and enter the red nucleus. The antcro-Iateral oscendlng column extends nearly the whole length of the cord. Its fibres come from the anterior commissure and the sensory cells of the opposite posterior cornu. They pass up and end in the lateral nucleus. The j)ostero-lntemal column, or column of Goll, is composed of fibres which originate in the ganglia of the posterior roots, pass inward, and without crossing ascend, to end in a nucleus at the upper limit of the cord, the nucleus of Goll's column (postero- internal nucleus). The column extends the whole length of the cord. It is very small in the sacral region, but increases in size as it passes up. There are a few long fibres scattered in the anterior and lateral ground bundles. They degenerate down and are called the autcro- lateral descending tract. The names of the short'Jihre columns are the anterior and the lateral fundamental columns, the lateral limiting layer, and the column of Burdach. This latter column contains in its cervical part some long fibres which end in a nucleus at the upper limit of the cord, the jiostero-external nucleus of the column of Burdach. The posterior columns also contain three short-fibre columns whose cells of origin lie in the gray matter of the cord. The fibres in the cervical region lie in the shape of a comma (comma of Schultze), in the lumbar region in the shape of an oval (oval zone of riechsig), in the sacral zone in the shape of a triangle (triangle of Gombault). Besides this there is a zone of short fibres lying close to the gray commissure the whole length of the cord — ven- tral zone or posterior fundamental column. The Relations of the Different Parts of the Spixal Cord to the Peripheral Nerves, to the Braix, axd with Each Other I will begin with a description of the way in which the anterior and posterior nerve roots are connected to the cord ; then describe the mode in which the different: columns and cell groups are connected with each other; and finally I will indicate briefly the connections of the cord with the brain. The anterior nerve roots are connected directly with the anterior- horn cells, of which they are processes, and together with which they form the peripheral motor neurons. It is possible that in man they send off collaterals before leaving the cord. DISEASES OF THE SPINAL CORD. •217 The cells of the anterior horn are surrounded by two chief sets of "end brushes," one coming from the pyramidal tracts, the other from the posterior horns and roots. Thus these cells are in re- lation witli impulses from the brain and from the periphery. The 2^osterior nerve roots originate in the spinal ganglia. On entering the cord the fibres divide like a T and pass up for one or more inches, and down for a short distance only. They then enter (1) the column of Goll, (2) the anterior and posterior commissure, or (3) the posterior horn. They all send off collaterals, and termi- FiG. 107.— Showing the Cells of Origin of the Motor Nerves in the Anterior Horns op thk Si'inal Cord, and the Cells of Origin of the Sensory Nerves in the Posterior Spinal Ganglia (Van Gehuchten). nate eventually in end brushes surrounding nerve cells, Avliicli forin their terminal nuclei. These root fibres, with their cells of origin and the sensory nerve fibres, form the peripheral sensory neurons. There are at least three groujis of nerve fibres which enter by the posterior roots and nmke different connections with the cell groups or columns : 1. An innermost set. These pass across the postero-external column and enter the inodian or Ooll's column, Avhich they ascend, to end in the nucleus. 2. A median set. These pass along the inner side of the pos- terior liorn, and end either {a) in cells of the deeper jiart, {h) in the spindle-shaped cells, or (<•) go to the anterior horn; still others {d) cross over in tin; commissure to enter the antero-lateral tract. ?t. An outer set. These are very fine fibres which enter the tip or outer part of the posterior horn, and then run up and down, forming the rini zone. They eventually connect in the usual way with the sensory cells of the posterior horn. The dljjlevent jforts of the sji'nitil cord are connected by the short fibres which unite; different levels of the cord, and by commissural fil)res which unite the different lialves of the cord. These short 218 DISEASES OF THE NERVOUS SYSTEM. and commissural fibres originate in groups of nerve cells lying in tne central parts of the gray matter and are called associative or column nerve cells. They are small and multipolar. Some are distributed sj^arsely in the white col- umns. Fibres arise from them, run in the com- missures and short-fibre tracts, and end in brushes which put the fibres in relation with various cell groups (Figs. 109, 110). Phvsiology. — The de- tailed facts regarding the functions of the spinal cord may be gotten in physiological text-books. 1 shall give only those bearing more or less di- rectly on the localization of the functions. Tlie spinal cord is a conductor and centre of nervous action. It represents the lowest evolutionary level of the development of the nervous system. Its func- tions, so far as they are independent, are stable and well organized, but of a mechanical and rela- FiG. 108.— Schematic Drawing of Sb-Asoky Tracts. C/i, Spinal ganglion cell with one neuraxon going in the peripheral nerves to the skin s, and with one in the po.s- terior root; 1, fibres of the posterior root, ascending partly in the posterior column (3), parUy entering the tively simple order, posterior horn ; g^, cell of Clarke's column, passing from this to the cerebellar tract (3); (73, ganglion cell in gray mutter, sending fibres (4) to Gowers' tract ; (/j, cell in nucleus gracilis in medulla oblongata ; fmm posterior loot fibres also pass to (/4, anterior horn ganglion cell. Functio7is of the White Columns. — The white matter is a conductor of nerve impulses, and its functions are relatively sim])le. We have only to study the direction and kind of impulses carried by its various columns. The direct and crnsscil pijnfvrhhil tracts originate from cells in the motor cortex of the brain. They ^arl•y motor im])ulses downward from the brain. The crossed pyra- midal tract crosses in the medulla to the side opposite to that where it originates, and passes down the lateral column to connect the motor cells of the anterior horns. The direct pyramidal tract runs along in the anterior column, and at different levels sends fibres across through the anterior commissure to the motor cells of the anterior horns. These tracts normally exercise a continual inhibitory in- DISEASES OF THE SPIRAL CORD. 219 fluence on the motor cells of the anterior horns, so that when de- stroyed there develop spasmodic conditions of the paralyzed part. The anterior ground hiiniUe, hiteral ground bundle, and lateral limiting layer have the function of associating different levels of the cord and of connecting it also with nuclei in the medulla and centres in the cerebellum. The colli inns of Goll conduct special sensations from the muscles, articulations, and tendonous sheaths via the root on the same side. When diseased, there is a loss of the sense of position of the limbs, of the power of estimating weights, and of co-ordination of muscular effort (ataxia). The fibres cross over in the medidla. Via. 109. Fia. 110. Pio. 10!).— Snowixa the Connkctions op the A.vTKRiort axd Postebiob Roots AJfn CoR.NM-A WITH Kach Other (Cajul). A, Anterinr root; B, posterior root; rior corriiisi cell; b, c, d, !issf)eiiitlon flhn-s; c, pDStfrior a.ssociut ion (Hires. The columns of Jiiirdaeh conduct to a certain extent tactile sensations coming in from the opposite posterior root. They also contain many associative fibres, connecting different levels. Tain- sense fibres and excito-refiex fibres ivoiw the i>osterior roots run 220 DISEASES OF THE XERVOUS SYSTEM. tiarough these columns to reach the commissure or the anterior horns; other fibres run through it to Clark's cohmm and to the column of Goll. Hence it is a pathwa,y for all kinds of afferent impulses. When diseased, there may be pain, anaesthesia, ataxia, and loss of reflexes. The fibres cross over at once to the oppo- site side. The direct cerebellar tracts carry Impulses to the cere- bellum M-hich assist in maintaining equilibrium. The antero-Iateyul ascending tract conducts sensations of pain and temperature, coming in from the opposite side, through the anterior commissure. There are considerable variations in the paths of conduction of tactile temperature and pain sensations, and their exact position is not positively known. In transverse lesions of the cord these tracts do not degenerate upward so completely or uniformly as do second- ary degenerations of other long-fibre tracts. Hence they probably receive some interruptions in their course. In fact, it is probable that the paths for these impulses are very wide and not arranged in a compact bundle like the motor tract. The f/raii matter contains chiefly cell groups which act as centres and distributors of nerve impulses. In the anterior horns the cells have a motor and trophic function. The larger cells are at the outer parts of the horn and send fibres to the larger skeletal muscles. The more central cells are con- nected with small muscles and those having more delicate func- tions and adjustments. In the still more central and interme- diate part, also, are separate trophic cells for the muscles, bones, and joints, and cell groups which preside over vasomotor and secre- tory functions. Among these groups are the splndle-sliaj^jcd cells, which send fibres to the vasoconstrictors (Gaskill), through the anterior (Hill) and perhaps posterior roots (Gaskill). The cells of Clark's column receive fibres from the viscera. Impulses pass to these cells and thence to the direct cerebellar tract and cerebellum. Their function is to conduct impulses from the viscera relating to equilibrium and sense of position. They are analogous to the fibres of the column of Goll. According to Gaskill, Clark's column is a centre for the vasodilators. This is unlikely. Ai/to/nath Centres. — The nerves and cells of the cord are ar- ranged in complex groups which preside over certain functions or respond in a definite way to certain stimuli. These are called the spinal automatic centres. They are the cilio-spinal, secretory, vasomotor, genital, vesical, and rectal. The important parts of these centres lie deep in the gray matter on either side of the cen- tral canal, but nearer the base of the posterior horns. Lesions of the Avhite matter, or of the anterior or posterior horns, do not directly affect them. The cilio-sjnnal centre reaches from the seventh cervical to the second dorsal segment, inclusive. Its stimulation causes the pupils to contract. DISEASES OF THE SPIRAL CORD. 221 The (/fnitol centres, iucludiug those for erection and ejaculatioD, reach from the first to the third sacral segment, inclusive. Fig. 111.— Shcwino the Relation op- the PpiNors Processes to thk Pointb op OBioiif IK THK COKD or Tlitt SlMXAL NeKVES. Tlie hlodder and rertal rmtrrs are in the fourth and fifth sacnil segments, extending up and down a sliort distance, the bladder being perhaps a Jittlo lower. The spinal vasomotor centres extend from the sec-ond rlorsal to 222 DISEASES OF THE XERVOUS SYSTEM. the second lumbar segments. The vasodilator nerves pass out by tlie anterior, the constrictor by the posterior root (Gaskill). The cells of the posterior liorns are sensory in function and are connected with the tactile, pain, temperature, and reflex fibres of the posterior roots. The iroplilc centres for the joints, hones, and skin apparently iie near the posterior horns. Their fibres pass out by the posterior roots. Topo(jr(qjJiij and Localization. — The neurologist and surgeon need to know, for purposes of diagnosis: 1. The relation of the spinal nerve roots, at their point of origin, to the spinous processes. This is shown in the figure (p. 221). In general it will be seen that the different pairs of nerve roots arise o}iposite the spinous process of a vertebra one or two segments above those between which it makes its exit. Thus the sixth cervical originates opposite the fourth cervical spine, the sixth dorsal between the third and fourth dorsal spines, the first lumbar between the eleventh and twelfth dorsal spines. There is consider- able variation in these relations. 2. The next points desired are the special function of each pair of nerve roots anterior and posterior, and the level of the various centres in the cord. This is shown in the following table, based on that originally devised by Starr, modified by Mills, Sachs, and my- self from personal experiments and the clinical and pathological ob- servations of Thorburn and others. McscLES OF Tongue, Palate, axd Phary>:x. Diseases in Name of Normal Symptoms of Defi- Innervated Represented which Aluscle is Muscle. Function. cient Action. by in 1 commonly In- volved. G e n i o Pushes tongue Tongue when pro- The twelfth Medulla. f glossus. to opposite truded deviates to nerve ( h y- i side. paralyzed side. poglossal). S t yloglos- Raises tongue , Tongue cannot be Tlie twelfth Medulla. Bulbar pal- sus. backward and moved backward nerve. sies (acute upward. or hollowed out (action deficienr in many healthy subjects). and chron- ic); in spe- cific and tu- 1 b e r c ulous L i n g u a 1 All movements When lying in The twelfth Medulla. diseases of muscle of the tongue mouth deviation nerve. base ; dys- proper. itself. to liealthy side ; when prutruded deviates to para- lyzed side; if one or both halves are trophies (rare). atrophied tongue looks shrivelled. A 3 y g o s Shortening of Uvula deviates to- Pro o a b 1 y Medulla. As above. uvulae. uvula. ward sound side ; if both sides are paralyzed there are nasal tone and regurgitation pharyngeal plexus; seventh nerve {':). thronerh nose. 1 ; DISEASES OF THE SPINAL CORD. 223 MtrsuLES OF ToxcLE, Palatk, and PnAKYXx. — Continued. Diseases in Xame of Normal Symptoms of Defi- Innervated Represented which Muscle is Muscle. Function. cient Action. by m commonly In- volved. Levator Raises the ve- Arch cannot be As above. Medulla. .\s above ; see palati. lum palati. raised in the in- tonation of "ah;"' if paralysis is bi- lateral flapping of arch and regurgi- tation of food through nose. also seventh- nerve affec tions. Palat o- Prevent food Regurgitation of The fifth Pons. Basilar affec- pharyn- from passing food; n a s a 1 1 nerve. tions. freal mus- toward up- speech. cles. per part of pharynx and post e r i r nares. Stylo- pha- Helps to draw- Imperfect degluti- Glosso - pha- Medulla. Bulbar affec- ryngeus. la rynx up- tion ; food gets ryngeal. tions and dis- ward so as to into windpipe. eases of the be closed bv base. epiglottis and o V e r 1 pped * by tongue. Cons tric- Help to push Food is swallowed Pharyngeal Medulla Diseases of the tors of food into gul- very imperfectly ; piexus. base (bulbarj. pharynx. let. sticks in throat. LarynKeal Movements of Hoarseness and Recurrent Medulla Bulbar trou- muscles. vocal cords in difficulty in 1 a r y n geal bles (similar respiration breathing: larvii- nerve ex- s V ni p t o ni s and m articu- goscopicexamina- cepting the may be caused lation. tion reveals false crico - 1 h y- position of vocal roid m u s- cords (see special cle. by tumors and foreign bodies in larynx*. text-books). Muscles dk TTkad and Xkck. Disea.s.-s in Name of Xonnal Symptoms of Defi- Iimervated Represented which Muscle is Muscle. p'unctioti. cient Action. by in commonly In- voly.-d. 8 te r n o- Raises and Inability to raise Spinal ac- Medulla and In bulbar and c 1 eldo- turns face to head from bed. or cessory. .second and cervical- Co ni mastoid. opposite Ride; other horizontal third cer- affections ; in head inclines ]>ositinn. if both vical seg- lii'er stages of to same sidt- ; musclfsarealTecl- ments. p rogr essivo if hotli niMS- ed; if oiif nuiKcle ni use u 1 a P cles act coii- is affected, no atrophies; lointly head Is brought marked change of occa sionally ])<>sition, un less in neuritis. forward. opposite muscle is contrnctiired ; spasm of muscle frequent ; head in- clined to one side. 224 DISEASES OF THE NERVOUS SYSTEM. Muscles op Head ais'd Neck. — Continued. Diseases in Name of Normal Symptoms of Defi- Innervated Represented which Muscle is Muscle. Function, cient Action. by in commonly In- volved. Rectus To flax head. Cannot flex head ~| Upper cervi- Upper c e r- capitis so as to bring cal. vical s e g- a n t i e u s chin on chest. ments. major. Rectus To flex head. capitis ant i cus mmor. Diseases o f the cervical Rectus Slight rota- Deficient rota- region (my- capitis tion. tion scarcely C elitis, men- lateralis. noticeable, un- less sterno-clei- do-mastoids are diseased. i n g i t i s , tumor; pro- gressive wasting o f Scaleni" Elevate r i b s- Deficient inspi- Lower cervi- Upper cervi- muscles). anterior wheu verte- ratory m o V e- cal nerves. c a 1 s e g- m e d i - bral column nients. ments. us, e t is fixed ; aid poste- m inspira- 1 rior. tion ; slight lateral flex- ion. Flexion of ver- Imperfect flexion Lower cervi- L n g u s tebral c o 1 - of upper spine. cal nerves. J colli. umn. Muscles op Shoulders and Upper Extremity. DISEASES OF THE SPINAL CORD. 225 Muscles of Siiouldehs and Upper Extremity. — Continued. Xaine of Muscle. Normal Function. Symptoms of Defi- cient Action. Innervated Represented by in .Adduction o f sc a pti 1 a to- ward median line. Oblique move- ment of scap- ula from be- low, upward and inward, so that infe- rior angle is brought near- er the medi- an line; liold spinal margin of scapula down to tho- rax. Draws superi- or iimer angle of scapula up- ward; aids in shrugging of shoul(iers. Rotation of shoulder- blade o u t - w a r d , a n d Blight eleva- tion of acro- mion; holds inner margin of scapula to thorax ;briMgs arm from hor- izontal to ver- tical position. To raise arm to horizontal position, and forward, out- ward, or back- ward ; move- ments possi- ble only if scapula is flxecl by ac- tion of aerra- tus and tra- peziuH. Rot ato r lui- mei'i poslicus ( Duchenni" i ; rotate arm outward. Rotator buine- r i a u t i c u s I Dnchenne ) : rotates arm iiiu'.'ird. T5 Margin of scapula is about ten cm. distant, instead of being five or six cm. distant from median line ; loss of adductor may be covered up by action o f rhom- boids ; roimding of back. Deep groove be- tween inner mar- gin of scapula and thorax; if serra- tusis normal, this groove disap- pears if arm is ex- tended forward ; shoulder blade cannot be approx- iinated to median line. (.Vccording to Duchenue this can be effected by upper portion of laiissimus dorsi.) Isolated paralysis rare. Scapida pidled up- ward; lower inner angle nearer the median line; arm caimot be raised above horizontal jjosition: if arm is stretched forward scaj) u 1 a is re- moved from tho- rax ("winged scapula" ) ; tlur- ing abduction of arm, scapula is- moved nearer tc meilian line, and crowds trapezius and rhomboids forward. Can raise shoulder but not a r m ; shoulder flattened (atrophy) ; groove between acromion and liead of hu- merus ; each di- vision of deltoid may be iiaralyzed singly. A r m cannot be moved outward. Dilllciilty in writ- ing (Duchenne). Arm cannot he III o V ed inward ; sciii>ula is rubbed against ribs. Spinal acces- Medulla and sory nerve, second and third cervi- c a 1 seg- ments. Fifth cervi- Fourth and cal. Third and fifth cervi- cal nerves. I'osterlor 1 1; o r acic nerve. flftli cervi- c a 1 s e g- ments. Circumflex. S u J) r n- scapiilar. C I r c u iii- fiex. Subscapu- lar nerve. Second and fourth (?) cervical segments. Fifth and sixth cervi- c a 1 seg- ments. Fourth, fifth, and sixth cervical segments. Fourth, fifth, and si.xtlt e e r v i c a 1 segments. Diseases in which Muscle is commonly In- volved. As above. Dystrophies and cervicat diseases. Progressive muscular atro- phies ( d y s trophies); neu ritisof part of the brachial plexus ; after traumatic in- juries to shoul- der : in cervi- cal-cord atleo tious. As above ; also in Erb's form of obstetrical paralysis. As in case of deltoid. 226 DISEASES OF THE NERVOUS SYSTEM. 31USCLES OF Shoulders aijd Upper Extremity. — Continued. Diseases m Kaine of Normal Sj'mptoms of Defi- Innei-vated Represented which Muscle is Muscle. Function. cient Action. by in commonly In- volved. Supras p i Helps to According to Du- Suprascapu- Fourth cer- As above. n«tus. steady shoul- der-joiut and to elevate arm forward and outward : outer angle of scapula is de- pressed. chenne, humerus is separated still farther from acro- mion, if supra- spinatus is affect- ed In addition to deltoid. lar vical. Latissimus Pulls the arm Arm cannot b e Subscapu- Sixth and As in progres- dorsl. when raisetl, moved backward : 1 a r, also seventh cer- sive atrophies down w a r d insufficient exten- branches of vical. and dystro- and b a c k- sion of dorsal dorsal and phies; in cer- ward; if arm spine; trunk can- lumbar vico-dorsal is at rest up- not be moved lat- nerves pass- lesions; in p e r portion erally. ing through neuritis. brings scap- muscle. ula nearer the median line ; united action of up- per third of both muscles causes exten- sion of dorsal trunk ; single action causes lateral move- ment of trunk. Teres ma- Rotates raised Very few symp- Subscapular. Seventh cer- Asabore. jor. humerus in- ward; adduc- tion of arm to thorax; slight elevation o f shoulder. toms; action sup- plied b y other muscles. vical. Pectoralis Clavicular Iinperfect ao'duc- Anterior Fifth, sixth. Amyotrophies major. portion d e - tion of arm; pa- thoracic. and seventh and dystro- presses h u - ralysis can be dis- cervical. phies, chiefly; merus from covered best by also in lesions raised posi- extending arms of brachial tion to hori- and trying t o plexus. zontal ; ad- press volar sur- duction of faces against arm, a s i n each other. giving a bless- ing; sternal portion d e - presses arm com pletely, and if arm is at rest draws acromion for- w a r d and backward. DISEASES OF THE SPIS'AL CORD. 227 Muscles df Ai'.m, Fokkakm, and H.\:n'd. Xaiue of 3Iuscle. Xorii>al Function. Triceps . Extends fore- arm; long head of tri- ceps, and cor- aco-brachialis help to keep head o f hu- merus in posi- tion. Fle.vion and supination of forearm. Su pill a t o r Flexes f o r e • Biceps . longus. arm and aids in pronation. Supinator brevis. Extenso r carpi ra- d i a 1 i H longus et brevis. Extensor carpi ul- naris. Ex tensor d igi t (.- rum com- imitds. Extensor iiidicis. Extensor mini m i digiti. Flexor carpi radial 18. Flexor carpi iilnnris. Pnl maris longuH. S u p i II a t e s hand when forearm is ex- tended. E.x tension and ab(hic- tion of wrist; tliH shorter mu.scle has p u r e exten- s i o n action only. Extension and uhdnction of wrist. Extension of fl r st i.ha- langesof all fingers and I abduction. 1 !'■ I e X i o n of wrist and pro- nation. I' I e X i o n of wrist and Kiipination. Flexion o f wrist only. Symptoms of Defi- cient Action. Disea.ses in Innervated Represented which Muscle is by in I commonly In- volved. Arm cannot be ex- tended except by its own weight: if long head of tri- ceps is affecti-.j subluxation o f head of hllmeru^s occurs easily. Flexion deficient, but can be carried out; in part by other muscles. Flexion and prona- tion deficient: muscle does not stand out promi- nently if aim is Hexed and a t- lempt is made by another to extend it forcibly; if mus- "•le is atrophied arm i s spindle- shaped. Deficient supina- tion of hand. Wrist cannot be fi e X 6 d dorsally (extended) or atj- ducted : flattening of forearm. Wrist cannot be flf'xed dorsally or ailducted; "drop- wrist " is charac- teristic of paraly- sis of e.vteiisors. First phalanges cannot be ex- tendi-clnorfingei-s abducted ; grasp is weak because fle.xor muscles are shortened a ii d cannot contract forcibly. Dfflcient flexion. Musculo- spiraL Musculo - cu- taneous. 51 u s c u 1 o spiral. Musculo- spiral. Musculo- spiraL As above. Musculo- spiral. Median FlexI'.ii and siij)!- Ulnar, nation impaired. { FIe,\lon impaired; n o a II om al oiis nosition of liand rmm paralysis of wristashaiid falls by its own weight; the flexors o f fingers may act as Sllbslitllles. Median Sixtli, sev- enth, eighth ; cervical seg- 1 ments. Fifth cervi- cal. Seventh cer- vical. Seventh cer- vical. Seventh cer- vicaL F.ighth cer- vical. Eighth cer- vical. Eighth cer- vioal. Fourth, fifth, sixth cervi- cal. Fourth, Tif th cervical. ] Poliomyelitis and o t li e r affections of cer v i c al cord ; trau- matic inju- ries ; amyo- ' trophies and dystro- phies (tri- ceps es- capes i I. many pe- ripheral ' palsies.) As above ; in- volved in pe- ripheral neu- ritis (traumat- ic), not in lead palsy. Diseases as above ; also i n periplieral palsies. \s before ; es- pec iaUy in neuritis. As above. As above. .Vs above. \s above. \s above. 228 DISEASES OF THE KERVOUS SYSTEM. Muscles ob" Akm, Forearm, and Hand. — Continued. Diseases in Name of Normal Symptoms of De- Innervated Represented which Muscle is Muscle. Function. ficient Action. by in commonly In- volved, Flexor Flexes second Second phalanx Median Eighth cer- .\s above. d i X i t o- phalanx t o - cannot be flexed. vical. rum sub- ward first. limis. Flexor Flexes last Last two phalanges Ulnar and Eighth cer- As above; d i g i t o- rum pro- two phalanges cannot be flexed. Median. vical. muscle should toward first. \>e tested with fundus. special care i n cases o f traumatic in- juries. Interossei Abduction and Fingers cannot be Ulnar, which Eighth cer- As aV)ove ; oft- and luui- adduction of abducted or ad- also s u p - vical, first en the first bricales. fingers if first ducted; inter- plies third dorsaL muscles to be phalanges are osseous spaces and fourth affected in extended ; are very marketl ; 1 u m b r i- progressive flexion of first ''Main en griflfe " cales ; medi- spinal a t r o- phalanges due to extension an supijlies phies. and simul- of first phalanges first two and taneous ex- and flexion o f so m e times tension of sec- second and third third lum- ond and third phalanges. bricales. phalanges. Thenar Extends first Impairment of ex- M us culo- First dorsal. As before; muscles : phalanx and tension and ad- spiral. more espe- Extensor abducts meta- duction ; flatten- cially in amyo- pollicis carpal bone ; ing of ball of trophies and brevis. acts with ad- ductor polli- cis Iongus. thumb. neuritis. Extensor Extends both Deficient extension Musculo- First dorsal. As above. pollicis Jongus. phalanges of and adduction ; spiral. thumb ; also second phalanx is adduction of flexed toward m e t a c a rpal first. bone and backward movement of thumb. Abduction of Abductor Deficient abduc- M u sculo- First dorsal. As above. pollicis Jongus. m e t a c a rpal tion of metacar- spiral. bone ; aids in pal bone ; if this flexion of muscle and ex- hand. tensor pollicis brevis are i>ar- alyzed adduction results. Abductor Musculo- poll i cis brevis. spiral. Opponens pollicis and outer ■ Opposition ' of thumb. No opposition Median. First dorsaL As above. movement. portion of the flexor brevis. I Abductor Flex first pha- No flexion; if mus- Median and As above. pollicis brevis ; lanx and ex- cles are paralyzed ulnar. tend second and atrophied, flexor jihalaiix (like ape hand is brevisand i nterossei), formed. adductor. also have an abduction and adduc- tion action. Flexor Flexes end No flexion of end Median. As above. pollicis iongus. phalanx. phalanx. DISEASES OF THE SPIXAL CORD. 229 Muscles of Back and Lower Extremities. Name of Muscle. Erector spinae; sa- cro-lumbalis ; _ lon- gissimus dorsi. Abdominal muscles. Quadratus lunibo- rum. Adductor muscles. Sartorius. Quadriceps femoris. Ilio-psoas. Tensor fasciae latae. External rotators: 1 Pyriformis. i Gemelli. ( Quadratus femoris. J Internal <»bturator. I External obturator )' Gluteal muscles. Biceps ; semitendi- iiosus and semi- membranosus. Gastrocnemius Cal- so plantarius and soleus). Anterior tibial mus- cles (tibialis anti- cus, extensor digi- torum, and exten- s o r pollicis lon- gus). Peroneus longus. Posterior tibial mus- cle. Peroneus brevis. Interos.sei pedis et luinbricales. Adductor; flexor brevis and abduc- tor liallucis. Innervated by Dorsal nerves. Second to twelfth dorsal segments. Dorsal nerves. Second to twelftli dorsal. Lumbar nerves. Obturator nerve, great sciatic and crural. Crura!. Third lumbar segment. Crural. Third lumbar. Crural Clumbar plexus). Fourth lumbar. Superior gluteal. Fourth lumbar. Sacral plexus (muscular branches). Fifth lum- bar. Obturator nerve (lum- bar plexus). Inferior gluteal (sacral plexus). Firstand sec- ond sacral. I Gluteal superior. First I and second sacral. Sciatic. Fiftli lumbar segment. SjTnptoms of Deficient Action. Internal popliteal, lumbar. Fifth Anterior tibial. Fifth lumbar and first sacral. Peroneal. First and sec- ond sacral segments. Posterior iil)ial nerve. First and second seg- ments. Peroneal. First and sec- ond segments. Posterior tibial. First and second segments. Posterior tibial. First and second segments. Lordosis of lower spine; perpendicular line from shoulder falls behind os sa- crum : unilateral palsy causes deflection of spine toward sound side. Lordosis with protrusion of nates and abdomen; other actions deficient; can- not straighten up from recumbent position without assistance of hands. Lateral movements of lower vertebrsa imperfect. No adduction; thigh rolls outward. Flexion impaired; acts imperfectly. Leg cannot be extended; to test it ask patient, who is lying down with hip bent, to stretch out the leg; when pa- tient is sitting down to extend leg. 1 Flexion difficult: in bed thigh cannot be I flexed; difficulty rising from horizon- tal position. Deficient outward rotation ; leg turned inward. Xo extension of thigh: great difficulty in climbing: no abduction of thigh; wad- dling gait, exaggerated movement of pelvis. Deficient flexion; action of quadriceps may cause excessive extension ; m standing thigh is flexed to excess; trunk moved backward. Deficient flexion of foot ; heel cannot ba raised ; cannot stand on tiptoes. Deficient extension; "dropfoot," toes serav>e floor ; to clear this, excessive flexion at knee and hip ; contracture of flexors and pes equinus orequinovarus. Deficient abduction ; plantar arch les- sened; increased by contracture. Flat- foot ; walking tiresome. I Deficient abduction or adduction ; de« r formities result from deficiencies. .Vbdiiotion and adduction of toes defi- cient ; i)aralysis of interossei ; hypere.x- tension of first phalanges; second and third flexed (clawed foot). Deficient flexion of toes; foot cannot be l)usheil off ground easily. The hlood supply of the sptxal cokd is a subject of great practical iniportaiico; and, ns our knowledgt; of it has lately been increased, I shall present the matter here in some detail. The spinal cord is supijlied -with blood by branches from the vertebral, ascending cervical, and superior intercostal arteries above, and by the dorsal intercostal, luiubar, and sacral arteries below. These send off small ])r:inc]ies which enter the spinal canal 230 DISEASES OF THE NERVOUS SYSTEM. through the foramen magnum above and the intervertebral fora- mina at the sides; they pierce the dura mater and are distributed on the pia mater and in the cord. The arteries that thus supply the cord are these : Primary Arteries. Anterior spinal. Posterior spinal. Lateral spinal. Lateral spinal. Lateral spinal. Lateral spinal. Lateral spinal. Origin from Ending in "Vertebral {from subclav.). Anterior median spina] artery. Vertebral. Vertebral. Ascending cervical (from sub- Anterior and posterior spinal clav.). root arteries Superior intercostal (from sub- Anterior and posterior spinal clav.). root arteries. Thoracic intercostal (from Anterior and posterior spinal aorta). root arteries. Lumbar (aorta). Anterior and posterior spinal Lateral sacral (from int. iliac). root arteries. The anterior spinal arteries are branches of the vertebrals. They unite to form the anterior median artery, which runs down the whole length of the cord, receiving re-enforcements from the lateral arteries (Fig. 112). The anterior sinned arteries themselves nourish only a few upper segments of the cord. The anterior median artery is not, as has been taught, a true prolongation of the anterior spinals, but is really made up by the lateral spinals. In other words, the vertebral artery through its branches nourishes only the upper cervical region of the cord. The j^f^^'^^''^^^^' spinal arteries are smaller than the anterior and unite on the posterior surface of the cord. They do not continue down as a posterior median artery— there is no such artery; but they help to form two plexuses on the postero-lateral surfaces of the cord. The lateral spinal arteries are derived from branches of the sub- clavian artery as far down as the second dorsal root; below this point by the thoracic and abdominal aorta and the internal iliac. It is an interesting fact that at or a little below the point where the bloocl supply changes from the subclavian above the heart to the aorta below, pathological disturbances frequently occur (transverse myelitis). Root Arteries. — The lateral spinal arteries, after they enter the spinal canal, are called the root artei'ies. They pierce the dura mater and pass, some along the posterior and some along the an- terior roots, to the cord. There are about eight anterior-root arteries (five to ten) and about sixteen posterior-root arteries (see Figs. 112, 113). The anterior arteries are twice as large (one milli- metre in diameter) and one-half as numerous as the posterior. The root arteries of the cervical region are rather the more numerous. There is a large and constant anterior-root artery in the dorso- lumbar region. The last two lumbar, the five sacral nerves, and the unpaired coccygeal nerve when it exists, are accompanied by small root arteries which do not reach up to the cord itself. The lower part of the spinal cord is supplied by large root arteries from DISEASES OF THE SPINAL CORD. 231 the lateral spinal arteries. Heuce the theory of ^Nloxon that the cimilation here is feeble is not supported by Kadyi's investiga- tions. -'/', ^ <^\ /^i. FlO. 1 12.— The Spinal Coru, Antkuiou Surkack. slidwiiiir llie nerve roots, root arteries. anil anterior |)li'xns (Kaiiyi). 232 DISEASES OF THE NERVOUS SYSTEM. The Plexuses. — The anterior root arteries pass to the anterior median fissure, and then divide, partly to form the anterior median artery and partly to form a rich plexus between the anterior roots ; this is called the anterior arterial 2}lexi!s. The posterior root arte- ries subdivide before they reach the cord, and send twigs to its lat- eral and posterior surfaces which form the posfero-laferal arterial plexus. The posterior-root arteries do not anastomose to any ex- tent with each other or form a posterior spinal artery, as is done by the anterior-root arteries. There are therefore three relatively in- dependent arterial plexuses : the anterior plexus, the two postero- lateral plexuses. Ve'ms. — The veins of the spinal canal outside the dura mater have valves, those within it have none. The veins reach the pia mater and cord by passing along the nerve roots. Hence we have anterior and posterior root vehis, corresponding to the root arteries, but more numerous, there being a total of forty or fifty. The an- -£' Fig. 113.— The Arterial Supply. A, The artery of the posterior fissure; B, the inter- funicular; C. artery of posterior horn ; D, of posterior root; £, of posterolateral column. terior-root veins are more numerous than the posterior, but smaller (twenty-five to twenty). The veins are a little larger than the arteries, the anterior veins being one-half to one millimetre, the posterior one and one-half to two millimetres, in diameter. Thus we see that the posterior surface of the cord has more and smaller arteries, fcAver but larger veins. The posterior surface is on the whole more richly supplied with veins, the anterior surface with arteries. The lateral surfaces are the least vascular. DISEASES OF THE SPTXAL CORD. 233 Anterior root arteries. Anterior root veins. . . Posterior root arteries Posterior root veins. . . Number. 5 to 10 25 to 30 16 20 to 25 Size. 1 mm. i to 1 mm. i mm. li to 3 mm. Vessels of the Cord Substance. — The cord is suppplied by (1) central arteries -which are branches of the anterior median, and by (2) peripheral arteries which come from the plexuses on the pia mater. These two systems have been called also the centrifugal and centripetal respectively. They are not absolutely independent, but are in a good measure so. The central arteries nourish chiefly the gray matter, the peripheral arteries the white. Both systems are made up of " end arteries," i.e., they do not anastomose with each other. Neither the central nor the peripheral arteries are dis- trilnited in accordance with anatomical relations or physiological functions. Each cell group, for example, has a vascular supply from several sources. The central arteries are given off from the branches of the an- terior median at the bottom of the median fissure and number about two hundred, each spinal segment having six or seven. The accompanying central veins are small and their total capacity is less than that of the arteries, so that the central arterial pressure must be high, on account of the poor venous outlet (Kadyi). Some of tlie blood escapes by the peripheral veins. The jieri/jJieral arteries pass into the spinal cord for the most part along the various connective-tissue se})ta. There they branch and supply chiefly the white matter. They supply the apex and some of the deeper substance of the posterior horns and Clark's columns. The arteries of the posterior septum are the largest and most numerous, often reaching to the gray commissure. The peripheral arteries are smaller than the corresponding veins (0.04 to 0.2 mm.). The relation is just the reverse, therefore, of that of the central arteries and veins. The peripheral arteries are small, and after passing into the cord branch into minute vessels which jiass up and down and soon become capillaries. The central arteries, on the other hand, continue large, and run up and down some dis- tance before they are subdivided into capillaries. To sum up: The arteries predominate in total capacity in the anterior plextis and central arteries; the veins in the posterior plexuses and peripheral vessels. The central arteries are larger and longer than the peripheral. Hence the blotnl circidates more quickly and under greater pressure in the central gray of the cord. Conditions of enfeebled circulation would affect the posterior col- umns and roots more than the anterior and ceuti-al parts of the cord CHAPTEK XII. THE DISEASES OF THE SPINAL CORD. There are about thirty diseases which may be classified as be- longing to the spinal cord. Most of these are organic in character and come under the head of inflammatory and degenerative or sys- tem diseases. Functional disorders referable to the cord alone are rare; while of organic diseases, those that result from injury and inflammation are the most common. Ettolo(jy. — The causes of spinal-cord diseases can nearly all be formulated under the heads of injury, exposure, poisons, autotox- semias, infections, and excessive functioning. Persons of middle life are the most predisposed, while heredity does not play an im- portant part. Symjdoins. — The symptoms of all disorders of the nervous cen- tres can be included under the heads of those of irritation, depres- sion, and perversion. The principal irritative symptoms in spinal- cord disease are pains and parsesthesias of the back and limbs, hyperaesthesiaand feelings of constriction around the waist, rigidity, spasms, exaggerated reflexes, and irritabilit}' of the visceral and vascular functions. The principal symptoms of depression and destruction are anaesthesia, ataxia, paralysis, wasting, and loss of power over visceral centres. The common form of paralysis in spinal-cord disease is paraplegia, in brain disease hemiplegia, in multiple neuritis quadruplegia. Symptoms of irritation and de- pression often accompany each other. The more superficial and meningeal the disease, the move are the symptoms irritative; the more central and myelonic the trouble, the less the irritation and the more the paralysis and visceral disturbance. Thus meningitis, meningeal tumors, and hemorrhages are extremely painful; while central myelitis is almost painless. Pathologij. — Inflammations of the meninges of the cord are not rare; the opposite is true of primary inflammations of the cord itself. As will be shown later, most of the diseases that used to be called chronic myelitis are secondary to injuries and softenings. Degenerative diseases of the cord, which include such affections as locomotor ataxia and progressive muscular atrophy, used to be called THE DISEASES OF THE SPIXAL COED. 235 "system diseases," because they affected ceitaiu Jong-fibre tracts or systems of ceil groups. The name implies restrictions which are not justified in fact, and it can be retained only as a matter of convenience. Secondary degenerations alone are always systemic. The cord is relatively free from abscesses, hemorrhages, and tumors. Diagnosis. — In making a diagnosis of spinal-cord diseases, one is most helped by a thorough knowledge of the cord functions. In no part of the economy do physiology and anatomy point out more clearly the path to the clinician. Prognosis. — The sj)inal-cord tissue once destroyed can never be renewed, or only to a limited extent, and that as regards the nerve fibres, not the cells. It has considerable power of adjusting itself to damage ; but, on the other hand, serious injury is likely to extend by the process of secondary degeneration. Functional diseases, vascular and nutritive disturbances, of the cord can never be so severe or chronic as to exclude the possibility of recovery. The special diseases of the spinal cord are the following : 1. MuJformations : Myelocele, meningo-myelocele (spina bifida), meningocele, heteropia, arayeiia, micromyelia, macromyelia, double cord. 2. Vascular Disorders : Anaemia, hypersemia, hemorrhage, end- arteritis Avith aneurism, embolism or thrombosis, oedema. Second- arij to these conditions are softenings and sclerosis. 3. Inflainniations : Meningitis, myelitis, abscess. Secondarily, softenings, sclerosis. 4. Degenerations: Primary: locomotor ataxia, combined sclero- ses, hereditary scleroses, progressive muscular atrophy, and allied types. 5. Tuherculosis : Miliary and solitary. G. Sgjt/iins: Gumma, meningo-myelitis, vascular disease. 7. Tumors. 8. Fiinetional and to.vic disorders. MALFORMATIONS. SprxA liiFiDA (Rhachischisis Posterior). Spina uilida is a congenital hernia of the spinal membranes, and sometimes of tlie cord, through a clett in the vertebra caused by absence of the vertebral arches. It is really a malformation of the vertebral canal rather than of the cord. Ktiolo(pj. — The condition is not very rare, about 1 child in 1,200 (French statistics) being affected. It is often associated with hy- 236 DISEASES OF THE XERVOUS SYSTEM, drocephalus or with some other defect iu development, such as ventral hernia, imperforate anus or pharynx. Hereditary influence is sometimes a factor. It is a true developmental defect, and is not due to a primary dropsy of the cord, as Avas once taught. It occurs rather oftener in females. Forms. — There are three varieties described: 1. Spinal meningocele is a condition in which the spinal mem- branes alone protrude into the sac. 2. Spinal meningo-myelocele is a form in which the membranes and cord both protrude. 3. Syringo-myelocele (hydrorrhachis interna) is a form in which the fluid is in the central spinal canal, and the inner lining of the sac is formed by the meninges and thinned-out spinal cord. O b CA a bca Pg. 114.— Meningocele. MeNINGO-MyELOCEI^. STRtXno-MYELOCELE. walls; 6, cord; c, membranes. a. Vertebral Anatomy. — The first two forms are the most common and are called hydrorrhachis externa. The fluid here lies in the subarach- noid sac, and hence the wall of the protruding cyst is lined with the dura and arachnoid. The nerves and cord protrude into the sac in two-thirds of the cases (forming a meningo-myelocele), but in some of these only a few nerves are found. These structures, when pres- ent in the sac, as in meningo-myelocele, lie on its iK'^teyior and median surface. They are attached to and form part of the wall. The spinal nerves therefore start from the wall of the sac and go back into the vertebral canal. The tumor contains cerebro-spinal fluid, and occasionally connective tissue and fat (Fig. 114). The external surface is often red and smooth, and there is sometimes a depression on its median surface where the cord is attached. Symittoms. — Spinal bifida occurs almost always in the lumbar and sacral region, the reason being that the laminae here are the last to solidify. Usually but two or three vertebrae are involved. THE DISEASES OF THE SPINAL CORD. 23? The tmnor varies in size from 3 cm. (one inch) to 15 cm. (six inches) in diameter, and may have a broad base or be pedunculated. The outer skin is often glossy, or tough, thickened, or ulcerated (Fig. 115). Children with spina bifida are usually feeble, badly noiu-ished, and poorly developed mentally. Paraplegia occurs in half the cases, sometimes "with anaesthesia and involvement of the sphinc- ters. Talipes occurs quite often. The 2>i'Offnos is is grave. Most subjects die unless treatment is applied, and even then the prospect is not very good. The prognosis is best for meningocele. The diagnosis is easy. It is generally only necessary to exclude congenital tiimors which happen to be located in the lumbo-sacral region. The most import- ant question to decide is whether the cord and nerves are present in the sac. This may be assumed as probable if there is much paraplegia, ana3sthesia, and sphinc- ter trouble, and if there is a depression on the median external surface. The intro- duction of an insulated needle connected with an electric battery may be tried. The treatment is strictly sur<4ical, and then is of avail only in meningocele. At present, injections of Morton's fluid (iodine, gr. x. ; potas. iodid.j gr. xxx. ; glycerin, 3 i. Dose, 3 i.) seem to be most successful. These injections should be made in the lateral portion of the sac, and the child should be kept on the back. Puncture and withdrawal of fluid with compression is not a justifia- ble operation. Ligat\u'ing or opening and excising of the sac are dangerous, especially if, as is often the case, part of the cord and nerves lie in the sac. In recent years, surgical results have been juore fav(jrable and warrant serious consideration. No surgical treatment should be attempted, however, until two or three mouths after birth. Hktkkopia is a rare malformation in which masses of gray mat- ter are found in abnormal situations. A false heteropia may be caused (Van Oieson) l)y manipulation of the cord in its removal after death. Tlie displaced masses consist of nerve cells or neu- roglia. AMVKi.tA or absence of the spinal cord can exist only when the brain is absent; but absence of the brain may occur without absence Pig. 115.— Spina Bifida. 238 DISEASES OF THE XERVOUS SYSTEM. of the cord. In amyelia the spinal nerves are usually present. Amyelic monsters cannot live. Double CokdIs a very rare defect and involves only part of the cord except in cases in which there is a double vertebral canal. Double cextral caxal is not rare. It usually involves only a part of the cord. The two canals are side by side. AsvMMETKY of the cord, usually due to abnormality in the course of the pyramidal tracts, is not extremely rare. Splittixg of the cord and defects in development at special levels are occasionally observed. MicROMYELiA is a condition in which the spinal cord is abnor- mally short or small in size, and is not a very rare anomaly. The normal adult cord has a diameter in its various parts of 6 to 9 mm. (dorsal), 8 to 11 mm. (upper cervical), 15 mm. (cervical swelling), and 12 mm. (lumbar). SPINAL HEMORRHAGE (SPINAL APOPLEXY). This general name may be given to (1) spinal meningeal hem- orrhage or haematorrhachis, and (2) hemorrhage into the cord substance, or hsematomyelia. 1. Spixal mexixgeal hemorrhage is far the most common form. It may be outside or inside of the dura, the former being rather oftener seen. Etlolorjy. — It occurs in newly born children and in adults, and is more common in men than in women. Injuries, falls, fractures of the spine are the most frequent exciting causes. Severe convul- sions from epilepsy, eclampsia, tetanus, chorea, or strychnine may be a cause, also severe muscular exertion. Purpura and the blood states following malignant infectious fevers, bursting of an aortic or vertebral aneurism, and cerebro-spinal meningitis are rare causes. Sym-ptoms. — In small hemorrhages there may be no symptoms. In large effusions there are sudden, very severe pains in the back, extending into the limbs, numbness, tingling, hyperaesthesia, and muscular spasm, especially of the back muscles. Later there may be weakness or paralysis and angesthesia, with disorder of the vis- ceral centres. The symptoms reach their height usually in a few hours. . Then amelioration may occur, followed by slow recovery or with symptoms of chronic meningitis, llarely death occurs early from exhaustion. Diagnosis. — A history of injury or childbirth, sudden onset of attack, with symptoms of pain and irritation which rather rapidly subside, point to extradural hemorrhage. In hgematomyelia there are less pain and irritation, but more profound paralysis and anaes- thesia. The same is true cf crush of the cord from fracture or dis- THE DISEASES OF THE SPIXAL CORD. 239 location. In tetanus there is a slower development of the symp- toms, and trismus is present. The prognosis is grave in severe cases, but if the patient survives three or four days the prospect of partial or nearly complete recov- ery is good. The treatment is perfect rest in bed and the administration of remedies to move the bowels and relieve pain; leeches and other local applications are of doubtful value. It is of no use to give styptics except in purpura, when mineral acids or suprarenal ex- tract may be tried. Later, one may give iodide and mercury and use blisters to the back. 2. Hemorrhage into the Substance of the Cord (H.emato- myelia) — Etiolfxjij. — The condition is not very rare. It may be primary from disease of the blood-vessels or purpiu-a hsemorrhagica; or it may be secondary to myelitis and tumors. Primary hemor- rhage occurs sometimes in infancy, but usually in males between the twentieth and fortieth year. Injuries, overexertion, exposure, excessive coitus (Gowers), syphilitic disease of the blood-vessels, and convulsions are causes. The disease sometimes occurs in old people with degenerated arteries, which break and lead to a spinal apoplexy, just as occurs in the brain. The symptoms develop rapidly, with at first feelings of numb- ness or weakness for one or two hours or longer. Then there is a sudden paraplegia, Avith anaesthesia or ataxia or both. The anaesthesia is often dissociated, there being loss of pain and thermic sense with retention of considerable tactile sense. The si)hincters may be paralyzed; the urine has to be drawn. The reflexes may be abolished at first, but soon return and become exaggerated. There is considerable pain in the back. If the lesion is high up, the arms and thorax are involved. The acute symptoms begin usu- ally to subside at the end of seven to ten days and the disease takes the character of a chronic myelitis. If improvement does not oc- cur, evidences of acute myelitis appear and the patient dies. L'ntholuyy. — The vessels involved are the central arteries, which supply the gray matter and are under relatively high pressure. The rupture of the vessel, when due to disease, is ca\ised by a fatty ilegeneration of the coats or syphilitic endarteritis; miliary aneu- risms, such as are found in the brain, rarely develop in the cord. Hemorrhage often precedes or begins a myelitis, of which it may be the cause or the result. Tlit^ clot may be absorbed, leaving a cavity as in the brain ; or the broken-down tissue may become the centre of a myelitic focus. The hemorrhage is u.sually single, but there may be several. Multiple capillary liemorrhages occur, but 240 DISEASES OF THE NERVOUS SYSTEM. usually only from asphyxia and convulsions. It is possible that some of the cases of disseminated myelitis occurring after infec- tious fevers start from small hemorrhages. Hemorrhage sometimes results from the invasion of the cord by a new growth, as in syringo- m^'elia. Diagnosis. — The points to be noted are the sudden onset without long premonitory symptoms, and the absence of fever followed later by gradual improvement. There is much less pain than in menin- geal hemorrhage, and the dissociation of cutaneous sensations is very characteristic. In acute softening there is less of the dissoci- ation of sensations and usually a more extensive paralysis. The disease is often mistaken for acute primary myelitis, which does in fact often follow it. Meningeal hemorrhage is more painful, and there is less paralysis, more spasm, and a more complete recovery later. Prognosis. — This is often serious as regards life, and always serious as regards health. It depends on the extent and seat of the hemorrhages. Dorsal hemorrhages are more favorable, cervical the least. Treatment. — Absolute rest, ice bags to the spine, and small doses of aconite given early are all that can be tried, except the use of symptomatic remedies. Treatment must be aj^plied at once. Tlie late treatment is the same as that for myelitis. THE CAISSON DISEASE (DIVER'S PARALYSIS). The caisson disease is the name given to a more or less complete paraplegia which occurs in persons who work in caissons or diving- bells, and which is brought about by the sudden return from a con- densed air to the normal atmosphere. Etiijlogij. — Persons employed in caissons or bells work usually under a pressure of from one to four atmospheres, which means a pressure of from fifteen to fifty pounds to the square inch. Acci- dents rarely if ever occur when the pressure is not over one atmos- phere, and they are also rare if the person has not been subjected to the pressure for at least an hour. Different persons vary in susceptibility to the effects of this change in the atmospheric pres- sure, and those unused to the work are more liable to be attacked. Naturally the disease is seen only in men, and during the working period of life. The synq^toms set in usually very soon after the patient has come out from the caisson, but they may be delayed for half an hour or more. They consist of intense neuralgic pains in the lower THE DISEASES OF THE SPINAL CORD. 241 extremities, often affecting especially the joints. There is at the same time epigastric pain. Nausea and vomiting and weakness in the lower limbs, amounting in some cases to absolute paralysis, very soon appear. There may be headache, dizziness, and sometimes even coma. If the jjaralysis is considerable, it is usually accompanied by anaesthesia. Distiu-bances in the sphincters, with retention of urine and constipation, may also be present. The symptoms vary very much in severity, from pain, weakness in the legs, and nausea, up to frightful neuralgic attacks and complete paralysis, motor and sensory. The upper limbs are rarely affected. In a few instances hemiplegia, however, has been observed. The disease lasts from a few hours up to several weeks. Death occurs in some of the very severe cases. The symptoms having reached their climax gradually ameliorate, and a complete cure is not infrequent. In some in- stances, however, the patient is left with a permanent paraplegia and the ordinary symptoms of a transverse myelitis. Pathology. — When the patient is under atmospheric pressure in the caisson, the blood is driven from the surface of the body, and the internal viscera, including the brain and cord, are congested. The sudden change from the abnormal to normal pressure produces a rapid flow of blood from the internal organs to the periphery. The viscera not inclosed in bony cavities are enabled to relieve them- selves of this congestion without much harm, but the circulation in the brain and spinal cord is less elastic; that in the spinal cord being less even than that in the brain. The result is that congestions and small hemorrhages ensue, producing a destruction of the nerve tis- sue. In other cases there seems to be a blocking up of some of the small vessels, with consequent softening of different portions of the cord and to a less extent of the l^rain. It is supposed that one element in producing the morbid phenomena is the escape of oxygen and carbonic-acid gas from the blood into the tissues or into the blood-vessels. This mechanism, however, has not been proven. It will be seen, however, that on the whole the sudden change in at- mospheric pressure leads to vascular disturbances with rupture or obliteration of blood-vessels, with consequent destruction and ne- crosis of tissue. Following this is a reactive inflammation pro- ducing the phenomena of an ordinary acute myelitis. Tlnitri-(itiin')it is largely prophylactic. The workmen engaged in the occupation should be carefully selected and should accustom themselves to their work. They should fcpend a longer time in com- ing out of the caisson. If symiitoms supervene, it is recommended that they be put back under a slight atmospheric pressure at once until these symptoms disappear. AVlicii the disease has developed, 16 242 DISEASES OF THE NERVOUS SYSTEM. it can be treated only by symptomatic remedies, The patient should be kept quiet, and given, if necessary, hypodermics of morphine. Dr. A. H. Smith recommends the UvSe of ergot. Later on, the vari- ous neuralgic and paralytic symptoms may be treated on the same principles as those employed in myelitis. SPINAL HYPERJSMIA, ACUTE AND CHRONIC. Etiology. — Acvite spinal hypersemia is produced by sexual ex- cesses, violent physical exertion, suppression of menstrual dis- charges, and certain poisons like strychnine. It occurs also in the first stage of acute inflammatory diseases. Chronic spinal hyperaemia is, so far as is absolutely known, a very rare condition. Chronic hypera?mia of the membranes may be the residuum of a meningitis or of injury, and these are probably the most common causes. As to the causes of the chronic hyper- semia of the cord substance itself independent of other diseases, we can say nothing definitely. The symjJtoms of acute spinal hyperasmia are feelings of heavi- ness and weight in the limbs and around the loins, numbness, creep- ing sensations and actual neuralgic pains, weakness of the lower limbs, with twitchings of the muscles. There may be also some disturbances in the sphincters, though of this one can speak less cer- tainly. The symptoms are nearly always confined chiefly to the lower limbs. The statement that they are increased b}' lying on the back and ameliorated by lying on the face is not always true, since pos- ture, ixnless greatly prolonged, influences but very slightly, if at all, the circulation in the spinal cord. The symptoms of chronic spinal hyperaemia, when this hyper- semia involves the meninges chiefly, are probably somewhat identi- cal Avith those of spinal irritation. They will be described under that head. Pathology. — The circulation of the blood in the spinal cord, as has been shown in the article on anatomy, is one which it is difficult to disturb, but which, ouce disturbed, is rather slow in being brought back to its normal condition. Thus violent activity of the heart and great increase in the arterial pressure, and the opposite condi- tions of weakened heart and lowered arterial tension, a})pear but lit- tle to modify the spinal functions. Hence it is unlikely that the large number of clinical symptoms that have at times been attrib- uted to hypersemia of the spinal cord, or rather to disturbances in the circulation of the spinal cord, have really been due to that cause. Treatment. — The treatment of spinal hyperemia consists in the application of cups to the back, quiet in the horizontal position, THE DISEASES OF THE SPIXAL CORD. 243 preferably upon the side or face, ice and counter-irritants to the spine, morphine and bromides internally. In the more chronic cases muriate of ammonium, iodide of potassium, and the galvanic current may be used. The use of ergot, which has been recom- mended, in my experience has been found of little or no value. SPINAL AN^^MIA. Even less is known in regard to the etiology and symptomatology of spinal anaemia than of spinal liyperaimia. Undoubtedly severe hemorrhages or diarrhoeal discharges, and an aortic obstruction which cuts off the circulation of the blood from the spinal cord, will produce a spinal anaemia, and when this is severe the functions of the cord are nearly abolished. But practically we do not know of any causes which produce an acute or chronic anaemia leading to serious and prolonged disturbances in the spinal functions, aside from dis- eases of the arteries of the spinal cord themselves, such as occur in advanced life. In the most profound anaemias, which must affect equally tlie spinal cord with other organs, very little special disturb- ance of this organ can be discovered. Here, too, the supposed test of improvement on lying on the back is, in the writer's opinion, a fallacious one. It has been customary to associate with spinal anteniia a class of symptoms characterized by pains in the back of the nature of spinal irritation, weakness of the legs amounting to paraplegia — a type of symptoms that has been called spinal concus- sion, but it is impossible in the present stage of science to say that a spinal anaemia actually underlies and causes this condition. INFLAMMATION OF IllE SPINAL MEJ^IBRANES (SPINAL MENINGITIS). The meningeal inflammations are: External nieuiii<;itis. I la ^- ^i i Internal meningitis. \ Effecting tlie y;einia. Wlien the disease arises from inHamiiiations in the vi.sceral cavities it is thought to be caused l)y an ascending neuritis. 244 DISEASES OF THE NERVOUS SYSTEM. Symptoms. — The symptoms are those of irritation of the motor and sensory roots ; later, compression of tlieni and of the spinal cord, local pain in the back, radiating pains, tenderness, hyper- sesthesia, twitching, paresis, paraplegia, exaggeration of reflexes, and involvement of the sphincters. Anaesthesia occurs in severe forms. The disease, when chronic, may extend to the other membranes and cord, causing what is termed "compression myelitis." Pathological Anatomy. — The inflammation, if acute, is generally a fibro-purulent one, this being the form usually caused by vertebral caries. The dura mater is covered by a layer of caseous, semi- solid matter, often very thick and most extensive posteriorly. It involves the dura vertically for several inches. In chronic forms the deposit is made up of connective tissue and the cord is com- pressed. In purely suppurative forms the cellular tissue outside the dura is infiltrated with pus throughoiit a great part of the canal. The diagnosis is based on the presence of the primary local dis- ease, the kyphosis, the radiating pains, and tenderness, and by the combination of motor and sensory irritation and paralysis. The 2J>'ognosis is generally bad, because the original disease is a serious one. Still, surprisingly good results are often obtained when the disease is taken early. The treatment consists in attention to the local caries or inflam- matory focus. It is therefore purely surgical. Some kind of jacket is almost always indicated. Internal Meningitis, Pachymeningitis Interna, Hemor- rhagic AND Hypertrophic. Inflammation of the inner surface of the dura mater occurs in two forms — the hemorrhagic and the hypertrophic. As the latter is generally but a sequel of the former, I shall describe the two together under the head of hyjyertrojjhic j^of'/iymenutgitis. Etiology.- — ^The disease occurs almost always in adult life. A few cases have been reported in children (Gibney). It usually af- fects males. Syphilis, alcoholism, exposure, and trauma are excit- ing causes, the first and last being by far the most important factors in the disease. My own experience is that the disease is always a syphilitic process. Symjitoms. — The disease begins gradually with symptoms of ir- ritation (irritative stage). The patient suffers from pain and stiff- ness in the neck. The pains radiate up to the occiput and down the back; numbness, prickling, and pain are felt in the arms, more in one than the other. The pains exacerbate and are worse at night. Stiffness and cramps may affect the arms. Nausea and vomiting sometimes occur. After five or six months symptoms of paralysis appear (paralytic stage). The arms are affected. They become w^eak, atrophy occurs, THE DISEASES OF THE SPINAL CORD, 245 associated with contractures and rigidity. There is still pain, and in addition anaesthesia, hypereesthesia, and trophic changes occur. Later, paraplegia, with rigidity, exaggerated reflexes, and spinal trepidation develop. The patient becomes weaker, and finally dies of exhaustion or from some intercurrent trouble. The disease some- times takes what is called the 2"'i''j>/feral ff/pe. Then the symptoms are more localized in the extremities. Usually it is of the cevciral tiipe and presents symptoms as described above. In either form the disease is a chronic and painfid one. Patholorjij. — The disease starts as a hemorrhage upon the surface of the dura. This leads to a chronic inflammatory process, new hem- orrhages occur, and a fresh inflammatory deposit is made until the cord is finally encircled and compressed by a dense connective-tissue mass, which involves the pia and to some extent the cord substance. The process is analogous to that of cerebral pachymeningitis hemor- rhagica. The cervical region is usually attacked. In other cases the lesion is a syphilitic gummatous process. Frotjiiosls. — A few cases have been reported practically cured, ^lore cases terminate in death. Sometimes, however, the disease comes to a standstill for a long time. Jjkifjnosis. — This must be made from tumor, myelitis. Pott's dis- ease, wryneck, and progressive muscular atrophy. The history of injury, the slow progressive course, and the localization of the symp- toms, their bilateral character and the pain, give the most heljj. It is not always possible to exclude a tumor. In spinal tumor the symptoms at the beginning are more sharply localized. They de- velop more rapidly and the course of the disease is shorter than in meningitis. Tumor though rare is really much more common than pachymeningitis. It is probable that some cases described as this were really forms of syphilis of the cord. 'Timtinent. — The not rare syphilitic origin of the disease must be borne in mind. Counter-irritants, electricity, hydrotherapy, and symjjtomatic remedies for the pain and spasms are indicated. It is possible that surgery may help these cases. Acute Spixal LEPToMKNixcjirrs (Ixklammatidx ok the Pia MaTEU of TlIK SlMXAL CoKp). Etliiloijij. — This is a rare disease, occurring alone, but is common in conection with disease of the cerebral pia mater. Cliildren are oftenest affected; and among adults, males. Al- coholism predisjjoses to it. The disease is always secondary to an infection with or without a traumatism. The infections are tuber- cle, syphilis, typhoid fever, and various pyogenic microbes. Exten- sion of inflammation from neigliboriug parts and surgical operations are occasional causes. The cases attributed to rheumatism, expo- sure, insolation, are in reality due to some infection, and the virus of cerebro-spiual f«'ver somftimes attacks the! cord alone. 246 DISEASES OF THE NERVOUS SYSTEM. Si/nijjto 1)1 s.— The disease begins with pain in the back, radiating along the nerves. There are usually a chill and some fever. The pulse may be fast or slow. The pain increases, and is accompanied by dorsal tenderness and rigidity of the muscles of the back, amounting sometimes to opisthotonos. The skin is very hyperaes- thetic and the reflexes are at first increased. There is constipation, and sometimes retention of urine. After a time symptoms of pa- ralysis come on, with anaesthesia and retention of urine. The patient becomes weaker, bedsores may form, and death from exhaustion follow. The disease lasts from a few days to several weeks. The dominant symptoms in the first stage are those of irritation, viz., pain in the back and along the nerves, hypersesthesia, and muscular spasm. In the second stage, paralysis, atrophy, and anaesthesia. In the tuberculous form of meningitis the symptoms come on more slowly. In sejotic meningitis the symptoms are of the severe and typical kind described. In meningitis from other infections the symptoms are not so severe, as a rule. FutJioIogical Anatomy. — Acute leptomeningitis shows a some- what different exudate according to the nature of the infecting micro- organisms. The common form is the suppurative exudate, which may be due to the streptococcus pyogenes and other pyogenic micro- organisms, and to the pneumococcus. The purulent matter is usu- ally distributed along the whole length of the cord, but more poste- riorly and often more in its lower portion. It may also be localized chiefly at certain levels. The spinal fluid is increased in amount. The arachnoid, the inner surface of the dura, and the tissue of the cord itself are usually involved. If the disease lasts several weeks, the purulent matter is absorbed in part and an increase in connec- tive tissue takes place, binding the dura, arachnoid, and pia to the cord. The nerve roots are surrounded and compressed by the inflammatory product. In tuberculous meningitis there is less exudate. It is more of a fibrinous character, and grayish in appearance. Tubercle granula- tions are seen distributed over the pia, arachnoid, and inner surface of the dura. Simple exudative meningitis rarely occurs. The inflammatory process often ends in a production of new connec- tive tissue and sometimes the establishment of a chronic lepto- meningitis. The diar/nosis must be made from myelitis, tetanus, rabies, rheu- matism of the dorsal muscles, gonorrhoeal rheumatism, and strych- nine poisoning. In myelitis there is relatively little pain and much paralysis; in tetanus there is trismus, fever is absent, and there is a historv of trauma. THE DISEASES OF THE SPINAL CORD. 247 Tuberculous meningitis comes on more slowly, is rarely spinal alone, and there may be evidence of local tuberctdosis elsewhere. The jjror/7ios is is not good, but is especially bad in tuberculous meningitis and in cases with high fever, severe pains, and early paralysis. Chronic meningitis sometimes remains after the acute symptoms subside. Treat ineM. — This consists first in perfect rest and quiet; leeches should be applied along the spine, then hot poultices or ice bags ; opium is to be given for relief of pain ; mercurial purges and small doses of iodide of potassium or sulphate of magnesium may be given at short intervals. Later, blisters and counter-irritation and luke- warm baths are indicated. Chroxic Lei-tomexixgitis axd Mexixgo-mvelitis. Etiolofjij. — This disease, which used to be often diagnosticated, is now believed to be rare, and always secondary to an acute proc- ess, such as a cerebro-spinal meningitis, or to syphilis and perhaps chronic alcoholism. It occurs oftenest in adults and in males. Trauma, and especially concussion of the spine, used to be thought a frequent cause, but in most of such cases the trouble is simply a hyperemia or else neuralgic and functional. The sjiiqjtoins gradually develop after an acute meningitis or an injury, and they are the same in character as those of the acute proc- ess. There are pain in the back, increased on movement and radiat- ing about the trunk and down the limbs; tenderness along the spine, stiffness of the back, twitching and spasms in the limbs with some weakness, and later some paralysis, wasting, and anaesthesia, with weakness of the bladder. These paralytic symptoms, if severe, however, nuirk an invasion of the spinal cord. Cutaneous eriip- tions, such as herpes, may appear. The symptoms run an irregu- lar course, with periods of improvement. They always become less when the patient rests. Fdthnlofjiral Anatoiiuj. — The inflammation consists of a prolifer- ation of connective tissue (productive inflammation of Delafleld). The result is a thickening and opacity of the pia mater and arach- noid. Tlie dura mater may be involved, but only in severe cases. The. ])rocess may invade the spinal cord, causing an " annular" or ringlike sclerosis, from which the disease extends into the cord in wedge-shaped masses at various i)arts, causing eventually an involve- ment of fibre systems and secondary degenerations up and down. This somewhat rare terminal condition is called meningo-myelitis. In syphilitic meningitis the lesion usually involves only part of the spinal cord, usually some of the dorsal segments. Here there is 248 DISEASES OF THE NERVOUS SYSTEM. the characteristic exudate of syphilis, not of a simple proliferative inflammation. The diagnosis must be made from spinal irritation, locomotor ataxia, myelitis, vertebral caries, and tetanus. In spinal irritation there are not the rigidity, severe radiating pains, twitchings, atro- phy, or paralysis; and neurasthenia or hysteria exists. In locomo- tor ataxia the knee jerk is lost, there is ataxia, and there is little paralysis, nor is there local tenderness over the spine. In vertebral caries the pain and tenderness are much more local- ized, and there is spasmodic fixation of the trunk. The pain is more continuous and dull, and is increased by lateral pressure and lessened by extension. There is usually also some deformity. If compression occurs there is exaggeration of the reflexes and para- plegia, without much aneesthesia. After all, however, with Pott's disease there may be a local meningitis. Treatment. — As chronic meningitis is usually the product of syphilis, or the relic of traumatism or of an acute process, the indi- cations for treatment are simple. Rest is the essential thing. With this can be combined the systematic and persistent use of counter- irritants. The hot iron is usually best, because its wounds heal so quickly. Cupping is also useful if done vigorously and often. In- ternally, iodide of potassium, small doses of bichloride of mercury, nitroglycerin, and digitalis may be given ; also the salicylates and ergot. Both the latter drugs should be employed in large doses, if at all. Electricity in the form of galvanism, and cocaine by local injection or cataphoresis, may be tried. Splints and plaster jackets are of much service in some cases. CHAPTER XIII. MYELITIS -IXFLAMMATION OF THE 8PIXAL COED. Myelitis is an inflammation of the spinal cord. It may be acute, subacute, or chronic. It may aifect the anterior horns chiefly, when it is called ante, rior polioinijelitis ; or both the gray and white matter, when it is called diffuse myelitis and transverse myelitis. The forms are still further divided, in accordance with their location, into cervical, dorsal, lumbar, and disseminated myelitis. Myelitis is given dif- ferent names also in accordance with its cause. Thus we have hemorrhagic myelitis, a form in which the initial process is due to or associated with a hemorrhage ; compression myelitis, due to ver- tebral caries; septic ov purulent myelitis or abscess of the cord; and tuberculous and syphilitic myelitis. For practical purposes the following classification is sufficient : Acute myelitis: l\. Anterior poliomvelitis. With exudation and necrosis. ] '- ''S'm-el^Hs''''"''' "' '''"""'^'' With su]ipuration. -' 3. Abscess of cord. Chronic myelitis: j 4. Ciironic anterior poliomyelitis. With necrosis and proliferation. / 5. Transverse myelitis. ■{ 6. Compression myelitis. Af'TTK Tl{.\XSVEHS?: MVELITIS (AcUTE SoFTEXIXfi OF THE Sl'IXAI, Cord.) Acute, diffuse, or transverse myelitis represents several different pathological processes. It may be a local infection causing exuda- tive inflammation, with more or less necrosis rescmlding acute ante- rior poliomyelitis. The difference in the symptoms here depend only on the severity of the infection, its rapidity of course and ex- tent. It may be initiated or accompanied by a hemorrhage or soft- ening from tliroml)()sis of arteries, and tlie latter is often the cas«'. Nor can we ;-linically distinguish between the cases due to a ])ri- 250 DISEASES OF THE NEEVOUS SYSTEM. maiy infection and those clue to a hemorrhage and softening. Vari- ous pathogenic microbes have been found, but they are not always present even in real infections ; because the microbe after starting its work is absorbed and disappears. Hence acute transverse myelitis may mean either an acute in- flammatory process or an acute softening. Eihih)(jij. — Predisposing causes are a neuropathic constitution, the male sex, early adult life, occupations calling for exposure, and muscular strain. The exciting causes are exposure to cold, blows, falls, fractures, strains, extension from neighboring organs, sy^jhilis, infective fevers, and septic infection. Injury is frequently an ap- parent cause. But most of these causes produce primarily mechan- ical destruction, hemorrhages, or thromboses, and the inflammation is secondary. Symptoms. — Prodromal symptoms are rarely present, but there may be slight parsesthesias or pain in the back and limbs. Some- times there is a chill, and in a few instances convulsions have been noticed. The iniilal symptoms consist of feelings of numbness, usually in the feet and legs, which seem heavy and weak. Some pain may be felt about the back. The patient soon finds that he cannot walk easily, that he moves his legs with an effort and that they feel stiff. In a f CAV hours or perhaps not till one or two days, a paraplegia with anaesthesia has developed, and if the lesion is in the cervical cord the arms are paralyzed also. All these symptoms may come on in the daytime or during sleep. Eetention or incontinence of urine and constipation are early symptoms. There may be some fever. Symptoms of the Attack. — If the patient is examined when the malady reaches its height, it will be found that he cannot walk or stand, but can move his legs a little. He complains of a sensation like a band around his waist or at the level of the spinal lesion (gir- dle symptom) . His legs feel numb and heavy, but there is little pain and no tenderness. Anaesthesia to touch, pain, and tempera- ture exists in various degrees on the limbs, as high up as the lesion. The anaesthesia, if not total, is greatest to touch, next to tempera- ture, and least to pain. He has vesical anaesthesia; the urine is retained and he has to have it drawn. The bowels are constipated, but if enemata are given the faeces may pass away without his knowl- edge, OAving to rectal anaesthesia. If the lesion is lumbar, there is abolition of the sexual power ; but if dorsal or cervical, strong erec- tions may occur without the patient's feeling them. When the le- sion is above the lumbar cord, also, the bladder may automatically and forcibly contract and expel the urine. In time the bowels re- MYELITIS — INFLAMMATION OF THE SPINAL CORD. 251 gain some power. The paralysis in the limbs affects the flexors of the feet and legs more than the extensors. The patient can push down his limbs better than he can draw them up. The temperature of the limbs for a few days is raised, but after this it falls a few degrees below normal. The skin becomes rough, cold, congested ; and excessive perspiration may take place. The general bodily temperature is usually normal throughout the dis- ease, but in some cases a fever develops of 102° to 104'' and contin- ues. The prognosis is then bad. Bed-sores may develop early, within a few days or weeks. They appear oftenest upon the buttocks and heels, and are due to trophic disturbance, combined with pressure and pyogenic infection of the parts. If the lesion is lumbar, the tendon and skin reflexes are much weakened and the paralysis is somewhat flaccid. The muscles also tend to waste and show degenerative reactions. If the lesion is dorsal, as is more often the case, the reflexes are present, and after a time become exaggerated ; there is ankle clonus and a flexor re- sjionse on irritating the soles of the feet; contractures and spasms develop; the legs become drawn up and deformities are ])roduced. If the lesion is so complete as entirely to cut across the cord, there may still be some excessive muscular tension, but the reflexes will be abolished (Bastian) . AVhen the cervical region is attacked the arms are involved as well as the legs, and generally to a severer extent. There may now be also unequal dilatation of the pupils from involvement of the cilio-spinal centre; and optic neuritis from some cause has been known to occur. In extensive involvement of the upper part of the cord there may be paralysis of the intercostal muscles and disturbance of the heart's action. The disease, having in a few days reached its height, usually re- mains stationary for a few weeks, and then, should the patient live, improvement slowly sets in. In some cases evidences of extension upward or downward occur (ascending or descending myelitis) ; the symptoms become more severe, and in a few weeks, or oftener months, death occurs. As improvement begins, a return of sensation is first noticed (one to six months) ; this is followed by return of more or less mo- tion (six to eighteen months). Spasms and contractures now de- velop, owing to a descending degeneration. A certain amount of ataxia from ascending degeneration, with a little anaesthesia of tlio skin, may remain, so that, if the patient has sufficient motor jtower to walk somewhat, he presents many featuresof" ataxic paraplegia" (see p. 305). 252 DISEASES OF THE NEKVOUS SYSTEM. Some improvement may be expected for from one to two years. A few cases get almost entirely well. The majority become more less or paraplegic and bedridden, in which condition they are re- garded as cases of chronic myelitis. Pathological Anatomy. — The early changes found in acute mye- litis are those of inflammation, hemorrhagic extravasation, and soft- ening. Often it is impossible to say whether the primary process was inflammatory or due to a hemorrhage or softening. Macroscopically, the cord at the affected part appears soft, swol- len, and either red and hyperaemic or pale and antemic. In rare cases no change is apparent to the naked eye. In later stages the parts are white or gray, shrunken, and hard. The cord may be re- duced to a thin shred. The meninges about the affected parts are often thickened, inflamed, and adherent. Microscopically, if the process is primarily inflammatory we find intense congestion, distended blood-vessels, emigrated white blood cells in great number, especially in the perivascular spaces, swollen axis cylinders and oedematous swelling of the myelin sheath, red blood cells, cells filled with fat granules known as compound gran- ular corpuscles, or Gluge's corpuscles. These are leucocytes which have taken up fat granules. A peculiar form of cell, stellate in shape, known as spider cells or Deiter's cells, may be seen. They are proliferated neuroglia cells. The nerve cells lose their granular or reticular appearance, become homogeneous, swell up, fat granules appear in them, and a peculiar coagulation process attacks the cell and body. The cell processes retract, become thick, and finally drop off. Vacuoles are sometimes seen in the nerve cells ; but these are very rare if the tissue is properly preserved. Besides the above evidences of vascular and connective-tissue activity and of cell de- struction, one sees granular matter, broken-doAvn nerve fibres, and other evidences of nerve disintegration. Pigment or extravasations of blood, and in later stages bodies resembling starch granules (cor- pora amylacea), may be seen. They are probably modifications of the myelin substance. If the lesion is primarily softening there may be much congestion, but the blood-vessels are less distended and fewer white cells are found in the perivascular spaces. The connective-tissue cells are less numerous. The nerve cells are swol- len, glassy, and stain badly. There is a great deal of granular matter and nerve detritus. It is thought that in inflammatory swelling of the nerve cells they take up the carmine stain, but in degenerative changes they do not.* * In the different stages of acute degeneration, the nerve cells, particu- larly those of the anterior horns, show various appearances. These have been MYELITIS — INFLAMMATION OF THE SPINAL COED. 253 The connective-tissue changes are most noticeable in the white matter. The axis cylinder and myelin sheath are here often sodis- hategrated that in thin sections they drop out, leaving holes in the section and giving it a vacuolated appearance. The lesion, whether destructive or inflammatory, may extend up or down the cord, often in the course of certain tracts. Sometimes a destructive process extends a long way through the central part of the cord (perforating necrosis) . After three or four weeks, if the patient lives, the process of absorption and cicatrization begins, and secondary degenerations are seen. The granular and fatty matters and leucocytes disappear, the blood-vessels are thick-walled and distended but less numerous, connective tissue gradually takes the place of the destroj^ed nerve cells and fibres. The axis cylinder is the last to be destroyed and has the greatest power of recuperation. The nerve cell, if once de- stroyed, is never developed again. The cord at the point or points inflamed or softened becomes reduced to a mass of connective tissue contaming, perhaps, a few nerve fibres and cells. In this stage the condition is one that is kno^vn as chronic myelitis. In some cases a cyst is formed iii the affected region. In fatal cases the inflammation and softening continue; fresh areas of cord are involved, much meninegal exudation takes place and finally death occurs. The process may in very rare cases be still more acute, suppui-ation and abscess occur, and here death also rapidly ensues. The inflammatory and softening processes above referred to are described in accordance with their a})pearance as red softening, yellow softening, or white softening. A form of so-called inflamma- tion known as inflammatory cedema is also described. It is an abortive inflammation, "a lymphatic congestion," analogous to vas- cular congestion. The diagnosis of acute myelitis must be made from hemorrhage, acute embolic or thrombotic softening, acute ascending paralysis, multiple neuritis, meningitis, and meningeal hemorrhage, and hys- terical, or functional paralysis. Spinal hemorrhage comes on sud- denly and is usually not attended by fever. If meningeal, it is attended with pain. Acute softening cannot always be distinguislicd f nun acute myelitis, of which it is probably the starting-point in many described liy Friedniiiiin as; 1, lioniogeucoua swelling, hyaline swelling ; 2, sclerosis; 3, simple atrophy ; 4, fatty and molecular (Icconiposition ; 6, clondy swelling. The degeneration begins in the cell body and then involves the processes and the nnelens ; finally the wliolc cell is involved. Nerve cells do not often inidcrgo the ac-ntc general death called coagnlation necrosis (Friedmann) , though the process of sclerosis, so called, resembles it somewhat. 254 DISEASES OF THE NERVOUS SYSTEM. cases. In softening there is no leiicoct/tosis, the i^rocess is slower, there is less pain and the dissociation of cutaneous sensations is less marked. In acute ascending paralysis the disease is progressive, there are no involvement of sensation, no atrophy, and little change in the electric irritability. In multiple neuritis the onset is slower, there are more pain and local tenderness and sensory disturbance, and the bladder and rec- tum are rarely involved. In meningitis there are pain and tenderness in the back and limbs, rigid- ity, cramps, a little pa- ralysis, and no bladder trouble. In hysterical paraplegia there are no marked atrophic changes, but little spasm or ri- gidity, no electrical chan- ges, and the stigmata of hysteria may be found. The sensory disturbances are variable and some- what characteristic (see Hysteria), and the knee- jerks are not greatly if at all exaggerated. The diagnosis of the location of tJie lesion is made by studying the height of the anaesthesia, the skin reflexes (see p. 47), and the distribution and extent of the paraly- sis. There is often a differentiation of the an- aesthesia as shown in Figs. 117 and 116. Le- sions of the lumbar re- gion involving the gray matter cause very complete paraplegia with sphincter troubles and degenerative electrical reactions. Lesions in the dorsal cord cause Fia. 116.— Acute Transverse Myelitis op Lumbar Cord, showing distribution of anaesthesia. Area in lines=total anaesthesia and analgesia. Dotted area =analgesia only. MYELITIS — INFLAMMATION OF THE SPINAL CORD. 255 a less comjalete paraplegia, but, owing to the secondary descending degenerationg of the lateral column, rigidity, exaggeration of the deep reflexes, and contractures occur. Lesions of the cervical cord cause paralysis of the arms, with degenerative reactions in the muscles. The paraplegia is spastic and there is not much muscular wasting. If the lesion cuts entirely through the cord the limbs are paralyzed and may be somewhat rigid, but the deep reflexes are absent. Prognosis. — The prog- nosis is worse the more complete and extensive the paralysis. It is worse in serious motor paralyses than when sen- sation is chiefly involved. It is best in dorsal myelitis and worst usually in cer- vical myelitis, other things being equal. Bed- sores and slight fever are unfavorable signs; so also is severe involvement of the bladder and rec- tum. Recovery of sen- sation gives good hoi)e of recovery of some motion. Total absence of recovery of sensation and motion after six months is vory unfavorable. Improve- ment may be expected up to eighteen months after the onset, and in some cases even longer. In (•om])ression myelitis there is more chance of recovery than in the other forms. Syphilitic cases have a more favorable prognosis. Treatment. — In the attack, the patient must be put to bed; Fio, 117.— Actttb Tkansversk :Mvkliti8 op LmaAB CoiiD, showing distrihutioQ of aniL'Sthesia. Area in liiiuKs total nntjcstheala and anolKesia. Dotted areaa niialgfsiaoiily. 256 DISEASES OF THE NERVOUS SYSTEM. leeches or wet cups should be applied to the spine, diaphoresis should be promoted, small doses of aconite and nitroglycerin should be given, and a calomel purge administered. The bladder should be watched. After a week, moderate doses of iodide of potassium should be given. After about three weeks, if there is no fever, electricity may be applied carefully and strychnine administered in small doses. Bed-sores should be guarded against by the use of water beds or cushions, absorbent cotton, bathing the parts with alcohol and weak solutions of tannin. Infusion of buchu, boric acid, and tincture of hyoscyamus will often help the bladder disturb- ance. The frequency of syphilis as a cause of myelitis (nearly one-half the cases) should lead to the persistent use of mercm-ial in- unctions and of iodide for a long time. After acute symptoms sub- side, tonics such as arsenic, iron, and strychnine in small doses may be given. Suspension may be tried carefully; mechanical ap- pliances may be used to help the rigid limbs; lukewarm baths, douches, and massage are helpful to some extent. Chkonig Myelitis (includixg Transverse, Diffuse, Dissemi- nated, AND Compression Myelitis). Chronic mey litis is the name given to a disease characterized by a chronic inflammation of the spinal cord and to the chronic re- parative processes which follow acute inflammation, injury, and softening. Chronic myelitis is usually a mixture of inflammatory, reparative, and necrotic processes. Forms. — Different names are given to chronic myelitis in accord- ance with the part of the cord affected. Usually the disease affects only certain levels, and then it is called transverse myelitis. More rarely it is diffuse or disseminated, central or marginal. When caused by pressure from vertebral disease, it is called compression nvi/elitis. Etiology. — The disease may be either primary or secondary. The primary form is somewhat rarer. It occurs chiefly in adults and in early and middle life, and much oftener in males. Expo- sure, shocks, infectious fevers, lead, and syphilis are the chief causes, but above all syphilis. Syphilis causes it by producing arterial disease and by setting up a specific mflammatory infiltra- tion. Secondary chronic myelitis is a rather common form. It is really only the later stage of acute myelitis, softening, hemorrhage, or injury. Meningitis may extend and cause a meningo-myelitis. A neu- ritis may possibh' ascend and cause myelitis, but such eases, if they occur, are very rare. Compression myelitis is usually a slowly de- MYELITIS — IN'FLAMMATIOX OF THE SPIXAL COED. 257 sti-uctive, not an iuflaininatoiy process, and it begins as a meningitis of the dura mater. Among 67 personal cases there were 61 men and 6 women. The causes that can be assigned were: Syphilis 23; injuries 12; ex- posure 3; acute infection G, of which 3 followed grippe, 1 typhoid and 1 meningitis, 1 mumps. Two were due to caisson disease; 4 were of arterio-sclerotic origin occurring in the aged, and 6 were due to tuberculosis. A study of the age shoAvs that in the decade between thirty-one and forty there were 23 cases; twenty-one and thirty, 14 cases; forty-one and fifty, 16 cases; fifty-one and sixty- four, 73 cases; eleven and twenty, 2; under ten, 2. Practically all the cases occur between tlie ages of twenty-one and fift}', and most of them between the ages of thirty-one and forty. Those cases occur- ring in the extreme of life are due to senile arterial changes or to tubercle or injury. There is not much difference in the age re- lations of the cases of syphilitic origin and those due to other causes. Between twenty-one and thirty, 5 out of 14 were of syphilitic origin. Between thirty-one and forty, 9 out of 23 were of specific origin, and syphilis may fairly be said to cause over one-half the cases of non-traumatic and non-tuberculous myelitis of adult life. Symptoms. — "When the disease begins primarily as a chronic affection the symptoms are as given below. And since nearly all the cases are of SA-philitic origin, the description of i)rimary chronic myelitis is practically that of syphilitic spinal paralysis. The i)atient notices that his legs seem heavy and easily get tired ; prickling and numb sensations are felt in the feet; occasionally a lit- tle })ain develops in the l)ack or there is a sense of constriction about the trunk. The legs are stiff, and tests often show that the reflexes are exaggerated, witli ankle clonus and flexor response (sign of Ba- binski). There is but little wasting of them, however. The sexual power declines ; the bladder gives some trouble, there being a ten- dency to retention; the bowels are constipated. After a few weeks or months there is a partial paraplegia, with rigidity of the limbs and exaggerated reflexes. Some aniesthesia exists, and occasional pain, which is not severe aiid is felt more in the back than the legs. The muscles have now wasted somewhat, but show no decided changes to the electrical current. The bladder becomes more in- volved, the urine has to be drawn, it is often alkaline, and unless care is taken cystitis develops. The patient is still able to walk, but he does so with a stiff, shuilling gait which is characteristic (Fig. 118). The disease may show signs of slowly extending up and down, more often up. The arms become involved; weakness and stiffness, with some wasting, anesthesia, and pain, develop, or the disease may cease its progress and the patient remain partly para- lyzed for j-ears. The general health during the course of the disease 17 258 DISEASES OF THE XERVOUS SYSTEM. deteriorates slowly ; the j)atients often become anaemic and have an unhealthy pallor. Eventually the paraplegia becomes complete, the patient is bedridden, the legs are atrophied, contractured, and rigid, with more or less angesthesia. Cystitis and nephritis develop, and the patient dies from these or other intercurrent diseases. Chronic secondary myelitie^ which is the form often seen, pre- sents eventually much the same picture as that just described. In this tyjje, hoM^ever, the symptoms are w^orse at first, then improve or regress, then become stationary, and finally grow worse. S(/nqjtoins of flic Dlffercvt Forms. — The usual type of chronic myelitis is the transverse dorsal or dorso-lumbar, and this gives symptoms as above de- scribed. It is, as stated, usually a syphi- litic spinal disease. If the lumbar region is affected there are more paraplegia, wasting, and involvement of organic cen- tres. If the myelitis is cervical the arms are involved, there may be pupil- lary changes, and the respiratory muscles are partly paralyzed; the paraplegia is not so complete and the disturbances of sensation are likely to be more varied. Compression myelitis, so called, is usually only a compression atro^^hy. It is due, as a rule, to vertebral caries, but its cause may be a spinal tumor, aneur- ism, and pachymeningitis. Compression myelitis is distinguished from other forms by its slow onset and the presence at first of irritative or "root" symptoms. The patient suffers from pain and tenderness localized at a certain point in the spine. The pain radiates about the trunk or down the limbs and is increased on movements. At about the same time some motor weakness develops, usually in the form of paraplegia. The muscles waste but slightly. The reflexes are ex- aggerated; twitchings, spasms, and contractures finally occur, and there is developed a spastic paraplegia or quadruplegia. With this there is usually some anaesthesia, though it is not complete. The disease is oftenest in the dorsal or lower cervical region, and hence the sphincters escape until late. Locally, evidences of spine disease appear early in the form of a kyphosis. K central or pjeri-ep/endymal myelitis caxi rarely be recognized with Fig. 118.— Attitude ik Chronic Myelitis. MYELITIS — INFLAMMATION OF THE SPINAL CORD. 259 certaiuty. It produces less pain and irritation, but leads to mus- cular atrophy, disorders of sensations such as thermo-ansesthesia, disturbance of vasomotor and secretory nerves and visceral centres. Fatliolo(jy. — The pia mater is thickened over the affected region and often throughout the cord. The cord itself has a gray, dis- colored look at the affected level, and is usuall}' shrunken or dis- torted and hard to the touch. In severe cases of secondary char- acter it is reduced to a small size, and the membranes about it are thick and inflamed. In transverse myelitis a vertical area of only two or three inches is involved. The microscope shows that the prominent changes are loss of nerve structure, great increase of con- nective tissue, and increase in the number of vessels, which often have thickened walls. In the more seriously diseased part little is seen but connective tissue. In parts less diseased some nerve fibres are seen, many having evidences of partial disintegration. There is also a good deal of amorphous material studded with nuclei. Stellate cells, graiuile cells, and nerve cells in various stages of degeneration are present. In the parts less affected the signs of congestion and vascular irritation are more pronounced. Didfjnosis. — This must be nuide from progressive muscular atropliy and amyotrophic lateral sclerosis, pachymeningitis and spinal tumor; from locomotor ataxia, multiple sclerosis, and brain palsies. In progressive muscular atrophy there is a peculiar atroph}- with- out involvement of tlie sphincters or sensory disturbance. In pachymeningitis there is often a history of an injury; tliere is more pain in the back and a more marked anaesthesia. The sphincters are not involved. Pachymeningitis is also usually located in the cervical region. Tumors usually cause much luore pain; the symp- toms come on slowly and are more definitely localized. A spastic paraplegia occurs from brain disease and as a functional trouble. In eitlier case there are no trophic or sensory troubles, nor is there involvement of the sphincters. In locomotor ataxia there is no great degree of motor paralysis, and there are peculiar ataxic and sensory disturbances. In multiple sclerosis there are eye symptoms, spee('h disturbances, Tind tremor. Paralysis from brain disease is almost always unilateral, painless, spastic, and free from disturb- ance of the visceral centres. Prnrjuosis. — Inflammatory processes have a tendency to cease when their reparatory and eliminative work is done. Chronic mye- litis, however, is often, as has been stated, a destructive process due to some defect in vascular siipply or to some medianical irrita- tion. I'.esides this, in the spinal cord secondary degenerations set in as soon as certain tracts arc interfered Avith. Hence chronic 260 DISEASES OF THE NERVOUS SYSTEM. myelitis, after a period of improvement, generally progresses, and the prognosis is not very favorable. Still, patients may live from five to tweny-five years. Dorsal myelitis is the most favorable form ; compression myelitis from caries can also often be success- fully treated. Those forms which come on rather rapidly are more likely to cease progressing (Gowers) . Serious involvement of the bladder is a bad sign, and naturally the prognosis is worse the more complete the paralysis. Treatment. — In the earlier and progressive stage of chronic mye- litis rest is imperative. The patient should lie down much of the time. Counter-irritation in the form of fly blisters, the cautery, or setons should be applied, and if no improvement results wet or dry cups used. The descending galvanic current along the spine should be tried; faradism and massage being used upon the limbs. Cold baths and cold applications must be prescribed carefully if at all. Lukewarm baths, 90^^ to 98° E., or half-baths with friction at 70" to 80° F., are more likely to be useful, but even these must be tried cautiously. The first baths should last not over five minutes and should be repeated only three or four times weekly. In later para- plegic and bedridden stages, electrical and hydro-therapeutic appli- cations should be followed up patiently and persistently. The pa- tient now may be allowed to remain and exercise in the lukewarm bath, for some time. Internally, iodide of potassium and mercury should be first given. After thorough trial with these remedies for six or eight weeks, the patient should be given courses of treatment with arsenic, nitrate of silver, phosphorus, and perhaps the chloride of gold. Pills of arsenite of sodium, gr. -^^, may be administered three or four times daily for two months ; if benefit ensues, the remedy should be resumed after an intermission of three weeks. Phos- phorus is best given in the form of an elixir in closes of gr. -yL- ter in die increased to gr. -J^-. The remedy should be suspended for three days at the end of each ten days. Silver is given usually in the form of the nitrate (dose, gr. i to -J). Not more than one drachm should be given without a three-months' intermission. Some assert that the hypophosphite of silver and sodium, and the albuminate, are surer preparations. I do not advise the use of ergot. Strychnine in small doses is sometimes useful. Por the bladder troubles, the internal use of boric acid, bvichu, sandalwood, and similar drugs is useful. Mechanical and surgical measures may be of some help. In some cases suspension does good, but it may do harm. Tenotomy is justifiable for the purpose of straightening contractured limbs. In compression myelitis sus- MYELITIS — IXFLAMMATIOX OF THE SPIXAL CORD. 261 pension on an inclined plane and the plaster jacket or other support are indicated. Cases have been reported in Avhich surgical opera- tions for the relief of a supposed tumor have cured compression myelitis from Pott's disease. Sea voyages are often useful and are preferable to mountain climates. Eest, quiet, fresh air, and a very regular life are the essentials in all climates. Acute Anterior Poliomyelitis (Ixfantile Spixal Paralysis, Acute Atuophic Paralysis). Anterior poliomyelitis is a disease of the spinal cord character- ized by a motor paralysis of rapid onset, followed by muscular wast- ing, without sensory symptoms. It occurs at all ages, but vastly oftener in infancy; hence it is often called infantile spinal palsy. Etiolo'jij. — The average age at the time of attack is two years. Most cases occur under ten, and four-fifths of these occur under three. It may be congenital, i.c^ occur in intra-uterine life (Sinkler), and it may occur as late as sixty. Most adult cases occur under the age of thirty.* Rather more of the infantile cases occur in boys, and most of the adult cases occur in males. Race and cli- mate afford no exemption so far as is known. The great majority of cases occur during the hot months of summer (Sinkler). ^Nearly eighty percent (78.8) occur between June and September, inclusive. Heredity has an influence in only one or two per cent of cases. Over-exercise and chilling of the body when heated are occa- sional causes. Infectious fevers (oftenest measles) precede the at- tack in about seven per cent (Sinkler). The disease has several times occurred as an epidemic. Dentition is rarely an excit- ing cause, as used to be supposed. Injuries and falls in a few instances appear to be the cause of the disease. The fact that the child is just beginning to walk at the period when most susceptible to poliomyelitis must be considered of importance, since the new movements call for an unusual activity of the spinal centres. To sum up, aye, scosnn, and i/ifi'rfioiis diseasi's are the three most important etiological factors. Si/mptoms. — There are rarely any premonitory symptoms. The * Among no personal cases, 39 were in children. Of tlie latter there were 24 males, 15 females. Ages: Under six months, 1 ; half to one year, 8; one to two years, 10 ; two to three years, 5 ; tliree to four years, 3; four to six years, 3; six to eight years, 3. Final result was palsy, ciiiefly in right leg, in 14 : chiefly in left leg, in 5 ; in both legs, 5 ; in riglit arm, 4 ; all four ex- tremities, 1 ; the remainder in various combinations. Disease followed scarlatina in 1, pertussis in 2, cholera infantum in 1, sonic "fever" in nearly all cases. 263 DISEASES OF THE KERVOUS SYSTEM. patient is taken with a slight fever, 100' to 102^ F., accompanied by vomiting, diarihcea, or convulsions. In a few iiours or a day paralj'sis develops; sometimes the i3aralysis is as much as a week in developing ("subacute form"). The fever lasts from one to three or four days. The paralysis rapidly reaches its height, then remains stationary for a time; then improvement sets in, which reaches a certain point and stops. We have consequently : 1. A stage of invasion — a few hours or a week. 2. A stationary period — one to six weeks, usually two weeks. 3. A stage of improvement — six months to a year. 4. A chronic stage. 1. The stage of invasion may be so sudden as to suggest hemor- rhage. Sometmies the child, alter a restless, feverish night, wakes in the morning paralyzed. Usually the initiatory symptoms last less than a day. With or before the paralysis a fever of 100° to 102^ F., vomiting, delirium, and, much less often, convulsions which are not severe, occur. After the general disturbance subsides there may be some pain in the back and limbs for a few days, and in rare cases the bladder is involved so that there is retention of urine. But the dominant symptom is motor paralysis. The paralysis is oftenest paraplegia, next one leg, next the arms and legs, and after this various combinations. The eye muscles, laryngeal and respiratory muscles, always escape in infants. In older persons the facial nerve may be involved. In certain peculiar cases the cranial nerve nuclei are attacked, in association with the anterior horns. When the eye-muscle nuclei are involved it is called " polio-encephalitis superior ;" when cranial nerve nuclei lower down are involved it is called "polio-encephalitis inferior." 2. The paralysis reaches its height in from one to four days. It remains at its height for from one to six weeks, and then im- provement gradually sets in. In two or three weeks a wasting of the paralyzed limb may be noticed. It is flabby, its temperature lowered, and the reflexes are gone. Slight tenderness may be present, but there is no anaesthesia. 3. The stage of improvement lasts for from six to twelve months. There is gradual disappearance of the paralysis, beginning in the limbs least affected. This continues until the paralysis has left all but one or two limbs. As a rule, it is the legs alone that are finally left paralyzed. In a quarter of the cases both legs, and in half of the cases one leg, oftener the right, remain affected. The muscles waste and show the reaction of degeneration, viz., loss of faradic ir- ritability, retention but lessening of galvanic irritability, sluggish MYELITIS — IXFLAMMATIOX OF THE SPINAL CORD. 263 contractions, and sometimes polar changes. In the leg the anterior tibial group of muscles is oftenest affected, in the arm the deltoid and shoulder group. The atrophy, having reached a certain grade, finally ceases, and then a slight improvement may set in. After the end of a year not luuch further spontaneous improvement can be expected. 4. The temperature of the affected limb is lowered several de- grees, the skin has a reddish-puv])lish, mottled look. The bones as well as muscles of the affected liiutjs do not grow so fast as those of the healthy limb. Hence in time the foot becomes smaller and the leg shorter. Owing to the contraction of unopposed muscles de- formities occur. The most frequent are talipes equinus, talipes Fio. 119. Fio. 120. Fm. 119. — ANTKRiori Poliomyelitis in Lumbar Skgmest (Demaschino). F^o. 120. —Same, Much E.vlaroed, showing congestion. valgus and varus. Deformities of the knees, contraction of the plantar fascia, and lateral curvature of the spine, also take jjlace. The general health of the patient is usually good. Fathohuji). — The dist^ase is an acute exudative inflammation with destruction of tissue, but without suppuration. It affects chiefly the anterior cornua, especially of the lumbar and cervical enlarge- ments (Figs. IIU, IL'O). It is not, as a rule, diffuse, but often the brunt of the trouble is felt only by certain cell groups. These are destroyed, and after a time connective tissue takes their place. In rare cases the larger part of the central gray and some of the white matter are involved. Later a certain amount of sclerosis occurs in the lateral columns. The anterior roots and motor nerves atrophy. The muscle tissue also wastes, aiul its place is supplied by connec- tive tissue. Dvujnosis — The disease must be distinguished from multiple neuriti.s, spinal hemorrhage, cerebral palsies, birth palsies, and pro* 264 DISEASES OF THE NERVOUS SYSTEM. gressive muscular atrophy. The diagnosis can be easily made in almost all cases by remembering these facts : 1. The age of the patient. 2. The abrupt onset and rapid development of extreme paralysis. 3. The tendenc}" to improve. 4. The absence of aucesthesia, bladder or rectal symptoms, rigidity, and pain. o. The electrical reactions. 6. The arrest of groAvth of the limb. Multiple neuritis and progressive muscular atrophy rarely occur in cliiidren. Myelitis and hemorrhage are usually accompanied by sensory disorders, bed- sores, and bladder troubles ; cerebral xmlsies are usually unilateral and accompanied by symptoms of stiffness and exaggeration of reflexes. Fror/?iosis.—The patient rarely dies, either from the disease or its sequelae. He always improves, but he hardly ever gets entirely well. The cases in which recovery is complete are those of simple exudative inflammation without any necrosis. Much can be done by careful and persistent treatment and by the help of orthopaedic surgery, even in old cases. The usual course is for the patient to get back the use of all but one leg. He grows to adult life with this short and weakened member. Treatment. — In the acute stage the child should be put to bed and kept there. Iodine or mustard plasters or leeches must be ap- plied to the spine. Internally, a smart laxative and a diuretic must be given (calomel, gr. iij.; tartrat. potas., gr. xx.). Then tincture of aconite is to be administered in doses of one drop every half -hour as indicated by the fever. To this may be added sweet spirits of nitre. Eest is the most essential thing. The limbs should be kept quiet and warm. At the end of two weeks electrical applications may be very cautiously made to the limbs three times a week, if there is no tenderness or fever. After four weeks, electrical treat- ment should be given daily for a month, each limb being treated for only two or three minutes. After a rest of a fortnight another four- weeks' treatment may be given. Treatment should be thus applied intermittently till the end of a year. After this it can be continued or stopped according to the condition of the patient. In old cases daily treatment for one or two years will sometimes produce valuable results (G. M. Hammond). That form of electricity which causes muscular contractions most easily should be employed, and this is usually the galvanic current. Massage is a most important adjuvant to electricity. It is best given daily for not over ten minutes to a single limb. It is imperative also that the physician overcome any MYELITIS — IXFLAMMATION" OF THE SPIRAL CORD. 265 contractures which develop, by splints, rubber muscles, and, if necessary, tenotomy. Warmth is very useful. The leg should be bandaged in cotton at night, and, if necessary, hot-water bottles placed beside it. Many parents cannot atford prolonged electrical Fio. 121. — Cask of Chronio Anterior Poliomyei.itip n« an Adcit, Bhowlni the wasted hand unil drop foot. ard massage treatment. In such cases they should be told to rub the limb twice daily with a stimulatiug liniment and wrap it in cotton or hot flannels at night. The child should be taught to walk and exercise the limb as much as possible. Tricycles and gymnastic apparatus may often be brought into use. ^Medicines are of liitle value in the chionic stage. Phosphorus, strychnine, iron, arsenic, cod-liver oil, physostigma, have been 2G6 DISEASES OF THE XERVOUS SYSTEM. recommended and are sometimes prescribed for tlie improvement oi the general health and solatii catcsa. Chroxic Anterior Poliomyelitis. — This form of myelitis is very rare, and most careful examination must be made to exclude on the one hand multiple neuritis, and on the other progressive mus- cular atrophy. Etiology. — Adults are chiefly affected, and men more often than women. Exposure, lead-poisoning, and syphilis are among the principal causes. Syvqjtoms. — The disease affects one or more of the extremities, often all four of them. There is a gradual paralysis, rapidly fol- lowed by atrophy, wath degenerative electrical reactions. There is but little pain or other sensory disturbance. The sphincters are not affected. The disease takes one of two courses .• 1. After reaching its height, improvement gradually sets in and recovery may become nearly complete. 2. The disease steadily progresses until the patient presents the picture of a case of progressive muscular atrophy. In a few months, or at the most one or two years, death ensues. Occasionally, how- ever, after reaching a very advanced stage, the process stops (Fig. 123) and a slight improvement may set in. These progressive cases of chronic poliomyelitis appear to stand half-way between ordinary chronic poliomyelitis and progressive muscular atrophy.* Diagnosis. — The disease is distinguished from multiple neuritis by the absence of pain, tenderness, and anaesthesia; from progres- sive muscular atrophy by the rapid onset, the occurrence of paraly- sis first and "wasting afterward, the early degenerative reactions, and the absence of fibrillary contractions. A history of lead poisoning may also help in the diagnosis. The treatment is mainly symptomatic and must be carried out on the lines indicated under the head of Acute Anterior Poliomye- litis. Iodide of potassium, mercury, and strychnine should be given. Acute axd Chroxio Senile Paraplegia. A rather sudden paralysis of both legs sometimes attacks old people as the result of thrombosis or hemorrhage of spinal arteries. In these cases the symptoms come on suddenly, as in acute mye- * Subacute Spinal Paralysis of Duckenne. — The diseases described under this bead are chiefly cases of multiple neuritis. In a very few there are both neuritis and myelitis; in others the condition is one of minute focal spinal hemorrhages with secondary myelitis. MYELITIS — IXFLAilMATIOX OF THE SPIXAL CORD. 267 litis, only tliere is not much pam. The patient has sometimes a decided pai-alysis, and sometimes moderate paralysis but very great ataxia, depending on the arteries involved, whether postero-iateral or central. The patient usually improves rather rapidly and may regam a large part of his strength, but relapse is likely to occur. Eest and proper attention to diet and elimination are indicated. A chronic form of paraplegia, slowly developing, is aLso seen in old people. It begins with simple weakness of the legs, followed by wasting and progressive development of a paraplegia. The sphincters eventually become involved. The disease affects the lower extremities first, but gradually extends, and finally involves the arms. The general characters are those of a progressive mus- cular atrophy; but the disease is distinguished from this by the fact that the sphincters become rather early involved, and that the pa- ralysis and wasting go on together without any fibrillary contrac- tions. The medulla and the facial and ocular muscles do not become involved. Clinically the disease cannot be distinguished from a chronic anterior poliomyelitis which takes upon itself a progressive type. On post-mortem, however, it is foimd that there is a soften- ing of the gray matter in the anterior horns of the spinal cord, more marked in the lumbar swelling. This softening is apparently due to the thickening and obliteration of the blood-vessels from senile changes in them. Dr. Gowers describes a disease which he calls senile para- plegia in which there are simple weakness of the legs and slow- ness of movement, without any atrophy, sensory disturbance, or alteration in the reflexes. He considers it to be a form of paralysis agitans. The disease which I have described, however, represents more tioily a simple senile paraplegia. Very little can be done for this trouble therapeutically. The use of nitroglycerin, iodide of potassium, sparteine, digitalis, and general tonic and hygienic measures are indicated. Acute Ascexdixg Paralysis (Laxdry's Paralysis). Acute ascending paralysis is a disease characterized by a rapidly developing paralysis which begins in the legs and then involves in turn the trunk, arms, respiratory and throat muscles, usually end- ing in death. There is little distui-bance of sensation, no atrophy or changes in electrical irritability, and no involvement of the sphincters. Efinfnrfi/. — The disease is a rare one. It occurs chiefly between the ages of twenty and forty ; men are affected oftener than women. 268 DISEASES OF THE NERVOUS SYSTEM. Exposure is an escicing cause, and it occurs sometimes after acute infectious fevers and syphilis. Tlie form of rabies known as '* para- lytic" causes a disease which is apparently identical with Landry's paralysis. Symptoms. — There may be slight premonitory symptoms for a few da^^s, consisting of numbness iu the extremities, pain in the back or limbs, and malaise. The first definite sign of the disease is weakness in the legs, which rapidly increases until in a day or two the patient cannot walk. The paralysis soon involves the arms and then the muscles of respiration ; the medulla is last affected, and then respiration becomes difficult; swallowing and articulation may be impossible. In rare cases there are facial and eye palsies. Dur- ing the course of the paralysis there is little pain or sensory disturb- ance, but some degree of angesthesia may occur. The deep reflexes are abolished. There are no vasomotor and no secretory disturb- ances, no noticeable atrophy, and no degenerative reactions in the affected muscles. The bladder and rectum are involved only in rare cases. There may be slight initial fever, but none occurs after the disease has well set in. The mind remains clear. The disease, as a rule, ends fatally, and it usually runs its course in less than a week. Death has occurred in forty-eight hours. On the other hand, death has been postponed three or four weeks. In other cases the disease stops short of the medulla. The pa- tient becomes totally or nearly paralyzed below the neck. He then begins slowly to improve, and this improvement continues for one or two years. Eventually a fair degree of health is obtained. Variations. — The disease has been known to begin in the medulla or cervical region and descend. Patliological Anatormj. — A number of different diseases have been described under the head of Landry's paralysis, and corre- spondingly a number of different anatomical changes have been found. Multiple neuritis, acute diffuse myelitis, and poliomyelitis existed in some cases. In others there was a dropsical exudation in the central canal of the spinal cord, or a hyaline change in the cen- tral arteries. In recent years decided changes in the anterior-horn cells have been detected by means of the Nissl stain •, and it is pretty well decided that the disease is in its ordinary manifestations an acute toxaemia of the peripheral motor neuron, a fulgurating type of ante- rior poliomyelitis. It, however, affects in some cases the gray mat- ter of the brain also. The paralysis is probably due to a poison of microbic origin. In some cases certainly this poison is that of rabies; but it is not impossible that other infections may pick out and suspend the functions of the anterior cornual cells, or, MYELITIS — INFLAMMATION OF THE SPINAL CORD. 2G9 as fiowers suggests, the " end brushes " of the motor tract which connect with these cells. This would explain the symptoms. Sometimes the poison may be so great in amount and so irritat- ing as to set up a myelitis or perhaps a neuritis. Cases illustrating these facts have been reported (Eichberg, Eosenheim, Putnam). l)ut in most cases the patient dies before the toxin can produce any inflammatory reaction. TJie prnfjDosis is very grave, but not absolutely bad. If there is reason to suspect the case of being one of paralytic rabies, no hope can be offered. Dio'jnosis. — This must be made from acute poliomyelitis, acute myelitis, and acute multiple neuritis. Its acute ascending com-se, absence of fever, of anaesthesia, atroi:)hy, decubitus, sphincter troubles, and especially the absence of degenerative electrical reactions are sufficient to enable one to make the diagnosis. The age of the patient, and the presence or absence of an alcoholic history should be considered. Treatment. — This consists of warm baths or packs, counter-irri- tation to the spine, laxatives, and rest. Large doses of ergotin, gr. ij., every hour have been successful in one case. Salicylate or ben* zoate of sodium, iodide of potassium, and mercury may be tried. CHAPTER XIV. THE DEGENERATIVE DISEASES OF THE SPINAL COED. Ixtroductory: The Naturk axd Types of Degexeration AND Sclerosis. — The degenerative diseases of the spinal cord are sometimes called "system diseases," and some are often spoken of as scleroses. There are no true system diseases, however, except locomotor ataxia, progressive muscular atrophy, and amyotrophic lateral sclerosis. These should really be called "neuron" rather than ■' system" diseases, and this latter term is best not used as a basis of classification. The term "sclerosis," also, is somewhat misleading. Properly speaking it is the fibroid (and neuroglia) induration which results from degeneration, destruction, or in- flammation of nerve tissue. We speak of degenerative sclerosis, of an infiamniatoyy and of a neuroglia sclerosis, or of a sclerosis of mixed origin, according to the nature of the primary disease which caused it. The words " degeneration" and " sclerosis" are often used to indicate the same thing, one being the pathological name, the other the anatomical. I shall use the term " sclerosis" here in its pathological sense, meaning the process of hardening, in pre- senting a classification of the degenerations of the spinal cord. f Posterior spinal sclerosis (locomo- I tor ataxia). Lateral sclerosis. Combiued sclerosis. Progress] ve muscular atrophy, amyotrophic lateral sclerosis. ( Ascending and descending degen- I erations. i Chronic myelitis and sclerosis fol- lowing destruction of cord. Multiple sclerosis. A few words of explanation are needed regarding these different conditions, since a world of confusion has been made on account of the different standpoints taken by writers when nerve pathology was young. a. Primary degeneration or primary sclerosis, as one may say Spinal scleroses or degenera- tions. ' a. Primary and de- ) generative. b. Secondary. THE DEGEN^ERATIYE DISEASES OF THE SPIXAL CORD. 2T1 for convenience, is a process Avhich begins in the nerve tissue itself and ends in its atrophy, -with substitution of connective tissue. As to its nature, so far as the microscope shows us, it is a gradual decay and death of the neurons. In some sclerotic processes, like loco- motor ataxia, this decay is accompanied by the development of irritating products, leucomains or toxalbumins, "which may pro- duce so active a change in the connective tissue as to lead to some- ihing resembling a secondary or reactive inflammation. This is Fio. l^Ji. -SuowiNO THK Tracts Affk.cted i:j Secondary Dkoenerations or> the Spinal, Cord in Lesions at I)iffeuext Lkvels. 1, Descending det'eneration after lesion at sixth ervical; 2, ascendJMjj and descending deKeneration, lesion at sixth dorsal; 3, ascending and descending^ degeneration, lesiou at twelfth dorsal; 4, ascending degenera- tion, lesion at first sacral. never of high grade, however, and in some forms of tabes is very slight. In progressive muscular atroijhy the decay and death produce ffW irritating ]tioducts, thougli enough, perhaps, to account for the iibiillary twitchings and occasional hyjjertonic condition of the muscles. The ultimate cause of these degenerative processes is not known. The progressive character of the diseases like locomotor ataxia and 273 DISEASES OF THE XERYOUS SYSTEM. progressive muscular atrophy would lead one to tliink that there is a poison at worxi. and constantly acting on the diseased tissue. So far, all bacteriological examinations have failed to disclose any microbe, but the fact that many degenerative processes follow in- fectious fevers or syphilis has led to the suggestion that pathogenic germs have poured into the system a poison, or have so modified the cellular uutriticu that there is a poison constantly thrown out, which irritates and destroys certain areas of nerve tissue. The normal immunity of certain neurons to metabolic poisons is lost. All the primary degenerations or scleroses have a certain degree of kinship. Their causes are in many respects the same, the course of all is uniformly progressive, and one not very infrequently com- plicates another. The sharpest distinctions are found between those affecting the peripheral motor neurons and the peripheral sen- sory neurons. Degenerative processes implicating the former are much rarer- and their course is more rapid and fatal. The degenerations of the spinal ganglia and the peripheral sen- sory neurons are more common, slo\\er in course, different in etiol- ogy, and much more varied in symptomatology. Locomotor and the hereditary ataxias furnish examples of this type. b. Secoxdaky Degeneratioxs of the Spixal Cord. — When any of the long-fibre tracts of the cord are cut across or de- stroyed, there soon results a degeneration. This extends up or down in accordance with the direction in which the tracts carry im- pulses. Thus, when the crossed pyramidal tract is cut across the degeneration extends down; when the column of GoU is involved it extends up. The degenerative process begins almost immediately and is complete in a few weeks. The myelin sheath swells, grad- ually breaks up, and disintegrates; the axis cylinder is involved next. At the same time the connective tissue proliferates and takes the place of the wasted nerves. Finally, long tracts of con- nective tissue have taken the place of the nerve tissue. The proc- ess may not be a complete one if the lesion does not entirely de- stroy the tract. The short-fibre tracts degenerate only a little way up and down. Secondary degenerations complicate and add to the pathological change in all organic diseases of the cord. In brain disease, involv- ing the motor tract, as in hemiplegia, secondary degeneration extends into the cord and adds to the seriousness of the disease. Degenerations of the spinal cord, however, do not extend up to the brain except in the case of disease of the cerebellar tracts. Those forms of sclerosis found in chronic myelitis are similar to the connective-tissue scars following destructive inflammation else- THE I)EGEXf:RATIVE DISEASES OF THE SPIXAL CORD. 573 where. A persou who has a chronic myelitis has a cicatrix in his spinal cord. The sclerosis of multiple sclerosis is probably inflam- matory also, but it is a neuroglia rather than a connective-tissue cicatrix. The diagrams in Fig, 122 show the principal secondary de- generations. Thus a lesion at the level of the sixth cervical bCg- ment shows a descending degeneration in the pyramidal tracts and the comma-shaped tract of Schultze below, A lesion at the sixth dorsal segment shows ascending degeneration m the column of Goll, Fio. 123.— Showing os the Kight Side the MrsoR and Short Tracts Degeneratinq AFTF.R Skctiox of the Cord. ^1. ascending sulco-marginal; B, inttrmediaie lateral (de- seending); C, comma tract (descending); D, posterior sulco-marginal ; L, Lissauer's Those tracts lined across degenerate downward, the others upward. direct cerebellar tracts, and a ntero- lateral ascending tracts above, and in the pyramidal tracts below. Short Deyeiwrafing Tracts. — By the use of more delicate stains other degenerating tracts have been discovered. In the lateral column, scattered fibres exist which degenerate down war 1. This is the " intermediate tract of the lateral column" (Fig. 12.'^, Jl ]. Others of the same kind are found in the anterior column. This is the "sulco-marginal tract" (Fig. 123, J). The descending fibres, some of wh'ch degenerate downward, some up- ward, come in part from the cerebellum, ic -ming a descending cere- bellar tract. In part they are long commissural fibres connecting upper and lower spinal segments. In the posterior column are two small tracts called the "comma tracts," because of their shape. They lie at the junction of the columns of Goll an). LOCOMOTOR ATAXIA (Posterior Spinal Sclerosis, Tabes DORSALIS) . Definition. — Locomotor ataxia is a chronic progressive disease, involving primarily the posterior spinal ganglia or analogous neu- rons, and later the spinal cord and peripheral nerves. It is charac- terized clinically by iuco-ordination, pains, angesthesia, and various visceral, trophic, and other symptoms, and anatomically by a degen- erative sclerosis chiefly marked in the posterior columns of the cord and posterior roots, and to a less extent in the peripheral nerves. Forms. — Besides the common and typical form, there are anom- alous and complicated types. f 1. Common form. I 2. Neuralgic. Types. ^ 3_ Paralytic. 4. With initial optic atrophy. ^ ,. , / With muscular atrophy, forn^ ^ With other scleroses. ( With general paral3'sis. Etiology. — The disease occurs oftenest in middle life, between thirty and forty, next between forty and fifty. It may occur as early as the tenth and as late as the sixtieth year. In the very early cases it is usually due to hereditary syphilis. It is much more common in males. Hereditary influence is very unimportant and is only indirect, i.e., the parents may be neurotic. Diathetic influence is slight. Exposures to wet and cold, combined with muscular exertions, are effective causes. Soldiers, travellers, and drivers are rather more susceptible. Excessive railroad travelling, excessive dancing with exposxn-e, favor the development of the dis- ease. Excessive sexual intercourse, combined with irregular living, is a predisposing cause. Syphilis is by far the most important single factor. A history of the disease is obtained in from sixty per cent to ninety per cent of the cases. In my own cases sixty- five per cent had had syphilis. The patient has usually contracted the venereal disease ten or fifteen years before, and has rarely had noticeable secondary symptoms.* Syphilis is not a direct factor, * The following statistics from my own experience show the pliysiognomy of the disease in a cosmopolitan American city. Total cases, 190 ; males. 173 THE DEGENERATIVE DISEASES OF THE SPIXAL CORD. 275 but prepares tlie system for the degenerative process. Syphilis followed later by excesses — mental or physical — and by exposures especially lends to produce locomotor ataxia. Lack of proper treat- ment for syphilis is believed to favor the development of the disease, but a careful study of the statistics of my clinic and of his own cases by Dr. Joseph Collins seems to show that antisyphilitic treat- ment as at present carried out does not prevent the disease if the other favoring conditions, such as exhausting work and sexual or alcoholic excesses, are present. Among other causes are profoundly depressing emotions, acute infective diseases like typhus, pneumonia, and rheumatism, difficult labors with severe hemorrhage, prolonged lactation, injuries with shock, and excessive smoking. Locomotor ataxia in a somewhat atypical form may result secondarily from gummatous inflammation of the spinal meninges, from a tumor, and possibly from an ascending neuritis. iSi/mjdoms. — The disease is generally divided into three stages: the initial or pre-ataxic, the ataxic, and the paralytic. 1. The initial stage. The patient first notices a slight uncer- tainty in walking, especially at night; he has numb feelings in his feet, and at times darting pains in the legs or rectum. His sexual function becomes weak, his control over the bladder slightly im- paired. He has temporary attacks of vertigo and of double vision. A continuous sense of profound weariness oppresses him, eveu though he has made no exertion. The knee jerk is lost. Such symptoms may last a few months or several years. 2. The ataxic stage. The gait now becomes so iinsteady that others notice it; the patient has to use a cane, and when walking Avatth his feet and the ground. If he stands with his eyes closed, he totters and nuiy fall. His feet feel as though there was a layer fcinulL'S, 17. Ages wlicn disease began: Twenty -one to thirty, 19; thirty- one to forty, 84; forty-one to tifty, 60; fifty-one to sixty, 22; sixty -one to seventy, 5. Average age at time of onset, 40; beginning a year or two earlier in private patients, and in those witli a history of syphilis and active antisypliilitic treatment (Collins). Percentage of sypliilis, CO. Tliis is mak- ing tiic nio.st liberal allowances. In one set of eighU'en hospital patients, all carefully investigated, tiie percentage was 70. Average period between infection and tal)es, fifteen years, ranging from one and one-half to twenty- five years. Tliis is nnich longer than Erb's estimate, but is reached by three independent studies of my cases. Average duration of disease when seen by me. eight years; average duration of life in fiVc fatal rases, twelve years, ranging from five to twenty years. Complications: optic atrophy, 6 per cent; marked arthropathies, 5 per cent; with general paresis. 4 per cent; paraplegia, 1.5 per cent; Iiemiplegia, 1.6 per cent; eye palsies, 8 per cent. 276 DISEASES OF THE NERVOUS SYSTEM, of cloth or cotton between the soles and the ground, ir'aroxysms of lightning-like pains attack the legs, and tests show anaesthesia pres- ent in the toes and feet or in patches on the legs. A sense of con- striction is felt around the waist. The sexual power is often lost; the bladder is weak, and care has to be taken to empty it. The bowels are constipated; at times he has attacks of intense pain in the epigastrium, with vomiting and perhaps a diarrhoea coming on without cause. The pupils are small and do not react to light but do react to accommodation; vision is still good. The inco-ordina- tion and pain and anaesthesia after a time begin to alfect slightly the arms. This stage lasts several j'cars. 3. The paralytic stage. After several years with various remis- sions and improvements, the patient loses altogether the power of walking. His legs are somewhat wasted, but the muscular strength is fairly good. The anaesthesia and ataxia are very great. The patient does not feel the prick of a pin or touch of the hand; nor with closed eyes does he know where his legs are. His bladder is anaesthetic and paretic, so that the urine has to be drawn. The pains are much less, but are still present at times. The arms are more involved, but never so seriously as to make them useless like the legs. The intelligence remains good, and the patient may con- tinue bedridden for years, dying finally from some intercurrent affection. The following table shows the prominent symptoms in the usual order of their appearance : First Stage. (Half to twenty years.) Second Stagre. (Two to ten years.) Third Stage. (Two to ten years.> ( Motor < Eye palsies. Ataxia. JIuscular Aveakness. Less. Increased. Paresis. Increased. Paraplegia. Sensory i Pains. Pains. Anaesthesia. Pain less. Increased. Exci to-reflex . ■\ Loss of knee jerk. A. -R. pupil. Trophic Arthropathies. More rare. Rare. Visceral < Sexual weakness. Vesical weakness. Constipation. - Increased. Increased. Special senses. ' Diplopia. Optic atrophy. Rare. Rare. Deafness. Increased. Increased. Paralysis of accom modation. THE DEGENERATIVE DISEASES OF THE SPINAL CORD. 277 The symptoms must noTV be aualyzed more closely. Locomotor and static ataxia are present very early, but only to a moderate extent. Tests, such as making the patient walk and stand with the eyes closed, noting the position of limbs and the weight of objects, will reveal an ataxia due largely to beginning anaesthesia of the joints and tendons. By the use of the ataxigraph, one can with care assure himself that the patient has an excessive degree of static ataxia. In my experience, when the ataxigraph records over three inches' oscillation, the patient not being paraplegic or under the in- fluence of any drug, it is abnormal. The patella'tendon reflex or knee jerk is abolished very early in all typical cases. This constitutes a very important symptom, therefore. The ga It and station in ataxia are characteristic. In walking, the pa- tient keeps his eyes on the ground and on his feet. The latter he throws out rather forcibly, owing to overaction of the extensors of the foot. In watching such a patient walk barefooted, the extensor ten- dons can be seen to stand out with each forward movement of the limb. The foot is brought down sharply on the heel and the legs are spread apart a little. Turning a corner, turning around, and going downstairs are done awkwardly, and the patient is apt to totter and fall. Walking on a chalked line is very difficult; so also is walking backward. Tlie gait improves after the patient walks a while, and he will generally say that the practice of walking docs him good. Still, he soon gets tired (Fig. 124). Severe rectal iKvurahjln, associated perhaps with hemorrhoids, is sometimes an early symptom. Persistent neuralgia and functional disturbance of the bladder and rectum should cause suspicion of ataxia. Lancinating or li^ditniiig pains occur and are very cluirac- teristic. The pains dait down the legs along the course of the sciatic, or they suddenly appear as patches of pain on the foot or leg or thi'jch ("spnt pains"). Tlie pain cnines unexpectedly and with Buch severity that the patient involuntarily jumps or jerks the limb. Fio. 124.— SnowiNo Station in Sf.co.vo Stage of Locomotor Ataxia. 278 DISEASES OF THE NERVOUS SYSTEM. He speaks of his " jerking" and " twitching pains." The pains may affect the bowels or be felt as a squeezing sensation aroxind the waist (girdle pains). The pains of ataxia are often the most obsti- nate and distressing symptom. They usually come on in great in- tensity once or twice a month, and last for two or three days. They then leave the patient for a time. They are often worse in cold and damp weather. In some cases the pains are almost continuous, 135 140 Fia. I;i5. — Ireegulakly Contracted Visual Fieu> in Case of Tabes with Optio Ateophy, Left Eyk (Berger). coming on, if not every day, at least two or three times a week. Such cases are associated with much cutaneous hypersesthesia, espe- cially during the attacks. This type of cases is called " the neural- gic" The patients rarely have as much ataxia, paresis, or visceral troubles as the typical forms present, and in certain respects such cases are favorable. The pains of the disease continue well into the second and even third Etage. Meanwhile the anaesthesia becomes much more marked. It affects most the feet and next the legs, rarely extending much over the thighs, but passing to the fingers and hands. The anses- THE DEGEXEnATIVE DISEASES OF THE SPIXAL CORD. 279 thesia is greatest to pain, but touch and temperature sense are also involved. There is often delayed conduction and polyaesthesia; many other curious perversions of the cutaneous sense are noted. Some anaesthesia usually develops over the finger tips and hands, and sometimes a band of anaesthesia develops about the trunk. The facial and cranial nerves are not much affected, but there may be trigeminal neuralgia. Ojdlc atropliij occurs in about six per cent of cases, in my experience. Optic atrophy usually develops in the pre-ataxic stage. If a patient has reached the second stage without it, he will ^jroh- ahly escape it altogetlter. Cases with ocular paralyses are slightly more disposed to it (Berger). It attacks the left eye of tener than the right. The atrophy begins sometimes with increased sensi- bility to light, flashes of light, and muscae volitantes. With the failing vision, disturbance of color sense often and contraction of the visual field always occur. This contraction is irregular, with sector-formed defects; not hemiopic (Fig. 12/5). The atrophy pro- gresses slowly with slight remissions. It may cease its progress, but this is rare. Blindness comes in about three years. Ophthal- moscopically there may be seen slight evidence of congestion m the early stage; later, pallor of the disc, which finally becomes grayish. Disorders of hearing are frequent in tabes, occurring in about one-fourth of the cases, but in the majority of instances the aural trouble is an accidental complication due to middle-ear disease. Primary atrophy of the auditory nerve is very rare, as might be expected, since this nerve is structurally not like the optic nerve. Its existence has been inferred on clinical grounds. Another form of tabetic deafness is of trophic origin and due to a sclerotic condi- tion of the middle ear (Treitel). It is caused by involvement of the trophic or vasomotor fibres of the fifth nerve. The senses of tat^tc and smell are rarely affected. The oje vivsclcs are implicated in some way in nearly all cases of tabes. The following are the disorders : 1. Loss of the light reflex, and myosis. 2. Sympathetic-nerve ptosis. 3. Paralysis of branches of the third nerve. 4. Paralysis of the sixth nerve. Paralyses of the ocular muscles (third and sixth) occur rather oftener in distinctly syphilitic cases. Other ofular troubles are not inHiicnci'd ]»y exudative syphilis. Ocular palsies are early synip- toMis of the disease, oeciurring, as a rule, in the jjre-ataxic stage. 1. Tioss of light reflex and pupillary rigidity. The ])upils are small and sometimes uneven ; they do not respond to light, but they 280 DISEASES OF THE NERVOUS SYSTEM. do to accommodation. This condition is known as tlie Argyll' Rohertson pupil. In early stages the light reflex may be simply sluggish. In the late stages the accommodation reflex is also lost. The Argyll-Kobertson pupil is practically found only in tabes and in general paresis. The ocular skin reflex usually disappears early. The myosis in tabes is due to paralysis of the sympathetic dilating fibres. The pupils are sometimes irregular in shape. In some cases there is a loss of both light and accommoda- tion reflex. This is especially characteris- tic of an exudative brain syphilis (Sachs). 2. Sympathetic- nerve ptosis. A slight drooping of one or both lids is not infre- FiG. 126.— Arthropathy or Ankle. Fig. 137. —Arthropathy In\'olving Knees AND LoNQ Bones of Legs. quent. It begins early and progresses slightly up to the later stages of the disease. It is due to paralysis of the sympathetic-nerve fibres of the lid. 3, 4. Paralysis of the external eye muscles. The external rectus is oftenest affected of single muscles, but the various branches of the third nerve taken together are oftener involved than the sixth. Of the third nerve's branches, the levator palpebrse and internal recti muscles are oftenest involved. There maybe multiple palsies. These occur oftener in syphilitic cases. Progressive ophthalmo- plegia may be associated with tabes. The ocular nerve -jalsies may be transitory or permanent. Those occurring in the pre- ataxic stage THE DEGENERATIVE DISEASES OF THE SPIXAL COKD. 281 are usually transitory, lasting a few hours, days, or weeks. Cases have even lasted two years and got well. The permanent palsies develop usually in the later stages. The early palsies are usually due to a syphilitic exudation at the base of the brain ; the late pal- -<^d«a ,^^ H * P Tia. !;».— ARTHROPATHY OF KnEE3 IN TaBES, ShOWINO RELAXED .ToINTa. flies are usually duo to degenerative lesions of the nuclei of the ocular nerves. The arthropathies of hirninntor ataxia. Degenerative diseases of the joints, tofhnically known as arthropathies, and spontaneous fractures of bones form important symptoms of tabes. They occur in ten per cent (Charcot) or five jier cent (author) of cases. The arthropathies are three or four times more frerpieut than 282 DISEASES OF THE NERVOUS SYSTEM. the fractures. The joints ofteiiest affected are the knees, ankles, andliips; but the elbow, shoulder, wrist, and small joints may be attacked. Spontaneous fractures occur oftenest in the shaft and neck of the femur, next in the legs, forearm, humerus, and clavicle. The pelvis, scapula, vertebrae, and under jaw may be fractured. Arthro- pathies are often accompanied by fractures, especially of the heads of the bones. The two sides of tlie body are about equally affected. The arthropathies are characterized by a sudden, apparently spontaneous painless swelling of the joint. The symptoms may de- velop in twenty-four or forty-eight hours. In rare cases there is a history of some preceding rheumatic pains or of an injury. After a time there is an osseous hyperplasia of the joint, which becomes enlarged to enormous jjroportions. There is also a tendency to luxation of the joint. It crepitates on moving. There is no tenderness on pressure; the hand finds evidence of synovial exu- dation, roughened surfaces, and perhaps fractures of the enlarged parts. In the milder forms there are simply swelling from synovial exudation and some enlargement of the bones with roughened sur- faces. After a few weeks this swelling may subside and the joint return to nearly its natural size. In other cases the process pro- gresses, the ligaments relax, the bones of the joint can be moved about freely, and luxations are easily produced. There is still no pain, but the limb becomes almost or entirely useless ou account of the loose and relaxed condition of the parts (Fig. 130). As time goes on, some absorption takes place and the head of the bone may almost disappear. The arthropathies have been divided into benign and malignant; but no sharp line can be drawn or certai]i prognosis made in the early stage. The arthropathies appear in the prodromal and early stage of the disease in over half the cases, and are often at first unrecognized. One-third occur after the tenth year of the disease. The spontaneous fractures are usually brought on by a slight trauma, such as a fall. Violent muscular movements may produce them. They also are painless, as a rule. The fractures usually heal well, often with abnormal readiness, but occasionally there is delay, and often healing is accompanied by great throwing out of callus. Pathologically the arthropathy is a rarefying osteitis. It does not differ anatomically from arthritis deformans, except that frac* tures may accompany it. Clinically the chief difference lies in the abruptness, spontaneity, and painlessness of the process. The dis ease, on the whole, cannot be considered specifically different from arthritis deiormans, modified by the analgesia of the parts. It is THE DEOENERATIVE DISEASES OF THE SPIXAL CORD. 28? due probably to a degenerative change in the nerves supplying the joints and bones. The process may begin in the cartilage, bone, or ligaments. Eventually all these parts are involved. There is con- gestion of the synovial membranes with hydrarthrosis, then atrophy and rarefying h^-pertrophy of the epiphyses, relaxation of the liga- ments, formation of osteophytes and bony stalactites. There may be a rarefying osteitis of the long bones, "without much joint involve- ment at first (Fig. 127). Various trnplilc dlstiirhojiccs of the skin maj" appear, generally late in the disease. The most common are herpes and lichen. Be- sides these, bullae, transitory ery- thema, urticaria, eczema, pemphigus, ecthyma, ulcers, ichthoysis, and i)ete- chiae have been described; but they are rare and often only accidental complications. A peculiar round per- forating ulcer sometimes develops on the sole of the foot, often as the re- sult of cutting a corn. In rare cases the nails and teeth fall out. In dis- tinctly sj-philitic cases there is usually baldness. Peculiar " crises " of various kinds occur in tabes. The most common are gastric crises. These consist of at- tacks of intense pain extending from the groin to the epigastrium or en- circling the waist, accompanied by vomiting and sometimes diarrhoea. The attacks are often associated with pains in the legs. They last two or three days, then pass away. Laryngeal crises consist of attacks of spasm of the adductors or paralysis of abductors, with noisy, croupy res]iiration. The attacks come on suddenly, the patient coughs and struggles for breath, and he may be seized with vertigo and fall down. The pulse may be very fast. The paroxysm lasts for a few minutes to several hours. The symptoms are very distressing, but not dangerous. Paroxysms of cough have been described as *' bronchial crises." There are also cardiac crisrs, in which there are dyspnwa and rapid heart beat and sense of suff(;<'ation resembling angina. Tlie heart itself sometimes is diseased, but wh(>ther from neurotrophic disturbance or not is doubtful. The pulse is often small, rather rapid, and weak. The laryngeal and heart crises both depend on a degenerative disease Fifi. l.ii».— Pkrforating Ulckp. Foot ix Tabes. 284 DISEASES OF THE NERVOUS SYSTEM. and irritation of the vagus, and may be more or less united in symp- toms. A sense of great iveariness and heaviness in tlie limbs, present constantly, no matter how much rest is taken, is a characteristic early s3nnptom, and is due to an irritability of the nerves of muscular sensibility. Muscular atropl lies occur sometimes in tabes. They are of three kinds : 1st, a true progressive muscular atrophy due to degeneration of trophic and motor cells ; 2d, localized muscular atrophies due to degenerative atrophy of nerves ; 3d, a general wasting. Under the first head one finds ophthalmoplegia, bulbar paralysis, and spinal amyotrophy: Under the second, wasting of certain groups of muscles in the legs or arms. Besides these, there is a generalized atrophy which occurs in the paralytic stage and is due probably to a slight involvement of the anterior horns in the progressive process that affects the cord. Attacks of hemiplegia in rare instances occur in tabes. They are usually of temporary character and occur early in the disease. They may come on late and are then more likely due to acute soft- ening. In all cases the trouble is due to embolism or to disease of the cerebral vessels, of syphilitic origin. Acute paraplegia comes on occasionally also, and this sometimes almost disappears. The sexual poioer may be at first greatly exaggerated j but this is rare, and usually there is progressive weakness and loss of desire. The bladder and sexual functions are rarely entirely lost and rarely equally impaired in the first stage; one may continue good while the other is affected moderately. Usually the sexual function goes first. Some cerebral syinjjtoms occur in tabes, chiefly in the early stage. They are insomnia, which may be very obstinate; and occasional vertigo. An irritability of temper and tendency to despondency, sometimes noted, cannot be considered unnatural. Apoplectiform and epileptiform attacks are described, but are very rare, and should cause a suspicion of a complication. The disease in very rare cases terminates in general paresis. Course. — The disease has been termed progressive, but it is not so in a large number of cases. With proper treatment the symp- toms can often be kept in control for years. The first stage may last twenty years or more; the second stage five to fifteen years. The total duration of the disease varies enormously, ranging between three and thirty years. A few acute cases have been observed, running a course of less than a year. Coriipllcations. — These are acute myelitis, generally syphilitic; THE DEGENERATIVE DISEASES OF THE SPINAL CORD. 285 lateral sclerosis, progressive muscular atrophy, hemiplegia from embolism or endarteritis, general paresis, and heart disease. PatJiolotjktil AnntonDj and Fafhology. — The characteristic changes are found in the spinal cord, posterior spinal ganglia and posterior roots, and to a less extent m the peripheral nerves. The spinal cord usually is reduced in size and flattened antero- posteriorly; the pia mater is thickened somewhat. One can see with the naked eye that the posterior columns of the cord are shrunken and have a grayish appearance. Fio. lid). Fifj. 1:11. Flo. 1- 10. —Locomotor Ataxia, showing areas afTected In first kIuro at five difTerent levels. Drawn from speciiiieiis in author's posaettsioa and from comparativti study o( orer thirty other ii of j)ost«*rior coliitiinH iiiid cerelK'lliir tracts as sliown lu 3 (oppcii- ln'iin>. 288 DISEASES OF THE KERYOUS SYSTEM, should be the case in order to observe the neuronic homologies. The process here is an atrophy beginning at the periphery and extending brainward. The third, fifth, and sixth neives are occasionally in- volved; still more rarely the olfactory and auditory. The vagus Tierve and sometimes its nucleus and that of the glosso-pharyngeal are implicated, it may be, rather early in the disease. It is believed that these facts explain many of the laryngeal and visceral crises. JlefV G-anjl 1 -A.R, Fig, Fia. 1:35. Fig. 134.— Posterior Spinal Ganglion in Thirh Stage op Tabes. root; A.R., anterior root (Oppeuheim). Fig. 135. — Healthy Spinal Ganglion. P.ff., posteriox Tathohxjij. — The pathology of locomotor ataxia cannot be thor- oughly understood without a knowledge of the pathology of syphilis in its relation to the nervous system — a subject which is discussed later. It may be said here, however, that syphilis leads to two sets of changes in the nervous system: one, the earlier, is inflammatory; the other, and later, is degenerative. The inflammatory changes attack the blood-vessels and serous membranes, leading to the deposit of exudates, and these are the characteristics of secondary syphi- lis when it involves the nerve centres. The degenerative changes attack the nerve tissue directly. They follow long after the infec- THE DEOEXERATIVE DISEASES OF THE SPINAL CORD. 289 tion and are the result of the. syphilitic poison which has been ])er- meating the system. Degenerative syphilis of the nervous system is not, strictly speaking, syphilis at all, but rather the effects of Fig. lljti.— Plantar Nerve, Simple Atrophy in Tabes. it, just as the parched and dying turf is the result of the fire which has swept over it. Neurology knows no tertiary syphilis, but the disease departs, leaving a trail behind it which sets in motion the processes of decay and death of the parts. This is Avhat happens in locomotor ataxia, which is tlip Parthian shot of the conquered infec- Kio. i;i7.— Ulnar Nerve, Tiwkd Staoe Tahe.s, Atrophy with Proliferation op Connec- tive TissrE (Opiifiiheiin). tion. Syphilis often invades the nerve centres and frankly shows itself in the form of inflammatory and gummatous exudates, but often it does not betray its presence and does its final work quietly through years of apparent health. All the time, liowever, its poison 11) 390 DISEASES OF THE NERVOUS SYSTEM. is at Avoik instituting a tendency to death and degeneration in certain parts of the nerve centres. The parts wliich are usually first selected are the posterior spinal ganglia, and, particularly, the neuraxons which pass from the nerve cells of these ganglia into the posterior roots and columns of the spinal cord. Locomotor ataxia, tlierefore, is not primarily a sclerosis of the posterior spinal columns, but of the peripheral sensory neurons. It is true that the posterior spinal ganglia are not always so seriously diseased as the posterior columns of the cord. This, however, is because the severity of the disease is first shown in the neuraxons and their collaterals, just as in alcoholic neuritis the peripheral parts of the motor neuraxons are most and earliest affected by alcohol. As the disease extends, it involves both the peripheral and central parts of these sensory neurons; that is to say, both the sensory fibres and the posterior spinal roots. Still later it attacks other portions of the nerve centres, so that in the last stages much of the nervous sys- tem is diseased. The reason why the peripheral sensory neu- rons are especially affected rather than other parts seems to me to be this: the syphilitic poison is brought to the nerve centres in the blood, whence it passes into the lymphatic sheaths of the blood-vessels or is thrown out upon the serous mem- branes in the subdural sacs. In the attempts of nature to get it out of the spinal canal and eliminate it, the poison is carried along the serous sheaths which surround the cerebro-spinal nerve roots. The nerves, as they pass out from the spinal cord, are covered with three membranes: the dura mater, the arachnoid, and the pia mater. The dura and the arachnoid surround them less tightly than the other. The dura becomes fused Avith the connective tissue support- ing the nerves as they pass out, and the arachnoid becomes fused with the epineurium and perineurium. Now, fluid injected into either the subdural or subarachnoid spaces passes readily along the nerves for some distance (Macewen), and syphilitic exudate in the subarachnoid and subdural spaces of the spinal cord will thus have a tendency to infiltrate along these sheaths, but as it passes out of the vertebral canal or cranial cavity it meets mechani- cal obstacles, owing to the constriction of the parts, and there is therefore a certain damming up or accumulation of the poisonous material at these points of exit. Generally at this point it meets with the posterior spinal ganglia, a highly organized structure with special vascular supply, and it therefore naturally deposits its poison upon this part, which furnishes much more opportunity for mischief than the non-vascular anterior roots. It is a fact that many of the initial symptoms of locomotor ataxia are thus connected with such THE DEOENEKATIVK DISEASES OF THE Sl'IXAL CORD. 291 troubles as would occur from an exudate trying to get out along the course of the spinal or cranial nerves, A frequent initial symp- to)u, for example, is palsy of one of the third nerves or of the sixth or seventh nerves, due to exudates clinging around their roots. Still more frequently the initial symptom is a neuralgic pain in the course of the sciatic plexus, due to the effects of this poison upon the ganglia lying in the lumbar intervertebral spaces. I assume in this description that it is a syphilitic poison -which is always at work as a cause of tabes dorsalis. This, however, is not necessarily the case, for it may be the infection of other diseases, and the results of other poisons, such as ergot, pellagra, lead, etc., are to be explained in the same way. There is an inadequacy of the lymphatic and venous systems to thoroughly rid tlie spinal canal of the poisons that lie in it; the body of the cord is cleared, but the roots do not get rid of the poison. In a word, I would say that locomotor ataxia is a post-infective degeneration which first attacks the posterior spinal ganglia or corresponding cells of the special senses, due to a prolonged poisoning of these parts by the toxins of the infection, whatever this may be. As to why this process attacks some and not others, it can only be said that certain people are boin with defective power of resist- ance as regards their nerve centres, and that others induce this defective state by physical and other excesses. The didijnosls is not difficult in the advanced stages. In the first stage the disease has to be distinguished from hered'tary ataxia, multiple neuritis, chronic myelitis^ spinal tumor, spinal syphilis, general paresis, and neurasthenia. In hereditary ataxia the age, the history of the disease, and the absence of lightning pains are usually sufficient to distinguish it. Multiple neuritis, in its sen- sory or pseudo-tabetic form, sometimes resembles densely locomotor ataxia. The differential points are given in the sections devoted to that disease. In myelitis there is more paralysis, generally exag- geration of reflexes, and an absence of disturbance of special senses. The diagnostic criteria of locomotor ataxia in all cases are the presence of lightning pains, numbness of the feet, loss of knee jerk, ataxia of station and gait, without much loss of muscular powt-r, the presence of the Argyll-Kobertson l)upil, the history of syphilis, and the slow onset of the disease. .\ lost kut'i' Ji-rh, Utihtnhuj jiciiis, and stiff jHiiiils are usually quite en(nigh to assure a diagnosis. I'riii/nosis. — In the first stage a small i)ercentage nuiy have the disease stop|ie(l and get practically well. :Vfter the second stage a cure is im])ossil)le, l)ut great improvement may be secured and the patient made relatively (•(init'ortal)le lor years. 292 DISEASES OF THE NERVOUS SYSTEM. In the third stage little can be clone except to relieve the symp- toms, but life may be prolonged. Death usually occurs from some intercurrent malady, or from kidney disease caused by the bladder trouble. Patients very rarely indeed die from the disease itself and its various "crises." Treatment. — The treatment of locomotor ataxia is a subject the discussion of which cannot be made dogmatic, for the treatment de- pends very largely upon the patient and the stage and cause of the disease. My experience is that any treatment depends enormovisly upon one's opportunities of getting the patient in the earliest stages. Supposing this be done, the first thing is to be quite assured that there is no trace of a secondary (or exudative) syphilis underlying the trouble. If some of the symptoms are caused by such exudate, inunctions of mercury, warm baths, and iodide of potassium should be given vigorously and persistently. 1 have seen no proof that inunctions are better than the internal use of mercury, but they are recommended by authorities eminent in neurology if not in cutaneous sensitiveness. I usually pre- scribe the bichloride in gr. -Jq- doses and combine it with tinc- ture of iron. The iodide of strontium is often a grateful change from potash. It is to be given in daily doses of about GO grains, but this may be increased to 600 grains or 900 grains daily, with good effect. Since it is a fact that at times there are S3-philitic exudates along with the true degenerative process in tabes dorsalis, this kind of treatment will occasionally give some good results. In the great majority of cases, however, mercury and potash do no good and they may actually do harm by hastening on the downward course of the disease; hence mercury in particular should be given with great watchfulness, and if improvement does not appear within six weeks it should be suspended. IMy own experience and the careful investigations of my friend, Dr. Collins, show that antisyphilitic treatment pursued at the time of infection may hasten the onset of the disease. It has been observed by others also that excessive mer- curization tends to produce a neurasthenic state most prejudicial to the patient and one which may even lead to a certain amount of neuritis. When the physician has assured himself that any possi- bility of relief from mercurials or iodide is not to be hoped for, these drugs should be dropped; if they do benefit the patient, they should be repeated at intervals of three months. Along with these first medicinal measures, the physician should prescribe something which is much more Important, and that is simply rest. Every patient with locomotor ataxia should at once have the importance of rest strongly impressed upon him, and the prescription of sixteen weeks THE DEGENERATIVE DISEASES OF THE SPINAL CORD. 293 in bed is sometimes advisable. Equally good results can be usually obtained, however, bj' obliging the patient to go through a simpla and regular life, involving no walking and no work. Institutional life for three months is of enormous advantage. It is a rule to which I have seen hardly an exception that tabetic patients brought to the hospital improve in a striking way simply from the quiet routine of life there, and despite the thinness of city milk and the odorous strength of hospital eggs. The drugs Avhich are at this time used to help in the cure are mainly the nitrate of silver, the tincture of iron, the preparations of phosphorus. I have not been able to convince myself that arsenic, strychnine, gold, ergot, barium, or aluminium do any good, although these drugs are all recommended by high authorities. The various preparations of the phosphates, such as glycerin phos- phate of lime, the hypophosphites of lime, phosphoric acid, seem to me to be of some benefit. Strychnine occasionally does good in small doses, but in large doses it may lead to disastrous results and it should always be given with caution. A great many other drugs may be given for the relief of symptoms. For the pain, pheuacetin is the drug which gives the most satisfaction excepting morphine. It may be combined with bicarbonate of sodium, with codeine, or with some of the other coal-tar products, such as antipyrin, antifebrin, etc. A teaspoonful of baking-soda internally will sometimes stop the pains. Hoffman's anodyne and cannabis indica may be tried. For tlie bladder trouble, the fluid extract of buchu in doses of twen- ty drops, combined with ten drops of the tincture of hyoscyamus, is very helpful. Small doses of strychnine may be combined with this. Small amounts of strychnine can always be given for the sexual weakness, but the dose should never be made a large one. For the gastric crises, nothing is so good as a hypodermic injection of morphine, and for the severe crises of pain an occasional hypo- dermic of mnrpliine shouhl be given. The locomotor ataxic, how- ever, wlio becomes addicted to the uso of morpliine for his pain? is indeed in a hopeless condition. In persistent constipation the diet should be light and mainly of li(pnds such as milk, malted milk, broths, etc. In persistent diarrhoeal states I have found ich- thyol of use. This drug also relieves tlie pains. The annoying insomnia is to be treated by fresh air and seashore life. If drugs must be used, bromide of lithium with a few grains of chloral, and jjaraldeliyde in net over thirty-drop doses, are tlie best. In neuralgia of the rectum and bladder, suppositories containing iodoform and belladonna, or codeine, or antijn'rin, may be used. 294 DISEASES OF THE NERVOUS SYSTEM. Sometimes simple gelatin or gluten suppositories act very well. Some of the cases of rectal neuralgia or hypersesthesia are due to in- sutficient clearing of the lower bowel when a movement occurs, and if the patient washes out the bowel with a pint of warm water after each movement he is very much more comfortable. There is no diet which has a specific effect upon locomotor ataxia, but the patient should be given those foods which are non- fermentative and digestible. Nitrogenous and fatty foods should be prominent. Hydrotherapy is of considerable benefit. The most efficient of the single measures is the lukewarm bath at a temperature of about 95° F. for ten or twenty minutes daily. After the bath it is well to have a little cold water poured over the back and then the patient should be diligently rubbed. In most cases a simple lukewarm bath is quite as effective as anything. In others the patient feels better if there is added to it some slight stimulant to the skin — a table- spoonful of pine-needle extract, or a regular pine-needle bath may be given. The Charcot douche given in moderate strength is helpful in cases that are not advanced or particularly weak. I have some hesitation in recommending any special watering-places or cures. I have had patients return benefited from the Hot Springs of Vir- ginia and other American resorts. In Europe, the baths at Lamalou, France, and at Nauheim, Germany, have some reputation. Hot baths are sometimes injurious, and bathing may be overdone by the ataxic. Electricity is of use from its general tonic and reflex effects, and perhaps exercises some direct influence on the diseased process. Strong galvanic currents (15 to 30 ma.) should be applied along the spine, through the trunk, and down the legs and arms. The com- bined galvanic and faradic current is even better, given in the same way. The faradic brush should be applied over the extremities and along the back. The actual cautery is efficient in stopping pains. It should be applied to the back as often as twice a month at least and sometimes twice a week. Dry cups may be applied rapidly and in great number (80 to 100) along the spine and along the course of the sciatic nerves. In very painful cases occasional wet cups and leeches are useful. Blisters and various forms of counter-irritant sometimes do good. Suspension by the neck and arms is helpful in some cases. It is best adapted to persons in the second stage and to those who have a good deal of bladder trouble and pain. It is of little value in the paralytic stage, and must be used with care in the early stage and when patients are large and heavy. Suspensions should be given THE DKGENERATIVE DISEASES OF THE SPIXAL CORD. -295 fur from one to three minutes three times a week until twenty-five or thirty are taken. After three months a second course may be given. The treatment of locomotor ataxia by systematic exercises, tnown as the Fraenkel method, is one that (^f late has been considerably used. It consists in having the })atient go through regular exer- cises which teach him to co-ordinate the different groups of juuscles of the trunk, legs, and arms. A list of the exercises such as I have used for some time is given in the Appendix. The i'raenkel method is one which can be used w' th advantage with pei- sons who are passing into the second stage of tabes and in whom the disease is not making progress. It often enables the patient to walk better and use his arms better, but it does not especially affect the progress of the disease. Finally, it has seemed to me that those sufferers from locomotor ataxia do best who persistently and courageously fight against their malady. Those who, despite suffering and discomfort, will three or four times a year take some form of treatment, medicinal, hydro- therapeutic, or electric, such as will have some beneficial effect upon their general nutrition, and such as will buoy up their hopes and im- prove their mental condition, are quite sure to be rewarded and after a hard fight emerge into a state of comparative relief from their symptoms and secure a measurable degree of rest from the progress of their disease. SPASTIC SPJ.XAI. 1'AI{AI>VS1S (La ikhai. Si-inai. S( lkkosis). Lnn.K's DisKASE. This is ((() a term used to describe a form of paraplegia cai;sed by chronic myelitis, and (/>) a congenital disorc'.ei'. known as Little's disease, in which there is sclerosis of the lateral columns of the cord. The special interest attached to this form of disease, on accouui of the controversies concerning it, leads md to say a few Avords about its history. Between the years 184G and 1877 an English surgeon, Little, published a number of articles on a disorder wliich he termed "congenital spastic rigidity of the limbs." Tn 187o and again in 1870, Dr. E. C. .Seguin, of New York, described a condition which lie termed "tetanoid paraplegia." After the first article of Dr. Seguin, t<> whom priority belongs. Professor Erb and Professor Charcot iiidcpendently published articles in the year 1875 upon what Erb called " spasmodic spinal paralysis'' and Charcot "spasmodic dorsal tabes." Starting from the writings of these three authorities, there de- veloped in tlie course of a few years a description of the disease 29G DISEASES OF THE XEUVOUS SYSTEM. which became known as "spastic spinal paralysis" or "lateral sclerosis." This for a long time was accepted as an independent malady by most writers. Of late years, however, its real existence has been strenuously denied, and the cases supposed to represent this disease were asserted to be either forms of dorsal myelitis or the result of some cerebral defect. Eecently both French and Ger- man writers have revived the work of Little, and, having supple- mented his observations with their own, have rehabilitated spastic paralysis into a separate disease again, giving it the name of "Little's disease." * Etiology. — The new spastic spinal paralysis, or " Little's disease," is an affection w-hich is always of congenital origin and is due, it is supposed, to a lack of development of the pyramidal tracts. This lack of development leads to a sclerosis of the lateral columns of the spinal cord and to symptoms of rigidity of the legs and arms, exag- geration of the reflexes, with some real muscular weakness and atrophy. The disease is always of prenatal or natal origin, being due to some developmental defect or, as Little supposed, to prema- ture and forced deliveries. It may also be a hereditary family dis- ease. Through these causes the pyramidal tracts cease to grow, or, at least, this process is greatly delayed. Symptoms. — The malady appears within a short time after birth, usually within a year, but it may be delayed in family types to the fifth year or even later. Some cases of Little's disease may, it is believed, develop as late as after maturity. It is not my purpose to give a description in detail of the symptoms of this trouble, because they are given imder the head of cerebral diplegia or birth palsy. The only difference between ordinary cerebral diplegia and the dis- ease under present consideration is that in this latter form there are no marked mental defects; the child is not small headed and idiotic, nor does it have epilepsy or cranial nerve x>alsy or hydrocephalus. The brain seems to be spared except so far as its motor fimctions are concerned. It is convenient to separate this type of disease from the ordinary spastic cerebral palsies with mental defect, for the reason that the future of these cases is in some instances more hope- ful. As they mature, the lateral columns occasionally gain in de- velopment and some increase in the strength and control of the limbs is obtained. I base this statement upon the experience of * Sometimes a spastic paraplegia develops quickly ; after a few weeks the symptoms improve and the patient gets well ; this has been called "hyper- tonic paralysis. " There is here, however, simply a slight grade of myelitis or meningo-myelitis, and no separate name is required to show what is the matter. THE DEGEXEKATIVE DISEASES OF THE SPIXaL CORD. 297 others. In several cases of Little's disease at the age of fifteen to twenty-live which I have seen, there has been no marked improve- ment. Mentally, however, these patients are often very briglit.'-^ Children with this trouble on trying to walk are obliged to cross one leg in front of the other as they are heljsed along, giving them a characteristic " cross-legged'* progression. The arms are less affected than the legs. The facial and throat muscles may be slightly involved. There is no pain. In some cases the disability increases as the child grows older, owing to the greater size and clumsiness of the patient. The arms become much stiffened and contractured, and the hands are flexed so that the patient can neither walk nor help himself. Epilepsy and mental deterioration also may develop at the time of puberty or adolescence. Fi'ofjnosls. — The mild cases that learn how to walk and can use the arms and hands may grow up, slowly improving, and reach a good age and a fair degree of health. The severer cases rarely reach adolescence, but grow gradually more helpless and generally succumb to some intercurrent disease before they are twenty. Diagnosis. — The disease is distinguished from ordinar}' cerebral diplegia (birth palsy) due to brain lesion by the absence of epilepsy, mental defects, and mierocephalus. From compression myelitis, the involvement of the arms, and the absence of pain and disturbance of sphincters are distinctive. Hereditary spastic paraplegia nms in families, begins at the fourth or fifth year, and involves chiefly the legs. Treatment. — This is altogether one of mechanics and attention to luitrition. Tlie limbs must be persistently mussed ; tenotomies shoulil be performed so' as to straighten the legs; constant voluntary effort to use the stiffened muscles should be riiade. Braces, roller crutches, etc., should be used. Patience is often greatly rewarded in this disease. Hkreditaky Spastic .Sit.vai. 1'auaiasis. — Spastic paralysis in very rare cases is found to run in families, affecting different mem- bers of many succeeding generations. In the cases described, it begins at about the age of five, affects only or mainly the legs, runs a very slow course, is not accompanied by pain, ataxia, or visceral .symptoms; and runs a course lasting twenty or thirty years. Dr. Rayley, of Philadeljjhia, has described a family of typical cases. * It is due to Auicricau neurology to sjiy that Dr. Seguin as long ago as 1879 said: "It is possible Miat tetanoid i)araplegia in yoinig eliildren may be due to deficient cereljral development and consciiuently agenesis of certain tracts of the cord. " 298 DISEASES OF THE NEKVOUS SYSTEM. THE COMBINED SCLEROSES. By tlie combined scleroses is meant those forms of degenerative sclerosis in which both the posterior and lateral columns are in- volved. There are several diseases in which combined sclerosis exists. They are: 1. Combined scleroses of profoundly anaemic and toxic states (Putnam's type). 2. Hereditary spinal ataxia (Friedreich's ataxia and hereditary ataxic paraplegia) . 3. Combined scleroses complicating general paresis. 4. Accidental forms (Gower's ataxic paraplegia). There are many cases reported in literature of combined scleroses but the clinical pictures vary very greatly. These cases are prob- ably in the most })art forms of chronic myelitis or meningo-myelitis with ascending and descending degeneration. Marie has shown that the vascular supply of the spinal cord is such as rather to favor the development by extension of sclerosis in the lateral and l)Osterior columns from a chronic leptomeningitis, and his sug- gestion that many of these cases are perhaps of syphilitic origin ac- cords with my experience and conviction. Some years ago, Gowers described a disease that he called ataxic paraplegia, the lesion in which, he believed, lay in the lateral and posterior columns. Most of the cases which belong to this clinical description I think can be properly classed either with the cases of locomotor ataxia, of multiple sclerosis, or of some form of chroi^ic myelitis. It seems to me, therefore, inadvisable to encumber oui neurolog}^ with a descrip- tion of this disease. There is, however, a hereditary form of ataxia with paraplegia which belongs to the group of congenital or family diseases and is closely related to Friedreich's ataxia; and there is a form of combined sclerosis in which some ataxic and some sensory and motor symptoms develop associated Avith pernicious anaemia and certain other cachectic states, but neither of these is the disease commonly spoken of as ataxic paraplegia of Gowers, which is, I repeat, no disease at all. Strumpell and many others have reported cases with autopsies showing combined scleroses, but there is no clinical picture that can yet be attached to such findings except those I have above indicated. Hence, of all the combined scleroses, it is only hereditary ataxia and the combined scleroses of anaemia that have practical clinical interest. the degexf:kativk diseases of the spinal cord. 299 1. Thk Combixed Scleroses of Pkrxicious Ax.emia axd Cachectic States (Putxam's Type). This fonu of disease, not so rare as has been supposed, was first described by Dr. J. J. Putnam, hiter by myself ; and in quite recent times has been expanded and placed in relation -with })eruicious anaemia by a number of observers. Etiolo(jif. — In the original cases the patients were mostly women and the ages ranged from forty-five to sixty-four years. Two of my cases were men, one was a woman ; all were over fifty years of age. A history of possible lead poisoning was obtained by Putnam. In my experience profound or prolonged malarial toxtemia was the only factor I could discover. The causes of pernicious anaemia must be placed in the list of the causes of this form of sclerosis. Disease of the suprarenal capsules and probably any very prolonged and profound toxaemic state may lead to the double degeneration of the cord. Not all cases of pernicious toxaemia or anaemia, however, cause these changes. Hence the element of a neuropathic state must be ai'ognosis is not good, but there are more favorable cases than those first observed, and I have a patient who has kept fairly well for over six years. Two others died within two years. The dia^gnosls is based upon the age of the patient, the presence of profound anaemia and perhaps of a malarial history, the parees- FxG. 138.— The Spinal Cord in Combined Sclerosis from Pernicious Anemia, Dorsal Rkgion. The columns of Goll, crossed pyramidal tracts, aud cerebellar tracts are affected. thesia, slight ataxia, marked and progressive weakness and emacia- tion, tendency to obstinate diarrhoea, and finally the rather sudden paraplegia. The treatment should consist of quinine, arsenic, iron, bone marrow, and possibly suprarenal-capsule extract. Besides this, the patient should have the most nourishing food and a stimulat- ing air, free from malaria. Hereditaky Spixal Ataxia (Friedreich's Ataxia). Introduction. — There are three forms of ataxia of congenital and often family origin. They are : Hereditary spinal ataxia, or Fried- reich's ataxia, hereditary cerebellar ataxia, and hereditary ataxic paraplegia. They are quite similar in cause and mode of develop- ment. The difference in symptoms depends upon the fact that the defect develops in the one case mainly in the posterior and lateral columns of the cord, in the second in the cerebellum, and in the third mainly in the lateral columns. THK DEGEXERAXIVE DISEASES OF THE SPIXAL CORD. 301 Friedreich's ataxia, the most cummon of all the forms, is a chronic degenerative disease mainly affecting the posterior and lateral columns of the cord. Clinically the disease is characterized by ataxia beginning in the lower limbs and gradi;al]y involving the upper limbs and the organs of speech. Curvature of the spine, talipes, vertigo, anJ finally pa- ralysis and contractures appear. The knee jerk is, as a rule, absent. There is but little pain or anaesthesia, and optic atrophy and visceral troubles are usually abisent. Etiohxjij. — The fundamental factor in predisposition is an in- herited or connate lack, of development of the spinal cord, more par- ticularly of the posterior columns and pyramidal tracts. This condi- tion is inherited directly sometimes, but indirectly as a rule ; that is to say, the parents or other members of the family usually show simjily a neurotic history, and it is in only a minority of cases that there is a history of ataxia in the direct line of ancestry. The more frequent condition is this: the parents or grand- parents have some neuroses, such as insanity, inebriety, or great nervous irritability ; then the ataxia occur in the children of the next generation. Sometimes in a single family the uncles and nephews or cousins may be foimd to have the disease. Hence the name "family ataxia," used by some Avriters. There are a good many cases in which the parents were apparently perfectly soimd and healthy. Yet it is most probable that the sufferers from Fried- reich's disease inherit a tendency to degenerative processes from some of their ancestors. This degenerative tendency may have been shown in those ancestors in a very slight degree. The pa- tients rarely have locomotor ataxia, though this has been observed in a few cases. The children of locomotor ataxics do not have Friedreich's ataxia except in the very rarest instances. S-yqihilis in the pai-ents is an element in some, ])robably in most casfs. Habitual intemperance in |)arents undoubtedly is a factor sometimes; much more rarely consanguinity and tuberculosis act as predisposing causes of degeneration. More cases liave been observed in America than in any other country; while the fewest have been reporttnl from France. The disease develops at about the time of jjuberty, most cases occurring between the ages of six and fifteen years. It is not very rare, how- ever, for 8ym})toms to develop even in infancy, though some of the cases reported at tliis time were probably of a syphilitic character. In a given family the disease^ as a rule, strikes the older members iirst, but the younger members are attacked at a relatively earlier age. The most typical time of development is a rather late one, i.e.., 302 DISEASES OF THE NERVOUS SYSTEM. after twelve years of age. The disease may come on after maturity. In American cases the age of development of the disease has been rather earlier than the average. The male sex slightly predom- inates, its proportion being about sixty per cent. In America the female sex has, however, been more affected (3 to 2). The patients are the children of the laboring and agricultural classes. They have been found in the country oftener than in crowded cities. The families have often been large, but this is not always the case, es- pecially in American cases. Nursing at the mother's breast is thought to have been an exciting cause. Usually the disease ap- pears after infectious fevers, such as diphtheria, variola, and typhoid. Si/inj^toms. ■ — The patient first notices an uncertainty in the gait and some feebleness in the lower limbs. These symp- toms gradually increase until they interfere seriously with progression, and force him to leave off active work. With this there may be some slight pains or numbness in the lower limbs, and an examina- tion will show, within a year or earlier, that the knee jerk is gone. After five or six years the arms become affected with inco-ordination, and a little later bulbar symptoms, such as thick or scanning speech, and often nystagmus, appear. During this time the patient suffers little pain and has no trouble with the bladder or rectum. Vertigo and headache are often pres- ent. Dorsal flexion of the toes, talipes varus or some other form of clubfoot, and lateral curvature of the spine are often observed (Fig. 1.39). Oscillation of the head and choreiform or inco-ordi- nate movements of the extremities may develop. As the disease progresses the legs become weaker, and finally paraplegia, witn contractures and muscular wasting, sets in. The disease makes slov.' progress ; often it remains almost at a standstill for years, and the patients usually die of some intercurrent disease, such as phthisis or an infectious fever. Among the rarely observed symptoms are tremor, spasms, de- creased electrical irritability, muscular atrophy, vasomotor paresis, Fig. 139. — Friedreich's Ataxia, showing deformities of legrs in the late stage. THE DEGEXEKATIVE DISEASES OF THE SPINAL CORD. 303 polyuria, glycosuria, ansestliesia, fibrillary tremor, clioking attacks, ptyalism, strabismus, diplopia, blepharospasm, a slight degree of ^^c-i' V '^i" v: ^W )km • i^' > ^ Flu. 140.— Spinal Cmtu in a Lono-standinq Case of Herkditahy Ataxia, Ckrvioau Dorsal, and Sacral Heoions. Besides the sclerosis, tlie cord is fllled wltb miiaU Tacuoles whicli are cillate's Disease). This is a disease characterized by a slow, progressive atrophy of the muscles of the extremities and trunk, with consequent paralysis, not accompanied by any notable sensory disturbance, and due to a progressive atrophy of the motor and trophic cells in the spinal cord. Etiologij. — The disease affects persons in the middle period of life (twenty-five to forty-five). Tlie extremes are fourteen and seventy years (Gowers). It is more frequent in males. Heredity is rarely, if ever, a factor. Great mental strain, exposure, trauma- tism, excessive use of certain groups of muscles, acute infectious diseases — especially typhoid, measles, cholera; childbirth, acute Fl(J. 141.— SHuwiN(i : 1, Se;,'iiient of si)iiial conl witli aiiterim-lioru Cfll, end brush, uud lateral tracts, the parts affectcil in proKrcssive iiuisciiliir iilrniihies; anil 2, tlie muscle and its nerves, the parts affected in progressive muscular dystropliies. rheumatism, syphilis, and, more than anything else, lead poisoning are causes. It may complicate locomotor ataxia. The causes, as may bo seen, are much the same as thos(^ of bulbar jiaralysis.* Symptoms. — The patient suffers at first from slight rheumatnid * Among 28 of my cases 33 were niaUs. The disease began between between tliirty-one and forty in 10 eases; between twenty -one and thirty in 7; in 5 it developed before tlio ago of twenty ; and in 2 after tlie age of fifty, but in more after sixty. It begins ratiier earlier in women. In the majority. 20, tlic malady began in liand or sboiilder and ran the classieal course; in .'J it began in the legs and ascended; in 3 it began in tlic meibdla; and ir> 1 in oculo-motor nuclei, speedily extending to tlio arms unil legs (polio- cncephalo-myelilic type). In 2, beginning in tlio medulla, it assumed tlio amyotrophic lateral sclerosis type. The occupation of Uk; patients is very suggestive. In 10 there was a history of excessive worlc with tlio arms, tho patients being smiths. Iron workers, bricklayers, boilcrniakers, liorseshoers, stonemasons, tailors, barbers, locksmiths. In :? there was a history of syphilis, in t of lead, iu 3 of grii)pe and the iiuerpcrium, in 1 of infantile spinal paralysis. 310 DISEASES OF THE XERVOUS SYSTEM. pains in the shoulder or arm, associated Avith some feelings of numbness and Aveariness. Muscular wasting then begins to appear, and usually in one hand. The adductor longus pollicis is very early affected, also the thenar muscles and the interossei. The atrophy spreads from muscle to muscle, and does not follow the dis- tribution of nerves, although the ulnar-nerve supply is most seri- ously disordered. The ball of the thumb becomes flattened, and the patient cannot abduct or flex it well. When the radial interossei are reached the forefinger cannot be abducted, and this is often an early sign. The disease gradually extends upward, attacking the flexors and extensors of the fore- arm, then the upper arm and shoulder. Meanwhile the hand has become thin and flattened, flexion of wrist and extension of fin- gers are lost, and a characteristic " griflfin-claw" appearance results. A-fter a time (three to nine months) the other arm begins to be affected. Occasionally there is a temporary remission. In a few cases the atrophy begins first in the shoulders and arms, attacking the deltoid, biceps, and triceps, then extending down- ward to the hands. This consti- tutes the "upper-arm type." If, as is usually the case, the Fig. 143.— Showing Wasting of Hands disease continues to progress, It IN Muscular Atrophy. passes from the shoulder girdle to the deep muscles of the back, then downward, involving succes- sively the hip and thigh muscles, the glutei, the crural extensors and abductors being oftenest chosen. The log muscles may be finally involved, but they usually escape. The disease as it de- scends continues its progress in the trunk, involving the intercostals. It slowly ascends the neck also, and finally leads to paralysis of the diaphragm, or a bulbar palsy may set in. It will be seen that the ordinary course of the disease is from the lower-arm muscle groups (ulnar and median) up to the shoulder group (middle cervical nerves), then down through the dorsal and lumbar nerves, rarely reaching the sacral groups. In very rare cases it begins in the legs and ascends. Along with the wasting there are a corresponding weakness and MUSCULAR ATROPHIES AN'I) DYSTROPHIES. 311 paralysis, but the paralysis is the result of the atrophy and does not precede it. Fibrillary twitchiugs of the muscles occur; the idio- pathic muscular contraction caused by striking it a blow is very marked ; m^oid tumors are easily brought out. In. some cases the muscles are flaccid and toneless, and the deep reflexes, knee jerk, and arm jerk disappear early (atonic atrophy), but in other cases the rigidity and tonicity of the muscles are increased, the knee jerks exaggerated, and we have tonic atrophy. This condition may be so marked as to make it resemble a special clinical type of progres- sive atrophy known as aviyotroph ic lateral sclerosis. The electrical irritability of the muscles lessens to both galvanic and faradic currents, but no marked qualitative changes occiu" at flrst. Eventually we may get partial degeneration reactions, but these occur late in the disease, unless this runs a very rapid course, when fairly typical degeneration reactions may be got. A peculiar contraction of the upper limbs is sometimes produced by placing the negative pole of the galvanic battery over the fifth cervical vertebra, and the positive in the triangle just below the lower jaw (diplegia contraction of Remak). A peculiar palmar spasm is described by Yoeter, caused by siuldenly interrupting a faradic or galvanic current passed along the affected arm. In typical cases of progressive muscular atrophy* there is no amesthesia; and when such symptoms develop the presence of peri- pheral disease or of syringo-myelia or spinal tumor must be sus- pected. The patients may suffer from rheumatic-like pains and from paraesthesias. The affected parts often show excessive sweating and congestion and evidence of vasomotor disturbance. Tliis may involve the face on one or both sides ; one i)upil may be larger tiian the other, due to irritation of the cilio-spinal centre. The iris reflex, however, is preserved, and the optic nerve is never involved. The sexual power is often weakened, but the sphincters are not attacked. The urine sliows variations in the amount of urea. There is usually an increase of lime salts. Comjdicationx. — The most common complication is an extension of the process to the medulla, causing disturbance of speech and swallowing. Muscular atrophy complicates locomotor ataxia, but is rarely complicated by it. A high degree of spasm and rigidity of the legs, i>articularly, may occur, causing the condition known as amoytro])hic lateral sclerosis. Course and Diirofloii. — The disease usually progresses steadily until it has reached an advanced stage, when it may stop. Remis- sions may occur earlier, however, and even some improvement tiike 312 DISEASES OF THE KEKVOUS SYSTEM. place; the disease then ordinarily progresses again. It lasts from two years to thirty or more, but on the average not over ten or twelve years. Death usually occurs from pulmonary disease, owing to the weakness of the respiratory muscles. Sometimes the exten- sion to the medulla and involvement of the muscles of deglutition and of the larynx are the cause of death. Fatholofjij. — The primary anatomical change is a degenerative atrophy of the cells of the central parts and anterior horns of the gray matter of the spinal cord. The atrophy gradually extends and involves the whole anterior horn. It also extends vertically, first down, then up. Along with this atrophy are degenerative changes in the lateral columns ; consecutive to this there is atrophy of the anterior roots, peripheral nerves, and the muscles. The disease begins in the deeper parts of the anterior cornua, involving the central and median groups of cells. These are more concerned in nutrition and in the finer muscular movements of the extremities. Hence atrophy always precedes, or at least keeps pace with paraly- sis. The levels affected are the lower cervical and upper dorsal; but if the disease is extensive the dorsal, lumbar, and sacral cord are also involved. The affected part is nearly' free from nerve cells, and those present are atrophied, their processes are short or absent, and the cell has lost its angular appearance. Sclerotic and pigmen- tary changes are observed. The neuroglia and connective-tissue cells are increased in number, but there are no marked changes in the blood-vessels, though these may be much dilated. There is always some degeneration of the lateral columns, and this may be very complete. It is confined chiefly to the pyramidal tracts, but extends somewhat anteriorly into the mixed lateral column. It does not affect the cerebellar or ascending lateral tracts. The degeneration has been traced up into the brain as far as the in- ternal capsule and even to the cortex. The anterior columns may be slightly affected. The posterior horns, columns, and roots are normal. The affected muscles show various degrees of degeneration. They are pale and streaked with yellow, due to fatty deposits. Some fibres may be simply narrow and shrunken; others have lost their striation and become granular from deposit of fat globules or degenerated muscle elements ; other fibres have lost their striations and appear as if filled with a homogeneous, glass}' -looking substance containing a few fat granules (vitreous degeneration) ; others show a longitudinal striation. The interstitial connective tissue is in- creased and in places has taken the place entirely of the muscles. The capillaries and small vessels are distended. Healthy fibres MUSCULAR ATROPHIES aXD DYSTROPHIES. 313 may be seen among the diseased. Changes have been foimd in the sympathetic nervous system, but they are unimportant. The diagnosis has to be made from the progressive muscular dystrophies, chronic poliomyelitis anterior, syringomyelia, neuritis, and neuritic family atrophy. In the muscular dystrophies there is commonly a history of heredity; the disease begins usually in childhood or adolescence. It attacks the lower limbs of tener; it is slower in progress; there are no fibrillary contractions, and the degeneration reaction does not OCCIU-. Chronic poliomyelitis anterior begins suddenly and, having reached its height, does not progress, but remains stationary or im- proves. The paralysis occurs first, the wasting follows. It affects groups of muscles physiologically related, while progressive mus- cular atrophy attacks muscles only anatomically related. There are cases, however, which seem to be on the border line between the two diseases. Syringomyelia is distinguished by the presence of peculiar sensory and trophic disorders. Neuritis caused by lead poisoning is detected by the history of the case, its tendency to affect the extensors of the arm chiefly, and the absence of a progressive tendency. Sometimes, however, lead poisoning and palsy end in true progessive muscular atrophy. Ordinary multiple neuritis is distinguished easily by its rapid onset and the presence of painful symptoms. The hereditary or " leg type" of progressive muscular atrophy is characterized by its beginning in the legs, by a good deal of sensory disturbance, typical degeneration reactions, and hereditary or family history. Trmtmtnt. — The patient should be well fed and have rest, quiet, and fresh air. Careful local faradization and galvanization of the spine and neck are indicated. ^Massage does no good. Hypodermic injections of strychnine in the affected member, gr. -^ to -^^ daily, the internal use of arsenic, phosphorus, iron, quinine, and cod-liver oil sometimes are beneficial. In a few cases with a 8y[ihilitic history, mercury and iodide of potiissium have proved useful. The essentials of treatment are rest, electricity, strychnine locally, the administration of powerful tonics, and overfeeding. Nitroglycerin, morphine, atropine, nitrate of silver, chloride of gold and of barium, and the nitrate of uranium may be tried. 314 diseases of the xervous system. Progressive Hereditary Muscular Atrophy of Leg Type (Charcot-Marie Type). This is a hereditary or family muscular atrophy of central (oi neuritic?) origin, beginning in the legs and extending upward. It affects males more than females, but the difference is not great. It almost always begins before the age of twenty. It attacks first the muscles of the leg, not the foot, involving the peronei, then the extensors of the toes, then the calf muscles. The thighs escape till later. After some years the upper extremities and small hand muscles are reached. The shoulder and arm, neck and trunk mus- cles escape. There are occasionally fibrillary contractions; and always partial or complete degenerative electrical reactions. The j)atients complain of some pain and numbness, but there is no anaes- thesia. The disease runs a long course, with remissions, and resembles in prognosis the dystrophies. The outlook is better than in the arm type, but the disease is not curable. Some authorities assert that the disease is due to a progressive degenerative neuritis. In the writer's opinion the anterior horns of the spinal cord are primarily attacked,* a view recently confirmed by jNIarinesco. The treatment is the same as for the other forms of hereditary muscular atrophy. Glosso-Labio-Lartngeal Paralysis (Progressive Bulbar Paralysis). This is a disease characterized by progressive wasting and pa- ralysis of the muscles of the tongue, lips, palate, and throat, due to an atrophy of the nuclei of the nerves supplying those parts. Etiolorjij. — It is a disease of the degenerative period of life, most cases occurring after forty and batween that time and seventy. The disease begins later in life than spinal atrophy. It occurs rather oftener in men than women, j- A neurotic heredity is some- times noted. Exposure to cold and excessive use of the muscles in talking, mental strain, debilitating influences, lead, and syphilis are causal factors. * The writer has seen the disease in a typical form in one member of the first generation, in two members of the second. A child of one of the latter had, at the age of two years, a typical attack of anterior poliomyelitis. f "While this is the usual statement, in my experience women suffer much oftener than men. MUSCULAR ATROPHIES AND DYSTROPHIES. 315 Synnjtoms. — The tongue is the part first affected. The patient speaks indistinctly and cannot articulate the lingual consonants I, r, n, and t. The tongue cannot be elevated and is protruded only a little distance. It looks scarred and wrinkled. The lips become weak and the patient cannot whistle nor make the consonants p, b, w, or the vowel o. The saliva begins to dribble from the mouth. Disturbance in swallowing soon develops. Hard solids are taken with difficulty, next fluids, while semisolids are generally managed best. The lips finally become so paralyzed that the mouth cannot be shut, and the lower part of the face is motionless and expression- less. The upper face wears an expression of anxiety and suffering, the saliva dribbles constantly, and the whole physiognomy of the patient becomes characteristic and pitiful in the extreme. The facial ner\'e may get somewhat involved. Articulation becomes almost entirely lost; the voice has a nasal twang from paralysis of the palate. The patient has tired and uncomfortable sensations of dryness and stiffness about the throat. There is no pain or anaisthesia, but occasionally there is impairment of the sense of taste. The throat reflex is usually lost, so that tickling it causes no reaction. Electric irritability is at first unchanged, but in the later stages partial degeneration reaction occurs. In rare cases there is a rapid pulse and still more rarely glycosuria. The laryngeal reflex becomes weak, the adductors also, but abductor paralysis is rare. The mind is not affected, but there are often an emotional weak- ness and tendency to tears — not entirely unreasonable in view of the distressing nature of the malady. The disease is often the terminal stage of spinal muscular atrojjhy; it may be associated with the latter, with amyotrophio lateral sclerosis, or with ophthalmoplegia. All these types may occur together. It runs a progressive course, with remissions of a few weeks or months. It lasts from one to three or four years. In one case it has lasted seven years. The termination is eventually fatal. Death occurs through in- terference with swallowing, and inanition or a broncho-pneumonia or bronchitis may develop which ends the patient's life. Pdtholofjij. — The primary lesion is found in the nuclei of origin of the hypoglossal, glossn-pharyngeal, vagus, and spinal accessory nerves. The raphe fibres and the anterior pyramids are also usually somewhat involved. There is soiiietinies atropliy of the cells of the facial nerve and of the nucleus ambiguus, wjiich is the motor nucleus 316 DISEASES OF THE XERYOUS SYSTEM. of the vagus. The brimt of the disease falls, therefore, upou those more superficial or posterior nuclei which ai-e representative of a continuation of the anterior cornual cells. If the disease is compli- cated with amyotrophic lateral sclerosis, or progressive muscular atrophy, or ophthalmoplegia, we find atrophy in the cord or ocular nuclei. The atrophic process is similar to that observed in the spinal disease. The muscles of the tongue, and to a less extent the orbicularis oris and the throat muscles, show evidences of degeneration and atrophy. In some cases the tongue is not shrivelled, owing to the presence of a fatty deposit, and on accoimt of this the disease has been divided into atrophic and paralytic types, but this distinction is unnecessary. Diagnosis. — The disease must be distinguished from polio-ence- phalitis inferior, bulbar apoplexy, tumors, and softening, from mul- tix^le sclerosis, and from chronic lesions of the cerebral hemispheres causing pseudobulbar paralysis. It must also be distinguished from asthenic bulbar palsy. The slow onset, the progressive course, the bilateral character, the absence of involvement of sensory nerves, and the degenerative reactions are sufficient for a diagnosis. In asthenic bulbar palsy there is great paralysis, but none of the typical atrophy of the parts. It is important always to note whether there are ophthalmoplegia and spinal muscular atrophy associated with the disease. Treatment. — The patient should be kept quiet; he must be over- fed and given massage and electricity in moderation. The same drug treatment as in the spinal disease is indicated. Small doses of morphine, gr. ^ to -^^g-, and of atropine may be given also. Elec- tricity should be tried for a short time twice or even thrice daily, if possible. The faradic current may be used, alternating or combined with the galvanic. Galvanization of the neck and medulla appears to do no good. After a time it may be necessary to feed with a tube or even to do tracheotomy. Asthenic Bulbar Pakaly'sis A2hD Asthexic Bulbo-Spinal Paralysis. These names are given to a chronic and progressive disorder characterized by the symptoms of progressive bulbar paralysis or by the symptoms of this disease and of progressive muscular atro- phy, the distiuguishing features being that there is no muscular atrophy, that the cases often continue on for many years instead of going on progressively to a fatal issue, and also by the fact that on autopsy no easily distinguishable microscopical changes are f oimd. MUSCULAR ATROPHIES AND DYSTROPHIES. 317 Etiology. — Little is known as to the cause of the disease. The majority of cases have been under the age of thirty, but a patient of my own was over fifty years of age and another over forty. It is sometimes associated with profound anaemia. Those causes which are found in progressive bulbar and spinal paralysis, viz., overwork, mental strain, are sometimes found here. Symptoms. — The disease usually begins gradually and oftenest affects the muscles of the throat and face and of the eyes. A fre- quent symptom is ptosis of either one or both eyes. This may be f(jllowed by weakness or paresis of the muscles of mastication, de- fect in articulation, and difficulty in swallowing. The voice becomes nasal and the appearance of tlie patient very much re- sembles that of a case of glosso-labio-laryngeal paralysis. At the same time, with some ophthalmoplegia, there develop feelings of great exhaustion and extreme weakness in the arms and legs. The patient becomes incapable of anything but the sliglitest exertion and at times he is unable either to raise the arms or to stand upon the feet. The symptoms are characterized by remissions ; after a pa- tient has reached a point at which he is almost moribund, he begins to get stronger again and may shjwly get into a state of comparative strength; then the symptoms slowly return. In this way the dis- ease may continue for a number of years. The patient usually dies of exhaustion, but he sometimes recovers. Pathological Anatomy. — In the half-dozen careful autopsies so far made, no lesion of the nervous system has been foimd, except microscopical changes in the cells of the motor nuclei. Dlagnosh. — The clinical characteristic which distinguishes this disease from progressive muscular atrophy and true bulbar palsy is the fact that there is no true atrophy of the muscles of the face or tongue or extremities, there are no fibrillary twitchings, and the Cdurse is irregular with remissions. Like these other diseases, however, astlienic paralysis is not accompanied by any disturb- ance of sensibility or any impairment of the uphincters. The patient may die in six months, or he may live for six years, or even rec-ovcr. The treatment consists in complete rest, careful attention to feeding, and the use of iron and arsenic, and, possibly, of quinine. Strychnine and muscular stimulants should bo given with great care. Faradism is not advisable, but the use of a stable galvanic current is reported to have done good. 318 diseases of the nervous system. Amyotrophic Lateral Sclerosis. (Spastic Form of Progressive Muscular Atrophy.) This disease is oue which has the closest possible kinship to pro- gressive muscular atrophy which we have just described. There has been an enormous amount of discussion as to whether a distinct place should be given to the disorder. The question is a very academic one, for in everything that really constitutes a special malady it is essentially the same. However, its clinical symptoms are somewhat different, and anatomically there is a somewhat more extensive and peculiar change. Amyotrophic lateral sclerosis, or Charcot's disease, is character- ized by progressive paralysis with atrophy, rigidity, and contractures of the limbs. Etiolofjij. — It is a rarer disease than progressive muscular atrophy, and occurs most often between the ages of thirty-five and fifty, involving the second part of adult life. Rare cases, however, have been reported as occurring in childhood. According to Marie, the female sex is rather more often affected. According to the same author, no definite exciting cause is known. It is not due to syphi- lis or lead poisoning, nor does it follow the acute infectious dis- eases. It is therefore considered a disease of involution, i.e., tera- tological defect, the first and second motor neurons degenerating because of inherently deficient vitality. This state of affairs, how- ever, underlies the other atrophies also. Symptoms. — The disease begins most often with symptoms refer- able to the medulla, but it may affect first the arms, and less often the legs. The patient first notices some difficulty in speaking or swallowing. He feels at times a spasmodic drawing of the tongue or stiffness of the cheek or lips. Soon after there appear a weakness and stiffness of the legs and arms. The symptoms progress rather slowly. The speech becomes disturbed; swallowing is difficult; the arms atrophy and become stiff and rigid, producing characteristic deformities. There is great exaggeration of the reflexes; the legs show the presence of ankle clonus ; all the arm reflexes are increased, and the jaw is stiff and has a very lively jerk when struck. The patient suffers little from pain. There are no anaesthesia and no sphincter trouble, except in the last stages of the disease. In the course of a year the patient may become quite bedridden, with rigidity and deforming contractures of both arms and legs. In other cases the atrophies and contractures of the arms are not so marked, and the disease shows itself mainly in bulbar symptoms, progressing very much like a case of glosso-labio-laryngeal paraly- MUSCULAR .\TKOPniP:S AND DYSTROPHIES. 319 sis, plus a certain amount of rigidity and excessive reflex irritability of the throat and jaws. The course of the disease is variable but usually not long. When it begins and is most marked in the medulla, the duration is shortest. It rarely lasts, in any case, more than two or three years. Futhologkal Anutom I/. — Post-mortem examinations show a very marked sclerosis involving the direct and crossed pyramidal tracts; also some of the short-fibre systems of the lateral column. The anterior eoruual cells are atrophied, as in progressive muscular atrophy. Lesions are also seen at times in the columns of Goll. In fact, the post-mortem findings resemble entirely those of pro- gressive muscular atrophy, except that there is a sharper accen- tuation of the disease in the lateral tracts. In the medulla tlie nuclei of the hypoglossal and other motor cranial nerves will be found diseased and the pyramidal tracts also. The lesion of the white columns diminishes in intensity from below up, so that as one gets into the cerebral peduncles very little if any is to be seen. In a few cases, however, the process has been traced to the motor cor- tex and changes even iu that part have been discovered. In a case of my own, which Avas very closely studied and reported upon by Dr. Jos. Collins, the sclerosis of the moior tracts did not reach above the medulla, and there was no lesion of any moment in the cortical motor cells. Fotlioloijij. — In amyotrophic lateral sclerosis the degenerative process attacks first the terminal fibres and collaterals of the cor- tical motor neurons. It seems to destroy the tips of the nerve proc- esses, so to speak, without involving the nerve-cell body itself. The next part attacked is the anterior cornual cell. We have there- fore the curious and perplexing phenomenon of a disease which attacks the cell body of one neuron and the terminal neuraxou of another neuron just above it. It is difficult to explain this upon the ordinary lines of nerve-cell pathology. Still, we have analogies, perhaps, both in locomotor ataxia and in multiple neuritis. The (fiKf/nosis of amyotrophic lateral sclerosis must be made from transverse myelitis, multiple sclerosis, and the other forms of pro- gressive muscular atrophy. The diagnosis is based upon the very striking and progressive atrophy associated with exaggerated re- flexes, rigidity, and contractures, and without any sensory symptoms or sphincter troubles. The diagnosis from ordinary bulbar palsy depeiuls upon the a])pe!iranc(' of .sLiiTness, cramps, exaggerated reflexes, and rigidity disjilayed by the muscular supjdy of the facial, the trigeminal, and the glosso-pharyngeal, and the tenth, eleventh and twelfth cranial nerves. 320 DISEASES OF THE NERVOUS SYSTEM. The 2:>roffnosis is invariably bad, but in those types beginning in the legs and arms life may be prolonged a number of 3'ears. The treatment is the same as that for -Progressive muscular atrophy. THE PROGRESSIVE MUSCULAR DYSTROPHIES. As I have already stated, there are various forms of progressive muscular atrophy to Avhich the special name of " dystrophy" is A. B. Fig. 14;1— Showing the Parts First Attacked in the Different Types of Musotr* LAR Dystrophy and Muscular Atrophy. The shaded parts in A show the place of onset of progressive muscular atrophy of ordinary or Duchenne-Aran type, of leg type, and of types -i and 3 in text. B shows place of onset of types 1 and (o) in text. given, because they are hereditary in character and because the mus- cular end of the motor neuron is apparently the first and the most severely attacked. Eecent and closer study of the pathology of muscular dystrophy tends to show that the lesion is not in the muscle and terminal of the motor nerves alone, but that the pe- ripheral motor neuron is also to some extent affected. The clinical characteristics of the muscular dystrophies, however, are pretty distinct and are sufficient to justify the separation of them into a different class. MUSCULAR ATROPHIES AXD DYSTROPHIES. 321 A number of types has been described, the distinctions being based chiefly on the part of the body first affected. These types are not of great importance, but may be enumerated here for con- venience (Vig. 14.')) : 1. Pseudo-muscular hypertrophy. (a) Leyden-Mobius or hereditary tj'pe, appearing in children, beginning in the back and lower limbs. 2. Erb's juvenile type, or scapulo-humeral type, beginning in childhood or youth, usually in the shoulder girdle or trunk. 3. Landouzy-Dejerine type, or infantile progressive muscular atrophy of Duchenne, or facio-scapulo-humeral type. It resembles the preceding form, with the exception that it involves the face. 4. The peroneal or leg type has been classed with the dystro- phies, but is probably of spinal or neuritic origin, and has been described with the atrophies (see page 314). The essential unity of all these different forms is shown by the fact that cases occur in which pseudohypertrophy takes place in the scapulo-humeral and other types, by the fact that a disease re- sembling pseudohypertrophic paralysis occurs without any hyper- trophy, and by the fact that different types occur in the same family. The unity of the spinal and muscular forms is shown by the same kind of clinical evi- dence. At the same time the classical types of dystrophies are very dif- ferent clinically from the sjiinal amyotrophies and hence must be separately ilescribed. The differ- ences will be shown under the head diagnosis. PsKUUO-Mu.S< L'LAK HvPEUTUOPUV (AtKO- PUFA Musculorum Lipomatosa). This is a disease beginning in child- hood and characterized by a progressive weakness of the legs, associated with an apparent muscular hypertrophy due to a deposit of fat in the wasting muscles. Kti)I()iji/. — The disease attacks boys much oftener than girls. It begins, in the vast majority of cases, under the age of ten, often at the close of infancy, very •11 FlO. 144. -P.SKUDO-Ml'SCULAB ItVI'KRTHOPHT (Efb). 322 DISEASES OF THE NEKVOUS SYSTEM. rarely not till after puberty. Heredity is a very important factoi (iu three-fiftlis of the cases), the hereditary influence being al- most always transmitted by the mother. A psychopathic or neu- ropathic condition is often found in the ancestry. Neuroses, syphilis, intemperance, consanguinity, are not factors in heredi- tary causation. Injury and an acute disease sometimes appear to act as exciting causes. Symjjtoms. — The first symptom noticed is a weakness in the legs, which shows itself in a peculiar " waddling gait" and a ten- dency to stumble and fall. A little later (fifth or sixth year) an apparent hypertrophy of the leg muscles, particularly of those of the calves, develops. The ex- tensors of the knee or one of them and the gluteal and lumbar muscles may also be affected. Sometimes the hypertrophy is very great, at other times it is barely noticeable. The affected ]jart has a peculiar, hard, non-elastic feeling to the hand, not like that of nor- mal muscle. In the up- per part of the body the hypertrophy oftenest at- tacks the infraspinatus. The supraspinatus and del- toid may be somewhat in- volved (Fig. 145). The lower parts of the pecto- ralis major and latissimus dorsi are also usually atrophied, giving a charac- teristic appearance to the shoulders. The u p p e r- arm muscles are often slightly wasted, the fore- arm, neck, and face rarely. The tongue may be hypertrophied. Along with the pseudohypertrophy there occurs an atrophy of certain groups of muscles; and after a time the pseudohypertrophy disappears and an atrophy takes its r)lace. In the lower limbs the Fig. 145.— Pseudo-Muscular Hypertrophy, in- volving legs and shoulders (Curshmann). MUSCULAR ATROPHIES AND DYSTROPHIES. 323 muscles most atrophied are the flexors of the hips, then the exten- sors of the knee and tho.se of the hip. The calf muscles fail before the anterior tibial. The atrophy and consequent weakness of the lower-limb muscles cause great difficulty in going upstairs, the gait becomes more waddling, and the patient loses the power of getting up when lying on the floor. These peculiarities are due chiefly to the weakness in the extensors of the knees, the extensors of the hip, and the flexors of the hip. By reason of the same de- fects, the child when standing has an antero-posterior curvature of the spine with the concavity backwaid (lordosis) (Fig. 144). This is due to the weakness of the extensors of the hips, which, acting from the hips, are unable to tilt the pelvis back. On sitting this lordosis disappears, and is replaced often by a curve in the opposite direction due to weakness of the erectors of the spine. There may be some lateral curvature also. In consequence of the weakness and contractures of the leg muscles, there early develops a talipes equinus, and later the legs may become flexed on the hips and the forearms on the arms. The muscles show no fibrillary twitchings and rarely any degen- erative reactions, but there is sometimes a peculiar tetanic contrac- tion with both the faradic and the galvanic current. The knee jerks and elbow jerks gradually weaken and in time ire lost. There is no pain or other disturbance of sensibility. The affected parts feel cold and look reddened, as if from deficient vasomotor innervation. The organic spinal centres are not involved. Intelligence is usually good. C'oiirsfi. — The disease runs a chronic but variable course. Its progress is at first slow; after walking becomes impossible it may cease to ])rogress. It lasts from ten to twenty-five years. In a few cases patients have reached the age of fifty or sixty years, even when the disease began in youth. The earlier the disease begins the more rajjidly it extends; the more pronounced the tendene-y to lipomatosis, the more rapid is the course. rnthnlof/iad Atidtoini/. — The disease, like other forms of dys- trophy, is a degenerative atrophy, the i)rocess affecting first the muscle fibres and nerve terminals and the connective tissue being secondarily involved. In a simjile atrophy of muscle, such as fol- lows disuse, the muscle fibres simply grow smaller and graduallv i)r»'ak up and disappear. In degenerative atrophy, the process is accompanied by evidences of irritation, such as swelling of the muscle fibre, proliferation of musch^ nuclei, splitting of the fibre longitudinally, and connective-tissue proliferation. All these phe- 324 DISEASES OF THE NERVOUS SYSTEM. nomena are seen in the pathological process which takes place in the dystrophic muscles. All the varied changes may be noted in the same muscle. In the early stages there is a true hypertrophy of some of the fibres, a condition thought to be characteristic of the muscular dystrophies in distinction from the spinal atrophies. Besides swelling aud hypertrophy of fibres, one sees atrophy of the fibres; the bundles are rounded; there are increase of muscle nuclei, Fig. 146. —Partially Diagrammatic, showing: A, hypertrophied fibres ; £, mixture of hypertrophy and atrophy; C, D, atrophy and fatty deposit; v, vacuolization; s, splitting; A, hypertrophy of fibres ; g, thickened blood-vessel (Erb). splitting of fibres, vacuolization, and a tendency to break up into fibrillffi (Erb). The connective tissue at first shows evidence of irritation and proliferation. Finally, as the muscular atrophy pro- gresses, connective tissue increases and takes its place, until a dense, hard myosclerosis results (Fig. 146). In some parts there is deposit of fat in the connective-tissue cells, and this may in- crease until an extensive lipomatosis exists. In the later stage of the disease the fat deposits are absorbed and there are only atrophied muscle and connective tissue. The nerves and spinal cord are usu- ally normal ; when changes are found they are secondary to the musctdar disease. The process is then, first, hypertrophy of muscle fibre and MUSCULAR ATROPHIES AND DYSTROPHIES. 325 increase of muscle nuclei, swelling and rounding of fibres, and splitting of the same; then increase of connective tissue, Avith corresponding atrophy of muscle and deposit of fat. The process is a primary degeneration due to an inherent nutri- tional weakness of the nuiscle. In a measure it is true that those muscles embryologically latest developed are earliest attacked. The juvexilp: uystuophy OF EKiJ, or scapulo - humeral form of dystrophy, begins in childhood or early youth, a lit- tle later than pseudohypertro- phy. The shoulder girdle is first affected, later the arm. The forearm and legs are at- tacked very late. Part of the pectorals, part of the trapezii, latissimus dorsi, rhomboid, iipper-arm muscles, and supi- nators are affected, while the supra- and infraspinati and forearm and hand usually es- cape. There nuiy be true and false muscular hypertrophy. There are no fil)riliary contrac- tions or degenerative reactions (Fig. 147). The FACIO - SCAl'ULO - iw- MEKAL yoKM, Or infantile pro- gressive muscular a t r o p h y, begins in early childh(X)d (third or fourth year) usually, but may d<'velop late. The atro- phy attaciks first the face, giv- ing a characteristic ai»pear- ance known as the "myopathic face." There is a weakness of the oral muscle, which causes the lij)S to ]>rotiude and produces a symptom called tlie "tapir mouth." T]h> atrojihy resjiects the eye muscles as well as those of mastication and deglutition. It extends to tlit; slioulders FlO. 147.— JfA'KNlLK TVI'KOF PlliKfUKssI\ K Mi'hci'Lah I)vstri>i'iiv; sixth yi'iir of ili«- 320 DISEASES OF THE XERYOUS SYSTEM!. and arms next, then it pursues the ordinary course of the dys- trophies. Fi'Ofjnos'is. — The patient never recovers, but the disease some- times comes to a standstill and there may even be some improve- ment, especially in cases beginning late. Treatment. — The prophylaxis is important. It consists in pre- venting the marriage of women belonging to dystrophic families; if a dystrophy has developed in one child, it would be Tuiwise to take the risk of bringing others into the world. Or if children are already born, they should receive the most careful nourishment, outdoor life should be secured, and the dangers from trauma and the infective diseases be prevented. Infants should not be suckled by the mother if she belongs to the dystrophic family. The moderate use of massage and gymnastics is very important and useful. All kinds of tonic measures are indicated, such as cold baths, good nourishment, arsenic, strychnine, and phosphorus and fats. Tenotomy and other orthopaedic measures may be useful in the later stages. Feeding with thymus gland may be tried. Summary of the Hereditary or Family Nervous Diseases. The student may well be confused by the large number of so- called family nervous diseases which modern neurology has dis- covered and differentiated. The practical importance of them all is, perhaps, slight, for they are extremely rare, yet it is necessary that they be recognized and properly distinguished, for the prognosis and degree of suffering differ very much in different cases. They are all characterized by the fact that they are found in different generations and in different collateral branches of a given family, and that they are not necessarily or often passed on directly from one parent to another. The list which I append may not be en- tirely complete at the time of publication of this book, but it is ample. Ileredltanj Chorea. — This is really a kind of hereditary paresis or brain softening. It does not develop until adult life, as a rule, and patients with it may live until middle age. lleredUarij ainaiirotic kllory is a family disease first described by Dr. Sachs, characterized by lack of development of the brain and associated with blindness and a peculiar degeneration of the optic nerves. Ileredltanj Cerebral D'qjlefjia. — This is a family disease in which children between the ages of one and five develop spastic paralysis and sometimes imbecility. Jleredltavu JIeiniplp'o(/>iosis is good. If the arthritis gets well the muscles are also restored. The treatment consists of electricity and gentle massage and exer- cise. Internal treatment must be directed to the arthritis. Occupation Musculak Atrophies. As a result of constant overuse muscles sometimes atrophy. This applies especially to the smaller muscles of the hand. Thus ■"•«^. Fig. 148.— Showing Changes in Arthritic Mu-scular Atrophy. 1, Normal fibre; 2, atrophied fibre; 3, vacuolated fibre; 4, connective-tissue proliferation (Darkschevritch). there occurs an atrophy of the thenar eminence in lapidaries and in persons who constantly use this group of small muscles. Typical atrophies of this kind may be seen in persons who run elevators and who have constantly to grasp the rope in one hand. The biceps sometimes wastes in smiths and the calf muscles in ballet dancers. In most cases this occupation atrophy of muscles reaches a certain stage and stops. If the patient is given rest, recovery takes place. This is especially true if the patient is young and in vigor- ous health. In other instances, the simple occupation atrophy will MUSCULAR ATROPHIES AND DYSTROPHIES. 3'i9 actually pass over into progressive muscular atrophy. The condition is distinguished from a true progressive muscular atrophy mainly by the fact that the patient has none of the aching pains and vaso- motor symptoms, such as sweating in the arm, and very little if any fibrillary tremor. The electrical reactions are the same as in spinal atrophies. In ordinary occupation atrophy the seat of the disease is probably in the muscle itself. The treatment is rest and tonics, the carefid application of electricity, and hypodermic injections of strychnine. CHAPTER XYL TUMOES AND CAVITIES OF THE SPINAL CORD. Spixai. Tumors. Etiology. — Tumors rarely occur in the spinal cord. The com- monest age is thirty to fifty; tubercle occurs earlier (fifteen to thirty-five — Herter) and lipoma is congenital. Males are more sub- ject than females. Tuberculosis, sj'philis, and cancer predispose to the disease. Injuries and exposures appear sometimes to excite the growth of spinal neoplasms. Symjjtom's. — These vary with the location, character, size, and rate of the growth of the tumor. No definite clinical picture can be drawn. The symptoms are such as result from a foreign body slowly and progressively irritating and destroying the roots and sub- stance of the spinal cord. Pain appears early and is very constant, continuous, and severe. It is generally referred to nerves running out from the cord in the region of the tumor; a girdle sensation is felt. Numbness, hypereesthesia, and later anaesthesia occur. Ten- derness over the spine and rigidity are not very frequent. The sensory symptoms are usually more on one side, but may become bilateral. Spasm, contracture, and exaggerated reflexes usually soon develop, involving one or both legs or an arm and a leg. Later paraplegia, atrophy, loss of control of the bladder and rectum, and bedsores folloAv, and death ensues from exhaustion. When the disease is cervical the four extremities and trunk muscles may be gradually involved, and there are rigidity of the neck and optic neuritis. If lower down, there develops a hemiparaplegia, later a complete paraplegia, usually with exaggerated reflexes. If the tumor is in the lumbar region the reflexes are sooner lost and the sphincters early involved. A rather frequent type of symptoms caused by spinal tumors is that known as a Broxmi-Seqiiardi^avahjsis or hemiparaplegia. In a typical case of this kind there are paralysis of motion and muscle sense on the side of the lesion, paralysis of cutaneous sensation, es- pecially of pain and of temperature on the opposite side. On the side of the lesion the temperature may be slightly raised ; there is often hypersesthesia, and reflex action is increased. There may be a TUMORS AND CAVITIES OF THE SPINAL CORD. 331 band of anaesthesia at the level of the lesion and on the same side (Figs. 149, 150). The symptoms vary according as the tumor is outside or inside the dura. The common extradural forms are lipoma, cancer, gumma, and sarcoma. The greater amount of motor and sensory irritation, the evidence of some vertebral disease, existence of malignant tumor elsewhere, the absence usually of hemiparapie- gia, characterize extramedullary tumors. The common forms of intradural or medullary tumor are glioma and tubercle. In these cases pain and spasm and rigidity are less common in the early stage; hemiparaplegia is more common. A secondary my- elitis sometimes develops. The duration of the disease ranges from three to uve years, the average being two or three years. I'atliohjfjij a lid I'afliohxj'trdl Anatomy. — All forms of tumor occur, but the commonest are gli- omata and sarcomata, and after this fibromata, myxomata, gum- mata, and tubercles. Cancer is rare; echinococcus and cysticer- cus are the only parasitic tumors found. Most new growths start from the membranes, the next ,,,...£, ^ „ , . ' Fio. 14«.— Showino TRE Condition in a largest numbers from the cord, Buows-SfeqiAnD Paralysis Dik t<) a Tu- and fewest from the vertebrae. MOIl CilK iWI.no I.V the LeFT SiUK OF THE Spinal Corii. On the left sUlt*, hj-peni's- The meningeal tumors are thesla. nta-xla. paralysis, exuK^'erated r."- flexes. At tlie lip|»T limit is a band of anawthesla. On riK'lit side, anii'sthesia. mostly sarcomata and their vari ous jModiticiitions, libroma, en cliondromu, caicinoma, and liponui. The myelonic or intraspinal tumors are coniuionly gliomata, sarcomata, tubercle, ;uihalu8 or with spina bifida, or it may be iiulependent of these condi- tions. The dilatation may be cystic and irregular, or, as is more usual, extend throughout the cord. The dilatation extends more ])()steriorly, because the i)Osterior columns are formed latest. The abnormality may be slight and give rise t>. 336 DISEASES CF THE NERVOUS SYSTEM. passes down and may reach the whole length of the cord. It also extends upward and may involve the medulla and the nuclei of the cranial nerves. The cavities are of irregular shape, small size, and Fig. 156. Figs. 1.54-15f!. — Sections op Spinal Cord at Dip- PEREKT Levels in' Syringomyelia (Bruhl). 12D Fig. 157.— Syringomyelia, show- ing cavity with gliomatous tissue around it, and ascending and de- scending degeneration. filled Avith a liquid like the cerebro-spinal fluid. They are situated oftenest posterior to the commissure and involve one or both pos- terior horns, but they may be so extensive as to involve almost the whole of the centre of the cord at some levels. The walls are usu- ally lined by a membrane and surrounded by a gliomatous tissvie (Figs. 154-i57). This membrane is composed of a rather dense gliomatous tissue. TUMORS AND CAVITIES OF THE SPINAL CORD, 337 It may be absent in some parts. The glla cells are in various stages of development and degeneration. In parts of tlie cord the new growth may form a large and solid mass occupying most of the centre of the cord. Small hemorrhages and foci of myelitis may be present. 1\\ some cases there is evidence of a dilated central canal, with neuroglia hyperplasia of the walls and a gliomatous infiltration about this. The epithelium of the central canal may form part of the wall of the cavity. l\dholo(jij. — At about the sixth week of foetal life the central canal of the cord is large, diamond shaped, and reaches nearly to the anterior and posterior surfaces of the cord. This cavity gradu- ally contracts and unites in the middle, the anterior part forming the central canal and the posterior part the posterior septum. The posterior part may, through some embr^'ological defect, fail to close, and a congenital cavity may be left. About this a glioma may de- velop, and we have syringomyelia. The central canal may remain imperfectly contracted, and a syringomyelia may develop in con- nection with it. Probably most cases of syringomyelia are de- veloped on the basis of an embryonic defect. Gliomata were formerly thought to be practically identical with sarcomata. It is believed now, however, that they are of epiblastic origin, and like nerve cells are modifications of epithelial tissue. This tissue in its normal state is called neuroglia. It is a nervous substance. It is composed of small cells, round or of ii-regular shape, with a large nucleus and fine fibrillary prolongations. In glioma these cells are relatively much more numerous, while the fibrillary network is less conspicuous. There is considerable varia- tion in the relative richness of cells and fibres, however. When the former are very frequent the term gliosarcoma has been wrongly given to the tumor. The glioma is penetrated by small blood- vessels whose walls are often diseased, so that minute hemorrhages occur and the glioma becomes stained and pigmented. In other cases it is gray or yellowish in color. The rich cellular prcjliferation in gliomata has suggested an analogy in its growth to that of inflaniniation, and the term gliosis is used as analogous for neuroglia to sclerosis of connective tissue. Gliosis differs from sclerosis, however, in the fact that in the latter process the multiplication of fibres dominates, while in the former it is the cells; besides this, in gliosis there is a tendency to soften- ing and formation of cavities, and all nerve fibres disajjjjcar. In scleujsis some nerve fibres remain, and one observes the presence of granular and amyloid bodies. Fernlhir Ti/jh's. — 1. Tiie disease may be latent, giving rise to very few sym])t(inis or to none that are characteristic. 2. There may be a period of irritation and })ain in the ex- tremities followed by paraplegia, witli few sensory troubles, the course suggesting a chronic transverse myelitis or a lirown-Sequard paralysis. 3. Theie is a type in wliich bulbar symptoms develop early, but 33S DISEASES OF THE NERVOUS SYSTEM. differing from ordinary biilbar paralysis in tlie involvement of the trigeminus and other cranial nerves not commonly attacked. 4. There is a form characterized by a rather rapid ascending paralysis. None of these types can ordinarily be recognized during life. 5. There is a type characterized by the symptoms of muscular atrophy with analgesia and felons (Morvau's disease). In this type there is probably a complicating neuritis. Some assert that all cases of Morvan' s disease are cases of syringomyelia, but this is not proven. Diagnosis. — The disease is distinguished in its classical form by (1) its beginning at the ^^jeriod of adolescence, (2) by the progressive muscular atrophy combined with the peculiar dissociated disturb- ances of sensibility, (3) by the trophic disturbances and scoliosis. It has to be distinguished from progressive muscular atrophy and dystrophy, and amyotroi)hic lateral sclerosis, hypertrophic cer- vical pachymeningitis, chronic transverse myelitis, Morvan's dis- ease, and anaesthetic leprosy. The sensory and trophic disorders and scoliosis enable one to distinguish it from progressive muscular atrophy. In leprosy the dissociation of the sensory symptoms is not present, and the anaes- thesia is distributed along the course of the nerves or in sharply cir- cumscribed plaques. In some cases the peculiar tubercular disease of the skin and the history of the case make the diagnosis easy. In leprosy, also, there is a perineuritis, and the enlarged inflamed nerves may be felt. Portions of the skin may be excised and examined for the leprosy bacillus. As regards the differentiation from Mor- van's disease, this cannot often be done. Still whitlows are rare in ordinary forms of syringomyelia. Morvan's disease begins in one hand and slowly extends, with remissions, to the other. Usually there is loss of tactile as well as thermic and pain sense. The iirofjnosis so far as life is concerned is bad; but the disease has often a long course, ranging from five to twenty years, and periods occur in which the progress of the disease seems arrested and improvement occurs. Treatment. — It is not impossible that we may find some drug which acts specifically on gliomatous tissue, checking its growth. At present we know of only two things which may possibly do this : nitrate of silver and arsenic. These drugs should be given; and for the rest, tonic and symptomatic treatment is indicated. Functional Disorders of the Spinal Cord. The functional disorders of the spinal cord include only condi- tions of irritation and depression, to which the names of spinal ir- ritation and spinal exhaustion or spinal neurasthenia are given. The symptoms of these states are sufficiently described under the head of neurasthenia. TUMOKS AND CAVITIES OF THE SPINAL CORD. 339 3,"- . FUi. !>. llii«INc.l VI lu K.ijl ISA, N MIKAL SI7.K (MUlIlT). TheRecogxitiox (»k Diseases OF THE Cauda Equixa. Anutomy. — The cauda equina is made up of five lumbar, live sacral, and one coccygeal nerve roots. They lie in the dura mater forming a thick bundle and extending down the verte- bral canal for 14 cm. They are still distinct motor and sen- sory roots, and do not unite till they have passed out of the dura. The cauda begins at the lower tip of the cord, at the level of the lower edge of the second lumbar vertebra. The term conus is applied to the lower end of the cord and includes the parts below the second sacral segment. The cord here becomes much small- er, loses some of its distinctive microscopical structure, and the anterior root fibres are smaller and less numerous than 1 lie posterior or sensory. The airangement of the segments and nerves is shown in Figs. 158 and 159. The ar- rangement of the visceral cen- tres is given by IMiiller a.s fol- lows: Second sacral, erection centre; third sacral, ejaculation centre ; fourth .sacral, bladder (detrusor) centre; fifth sacral, sphineter-ani centre. The dis- tribution of tlie sensory nerves is shown in the Tigs. H">() and ir.i. Si/injifi)ins mil/ /ti'it/imsis. — The diagnosis of cauda lesions 340 DISEASES OF THE NERVOUS SYSTEM. involves differentiation of (1) lesions of the lower end of the spinal cord ; (2) cauda lesions due to compression ; (3) those due to de- struction ; (4) lesions of the peripheral nerves. 1. Lesions of the lower end of the cord usually come on rai)idly, i.e., in a few days (myelitis, softening, hemorrhage); there is little >0 III \J= Fig. 159.— Showing Arrangement of Segments and Nerves of Cauda Equina (Peterson). pain or sensory irritation, and later there is dissociation of sen- sations. Fibrillary contractions and involuntary twitchings of the leg muscles occur. Paralysis rapidly appears, involvmg the lower limbs in accordance with the segmental distribution of the nerves. It is flaccid, and is followed by atrophy. The visceral centres are involved. If the conns is not implicated the paral- ysis does not seriously involve these centres, nor the muscles of the TUMORS AND CAVITIES OF THE SPINAL CORD. 341 pelvic girdle. The motor disturbances are more conspicuous and troublesome symptoms than are the sensory disturbances. The cord being small and destroyed, not much improvement takes place. 2. In disease of the cauda, since it is usually a tumor, tlie symp- toms come on slowly ; in injury, however, the onset is sudden . Tlicre L«'si(iii at second lunilcn Mirintiit. Lesion at thirrt liinit)ar scs/iiicnt. l^tfion at Ilfth lumbar scpiiii'nt. Lf'sinn at flrstsaenil seifinent. FHJ. 1*10. LESIO.V.S at DIKKKRK.XT LKVKIJ* of TIIK LlMBAR AM» SACRAI. CORP. SlIOWINO ARKA.'< OK A.N.tlSTIIKSIA (MttlltTI. is often severe )iaiii Itlt in tin- liladdcr and distribution of the sciatic nerves, and usually bilaterally. Tlicrr follows afti-r a tiiiM" anaesthesia in the course of the sciatic nerves. There is little motor irritation, and paralysis follows slowly, accompanied with pain, the sensoiy symptoms being all along in the foreground. The sexual, bladdtM-, and rectal centres are later paralyzed. The course is pro- gressive unless there is ettective operation or medical int«M'ference. .S. The svmptoms in comiJression of the caiiila without destrnc- 543 DISEASES OF THE NERVOUS SYSTEM. tion are much the same as the above, Init there is less motor disturb- ance, and there may be no involvement of the visceral centres. 4. In lesions of the peripheral nerves, the trouble (usually neu- ritis or injury) conies on rather rapidly. There are sciatic pains, tender points, the lesion may be only unilateral, the pains are not Lesion at second sacral segment. Lesion at third sacral sef^iuent. Lesion at fourth sacral segment. Fig. 1P)L— Lesions at Diffeuext Levels of the Sacral Cord, Showing Areas of ANJiSTHESiA (MiiUer). so severe, and there is no marked anaesthesia. There is little or no paralysis in sciatica, but it may occur in neuritis. There is no paralysis of the visceral centres ; the sensory and motor symptoms go together, the sensory slightly predominating ; there is often a history of sciatica and alcoholism, or injury. Examination may disclose the presence of a tximor or of some disease affecting directly the sciatic plexus, and the prognosis is favorable. CHAPTER XVII. Ais"ATOMY AND PHYSIOLOGY OF THE BKAIN. Anatomy. — The nervous system is developed from a hollow tube formed by a foldiug of the epiblast. The brain or encephalon grows out from its anterior part. This swells into three cavities called the anterior, middle, and posterior cerebral vesicles. From the Ccnvniss.pcst Cland-p'tneal. Thurjel. Crrebcilum Fig. 1i;j. Fia. 163. Flo. l(i:i.— Thk Cerebral Vesicles. Fio. liVl.— FuKTHEK I>EVKLOPME.NT OB" VESICLES.—/', Fore-brain or telencephalon : J>, 'tween-brain or dieiicephaloii; //, iiiid-braiu or ineii. — Left Hemisphebe, from without. anterior occipital fissures, below on its outer surface by the Sylvian fissure anil a line drawn back from its upper end to the lower part of the anterior occipital. In front it is limited by the fissure of Rolando. On its median surface it is limited in front by the as- cending branch of the Oalloso-niarginal or subfrontal fissure, behind by the parieto-occipital, and below by the subparietal fissure. Its important sulci are: 1. The parietal or interparietal. 2. The postcentral. The convolutions fcuiued are, on the convex surface: 1. The jjostcentral ov ascending jiarietal. 2. The superior parietal lobule, having on its meiliau suiface (»i the quadrate lobule or prse- cuneus. 3. The inferior parietal lobule, which is composed of (ii) the supranuirginal gyrus, (h) the angular gyrus. These latter gyri are varitmsly described, but it is best to regard one, (a) the supra- marginal, as that surrounding the jjosterior end of the fissure of Sylvius; the other, (/») the angular, as that beginning at the ni)per limit of the first temporal fissure and extending back as far as the anterior occi})ital fissure. llie Occijiiffil Ldhr. — This is limited on its convex surface, an- teriorly, by the ])arit'to-occipital fissure, laterally to this by the anterior occipital and inferior occipital fissures. These in apes form 348 DISEASES OF THE XERVOUS SYSTEM. a siugle continuous fissure sharply separating the occipital from the other lobes. On its median surface the parieto-occipital fissure limits the lobe in front. On the under surface the anterior edge of the tentorium about marks the anterior limit. The sulci are: 1. The transverse occipital (ape fissure of some writers). 2. The superior or lateral occipital. 3. The inferior froTitalj^^ FissA ""^^'^ lob. occipit.^ Fig. 167.— The Cerebrttm, from above. occipital. On the median surface: 4. The calcarine, which joins the parieto-occipital. 5. The inferior occipito-temporal or fourth temporal. The convolutions on the convex surface are : 1. The superior occipital. 2. The middle occipital. 3. The inferior occipital. 4. The descending occipital. On the median surface we find : 5. The cuneus. 6. Descending occipital. TJte Temporal Lobe. — The convex or lateral surface shows the following sulci: 1. The first temporal or parallel sulcus. 2. The second or middle sulcus. On the under and median surfaces are: 3. The third or inferior temporal sulcus. 4. The fourth temporal or inferior occipito-temporal or collateral sulcus, which extends into the occipital lobe. 5. The hippocampal sulcus. The convolutions are: 1. The first temporal convolution. 2. The second temporal convolution. 3. The third temporal convolu- tion. 4. The lateral occij)ito-temporal or fusiform convolution. 5. AXATOMY AND PHYSIOLOGY OF THE BRAIX. 349 The median occipito-temporal or lingual convoluticn. 6. The hip- pocampal convolution, which is an extension of 4 and 5. 7. The 'incinate convolution, -which is an extension of 6. The Island of Rc'd (lobus centralis, lobus caudicis). — This has a Fio. 108. — Right Hemisphere, from withii*. circular sulcus surrounding it, and several more or less short sulci dividing it into from five to seven short g}'ri. The limbic lobe, if described as a separate lobe, is made to in- Fic;. lf,!».— Undkr SiRFAfK or Urain. lot, latorul (HciplUMcinporal or fusl/omi lolw; MOT, nifdliiri iNciplto-tt-iiiiionil or lliii^ual lulx-. cliiilf anteriorly the gyrus furnicatus or gyrus cingiili; back of this the isthmus; tlien the hippocampal, uncinate, and dentate convolu- tions (Kig. 1(58). 350 DISEASES OF THE XERVOUS SYSTEM. The olfactory lobe is rudimentary in man. Its position is shown in the diagrams. T]i6 ojiciTidum is the part of the brain that overlaps the island of Reil. It consists of a fronto-parietal part, formed by the lower ends of the two central convolutions, a frontal part formed by the base of the inferior frontal convolution, and a temporal part formed by the tip of the temporal lobe. The cuneus, prsecuneus, and paracentral lobule are important subdivisions on the median surface of the brain. Their position and boundaries are shown in the cuts (Fig. 1G8;. ]\Iin'oscoj)ic(d Anatomij of the Convolutions. — The cortex of the cerebrum is composed of nerve cells, a network of nerve fibres and processes, and of neuroglia tissue. Superimposed upon it is a very vascular membrane, the pia mater, which sends a rich plexus of vessels into it. We shall proceed to study: 1st, the structure and arrangement of the nerve and neuroglia cells ; 2d, the arrangement and connections of the nerve plexuses. On both these points new facts are being constantly added, and the j^resent description must be in many respects only provisional. 1. Tlie cells are arranged to a certain extent in layers. In the outer layer, next the pia mater, is a deposit of neuroglia tissue con- taining also peculiar-shaj)ed nerve cells, called cells of Cajal. Beneath these are small, somewhat irregularly shaped pyramidal cells (angular cells of Lewis) ; next come large pyramidal cells ; and deepest of all irregularly shaped cells (including the granule cells of Lewis) and spindle-shaped cells (Fig. 170). In the above I have described four layers of cells, and this may be considered the type. Some anatomists describe five typical layers, the fifth being made by a subdivision of the fourth (by Meynert) or of the third (by Lewis). The common four-layer type is found in the central convolutions and frontal lobe. In the oc- cipital region there are six (Lewis) or eight (Meynert) layers de- scribed. These are formed by the interposition of granule cells which subdivide the third layer. Various types of cortex are de- scribed, depending upon the different degree of development of the cell layers and upon the fibre arrangements. The common or motor type, as has been stated, has four layers. The large pyramidal cells are here numerous and are arranged in clusters. The sensory type has at least five layers, as seen in the occipital cortex, and here the large pyramidal cells are few and isolated. The pyramidal cells everywhere are arranged with their apices pointing to the periphery (Fig. 170). They give off apical, lateral, and basal processes. The basal process of the pyramidal cells is continued as an axis cylinder. Some of them pass down into the white matter; others turn up and enter the fibre systems of the cortex. The spindle cells point toward the j)eriphery also, except at the bottom of the sulci, where they lie parallel to the surface. Their processes connect neighboring areas and are called association fibre.^. AXATOMY AND PHYSIOLOGY OF THE BRAIX. 351 ri I "i [?:=^3^;3i7=.:^--'^] ' Tangential fibres III UF 5^ } I striae of B»^chterew and de Kaes. ■ Supperradiary network \ (of the second and ' third layers). / Striae of Baillarger. SI) ;} I Interradiarj' network f (of the third and ': fourth layers). Meynert's intraeorilcal association fibres. Subcortical association fibres. Fio. 170. Fio. 171. FlO. 170.— SnoWINO THK DiKFERKST f'KM.II.AR LaVKHS OK TIIK HllAIN CnKTKX (nfttr Cajal). .U, ni'iiroi;lla layer: ;)/V/, small pynimlilnl luy<-r ; /'//, larni' ii> ruiiiidal liiyt-r; /Vi, irrcKiilnrlv s)ia)M-il ci-Ils. Thi» (•/•lis nf ('iijiil rnu !>«■ st-fii in tlif layt-r .u. Km. 171.-Sii»wiN<« TIIK Laykiw OK Nkhvk Kihiikh. rractieally the tangential flbri'S p.nd the 8trl8D of Baillarf^er are the only layers that show distinctly. 352 DISEASES OF THE XERYOUS SYSTEM. Tlie small pyramidal aud spiudle cells measure about 10 x 18 ,".; the large, 20 x 40 /x (j 2'o"o" ^ e u"o" ^- ) • There are in the upper cen- tral and paracentral convolutions giant cells (of Betz) \vhich meas- ure 125 X 55 ,". {^^ X -^i-jj- in.). (See Plate.) Despite the great variety ancl complexity of the cortex, it is probable that there are but three principal classes of cells : (1) those which receive nervous impulses and which lie chiefly in the second and granule layers ; (2) those which associate and co-ordinate these impulses, and which partly lie in the first and partly deep in the fourth layers (cells of Cajal and spindle cells); and (3) those which discharge impulses and which lie in the third layer (large pyramidal cells). 2. Tit a fibres and j^^exuses of the cortex are composed of proc- esses from the nerve cells and terminals coming in from the white matter. They collect into several close networks. One, lying in the neuroglia layer and running parallel to the surface, is called the tangential layer of fibres; a second layer runs among the large pyramidal cells, forming the outer stripe of Baillarger ; and a third layer, beneath this, is called the inner stripe of Baillarger. Besides these, there are radiating fibres, runniug in from the white matter and forming interradial and superradial networks (Fig. 171). The cortical gray matter, as will thus be seen, contains layers of nerve cells, into which nerve fibres penetrate. These terminate, as do all fibres, in end brushes, which surround the receptive or sen- sory cells. An enormous number of fine fibres is given off by the cells; some of these form layers in the cortex and connect neighbor- ing parts, others run out and connect more distant parts or pass down to lower levels. There are thus three kinds of fibres — affer- ent, associative, and efferent — just as there are three types of cells, and since nerve cells and fibres are really parts of the same unit — ■ the neuron — there are practically three kinds of neurons in the cortex. The diff'erent convolutions and lobes of the brain are connected with each other by association fibres and commissural fibres and to the ganglionic masses below them by projection fibres. The asso- ciation fibres consist of short fibres connecting neighboring convo- lutions and of long tracts which connect neighboring or distant lobes. The sliort association fibres are numerous; they lie close -be- neath the gray matter and connect convolutions of the same lobes. The course of many of the long association paths is not yet well known. The occipital lobe is connected by long tracts to the temporal lobe, and perhaps slightly to the inferior parietal lobe (H. Sachs). The temijoral lobes are connected only to the occipi- tal. The frontal lobe is apparently connected with the parietal. Its connection with the temporal is denied (H. Sachs). All the lobes of the two halves of the brain are connected with each other by commissural tracts in the corpus callosum and anterior commis- sures. I will describe the projectio}i fibres later. AXATO-MY AXD PHYSIOLOGY OF THE BKAIX. 353 TiiK CoKPoitA Striata which form the second ganglionic mass to be studied are composed of two parts : the caudate nucleus and lenticular nucleus. These two nuclei are separated dorsally by the white fibres forming the internal capsule. Below they are continuous. Their shape and relations are not easily appre- ciated except by actual inspection of specimens. They are indi- cated in the accompanying figures (172-174). The head of the caudate nucleus is connected with the gray matter of the anterior perforated space. The tail extends into the temporal lobe, where it is continuous with the gray matter of the cortex, called at this point Fig. 17~. — T^oNoiTi'DiXAL Section", showing tlie lenticular (hO and caudate nuclei (cti) separated by the internal capsule (/<•;, the corpus callusuiu (re), the anterior couunissure iac'), the optic tract (//.). the optic thalamus (tic thalamus is composed of 356 DISEASES OF THE XERYOUS SYSTEM. neiYe cells whose ueuraxons pass up to the cortex ; and of the ter* miual fibres from neurons lying in the cortex ahd in the sensory cranial and spinal nuclei below. Between these are the Golgi or Cerebellum Wl\5CnW\ Fig. 175.— Showing the Relations of the Optic Thalamus to Other Parts CEdinger). associative cells which unite these various afferent and efferent neurons. The optic thalamus is a terminal station of numerous fibres of sensation coming from the medulla and cord; it is also Fig. 176.— Section through the Corpora Quadrigemina (Q), Tegmentum CTGOi Aira Cerebral Peduncles. SS, Substantia ni^ra; /*/), peduncles; AS, aqueduct of Sylvius. the place of origin of cells which send processes to the cortex and the receiving centre of fibres coming from the cortex. It is therefore a very important sensory-motor ganglion connected with AXATOMY AND PHYSIOLOGY OF THE BRAIN. 357 the reception and distributiou of sensoiy and motor influence and with the automatic and ref ex movements. The Corpora Quadrigemixa.— The mid-brain contains as its chief ganglia the corpora quadrigemina. These consist of four tubercles, two anterior and two posterior (Fig. 175). In man they are rudimentary in structure and relatively unimportant in function. In man also the posterior tubercles are developed more relatively than in most lower animals. They together measure abotit 14 umi. ("^ in.) in sagittal direction. In front lie the pineal gland and Fig. 177. — Showiso Some of the Reluvtions of the C'orpoiia QvADRioEMiyA and Optic TnALAMi-s to (Jthuh Pakts 07', opti.'; tlialnimis; Cy, corp. (|uasf(iiitift yh/ro. — Below the corpora quadrigemina and lying between the npjier sensory i)art (fff/itn-nfitni) of the pechuieles 358 DISEASES OF THE XERVO[JS SYSTEM. of the brain and the lower motor part (cnista) is the substantia nigra. It contains large multipolar, angular, and fusiform cells deeply pigmented (Fig. 176). The Red Nucleus. — Dorsal to the s. nigra and at about its middle extent is the red nucleus. It is spherical or oblong, very vascular, and contains numerous small cells. Tlie suhthalamus (Luys' body) lies more dorsally but in about the same plane as the substantia nigra. It measures about i by ^- inch, and contains a few cells and a very fine plexus of nerve fibres. The position and relation of these bodies are shown in Fig. 174. TJie nuclei of the ijons Ywi'olll are irregularly distributed masses of nerve cells lying deep among the longitudinal and transverse Fig. 178. -Showing the Lobes and Other Si'BDrvisioNS of the Cerebellum, Dorsal Si RFACE (Edinger). fibres. A special nucleus lying low down in the pons is known as the superior olive. In the after-brain or medulla we have the gray matter of the floor of the fourth ventricle and its cranial nerve nuclei, the olivary bodies, and certain small deposits of gray matter called the nodal nuclei. The Cerebellum in man consists of a median portion or vermis and two lateral hemispheres. It is connected to the cord and rest of the brain by anterior, middle, and posterior peduncles. If- is composed of an external layer or cortex of gray matter, of cent.al white matter, and central ganglia. The gray matter lies in very close, narrow folds, producing with the white matter an appearance on section called the arbor vita;. The vermis and hemispheres are divided by sulci into a number of lobes and lobules. The vermis is divided into superior and inferior jiortions. Its further subdivisions and those of the hemispheres are shown in the cuts (Figs. 178, 179). In the white matter of either hemisphere is a nucleus of small multiijolar cells, the corpus dentatus or ciliary body. To the median side of this, and belonging structurally to it, is a small nucleus, the AXATOMY AXD PHYSIOLOGY OF THE liliAl.N. 359 emboliform nucleus. In the inferior vermis is a collection of larger multipolar cells, the nurlcus ftistlriium or tegmental nucleus; just to the outer side, between it and the emboliform nucleus, is a small collection of cells, resembling those of the n. f/isfir/it, called the nucleus globosus. 2^16 Cerehelhir Cortex. — If a section be taken through the gray matter of the cerebellum, it will be found to be composed of two Fig. lii*. — t'EKEBKLLVM, Vkxtr.vl Strface (KdiuKtT;. layers, an outer, or molecular, and an inner, or granular, layer. Each of these layers contains a large number of peculiar-shaped nerve cells, and very rich plexus of nerve fibres. The molecular Fio. 180.— .SEfTiiiN Tnjjnifin ."MiiiiM.K UK Vkhmih asi> Pons. layer contains two kinds of ccll.s, one large and known as i'?/;7./«/'''s cells, the other snuiller and known as sfvllute cells. The cells of Purkinje lie tiie more deeply, being, in fact, ])racti('ally at the boundary of the molecular and granular layers. They measure 40 x 30 /'. (^iij to -g,',^ in.) and have largf mund nuclei. Kadi cell g'.vo- 3G0 DISEASES OF THE NERVOUS SYSTEM. off au enormous number of branching dendrites, which run up toward the surface of the cerebelhim in the shape of a bush. Each little branch sends off from the side small buds, wdiich are called the (jenrmules or thorns. These branching dendrites do not pass up altogether like the branches of a round bush, but are flattened like a broom. The Purkin_]e cells give oft" from their base a neuraxon which runs down into the Avhite matter of the cerebellum (Fig. 181, P), *M' -...^r-d^^Stri- Fig. 181.— The Different Constituent Elements op the Gray Cortical, Layer op the Cerebellum. Lying throughout the molecular la}er are the stellate cells, which are much smaller in size, and which also give off" a number of den- drites (Fig. 181, ,S') . Each cell has also its axis cylinder (neuraxon ) and this sends off collaterals which end in a flue basket-like network which surrounds the body of the cells of Purkinje (Fig. 181 ). On this account they are sometimes called basket cells. There are other stellate-shaped cells in the molecular layer which lie more superficially, and do not have this particular connection with the Purkinje cells, but appear to belong to the same type. The granular layer contains a large number of very small gran- ular-like cells that Golgi was the first to show were really nerve cells. They are only about 5 ,". (^,70- in.) in diameter, and they have a number of short dendrites which end in clubbed extremities. (Fig. 181, G) . They give off a very fine axis-cylinder process (ueu- AXATOMT AND PHYSIOLOGY OF THE BRAIX, 361 raxon) which runs up iuto the molecular layer and there divides in a T-shaped fashion, the fibres running parallel to the surface of the convolution and passing in between the branches of the cells of Purkinje. There are besides these granular cells a few larger cells with axis cylinders that divide and subdivide, ending in a finely ramifying plexus. These are of the type known as the cells of Gohjl. They are found in other parts of the brain. The nerve fibres of the cerebellar cortex are, as in the cerebrum, radiating and tangential. The tangential fibres lie at the level of the Turinkje cells, among the processes of which they run. Just Stellate molecular layer Fig. 182.— Schematic Pr.vrjRAM of the Relations of the Cerebellar Cells. A, Aff»*r<'iit libre to basket (stellate) cell; i;, neuraxou of Purkinje cell; C, afferent fibre to I'lirkiiije cell; D, afferent (mossy) fibre to graim'e cell. beneath the pia is a thin connective or neuroglia tissue membrane wliich sends radial fil)res down through the gray matter, affording it a support. It will be Si'en tluit the general arrangement of the cerebellar cortex is analogous to that of the cerebrum. Associative and re- ceptive cells are found in the granular and molecular layers, and they send processes forming a rich network around Purkinje's cells, which are efferent in function (Fig. 182). The comparatively small number of the large cells is in liarmony with the view that the cerebelhim is an organ that receives and adjusts nerve im])ulses for co-ordinate distribution. All ]iarts of the c(>rebellar cortex are anatomically alike. The white matter of the cerebellum consists of nerve fibres, some of which go to form tlu; i)e(huicles. Others form anterior and pos- terior commissures, running through tlu; two extremities of the vermi.s and connecting the hemispheres. There is also a longi- tudinal commissure in the vermis. The white matter around the corpus dentatum is called \}\Qj1t'.ece. 362 DISEASES OF THE NERVOUS SYSTEM. The Projectiox System. Having described the general arrangement of tlie different divisions of the brain and the collections of gray matter found in them, we are prepared to study the tracts of white matter which connect the different parts. The white matter, as already shown, is made up of: ( Short. 1. Association fibres -j Long. ( Conamissura]. 2. Projection fibres. 1. The association libres of the cortex have been already de- scribed. 2. The 2)roJect ion fibres are those which connect different areas of the cortex with the basal ganglia and the ganglionic masses of the pons, medulla, and spinal cord. Recent researches by Flechsig have led him to assert that the projection fibres are much less numerous than has been suspected, and that they come only from the central convolutions, part of the first and second temporal, part of the oc- cipital lobe, the hippocampus, uncus, and part of the limbic lobe. These are the parts of the brain identified with the function of vol- untary movement and general and tactile sensation, hearing, sight, smell, and taste. The area of the cortex of the brain thus connected to parts below by projection fibres is only about one-third of the whole. The remaining two-thirds of the brain cortex is not in direct connection with parts below, but is closely connected with the projection centres by association fibres. Flechsig considers the parts of the brain which are thus connected by association fibres as higher centres, identical with the more complex mental acts, and he calls them the associatloii centres. The association centres according to this view are the frontal lobes, part of the parietal and occipital and part of the temporal lobes. The views of Flechsig have attracted great attention, but have not yet been generally adopted, and may require considerable modifica- tion. The projection fibres of the brain form the different pathways (a) by which the special and general sensations pass up to the brain cortex and (b) by which the voluntary, automatic, and psycho-reflex movements of the body are brought about. {li) The Motor Tracts. — The cerebro-spinal motor paths are of two kinds: the direct or voluntary and the indirect motor tracts. The direct motor tract originates from cells in the central convolu- tions; the neuraxons of these cells pass down and are gathered together in a narrow band which passes through and occupies nearly the whole of the posterior segment of the internal capsule. The fibres continue on into the pons Varolii and medulla, and at the latter point give off some terminals which cross (except those for the sixth nerve) to the nuclei of the motor cranial nerves. The rest of: AXATOMY AXD PHYSIOLOGY OF THE BKAI.N". 3G3 uhe bundle passes on through the medulla, and ninety per cent cross over at its lo^\■er portion, forming there the anterior pyra- mids. About ten per cent of the fibres do not cross, however, but continue on the same side. The crossed bundle passes into the lateral column of the spinal cord, forming the crossed pyramidal tract, which passes on, diminishing in size as far as the sacral jjart of the cord. It gives off terminal end brushes which surround the /^/rit^cl/et 'eim Fio. 183.— Diagram of the Direct or Fio. 1H4.— Diagram op the Intm- VoLUNT;.nY ^r()T.nl Tract, showinj,' the Rect or Involuntary Motor Tract. course of the nidtor impulses from the cerebrni cortex to the voluntary imis- cles (after Van Gehuchteu). cells of the anterior horns. The small uncrossed band of fibres con- tinues on in the mesial part of the anterior cohimii, forming the direct pyramidal tract, or column of Tl'irck. The fibres of this tract cross over in the anterior commissure at dilforent levels, and their terminals also connect witli tlio motor cells of the anterior horns. Thus it will be seen that tlic, direct motor tract is a long continuous strand of fibres, composed of single neurons putting the cortex of the central convolution directly in contact with the motor cells of the pons, medulla, and spinal cord of the opposite side. oOl DISEASES OF THE XERVOUS SYSTEM. Each pyramidal tract, as it reaches the spinal cord, contains about eighty thousand fibres (Fig. 183). TJie indirect motor tract arises from nerve cells in the anterior central convolution, and, perhaps to some extent in the frontal lobe adjoining. Its fibres pass down into the internal capsule, mingling directly with those of the direct motor tract and giving olf collaterals to the optic thalamus. The fibres pass through the cerebral peduncles, occupying their inner four-fifths, or motor part, and, finally, reach certain deposits of nerve cells in the pons Varolii knoAx-n as the pons nuclei. They surround these cells here with terminal end brushes. From these cells neuraxons cross the median line in the middle cerebellar peduncle and thence to the cortex of the cerebellum, where they in turn end. From here the nerve cells send fibres through the peduncles by paths not perfectly well known down into the spinal cord, where they pass along mainly in the lateral fundamental columns, to connect finally with the anterior- horn cells. Thus it will be seen that the indirect motor tract is composed of («) a cortico-pontine neuron, (11) a pons-cerebellar neuron, (c) a; cerebello-spinal neuron, and {d) the peripheral motor neuron (Fig. 184). The direct motor tract is concerned in all voluntary movements, and when the anterior-horn cells of the cord are cut off from it by disease there is a spastic form of paralysis. The indirect motor tract is concerned in the co-ordination of bodily movement and in the higher reflex and automatic acts. It is largely through these in- direct tracts that the skilled automatic movements take place. Playing musical instruments and the involuntary use of the hands and limbs in work or games of skill are under the control of this mechanism. When the spinal cord is cut oif from it, there is an unsteady and disordered gait and arm movement. The course of the direct and indirect motor tracts is sho^svoi in the accompanying diagrams. TJls Sensor ij Tracts. — The next important pathways in the brain and cord are the sensory, and they are concerned in bringing tactile, muscular and general sensations from the remoter parts of the body to the cortex of the brain. It will be easier to follow these tracts if we begin at the periphery and follow the course of the fibres up to their centres in the brain. Just as in the case of motor fibres, we find direct and indirect tracts, although here even the direct sen- sory path is more tortuous and broken than is the case with the motor tracts. Tlie Direct Sensory Tract. — A tactile irritation of the skin passes up the sensory nerve to a posterior spinal ganglion, where the cell body from which the fibre is derived is found. It passes di- rectly through the ganglion, enters the posterior root of the spinal cord, and. passes up to a group of cells lying in the posterior horns, where it meets and surrounds with its end brush a second sensory cell. A second neuraxon starts from the body of this cell ; it crosses over through the anterior commissure of the spinal cord to the AXATOMY AXD PHYSIOLOGY OF THE BRAIX. 3lJ5 lateral column of the other side, where it runs up in the antero- lateral ascending tract, reaches the medulla and pons, and passes through this until it comes to the optic thalamus. Here it sends its terminal to a third cell, which in turn sends a neuraxon to the cortex of the central convolutions. Thus the cortical centres of the direct Fig. 1K5.— TnE Direct Sknsory Tract, showing the urrangemciits of the neurons (Van Gfhueliten;. Fto. 186.— The Indirkct Sbksort TliACT. sensory path are practically the same as the motor area from which tlie motor tract started. The direct sensory tract is nuuh) up of (1) a peripheral sensory neuron, (li) a spinal-thalamic neuron, (3j a thalamic-cortical neuraxon (see Fig. 185).* TItc ImUrrct st'Dsorij tract conveys impulses which originate in muscles, joints, and the viscera. The imi)ulses pass up sensory * Tliero are also Rome direct sensory impulsrs which no from the posterior roots to tlie roliiiims of GoU and Burdach and tiuiicc to tiic optic thalami aud central couvoiulions. 366 DISEASES OF THE XERVOUS SYSTEM. aerves through the posterior roots. Some now pass directly into the posterior cohimn of the cord of the same side and ascend till they reach the upper end, where their end brushes surround the cells of the nuclei of the column of Goll and of Burdach. From there they cross over to the other side in the sensory decussation. Some then go to the cortex of the cerebellum, where they terminate. The cerebellar cells take up the impulse and transmit it through the superior cerebellar peduncles to the red nuclei and optic thalamus, where they terminate. Another neuron now carries the impulse on to the central convolutions. Other indirect sensory impulses go from the sensory roots to the cells of the column of Clark, thence by the direct cerebellar tracts to the cerebellum, thence to the red nuclei and thalamus, and finally to the brain cortex. The indirect sensory tract is thus composed of (1) a peripheral sensory neuron, (2) a spinal-cerebellar neuron, (3) a cerebellar-thalamic, and (4) a thalamic-cortex neuron. The clirect sensory tracts carry, for the most part, the sense of touch, pain, and temperature. The indirect sensory tracts are concerned with the sensation from the muscles and joints which have to do with co-ordination, and also with vis- ceral sensations. It is through the indirect sensory and indirect motor tracts that the automatic and psycho-reflex acts are per- formed. Other Frojectioii Si/siems. — The optic, acoustic, and olfactory projection tracts have been described in connection with their peripheral nerves. The Membranes of the Brain. — The membranes of the brain are the dura mater, the arachnoid, and pia mater. The dura mater lines the inner surface of the skull. It is attached loosely to the concavity, bat closely to the base. It splits into two layers to form the venous sinuses of the skull. The inner of the two layers at cer- tain points projects inward to form membranous septa. These are known as the great longitudinal or cerebral falx, the lesser longi- tudinal or cerebellar falx, and the tentorium. Hence both venous sinuses and membranous septa are formed out of the inner layer. The outer layer forms the periosteum of the bone. The dura mater is supplied with sensory nerves, chiefly by the trigeminus but pos- teriorly by the vagus. The blood supply will be described later. The arachnoid is a thin, transparent, fibrous, non-vascular mem- brane lying between the pia and dura and continuous with the spinal arachnoid. It bridges over the fissures and the depressions at the base of the brain and forms between the pia and itself certain lacunse or spaces. These are the central lacuna found at the begin- ning of the fissiire of Sylvius, the callosal, and those of the trans- verse fissures and of the lateral aspect of the pons Varolii. The space between the dura and arachnoid is called the subdural or arachnoid cavity. It is lined with epithelium and resembles other serous cavities. The inner surface of the arachnoid is connected with the pia by numerous delicate fibrous processes. The space between these membranes is called the suharachnoid space. It com- AXATOMY AND PHYSIOLOGY OF THE BRAIN. 367 municates with the subdural space by means of the foramen of Magenclie, which lies in the part of the arachnoid that passes over the pons and medulla, closing in the fourth ventricle. The subdural and subarachnoid spaces contain a serous fluid. The normal amount ranges from two drachms to two ounces, it being greater in old people. The arachnoid contains no nerves or blood-vessels. It is described by some as a part of the pia mater. The pia mater lies beneath the arachnoid and is closely applied to the brain in all its folds. It is continuous with the spinal pia. It is very vascular and supplies the whole periphery and part of the interior of the brain with blood. It consists of two layers: an outer holding the larger vessels, and an inner delicate layer closely associated with the superficial neuroglia of the brain. The pia mater folds upon itself and passes through the transverse fissure into the third and lateral ventricles of the brain. These vascular folds form the velum interpositum, which gives otf a choroid plexus to the lateral and third ventricles. Another fold, the inferior choroid plexus, is given off to the fourth ventricle. The pia mater has vasomotor, but no sensory nerves. Functions of tlie Bniiii Memhmne. — The dura mater, by its outer layer, acts as a periosteum; by its inner layer as a lymph sac. It is also, by virtue of its sensitiveness, a protection against injury and disease. The arachnoid forms the inner wall of the lymph sac. The pia mater is a vascular and nutritive organ. It is, however, also closely connected with the lymphatic system of the arachnoid. The blood supply and lymjih supply of the brain vary in amount. In congestion the lymph can pass into the spinal canal or be rapidly taken up by the absorbents. In anaemia there may be compensatory increase of lymph. This fluid in disease may ac- cumulate in the arachnoid sac, the subarachnoid space, or the ventricles, these spaces being all in communication Avitheach other. Thh: Ijlooi> SrppLY of thk Bijain axd its Mkmhraxks. — ■ The vascular supply of the scalj), skull, and dura mater comes from the external carotids ; that of the eye, brain, and pia mater from the internal carotids and vertebrals. The arrangement is shown here: f Occipital, inferior jncuiugeal, arteries. I Posterior auricular. i Anterior. Temporal- Middle. ( Posterior. Ascending pliaryngeal, posterior meuingeal. luternal maxillary, middle meningeal, small mcuiugeaL Anterior meningeal. Anterior cerebral. ^liddlo cerebral. Posterior commimicatlng. Anterior clioroid. l' j Posterior meningeal. „ , , , 1 I / Inferior cerebellar. Vertebral a n d 1 . ,„.„.„ E.xternal carotid gives off Internal carotid gives off u.uuu.a. ,.UM . Anterior cerebellar, basilar give off 1 sup..rior n-rebellar. y Posterior cerebral. 368 DISEASES OF THE NERVOUS SYSTEM. The general arrangement and distribution of the arteries of the scalp and dura are shown in the accompanying diagram (Fig. 187). The Hood supplij of tliemeninrjes comes from the anterior, middle, and posterior meningeal arteries. These all come, except the small anterior meningeal branches and a small posterior branch, from the external carotid. The blood passes into the diploic veins, and from there passes chiefly into the lower occipital and lateral sinuses. Fig. 187. — Showing the Blood Supply of' the Scalp and that of the Ddra Mater by the JIiddle Meningeal. Some of it, however, returns in the venae comites. It all returns down toward the base of the skull. The most important of the arteries is the middle meningeal, both on account of its size and its distribution above important functional areas. The blood svpply to the xna mater and Jram s?<5s^a%ce comes from the internal carotid and the vertebral arteries. The branches of the former artery give off the anterior and middle cerebral, the pos- terior communicating, and anterior choroid. The vertebral arteries give off the inferior cerebellar, while the basilar branch of the ver- tebrals gives off the transverse, anterior cerebellar, superior cere- bellar, and posterior cerebral arteries. AXATOMY AND I'HYSIOLOGY OF THE BRAIX. 3G0 The cerebral arteries, anterior, middle, and posterior, are the three largest and most important. By their anastomoses the circle of Willis is formed (Fig. 188). From the circle of Willis and the beginnings of the three arteries mentioned, several groups of vessels, six in all, are given off. They enter the base of the brain and supply ii'- Fio. IHH.— Showing the Arteries at the Base op- the Brain. On the right slile the brain Is cut away, showing the cen-hrnl arteries and llie course of tlie posterior cerebral. tlie great basal ganglia and adjacent wliito matter. They are called the central (irtn'ies, and they are the vessels usually affected in cere- bral hemorrhages of adult life. They do not ana.«tomose -with each other. The riniiml (irfrrirs are the terminal branches of the great cerebral arteries. They anastomose with each otlit-r but slightly. They are distributetl a cry widely and carry much more blood than the central groups. Their distribution is shown in Fig. 185). Tlie cortical arteries are distributed in the \th\, imd fium iliero they pass U 370 DISEASES OP THE NERVOUS SYSTEM. in two sets, a superficial and a deep, into the gray matter, and for a short distance into the white matter. They pass straight in at right angles to the surface. They have richly arborescent branches which do not anastomose; consequently a knife plunged straight into the braiu does not cut many vessels. The cortical arteries probably anastomose somewhat with each other, though not very freely. There is slight if any anastomosis between the cor'ical and central arteries. The pressure is thought to be less in the vessels of the gray matter. The capillaries are surrounded by spaces called perivascular spaces which serve as lymphatic channels. The neuroglia cells send Fig. 189.— Showing the Distribution of thb Artery ok the Sylvian Fissure, a Prolongation op the Middle Cerebral. The area in front of the sliaded part is sup- plied by the anterior cerebral, that behind by the posterior cerebral. processes which connect with or form passages to the vessel walls (Fig. 190). The blood-vessels of the brain have probably vaso- motor nerves, though this is denied by some. The blood of the convex an;l mesial cerebral surface, flowing up from the base, leaves the capillaries and enters veins. Thence it still passes upward, and for the most part enters the longitudinal sinus. The most of the vessels enter the posterior portion of the sinus and in a direction forward and upward, i.e., against the cur- rent in the sinus. The course of the blood current is, therefore, opposed both to gravitation and to the venous flow. The veins of the ce)'chnima.ve: 1, the superficial cerebral ; 2, the deep cerebral veins ; and, 3, the cerebral sinuses. The superficial cerebral veins are venae comites. Those on the convex and mesial surfaces empty chiefly into the superior longitudinal sinus, as de- scribed; those on tlie basal surface empty into the cavernous and lateral sinuses. These veins have no valves, and their walls are ANATOMY AND PHYSIOLOGY OF THE BKAIX, 371 very thin and -without muscular fibres. The deep cerebral veins, or venae Galeni, receive the blood from the lateral ventricles and from some of the central arteries supplying the basal ganglia. They empty into the straight sinus. The cerebral sinuses are fifteen in number. The important ones are the superior and inferior longitudinal, the straight, the lateral, the occipital, the cavernous, and the superior and inferior petrosal. They carry blood for the most part in a direction from before back- ward, and convey it eventually to the internal jugular. ^lost of the blood of the convexity and mesial surface must pass into the longitudinal sinus, but there is a slight connection of some Fio. 100.— Showixo I he NEunoGLiA Cells op the Brain, their Relations to thb Blood- VESSEL'^; ai-so the Sustentaculaii rKucEssKs of the KpiTHtLiAL Cells of the Lateral Vkstricle (Marclii). A, Epillielial cells liuiiij; lateral ventricle; o, process of same; 6, spider or neuroglia cell : c, blood-vessel. of the veins with the superior petrosal and straight sinuses. The superior longitudinal sinus also communicates slightly with veins of the scalp and with the facial vein. Some of the blood from the mesial surface also goes to the veins of Galen. On the Avhole, however, t)ie system of the convex and mesial cerebral surface is a close corporation, the blood luiving to pass into the sujjerior longitudinal sinus and toicular Ilerophili, where it meets that of the straiglit and o('(ii)ital sinuses, and flows forward through the lateral sinuses to the internal jugular. The circulation of the basal surface is less isolated. All the basal sinuses com- municate with each other freely, and there are slight communica- tions between the veins of the sialp and the cavernous, lateral, and ?nferior petrosal sinuses. It is safe to tie au}' of the sinuses, cxeept the lateral and the ])osteri(n- ])art of tlie longitudinal. The cere- bellar veins, su])»'rior, inferior, and lateral, empty into the straight, 372 DISEASES OF THE XERVOUS SYSTEM. the lateral, and superior pertrosal sinuses. None of the cerebral veins or sinuses have valves. The pressure in the internal carotid arteries is about 150 mm., that in the cerebral sinuses 70 to 80 mm. (Gerhardt), and that in the jugular veins is almost negative. Both arteries and veins are more delicate than the extracerebral vessels. Except in gray matter, the brain is not a very vascular organ, but this gray tissue ranks in richness of blood supply with the lungs and liver. The amount of blood in the brain at any one time is only about one to two per cent of the total blood in the circulation, or about four ounces (Ranke). The diameter of the common carotids is 6.7 mm. (Thorne), that of the subelavians 6.2 mm., that of the internal carotids 4 mm., and that of the vertebrals 3.55 mm. (Gerhardt).* The Fuxctioxs of the Bkaix — Cerebral Localization. — The brain is the seat of conscious intelligence and mental activity. It has also control and direction of voluntary movements, it is the seat of instinctive acts, and it regulates in a measure the vasomotor, trophic, and secretory mechanisms of the body. Tlie Prefrontal Lobes.— The prefrontal lobes, or that part of the brain in front of the precentral convolution, are concerned with volition and the power of self-control, concentration of thought and attention (Ferrier). They form one of the higher or associa- tion centres. The posterior part contains centres for the move- ments of the head and eyes. Injuries in this part of the brain produce changes of character, indicated by peevishness and irrita- bility of temper, mental enfeebleinent, lack of power to concentrate the mind or to control the acts or emotions. The Central Convolutions. — This part of the brain is called the sensorl-motor area, because it is concerned in the production of ner- vous impulses which cause voluntary motions of the body. Certain ])arts of this area are in relation with certain groups of voluntar}' muscles on the opposite side of the body. These areas preside not so much over single muscles as over those groups of muscles which act together in producing definite purposeful acts. The lower part of the central convolutions, known as the central operculum, is a centre for movements of the larynx, mouth, tongue, and face. Above this area and about the middle third of the central convolutions is the centre for the movements of the shoulder, arm, hand, and fingers. Still farther up, near the longitudinal fissure, and extending over into the mesial surface and back into the superior parietal lobule, is the area for the trunk, hips, legs, feet, and toes. The base of the *J. Crichton Brown gives the last two diameters 2.8 and 2.2 mm. re- spectively. AXATOMY AXD PHYSIOLOGY OF THE BRAIN. 373 first and second frontal convolutions is the centre for movements of the head and eyes. The exact arrangement of these centres, which have been determined by experiments upon monkeys and other lower animals as well as by clinical and surgical observations on man, is sliown in the accompanying Figs. 191, 191?. The motor area is also the centre for the cutaneous sensations of the parts corresponding to the muscular groups which it supplies, so that what is called the motor is really a sensori-motor area. The motor area, when irri- tated by disease, produces parsesthesiae and convulsive movements in the groups of muscles which it represents. Destruction of it causes not only a paralysis, but a certain amount of cutaneous anaesthesia. The various sensori-motor centres are not sharply limited, but lap one over the other, so that the motor area for the forearm, for example, extends over somewhat into that for the shoulder. The corresponding sensory areas are more diltuse, so that it takes a much more extensive destmction of a certain area of the motor cortex to produce an anaesthesia of the arm than it does to produce a paraly- sis of the arm. The sensori-motor area including some adjacent parts is called by riechsig the " somatosphere, " because here he thinks are received the afferent impulses of general (visceral) as well as special tactile and muscular sensations from all over the body. Bilateral It p. present at i(» I. — Those muscles of the two sides of the body which act together have a double representation in the brain. For example, each group of muscles used in inspiration has a centre in both hemispheres; consequently, when one centre is destroyed no paralysis results, for the reason that the other centre continues its work. In the same way some of the muscles of the face, such as those for closing the eyes, have a double representation, and a lesion destroying the centre for the orbicularis palpebrarum on one side will not usually cause paralysis, because of the continued action of the centre of the other side. The more perfect and habitual the associated action of the muscles of the two sides of the body, the more completely can one centre do the work of its associate. The best examples of the muscles having the double representation are the orbicularis palpebrarum, the muscles of the vocal cords, the muscles concerned in deglutition and in respiration. Tlie must-les of the viscera and blood-vessels have no known representation in the cortex of the human brain. The special sensations have a bilateral representation also; but the more specialized the sense the less can one hemisphere take, the place of the other. 374 DISEASES OF THE NERVOUS SYSTEM. Occipital, Parietal, and Temporal Lohes— Centers 0/ Special Sense. The special senses liave two centres— the primary and the secondary. The primary centres are connected with the ganglia at the base of the brain ; the secondary centres are situated in the cortex. The primarij centre for imion is in the jiosterior part of the optic thalamus, the external geniculate body, and anterior corpora quadri- gemina. The secondary centre is situated in the occipital lobe, and particularly upon its mesial surface and in that of the cuneus, known as the calcarine fissure. Each occipital lobe is the centre for visual impulses from the corresponding half of the retina of each eye ; for example, the left occipital lobe is the centre for vision of AXATOMY AXI> I'HYSIOLOOY OF THE BRAi:S. 375 the left half of the retina of each eye. This relation is shown in the diagram (see Optic Nerve). Total destruction of both occipital lobes, or even of a considerable part of them if the destruction in- volves the median snrfaco, -will cause blindness. Destruction of one Icbe causes ouly lialf-blinchiess or hi-miano^jsia. The jn-ii/itu-// r,-iitri',ft>r liniriiK/ is in tlie posterior tubercle of the cor]i(na (iuadrit,'('iiiina and the internal j^'cniculate body. The secon- dary centre is in the cortex of the first and second convolutions of 376 DISEASES OF THE XERVOUS SYSTEM. tlie temporal lobe. Destruction of one temporal lobe causes deafness in the opposite ear. This deafness, however, is not complete be- cause the sense of hearing has a bilateral representation; each ear, in other Avords, sends fibres to the temporal lobes of each side, al- though more fihres cross over than go to the lobe of the correspond- ing side. The consequence is that the loss of one temporal lobe is in a measure supplied by the other (^tiida Aphasia). The py'DiHivij centre for s)iu'U is in the olfactory lobes. The secondary centre is probably in the anterior part of the limbic lobe, the uncus and in part of the hippocampal convolation. Whether the tracts for the sense of smell are connected with the optic thala- mus or other ganglia is not definitely known. The primary centre for taste is not known, but sensations of taste may connect with the optic thalamus before passing into the secondary centre, which is in the hippocampal convolution. Centres for Memories. — There are certain classes of sensations and perceptions, simple in character and frequently repeated, so that they finally get to be used almost automatically in their work. These im})ressions relate to the use of the muscles in speech, in -\\Titing, and in gesture language; also to other frequently repeated purposeful movements of the limbs. The muscular movements in writing and speaking are so often repeated that certain areas in the cortex are set apart for the memories of these processes, memory being simply a revival of previously registered impressions. The visual sensations and tlie ideas elaborated from them, which are frequently repeated in learning to read, have also a centre which is set apart for them. This forms a centre for the visual memories of language. In the same way there are auditory sensations and ideas elaborated and so frequently repeated as to be used automatically in acquiring language. These are stored up as auditory memories. We have what may be called motor memories connected with speech and gesture. These special memories have been found to have a certain localization in the brain. The centre for the memories of the articular movements of speech is in the posterior part of the third left frontal convolution ; the centre for the memories of the movements of writing is not perfectly well known, but is thought to be at the posterior part of the second left frontal convolution. The centre for the memories of gesture language is unknown. The centre for the memories of ordinary co-ordinate movements is prob- ably in the inferior parietal lobule. The centre for the visual memories of written language is in the angular gyrus, extending backward fi'om there into the occipital lobe. The centre for the auditory memories of spoken language is in the posterior part of the ANATOMY AND PHYSIOLOGY OF THE BKAIX. 37 T first and the corresponding upper part of the second temporal con- volution. In right-handed people all the memory centres are in the left cerebral hemisphere ; in left-handed people they are in the right hemisphere. The destruction of these memoiy centres produces different forms of aphasia, as will be described later. In addition to that, disturbances in these centres are produced by lesions which cut off the associating fibres connecting these centres with each other or with motor or sensory centres proper. The Centrum Ovale, Corpus Callosum, and the Associative Func- tions of the Brain. — The different parts and centres of the brain are connected together by the associating tracts and Avith lower levels by the projection fibres. The simpler and less developed centres of the two halves of the brain are closely connected by fibres that run chiefly in the corpus callosum. The more highly specialized and less simple in function a centre, the less close is its commissural connection and the more independent is one half of the brain from the other. Thus the centres for the movements of the thorax in respiration are closely bound with each other; those for the pur- poseful movements of the hands less so; those for receiving visual impressions are aLuost independent; and the centres for the mem- ories, wliich are still more highly specialized, are practically en- tirely independent. We infer that the higher mental functions, therefore, work eithoT in one cerebral hemisphere or in the other, and that the two halves of the brain do not co-operate with each other in much of the higher intellectual work. The corpus callosum is the great commissural tract connecting the two cerebral hemispheres and their respective centres. The anterior commissure doe.-^ some of the same work, being more specially connected with the function of olfaction. Tlie posterior commissure has comparatively few bilateral connecting fibres, its finiction being more to connect the thalamus with the cranial nerve nuclei and other centres below. The Corpus Striatum. — This ganglion is in close relation with the cerebellum and with nuclei in the puns. It is also in connection Avith fibres that come up from the muscle-sense tract, in the spinal cord. Its functions are tlierefore probably connected with securing co-ordinate and purposeful movements. Destruction, however, of this ganglion in the human brain produces no definite symptoms, and local lesions of it cannot bo diagnosticated. It is therefore called clinically a hifrnt n-ijion. The Thalamus Ojjfirus. — The thaliimus is in relation by its pro- jection fibres with the frontal, ])arietal, occipital, and temporal cortex. The fibres that go to the occipital cortex are connected 378 DISEASES OF THE NERVOUS SYSTEM. with the optic tract, and have to do with the function of vision. The fibres that go to the temporal lobe are connected with the audi- tory tract, and have to do with the function of hearing. The optic thalanii seem to have some relation to the expression of emotions. In cerebral paralyses in which they are involved the patient cannot involuntarily express joy, grief, etc. Lesions of the posterior part of the thalamus will produce partial blindness. Other than this, lesions of the optic thalamus produce no definite symptoms which enable us to make a local diagnosis. Disturbances of hearing have not certainly been traced to lesions in the thalamus. It is probably a primary centre for sensations of touch, muscular sense, and per- haps for smell and taste, but no definite facts in human pathology have as yet satisfactorily proved this. Lesions of the thalamus sometimes produce various forms of mobile spasm, but these are generally attributed to irritation of the fibres of the internal cap- sule, which go close to it. Hence, aside from disturbances of vision, the optic thalamus also must be considered clinically a latent region. The Corpora Quadrigemina. — The anterior tubercles of the cor- pora quadrigemina, together with the external geniculate bodies, form part of the primary centres of vision. The anterior tubercles, however, have to do chiefly with reflex movements of the pupil and the ciliary muscles. The posterior tubercles of the corpora quadrigemina and the internal geniculate body are connected with the auditory nerve, and have to do with reflex movements associated with hearing and space sensations. They also appear to receive some fibres from the cerebellum; their injury or disease produces some disturbances in equilibrium and possibly in hearing. Owing to the fact that the nuclei of the third nerves and the red nuclei lie beneath the corpora quadrigemina, lesions of these latter produce irritations and paralyses of the third nerve, disturbances in equilib- rium, and forced movements. Lesions in this neighborhood some- times cause somnolent and stuporous states. The red nuclei are connected with the anterior cerebellar peduncles on the one hand and with the lenticular nucleus and optic thalamus on the other, and are concerned in securing equilibrium and the adjustment of the body in space. The CerebeUum. — The cerebellum is connected with the pons, the cerebrum, and spinal cord. It sends impulses down into the antero-lateral columns of the cord, and through the anterior peduncles to the red nuclei, the thalamus, corpora striata, and the central convolutions. It receives impulses from the cortex of the frontal lobes, which go down into the pons, connect with nuclei AXATOilY AND PHYSIOLOGY OF THE BRAIX. 379 there, and tlience pass up into its hemispheres (indirect motor tract) . It also receives impulses from the spinal cord, through its peduncles, which go on to the thalami and brain cortex (indirect sensory tract). There is therefore a nervous circuit between the cerebrum, brain axis, cerebellum, and spinal cord. The cerebellum has thus the function of securing the higher automatic and pyscho- reflex movements, and through its further relations with the space- sense nerve (eighth) of enabling us to keep our equilibrium and maintain our relations in space. The vermis or median lobe is the part which in man is most important in doing this work. Lesions of the lateral lobes or hemispheres produce few direct symptoms, and they are calbd latent regions. Injuries of the median lobe, however, produce disturbances in equilibrimn, forced movements, and a peculiar form of inco-ordination in gait which is known as cerebellar ataxia. Lesions of the middle peduncles produce forced movements also, the forced movements being either toward or away from the side of the lesion, according as it is an irritating one or a destructive one. The pons Varolii contains some of the cranial nerve nuclei and collections of nerve cells which are connected with fibres from the cerebral cortex on the one hand and the cerebellum on the other. It also contains the long tracts of nerve fibres that pass from the cerebrum down through into the medulla and spinal cord and trans- verse tracts of fibres which connect the two hemispheres of the cere- bellum. Lesions in it cause disturbances in function of the cranial nerves and of the motor, sensory, and commissural tracts. The inediiUa ohloiKjata contains centres of the cranial nerves, and in it also are various reflex and automatic centres controlling and regulating the vasomotor system, respiratory and cardiac rhythm, visceral movements and secretion. The oJii'dri/ hodii'n are connected witli tlie cerebellum, basal ganglia, and with tlie spinal cord. Wlien injured, distui'bances of equilibrium and co-ordination occur. The Latent Ret/ions nf the Jirain. — There are certain parts of the cerebral cortex destruction of which and irritation of which pro- duce no special and distinctive phenomena in man. These are the greater part of tlie temporal lobe of the right side and a portion of the temporal lobe on the left side. A part of the inferior parietal lobule also may be regarded as a latent region. The frontal lobe wo have already spoken of as being concerned with certain mental functions, but lesions here often jtroduce no symptoms, and may be to a certain extent regarded as latent. These latent regions are called by Flechsig the higher or associative centres. Tlie corpora 380 DISEASES OF THE NEEVOUS SYSTEM. striata, optic thalami, portions of tlie centrum ovale, and the two lateral hemispheres of the cerebellum are latent areas. Brain Weight. — The average weight of the male brain is 1,358 gm. ; that of the female, 1,235 gm. The weight varies with age, sex, race, and intelligence, and with a number of other factors. The average weight of the brain at birth is 327.8 gm. ; the braiu grows rapidly until the age of four, then more slowly until the age of seven, then very slowly up to the age of sixteen to twenty. At about the age of forty-five in man and fifty in woman it begins to lose weight slowly, and at the age of eighty or over it has lost about 120 gm. (4 oz). The brain of man weighs absolutely about nine per cent more than that of woman. Relatively to the body weight, the brain weight of man is about 2 per cent; that of Avoman a very Jittle less. The sexual difference is extremely small.* The brain weighs more in the civilized races, and more in cer- tain of the civilized races than others; the brains of English, Ger- man, and Scotch weigh more than those of French, Italian, and Russian. Some of the African and Australian tribes have the smallest brain, the average negro brain weighing 1,250 gm. When a brain weighs less than 1,130 gm. in man or 990 gm. in woman, it is called a microcephalic brain; if the weight is above 1,490 gm. in man or 1,345 gm. in woman, it is called a megalocephalic brain. Brain weight has a certain relation to intelligence, which is not, however, an absolute one. Among a hundred men of more than average intelligence, the percentage of large brains would be about 25, whereas the percentage of large brains among persons of ordi- nary or low intelligence would be not more than 4 or 5. In estimat- ing the importance of brain weight, one must consider the height, the weight or volume of body, muscular mass, and superficial area; these are called the somatic factors. The following formula has been devised by Snell for estimating the mental power of different animals • In this formula P represents the psychical factor or the amount of intelligence, H the brain weight, K the body weight, S the somatic factor. The somatic factor has been estimated to be for mammals about 0.666. Applying this formula, we find that, ex- pressed relatively, the intelligence of man equals 0.87; woman, 0.86; the ape, 0.42; the rabbit, 0.59; the birds from 0.167 to 0.09. The relative weight of different ]3arts of the brain is about as follows: frontal lobes, 28 per cent; parietal lobes, 36 per cent; occipital, 10 per cent; temporal, 13 per cent; lobus caudicus or island of Reil, 9 per cent; pons, 1^ per cent. The cerebellum weighs about one-eighth as much as the cerebrum. The proportion of the gray to the white matter in adults is 60 to 40 (Vierordt). * J. C. Brown finds that after making all allowances, woman's braiu weighs about one ounce less than man's. AXATOMY AXT) PHYSIOLOGY OF THE BRAIN. 331 The depth of the primary fissures is not quite an inch (20 to I'.'i mm.). There are from one thousand two hundi-ed to two thousand million cells in the cerebrum, and about ten million large cells in the cere- bellum (Meynert). About one million cells to a square centimetre is the estimate of Engel. Preservixg axd Cutting the Brain. The brain should be placed in a gallon of a 2i-per-cent solution of bichi-omate of potassium. This must be chauged daily for a week, then twice weekly for a fortnight; then it should remain in the solution for three or four months, a few crystals of thymol being added. After about three months place the brain in 95-per-cent alcohol. In a few days it will be ready for cutting. Or for per- manent or temporary use the Ijrain may be placed in a 4-per-cent solution of formalin. Later it nuiy be changed to alcohol or Miiller's fluid. In cutting the fresh or i)reserved brain for the purpose of locat- ing gross lesions, remove the pons, medulla,, and cerebelhun, place Fio. 10:{. — Showixo the Points at wnicn the Sections are Made. l''rciiliini, o; C, throiiKh suiierior preocntral and lowiT end of Rolandie fissures; D, throti;;!) re and |K>8terir>r end of Sylvian flssurrs; /^ tliroufrh aii(;nlar pynis and anterior occipital fissure; /•', tlirou^li iiarieto-occipital (1s>iun\. J! sliould be about lialf-way between -I and C ; K lialf-way between D and F. (See FiKa 101-106.) 382 DISEASES OF THE XERVOUS SYSTEM. the braiii on its base, and make sections in accordance with the directions (Fig. 193). The sectional views exposed are shown in the following series of cuts, which are based ujion those of Exner. Fig. liH. — Sectiok through Line A, I'ig. 193. Fig. 195.— Section throi-gh Line B, Fig. 193. ANATOMY AXD PHYSIOLOGY OF THE BKAIX. 383 Fig. 190. —Section through Line C, Fio. 193. Fio. 11(7.— Skction Tiiii(ir(iii Link />, Im. 10;i 384 DISEASES OF THE NEKVOUS SYSTEM. Fig. 198.— Section through Line E, Fig. 193, fto, 199.— Section through Lnra F, Fig. 193= CHAPTER XVm. DISEASES OF THE BRAIN AXD ITS MEMBRANES. General Symptoms. It will add to the intelligibility of descriptions of brain diseases and their symptoms if one first makes himself familiar with certain general symptoms that underlie more or less nearly all organic dis- orders of this organ. Symptoms due to disease of the brain may be placed in four classes : first, general symptoms of brain irritation ; second, general symptoms of brain presssure; third, symptoms of focal irritation or destruction ; and, last, those due directly to the pathological process itself. The symptoms of brain irritation are headache, vertigo, vomit- ing, photophobia, mental irritability, insomnia, peculiar feelings of fulness and pressure about the head, noises in the ears or in the head, tenderness about the scalp, and in severe cases convulsive symptoms and delirium. The symptoms of brain compression are headache, vomiting, mental hebetude or dulness, perhajjs sonio form of paralysis, con- tracted pupils, and eventually coma. "With this there are often constipation and retracted abdomen. The symptoms of brain irritation are often, perhaps usually, as- sociated with a hyper£eniia. The symptoms of brain compression may be associated with ansemia or oedema, and often in states of malnutrition in which the brain is impoverished the symptoms re- semble much those of compression. Bressure symptoms and irrita- tion symptoms often lap one into the other and they cannot always be sharply distinguished. Focal symptoms depend almost entirely upon the location of the particular lesion. If it is in a motor area, focal syniptoms of irrita- tion would be spasmodic phenomena, sucn as convulsions. If tlie iesion were destructive, the symptoms would be those of paralysis or anjcsthosia. The symptoms due directly to the patiiological process itself may be very slight. Thus in case of a tumor of the brain the symptoms are mainly caused by ])n'ssure, irritation, and local disturbance of cer- tain sjjccial parts of tlio brain. In supj)uration, however, the proc- 386 DISEASES OF THE NEKVOLS SYSTEM. ess itself may produce genera] symptoms such as are associated usually with sepsis — chills, irregular fever, mental hebetude, pros- tration, emaciation, and sweats. Among the symptoms produced by focal lesions there are a few which deserve some preliminary general stud}', because they may be caused by lesions of very different kinds and occur consequently in very different forms of diseases. Those symptoms which we wish particularly to study here are hemiplegia and aphasia. These represent the two great dominating symptoms pertaining on the one hand to motor disturbance and on the other hand to sensori-motor disturbance. Hemiplegia. — Hemiplegia is a paralysis of one half of the body involving the side opposite the lesion. The face, arm, and leg are usually all paralyzed; the arm most, the leg next, the face least. Hemiplegia may be either acute in onset or slow and progressive. Acute hemiplegia is the result usually of hemorrhages and soften- ings of the brain, more rarely of inflammations and injuries. Pro- gressive hemiplegia begins gradually, as its name implies, and slowly increases until the height of the disease is reached. It is usually caused by tumors growing in one side of the brain, but it may be caused by a slowly developing patch of sclerosis, which sclerosis may be in turn only a part of a multiple sclerosis. Further description of the peculiarities of hemiplegia will be given under the head of Special Diseases of the Brain. Aphasia. — Aphasia is a disorder of the faculty of language; and it has a number of varieties, in accordance with the particular part of the brain involved and the particular portion of the mechanism of this faculty that is destroyed. By the faculty of language we include the processes by which we hear, see, and at the same time appreciate the meaning of symbols. It includes also the faculty of expressing to others by voice, writing, or gesture our ideas. It has therefore a receptive side and an emissive side. We may have lesions in the brain which destroy that part of the language faculty concerned in our power of seeing and understanding written words or the gesture language. In reading understandingly one sees certain words; these words revive certain visual memories con- nected with past perceptions. Thus one sees the word "book;" this suggests to him past memories of form, color, tactile and other sensations associated with the past perceptions of books. There is a certain centre in the brain w^here these visual memories for letters and words are located. When this centre is destroyed the memories are destroyed and the word "book" or any other written word conveys no meaning. The patient can spell out the DISEASES OF THE BKAIX AND ITS MEMBRANES. 387 letters, he can see the letters, but he cannot read any more than if he had never been taught. The condition is known as alexia or word hlindness. Again a person may have learned to associate certain gestures with definite ideas, as the motion of carrying a glass to the mouth with that of drinking, or the motions of using a knife and fork with that of eating, or the motions of the deaf-and-dumb alphabet "svith certain words and ideas. These memories of gesture language are located in certain regions, and when they are destroyed the patient is no longer able to understand gestures or the sign lan- guage. This condition is known as sign blindness. When a person is not able to understand the significance or uses of things about him, he has upraxla. Apraxia, sign blindness, and alexia all come under the general head of vilnd blindness, because, though the patient can see, he does not imderstand what he sees. A person hears certain words, as, for example, the word "knife." This con- veys to him a certain idea of the form, color, and other properties associated with knife. The memories associated with the auditory perception of dilferent words are stored up in a certain locality which is the centre for auditory memories. When this centre is destroyed the person hears spoken words, but they convey to him no meaning. All that is said to him sounds as if it were in a for- eign language : he hears, but he does not understand. This condi- tion is known as v-ord deafness. So much for the receptive or sen- sory side of language. In communicating our ideas, we speak, write, and make ges* tures. In speaking we make use of tlie oigans of articulation, and this use involves the fine adjustment of a delicate nuiscular appa- ratus. In the act of expressing ideas we have to bring into play the memories of the past muscular movements of this articulatory mechanism. These movements were Jearned by a slow and painful l)rocess during infancy. After the power of speech is acquired, the mechanism works readily and almost automatically, because we only have to send a stimulus to the centre which presides over the stoved- up memories of the imimlses to innervate jjrojierly the mechanism of speech. There is, therefore, a centre for the memories of the movements of articulation — a centre wliich is of course closely con- nected with tliei motor areas that directly innervate the larynx, pharynx, and oral and facial muscles. When a lesion destroys this centre for speech memories, a person is unable to reproduce the words necessary for expressing an idea; for example, he sees a kuife, he knows what it is, but the memory of the motions neces- sary to express the word " knife" is gone. To him it seems that the name is gone, and that is the common way of expressing it. 388 DISEASES OF THE XERYOUS SYSTEM. He cannot say the word " knife. " Tlie patient may wish to express the idea of pain. He feels the pain, he knows that he has pain, but he cannot revive those motor memories which are concerned in expressing the word "pain;" he cannot tell, therefore, in words what is the matter with him. When a person is thus troubled, he is said to have a form of motor aphasia for which the particular name given is aphemia. In the same way there is a centre for the memories of the muscular movements concerned in writing; and when a lesion destroys this centre the patient is unable to write, though he may be able to speak. This condition is called af/raj^hia. There is a centre, less well defined, for the memories of the move- ments used in gesture language, and when this is destroyed the person is unable to express his ideas by gesture or sign language. This condition is known as amimia. Tn some cases, patients are able to speak and write, but they skip words, repeat often, and talk confusedl}'. There is here a lesion of the tracts associating the lan- guage centres, and tlie condition is called conduction aphasia, while to his stumbling speech the texm. jxi rap ha sia is given. In attempting to classify these various aphasic conditions we group together as much as possible those symptoms which we know are related to rather definite areas of the brain. The divisions are based on symptoms, yet each symptom group has an anatomical seat which in many cases can be exactly determined. The following are the principal forms of aphasia: Auditory aphasia. TUT 4. 1 • i aphemia. Motor aphasia, -j ^^^^^^^^^ Visual aphasia. Conduction aphasia. Mixed aphasia. Each of these forms has certain subdivisions of which the analy- sis and recognition are matters of great interest, but I shall only suggest the lines along which such investigations are pursued. The excessive use of diagrams has filled up literature with exceptional cases and impaired the clearness and sense of proportion with which the clinical pictures of aphasia should be presented. No doubt, however, the ultimate result will be useful. In the examination of a case of aphasia, the following twelve questions should always be put to the patient: 1. Can he hear sounds? 2. Can he hear spoken words? 3. Can he understand the words spoken? 4. Can he see objects? DISEASES OF THE BRAIN AXD ITS MEMBRAXES. 389 5. Can lie see words written or printed, and read them silently? 6. Can he understand written or printed words, i.e., can he read intelligently? 7. Can he speak voluntarily? 8. Can he repeat words? 9. Can he read aloud? 10. Can he write voluntarily? 11. Can he write to dictation? 12. Can he copy ? In auditory ajjhasia, the principal symptom is that the patient has word deafness. He is unable to ujiderstand spoken language, though he hears the sounds and is not at all deaf. The lesion is in the first and second temporal convolutions of the left hemisphere. ^Vhen the lesion is extensive, the patient has many other aphasic symptoms, because all speech centres are closely united functionally. Visual, auditory, and articulatory memories are brought into play together, and form a kind of internal language circuit around which the nerve impulses jjlay in the production of speech. If now a pa- tient has an auditory aphasia with deep and extensive injury of the temporal lobe, it will be foiuid that he cannot understand spoken words, neither can he read intelligently. He cannot repeat words or read aloud, and he cannot write to dictation, nor copy. He can speak voluntarily, however, but he skips words and is paraphasic. This form is called cortical sensory aphasia (Wernicke). If the lesion is smaller, or if the case improves and the injured tissue to some extent heals, it will be found that the patient still has word deafness and cannot repeat words or write to dictation ; but he can talk and read and write voluntarily. This forms a subcortical aphasia. In motor aphasia or aphemia the principal symptom is that the patient cannot speak voluntarily, he cannot repeat words or read aloud. He cannot write voluntarily or to dictation, but he can copy. He hears, sees, understands both written and spoken language. This is the most common type of aphasia and its seat is known to be in Broca's convolution, i.e., the third left frontal. In its com- pleter type as given ?bove it is called cortical motor aphasia, but this means nothing. In severe cases, the patient cannot read un- derstandingly except to a limited extent and the power of under- standing spoken words is also impaired. On the other hand, ia ligliter forms the patient can read and write and understand, and has lost only the power of voluntary speech, of repeating words and reading out loud. Ayrapliia is a symptom of nearly all the forms of apha.sia. It 390 DISEASES OF THE NERVOUS SYSTEM. is oftenest seen in aphemia and is most complete in this type. There is no form of aphasia, however, in which agraphia is the onljf symptom, and the evidence of a writing or graphic centre in the cortex is not proven, though it is probable. Visual I'jthasla is accompanied by an inability to read "words understandingly, though the patient can see them. He is able to speak and understand spoken words. Alexia is thus the character- istic sj-mptom. There are often hemianopsia and some hemiataxia or anaesthesia. Two principal forms have been described. In one there is considerable agraphia, as well as inability to read either silently or aloud. Here the lesion involves the cortex of the angu- lar gyrus and supramarginal lobule (cortical alexia). In the other form, the patient has a pure alexia, and can write though he cannot copy. There is usually hemianopsia present. The lesion here is in the subcortical substance of the angular gyrus. Conduction and Mixed Ajihasla. — There are very few cases of pure conduction aphasia. When it occurs there is paraphasia and paragraphia; the j)atient repeats words over and over in a kind of verbal intoxication, or mixes things so that the speech is almost gib- berish. Still he can express himself and can write, read, and understand. The lesion is usually in the island of Reil or the con- volutions about the lissure of Sylvius. Practically conduction aphasia is usually mixed with a visual or auditory aphasia. Malp^okmatioxs of the Bkaix ax"d its Envelopes. Congenital malformations of the brain are of little practical im- portance, for in most cases the monsters cannot live and in all cases they are better dead. I shall simply give a brief enumeration of the important forms. f Anencepbaly. Abnormal i t i e s J Micrencephaly and microcephaly, of the brain. 1 Porencephalj. (_ Absences or malformations of parts, e.g., cyclopia. Abnormalities f Acra^ia. of brain and \ ^lenmgocele its envelopes. | Encephalocele. * (^ Hydrencephalocele. Anencephaly is always present with acrania. In anencephaly the cerebellum and part of the basal ganglia may be present. In such case the child can live a short time (Fig. 200). Mlcrence^ihaly and Microcephaly. — Micrencephaly is a condition in which the brain is only partially developed. If, as is usually the case, the cranium is also abnormally small, it is called microcephaly. It is due, probably, in all eases to an inherent defect in the growth DISEASES OF THE BKAIK" AXD ITS MEMBRA XES. 391 of the brain. Yivchow lias asserted, however, that there is a fonii in -which the abnormality- is caused by a premature growing together Fifi. 2(10.— ACKANIA. of the cranial bones, a micrencephaly being a result of the mechani- cal condition. An adult cranium whose gross circumference iiieas* I'm;. :.it|.— CvfUiPiA. ures less than 4.3 cm. will contain a inicrencephalic brain. The normal miniinuin weiirht of the a(hilt brain is \H'A) grams for mau 392 DISEASES OF THE NERVOUS SYSTEM. and 880 for -svoman. It should bear the ratio to the body at birth of 14 per cent, and of 2.37 per cent in adult life (Vierordt). Porencephaly is often an artificial condition. It will be de- scribed later. In cyclopia there is an undivided anterior cerebral vesicle ; the orbits form a continuous cavity with a single rudimentary eye (Fig. 201). Meningocele is a hernia of the brain membranes, arachnoid, and dura mater through a cleft in the skull. In encephalocele the brain also protrudes. Both these forms occur usually in the occipital region and almost invariably in the median line. In hydrencephalocele there is a sac with fluid contents. Diseases of the Membranes op the Brain. The diseases to be considered under this head are anaemia and hypersemia, inflammation of the dura mater or pachymeningitis, and inflammation of the pia mater or leptomeningitis. Anemia axd Hyper.emia op the Membranes op the Brain. — Anaemia of the membranes of the brain is a condition that cannot be separated from anaemia of the brain substance, and will be considered in connection with it. Hyperaemia of the brain membrane, so far as it relates to hyperaemia of the pia mater, must also be considered in connection Avith hyperaemia of the brain tissue. Dural hyperaemia, or congestion of the dura mater, is a condition which occurs as the result of injuries, sunstroke, and of certain in- fective poisons, especially that of syphilis. The symptoms are those of pachymenl/.gitis of the slight grade, and will be described under that head. They consist mainly of pain, occasional attacks of vertigo, and sensations of fulness about the head. The treatment is that for the beginning stages of a meningitis. Inflammation op the Dura Mater or Pachymeningitis Externa. — It has been the custom to describe two forms of pachy- meningitis, the external and the internal. Internal pachymenin- gitis, or haematoma of the dura mater, is properly a hemorrhagic disorder, and is described under the head of Dural Hemorrhages. A true inflammation confined to the internal surface of the dura alone is of extremely rare occurrence. Pachymeningitis externa is a disease that involves, at first at least, the outer surface of the dura, and is usually of surgical origin and interest. Etiolorjy. — Accidents, injuries, caries of the petrous bone in mastoid disease, of the ethmoid bone in ozaena, necrosis, syphilis, and erysipelas are the usual causes. DISEASES OF THE BRAIN AND ITS MEMBRANES, 393 The symptoms are local headache, fever, delirium, sometimes even convulsions and paralysis. In the severe cases the disease has usually extended and involved the pia. Pus is generally formed, and burrows between the bone and dura. The disease is recognized mainly by the discovery of the local cause. The course is acute or subacute. The treatment is a surgical one. Inflammation of the Pia Mater, or Leptomeningitis. — In- flammation of the pia mater has the following types : simple menin- gitis due to some infection, epidemic cerebro-spinal meningitis due to a specific general infection, tuberculous meningitis, serous menin- gitis, and syphilitic meningitis. Most of all these forms of meningitis may be either acute or chronic, the chronic form being usually simply a sequela of the acute. Acute Simple Lkptomenixgitis — Etiolorjy Acute lepto- meningitis is always due to an infective process reaching the cere- bral membranes usually directly from without, but sometimes through the blood. Trauma, and especially acute alcoholism pre- dispose to this. The most common source of infection is disease of the middle ear and mastoid cells. Disease of the frontal sinuses and upper nasal passages; operations on those parts; disease, in- juries, and fractures of the cranial bones — are also common causes. Pneumonia is the most frequent infective disease in Avliicli the pyo- genic organisms are carried by the blcod. After this come pyaemia, septicaemia, variola, scarlet fever, more rarely endocarditis, empy- ema, rheumatism, measles, typhoid fever, and mumps. Occasion- ally a brain abscess reaches the surface and sets up a meningitis. Insolation can of itself not cause it. The disease is more frequent in males, and is distributed through all ages of life, though it oc- curs oftencr in the young. Sijmptonis. — The symptoms in the various types differ somewhat, but have a general similarity. They are to be broadly grouped into the prodromal, the irritative, the depressive, and the paralytic stages. Prodromal symptoms are shorter and less marked in simple men- ingitis than in tubercular. The patient suffers from malaise, languor, headache, vertigo, irritability, loss of appetite, and vomit- ing. Of these symptoms headache is the most notable. In the second stage the dominant symptoms are lieadache, de- lirium, rigidity of the neck, hypericsthesia of the skin, retraction of the abdonuMi, vomiting, irregular fever, contracted and often un- equal pupils, sometimes optic neuritis or retinitis. The headache 394 DISEASES OF THE NERVOUS SYSTEM. is usually persistent, with exacerbations of great intensity. Kathei early in this disease the patient's mind begins to -wander; he mutters incoherently; he may have periods of violence alternating with stupor. In some cases there is a continuous low muttering delirium. Vomiting also occurs early and is of a violent, explosive (projectile) character. This symptom is not always present. The head is bent back and the patient can be lifted from the pillow by jjlacing the hand under the occiput. There is sometimes a general rigidity which resembles catalepsy. Drawing a dull point along the skin causes a red line to appear (taclie cerehrale). Pinching or rubbing the skin causes much pain. The abdomen falls in and assumes a characteristic "boat shape." The pupils are usually contracted and uneven. The eyes are intolerant of light. Optic neuritis occurs often when the inflammation is at the base, but it is a late symp- tom. Convulsions and local paralyses of the cranial nerves, causing slight strabismus, ptosis, or facial palsy, may occur. The fever is irregular in course and not high — 101 "^ to 103°. The pulse is usually irregular or rather intermittent. It varies greatly in fre- quency and may be rather slow — 50 to 70. Eespiration is rather quickened and sometimes irregular. The bowels are constipated; the urine is small in amount and sometimes albuminous. In the paralytic stage the patient becomes stupid or comatose; there is still some rigidity, except in the very last stages. The abdomen is still greatly retracted, the pupils may now dilate, the skin become moist, and the patient's bowels and bladder move involuntarily. Death then occurs in one or two days as a .ule. When the disease is mainly on the convexity of the hemispheres there are more delirium, convulsive and paralytic troubles; when confined to the base there is less delirium, while paralysis of cranial nerves, optic neuritis, vomiting, and retraction of the head are com- moner or more prominent. Course and Duration. — The disease may begin suddenly, and the patient pass at once into the comatose state, dying in a few days. Usually the process lasts one or two weeks; it may be prolonged for several weeks. The x>i'cfjnnsls is very grave, but it is less serious than in tuber- culous meningitis and more serious than in the cerebro-spinal form. Tke dlarjuos'is is based on the presence of an exciting cause, such as disease of the ear or nose, trauma, infective fevers, and upon the presence of the symptoms given. It is usually easily recog- nized, the main difficulty being to distinguish, it from tuberculous and cerebro-spinal meningitis. To assist in diagnosis it is permissible to make a lumbar punc- ture, draw off the fluid, and examine it for bacteria. DISEASES OP^ THE BRAIX AXD ITS MEMBRANES. 305 T^dfJinJn'iif. — The disease is a fibi'o-])nnilent or imiulent inilam- mation. It involves usually the base more than the convexity, but the reverse may happen. The ventricles are often involved and may be independently inflamed. There are descriptions, therefore, of simple basilar meningitis, meningitis of the convexity, and ven- tricular meningitis or ependymitis. The inflammatory deposits are most conspicuous along the course of the Sylvian lissin-e and the vessels branching from it, about the optic chiasm, and at the pos- terior and under surface of the cerebellum and the sides of the pons. It may lie only in the subarachnoid cavity, but usually the aradi- noid and sometimes the dura are implicated. There is increase of fluid in the ventricles and arachnoid cavities, and this fluid may be turbid. The surface of the ventricles may show an inflammatory process. The micro-organisms found in meningitis are the pneimDococcus, streptococcus pyogenes, intracellular diplococcus, the pneumo-bacil- lus, and a bacillus resembling that of typhoid fever. Still others have been described, and the process is apparently a mixed infec- tion, though the pneumococcus is found oftenest. Treatvient. — Prophylaxis is the most important measure, as there is no specific treatment. Chronic disease of the ear and nasal sinuses should be attended to, and injuries of the skull treated with the strictest regard to antisepsis. The patient should be kept quiet, a dose of calomel given, and small doses of iodide of potassium ad- ministered at frequent intervals. An ice cap may be applied to the head and hot applications to the feet. Hot poultices along the upper spine are useful. Opium must be given for the pain, if needed; and antipyretics or phenacetin sometimes answer, in a measure. The internal use of iodoform has been highly recom- mended, gr. vi. to gr. xij. daily; shaving the head and rubbing upon it an ointment containing twenty per cent iodoform, then cov- ering the scalp with an oiled-silk cap, is a treatment highly spoken of. Surgical intervention is sometimes justitiable. Epidkmic CKiiP:Bi{o-SpixAL Mkmx<;itis (8roTTKi> Fevkk). — This is an acute infective disorder and is produced by a special micro-organism. It has certain peculiar clinical characteristics which lead us to describe it separately. Anatomically the changes involve the spinal membranes as well as the cerebral. Etlolof/jf. — The disease most frequently attacks children, but it may occur at any age. Males are affected rather more often than females. It prevails in the form of epidemics which alTcct cold and temperate climates especially, and which travel from one part of the country to another. It may occur si)oradically. It most frequently develops during the winter season, and attacks persons who are 396 DISEASES OF THE NERVOUS SYSTEM. living in crowded houses, tenements, or barracks. It is slightly- contagious. One attack does not confer an immunity against a second. Siimptoms. — The general appearance of a person attacked with the disease is that of one Avho has been poisoned by some agent which is extremely prostrating to the whole system and at the same time one which has a specific inflammatory effect upon the meninges of the brain and spinal cord. When the disease is rapid and ma- lignant, the patient seems to die of an acute toxaemia before any inflammatory process has time to develop. In milder cases and those of longer duration the prostration is less, and the evidences of inflammation of the meninges then develop in the typical way. The disease may begin with prodromal symptoms of malaise, dis- comfort, pain in the neck, vomiting, and headache. As it develops, the headache, accompanied by giddiness, increases, pain and stiff- ness in the neck become more marked, pains run down the back and radiate to the limbs ; there is photophobia, and delirium in many cases is present. The skin is hyperaesthetic ; the pulse rises to 120 or higher; the temperature varies very much and is usually raised to 103°, 104°, or even more. The bowels are generally constipated. In most cases there develop certain skin eruptions, usually in the form of purpuric spots; herpes, urticaria, and erythema are occa- sionally seen. These eruptions vary very much in different epi- demics ; the purpuric spots are the most important from a diagnostic point of view, and have given to the disease the name of spotted fever. As the disease progresses the symptoms of irritation and pain give way to those of somnolence, stupor, and paralysis. Optic neuritis, acoustic neuritis, and inflammation of other cranial nerves take place, and paralyses of the limbs may be added. The disease may run a short and malignant course, killing the person in a few hours or one or two days. In moderate cases it lasts about two weeks. A large number of different varieties of the disease are described, such as the abortive form, fulminating form, and typhoid form. The disorder is often complicated with pneu- monia and bronchitis, less often with inflammation of the joints and serous membranes. The disease often leaves very serious sequelae, the most important being deafness and spinal irritation or chronic spinal meningitis. A large number of deaf mutes owe their afflic- tion to this disease. Patliolofjlcal Anatomy. — In the very acute cases the post-mortem shows nothing but the evidence of very severe blood-poisoning. In the milder and more chronic cases an inflammation involving the pia and arachnoid of the brain and cord is found. This inflamma* DISEASES OF THE BRAIN AXD ITS MEMBRAXE3. 307 tion is fibrinous or fibro-purulent in character, and may be accom- panied witli the exudation of a good deal of inflammatory material. Bacteriological researches show that this disease is due to the pres- ence of a specific micro-organism which is apparently very much like that which causes pneumonia. The diagnosis is based upon the history of an epidemic of the disease being present, upon the presence of the ordinary symptoms of acute cerebral and spinal meningitis, such as headache, delu'ium, retraction of the head, the sunken abdomen, hypersesthesia, and pains; finally, the presence of the peculiar purpuric spots or of herpes of the face will enable one to make a positive diagnosis. One must learn to distinguish the disease from typhus, tetanus, uraemia, pneumonia, and from the other forms of meningitis, espe- cially the tuberculous. The diagnosis is often made difficult by the fact that cerebro-spinal meningitis may occur in a sporadic form, and it is well known that after a community has been ©nee visited by an epidemic these sporadic cases are apt to crop up from time to time for many subsequent years. The sudden onset of the dis- ease, the spinal symptoms, the skin eruption, the absence of his- tory of injury or of evidence of tuberculosis will usually enable one to recognize the disorder. Lumbar puncture may be used. T\\e 2))'offnosis varies much with the epidemic, but the disease is always a serious one. The mortality ranges from twenty to eighty per cent; it is worse when the disease comes on suddenly and severely, with early coma. It is better in persons over the age of ten. Cranial-nerve complications are unfavorable, in that they are apt to leave permanent deafness. Severe spinal complications are apt to leave their mark in the form of a chronic meningeal trouble. Treutmevf. — There is no specific remedy for the disease, and the ordinary antiphlogistic measures such as mercury and iodides are of less value than in other forms of meningitis. The patient should be given sustaining food, and everything possible should be done to counteract the depressing effects of the toxaemia. Opium or mor- phine internally, chloral, digitalis, quinine, benzoate of sodium and salicylate of sodium, and alcohol are the di-ugs which have been spe- cially recommended. Warm baths, hot moist applications, and loeclies have all been tried with more or less good results. Tuberculous Mexingitis (Acute IIyduocephalus). — This is a form of meningitis due to infection with the bacillus tuberculosis. It diifors pathologically from other forms in the character of the infective organism; anatomically, in the fact that the inflammation is usually and chiefly basilar and never purely purulent; etiologi- 398 DISEASES OF THE XEllVOUS SYSTEM. cally, in that it chiefly affects young ehikiren ; and symptomatologi cally, in the presence of pvodroniata and a more irregular course. Etlolofjij. — Tuberculous meningitis occurs chiefly between the ages of two and ten, sometimes in infancy, rarely in adult life, very rarely after the age of fifty. Males are rather more subject to it. A hereditary history of phthisis, a scrofulous diathesis, bad hygienic surroundings, and the presence of tuberculosis elsewhere in the body predispose to it. Tuberculous milk, the eruptive fevers, especially measles, blows on the head, and great emotional excitement appear to act as exciting causes. Symptoms. — A knowledge of the prodromal symptoms is espe- cially important. These are paroxysmal and intensely severe head- aches and darting pains in the head, vertigo, loss of appetite, ex- plosive vomiting without nausea, the vomited matter being usually colorless and watery, constipation, an altered disposition, and irri- tability. The tache cerehrale or cerebral macule, more rarely ptosis and facial paralysis may appear early.* The prodromal stage often lasts, with remissions, three or four weeks. When the disease sets in there is more persistent headache ; vomiting, fever, and the other symptoms of meningitis already described appear. The irritative stage gradually passes into the paralytic and comatose. Death occurs in two or three weeks. In infants the disease often runs a very obscure course, the patient showing chiefly symptoms of brain compression. Pathological Anatomy. — In rapidly fatal cases, with severe symp- toms, there may be only an intense congestion of the brain with numerous miliary tubercles in the pia mater at the base and over the convexity. Here we must assume that a bacillary toxin causes the symptoms. In most cases there are decided deposits of tubercles at the base, with fibrinous inflammatory deposits about the optic chiasm, along the fissure of Sylvius, at the sides of the pons, and elsewhere. Miliary tubercles are seen scattered over the convexity and in the choroid plexus and ventricles. They are gen- erally found in the spinal membranes also, especially over the cauda equina. The tubercles lie beneath the pia surrounding the small vessels. They may coalesce into large tuberculous nodules. There is usually an increase in the arachnoid fluid, and in most cases an increase in the ventricular fluid. Somewhat rarely there are very great distention of the ventricles and compression of the convolu- tions. This condition used to be called acute liydroceiolialus. Small spots of softening may be seen from obliteration of the vessels by the tubercles. The bacillus tuberculosis is found in the tuberculous nodules. DISEASES OF THE BRAIX AXI) ITS MEMBRANES. 309 Diagnosis. — As regards the form of the disease, this is based on the hereditary history, the age, the existence of tuberculosis of the lungs or other organs, and the peculiar prodroniata of the disease. Occasionally tubercles can be seen on the choroid. Lumbar punc- ture of the spinal canal with withdrawal of fluid and its examina- tion for bacillus is a method of diagnosis which may be tried. Prognosis. — This is usually absolutely bad, yet post-mortem ob- servation of patients dying with practically no inflammatory change makes it seem possible that the disease might be checked, and a good many cases are reported in which it apparently has been done. Some of these are, however, probably cases of hereditary syphilis. Treatmejit. — So far as is now known, this is not different from that given under the head of meningitis elsewhere. It seems, however, as if in time some antitoxin may be discovered which will check the progress of the poison and the development of the tubercle; meanwhile the best thing to do is to give small doses of iodide of potassium at frequejit intervals and use symptomatic treatment. Chronic Hydro* ki-ualus. This is a disease mainly of infancy, characterized by a gradual enlargement of the head, with mental deficiency and sj'mptoms of brain irritation caused by an accumulation of fluid in the ventricles of the brain. The old term, "acute hydrocephalus," meant an acute inflamma- tion with effusion, but the name is not needed and is best dropped. Chronic hydrocephalus is not an inflammatory process, but one due to mechanical causes or to defects in structure or nutrition. The fluid always accumulates in the ventricles of the brain; hence chronic hydrocei)halus is always internul. The so-called external fro,7//o.s/.s- is bad when the disease has become well developed 404 DISEASES OF THE NERVOUS SYSTEM. and when decided coma and rigidity have set in. A prognostic criterium which I have long used and which is fairly accurate is this : if the patient has not a stiff neck he will get well, but when stiff neck comes on the patient dies. The treatment of the disorder should be instituted at tne very beginning. If there are still any relics of the debauch, as shown in the condition of the stomach or intestinal tract, the stomach should be washed out and, at all events, a thorough purge should be given. The patient should tlien be fed most liberally with hot milk given every two hours j beef tea and an ^^^ beaten up in milk may also be given, but the condition of practical starvation on the part of the patient should always be borne in mind. Stimulants in the shape of whiskey should not be administered if it is possible to avoid it, but strychnine in doses of one-sixtieth of a grain every two hours is often useful. An ice cap should be applied to the head and at times leeches or large blisters seem to be useful applied to the back of the neck. The patient, however, should not be much depleted. Wlien he becomes comatose it means that the ventricles and arach- noid cavities are becoming filled with water. At this time tapping the spinal cord may be tried. I have done this in a number of cases and have at times removed two or three ounces of fluid with some amelioration of the symptoms and never any bad results, but the measure has never been tried early on promising cases and I have never seen it do any permanent good. CHAPTER XIX. DISEASES OF THE BRAIN. These diseases, like those of other parts of the nervous system, consist of malformations, vascukir disturbances, inflammations, softenings, hemorrhages, degenerations and scleroses, chronic infec- tions, tumors, and functional disorders. Cerebral nYPER.EMiA is a condition in which there is an exces- sive amount of blood in the cranial cavity; it may be acute or chronic, active or passive. Etiology. — In the description which is to follow I shall refer only to those conditions of hypersemia of the brain which are patholog- ical. It is a well-recognized fact that hyperaiiuia of the brain occurs physiologically under excitement and overactivity of the heart and from various stimuli; but a pathological condition of acute congestion may be induced by sunstroke, certain drugs such as alcohol, and by injuries; also by mechanical causes which pre- vent the exit of the blood from the cranium. An acute congestion also occurs in mania and in many forms of fevers, as Avell as in the initial stage of meningitis. A chronic cerebral hypercemia may be induced by the causes already mentioned as bringing on acute con- gestion. The prolonged use of alcohol, prolonged mental excite- ment, overwork, and worry may also lead to this condition. The foregoing causes lead to what is known as active congestion, in which the blood is driven in excess into the brain through the arteries. A passive congestion may exist in which the blood is pre- vented from leaving the brain and is kept mainly in the intracranial veins. The causes of passive congestion are chiefly mechanical, such as cardiac disease and mechanical obstructions about the neck from tight clothes, and an obstruction to the flow of blood from the lungs by playing on wind instruments. Si/i/ijdoms A great deal has been written regauling the symp- tomatology of cerebral hyperajmia, but many of the statements made are nothing but guesswork. Probably the main symittonis produced by an active congestion of the brain are a sense of fulness 40G DISEASES OF THE NERVOUS SYSTEM. and pressure, a feeling of constriction about the head, some head- ache which may be vertical, mental excitement or irritability, con- fusion of ideas, vertigo, insomnia, ringing in the ears, and pulsating sounds in the head. These symptoms are sometimes increased when the patient lies down, and are generally increased when the patient bends the head over so as to prevent the return flow of blood from the brain. It is impossible to diagnosticate passive hypersemia from active through the symj)toms alone, but probably in the former condition the disturbances and symptoms mentioned are less marked; in other words, an active hypersemia produces more phe- nomena than passive. In either case examinations of the fundus of the eye and of the tympanum furnish no sure criteria. PatJiolofjij. — Cerebral liyperaemia used to be regarded as nearly synonymous with cerebral neurasthenia. In the writer's opinion, it is secondary to the neurasthenic state, and is produced, if it exists in that state, by the impaired vasomotor innervation which is char- acteristic of neurasthenia. It is not wise, therefore, to make the diagnosis of cerebral hypersemia often as the primary condition. It is only after traumatisms and sunstroke or after a meningitis that we can speak of the cerebral hypersemia as being in a certain sense the primary condition to be treated. The statement made by some writers that cerebral hypersemia underlies certain conditions of acute delirium, of aphasia, of paralysis, and even dementia or in- sanity can hardly be supported. In umny of the cases of cerebral hypersemia, in wliicli symptoms are produced, there is imdoubtedly a condition of toxsemia which is a contributing factor to most of the symptoms. Treatment. — The specific treatment of cerebral hypersemia, when indicated, consists in giving large doses of fluid extract of ergot and bromide of potassium. One or two drachms of the ergot three times a day and fifteen or twenty grains of bromide of potassium may be prescribed. Wet cups to the back of the neck, the cautery in the same region, ice caps, purgatives, quiet and rest, and a care- ful regulation of tlie diet and the bowels are all important measures. Cekebkal Ax.emia. — This condition, like hypersemia, may be either acute or chronic. It occurs ainong the young; more often in females than in males. It is seen in early adult life, when it is induced by the various causes producing general ansemia, and again after the climacteric, when it is due to organic changes in the cerebral arteries of the nature of an obliterating endarteritis. Bright' s disease and syph- ilis, exhausting diseases and profuse hemorrhages, and such dis orders of digestion and nutrition as lead to general ansemia produce DISEASES OF THE BRAIN. 407 also cerebral anaemia. A potent cause of acute cerebral anaemia is fright. Symptoms. — The symptoms of acute cerebral anaemia are vertigo, confusion of ideas, nausea, faintness, or complete syncope. In chronic cerebral anaemia the symptoms are mental apathy and a feeling of disinclination to work, tendency to somnolence in the daytime and insomnia at night, mental depression, headaches which are usually frontal or vertical, occasionally some vertigo and tinni- tus. There may be spots before the eyes and undue sensitiveness to sounds. In children some very severe symptoms are attributed to cerebral anaemia, but here^ as in hypersemia, it is probable that there are other causes at work, particularly toxic agents or rellex disturbances. Diagnosis. — A chronic anaemia of the brain can hardly be recog- nized except through the evidences of a general anaemia. When this is present and there are also symptoms such as have been de- scribed, a fairly certain diagnosis can be made. We must look upon cerebral anaemia as being in almost all cases a secondary phe- nomenon, except in the aged, and then the trouble is due not alone to poverty of the blood, but to the fact that the circulatory appa- ratus is diseased. It is generally believed that in cerebral auaMuia tlie symptoms improve somewhat by the horizontal position and are made worse by the upright position. It is also asserted that in anaemia the pupils rather tend to be dilated, while in hypera^mia they are contracted. Treatment. —Treatment should be directed toward enriching the supply of blood and toward improving the general nutrition. It consists, therefore, in the administration of preparations of iron and of such tonics as the mineral acids, strychnine, quinine, and nitroglycerin. INFLAMMATION OF THE RTiATN. The forms of acute inflammation of the brain are acute suppura- tive encephalitis or brain abscess, acute exudative encephalitis with hemorrhage, and acute polio-encephalitis. The only important form of chronic inflammation is multiple sclerosis. Acute Sui'itijativk Exceimiamtis (Absce.ss of the Brain). Brain abscess is a suppurative inflaiiiniation which affects the parenchymatous and other structures ol the organ. It is always a focal disease, but may be single or multiple. 408 DISEASES OF THE NERVOUS SYSTEM. Etiology. — The primary cause of all forms of brain abscess is a microbic iufectiou. The form of microbe, its mode of eutrauce, and the part of the brain attacked vary greatly. The predisposing causes relate chiefly to age and sex. Brain abscess rarely occurs before the first year or after the fiftieth year of life. It is rather frequent in young people, and occurs on the whole oftenest between the ages of ten and thirty. Males are more often affected than females in the ratio of about three to one. The exciting causes are chiefly disease of the ear, of the nose, and of the cranial bones, injuries, and remote suppurative processes.* To this may be added infectious fevers and the presence of tumors. Chronic inflammation of the middle and internal ear is the most common cause of brain abscess, especially when that disease affects the tympanum and mastoid cells. Caries of the ethmoid and nasal bones and of the orbital cavity leads to brain abscesses in a consid- erable proportion of cases. After chronic ear and bone diseases in- juries are the most frequent cause. The injury may be a compound fracture with direct infection from the open Avound, or the abscess may be the result of contrecouji and may develop in a part of the brain opposite to that which was injured, or the abscess may develop below the point injured, there being apparently healthy tissue be- tween the surface of the brain and the diseased part. These ab- scesses develop through laceration of brain tissue and subsequent infection of the wound with organisms. The most common remote suppurative processes which are followed by brain abscess are tuber- culous inflammation of the lungs, fetid bronchitis, and empyema. Brain abscess may develop, however, from distant points of suppu- ration on the extremities or in almost any part of the body. Pyae- mia may lead to the production of brain abscess. Among the infectious fevers which are complicated with brain abscess are diphtheria, typhoid and typhus fevers, erysipelas, small-pox, the grippe. The oidium albicans or thrush may also be a cause. Brain tumors sometimes become surrounded by a suppurative en- cephalitis or may break down with the formation of mixed sujopura- tive and neoplastic tissue. Tuberculous tumors are most frequently accompanied by suppurative encephalitis. SijDiptoms. — Brain abscesses take sometimes an acute and some- times a chronic course. In acute cases the symptoms develop rap- idly and the disease runs its course in a few days or weeks. The symptoms come under the general head of those of pressure, those * In nine thousand consecutive autopsies at Guy's Hospital there were fifty-seven brain abscesses due to ear disease and one due to nasal disease (Pitt). DISEASES OF THE BRAIJT. 409 of poisoning from the diseased focus, and local symptoms due to iiritation or destruction of certain special areas of the brain. The pressure symptoms are those of headache which is often very severe and persistent, vomiting which is quite frequent though not invari- able, vertigo, and a condition of mental dulness which may pass into a delirium ending finally in coma. Optic neuritis often occurs. The pupils are apt to be irregular, but furnish no definite indica- tions. The pulse is usually slow, ranging from GO to 70, but it varies a great deal. The temperature is normal or subnormal as a rule, but this also varies, and it may rise several degrees above normal, always running an irregular coui-se. The toxic symptoms are those which we get in septic poisoning; namely, prostration, irregular fever, emaciation, anorexia, and such mental and sensory disturbances as have already been referred to. As a result of local irritation or destruction, tliere occur convulsions, paral3'sis, aphasia, and disorders of some of the special senses. Convulsions are not very common. "WTieu they occur they are generally of an epileptic character. The paralysis is usually in the form of hemiplegia. The cranial nerves are not often involved, if we except the optic. The urine is said to show a diminution in chlorides and an increase in phosphates. The patient dies finally in coma from exhaustion. In the chronic form of brain abscess the symptoms may for weeks, months, or years remain practically latent, after the exciting cause has been at work and after the abscess has been established. The patient during this latent stage may suffer from headache, ver- tigo, mental irritability, and depression; he may at times have a convulsive attack. Occasionally there will be an exacerbation of the disease, at which time he suffers from intense pain, vomiting, perhaps delirium or a con\n.ilsion. From this he recovers and con- tinues in a fairly good state of health again. After a variable period, usually of weeks or months, the terminal stage sets in. This terminal stage of the chronic form may assmue very much the characters of the acute fornx already described. In other cases it shows itself by a sudden apoplectic or epileptic seizure or a sudden attack of coma, in which the patient sinks and rapidly dies. These terminal phenomena are due to the fact that the abscess, which has been previously encysted and quiescent, suddenly breaks into a lateral ventricle or through the surface of the brain, or to the fuet that a hemorrhage occurs into the abscess. Cnnqjlic'itinns. — The common complications of brain abscess are a phlebitis of the superior petrosal and lateral sinuses and a meningitis. The phlebitis iircompames abscesses that are caused by disease of the ear. The meningitis may be caused by ear dis- 410 DISEASES OF THE NERVOUS SYSTEM. ease, but more frequently accompanies abscesses due to injury. When phlebitis is present there will be found an oedema about the ear and neck and a hardness of the jugular veins. In meningitis there is apt to be more rigidity of the neck, more pain, and there are often cranial-nerve paralyses. Pathologij. — Acute suppurative encephalitis resembles acute suppurative myelitis in the intimate nature of the changes that take place. There is an intense congestion of the parts, which gives it a reddened ajipearauce and which used to give to this process the name of red softening. This condition, however, is only the initial stage of the suppurative inflammation and does not deserve to be ranked as a special form of inflammatory process. It i^ possible that in some cases the inflammation may get no farther than the stage of red softening. The congestion then gradually disappears, absorption of exudate occurs, and a more or less complete recovery takes place. When the process continues, however, the parts be- come crowded with leucocytes and infiltrated with inflammatory exudate. The nerve fibres and cells are destroyed, in part mechan- ically, in part by the poisonous influence of the pyogenic organisms. The nerve cells lose their normal contours, swell up, and disinte- grate; the neuroglia cells absorb the broken-down detritus and swell up, forming what are known as granular corpuscles; the leucocytes increase until a purulent mass is formed. The total re- sult is a mixture of broken-down nerve fibres and cells, leucocytes, and granular bodies. Bacteriological tests show the presence of various pyogenic microbes. The abscess thus formed varies in size from one centimetre to six or eight centimetres in diameter (two- fifths of an inch to three inches). It is generally somewhat round, and if the case is chronic a fibrous wall is formed. It takes from three to four weeks for such a Avail to develop (Fig. 203). Brain abscesses are iisually single, occasionally there are two or three. In some conditions they are multiple; that is to say, there may be fifteen, twenty, or more. Multiple brain abscesses are always small and are usually due to pyeemic infection. Location. — Brain abscesses involve the cerebrum oftener than the cerebellum, in the proportion of about four to one (Barr). They occur rather oftener in the right cerebrum. They are very rare in the pons and medulla. The cerebral lobes oftenest affected are the temporal and frontal. In the cerebellum it is the lateral hemi- spheres that are most frequently attacked. The seat of the abscess has important relations to the cause. Abscesses due to ear disease are almost always either in the temporal lobe or in the cerebellum. If the ear disease is in the tympanum, the cerebrum is usually the DISEASES OF THE BRAIN. 411 seat of the abscess. If the disease is in the mastoid cells, the cere- bellum is usually 'the part affected. If the disease is in the laby- rinth, the abscess is also more apt to be in the cerebellum. This distribution of the seat of the disease is due to the anatomical rela- tions of the bony parts to the temporal lobe and cerebellum, respec- tively, l^rain abscesses due to injuries are more frequent in the frontal and temporal lobes. What are known as idioi)athic brain abscesses — that is, those which arise without any known cause — are Fin. :.'(i:j.— Ansf-Ess op CERF.nEi.i.fM. most frequent in the iiontal lobes. Tliis is because most such cases are due to an iinrecoL^uized aib'ctioii of the nasal cavities and ethmoid bone. J^rain abscesses due to suppurative jn-ocesses in the lungs and pleura are probably embolic; and, as the emboli are car- ried up into the middle c(>rebral artery, the brain abscesses liaving this origin are situated in the iield supplied by this artery. In children under ten, in whom brain abscess is usually duo to vav disease, the cerebellum is more apt to bo affected. Course. — Acute abscesst'S last from five to fourteen tlays, rarely over thirty days. Traumatic ca.ses run thu shortest course. Chronic abscesses may have a latent jjcriod of weeks, month.s, and in rare cases even one or two years. When terminal symptoms come on deatli occurs in a few days. In a lew cases brain abscesses 412 DISEASES OF THE NERVOUS SYSTEM. have been spontaneously evacuated through the nose. Aside from this, the termination is always a fatal one unless surgical interfer- ence takes place. There is sometimes a recurrence of the abscess after an operation. Dlarjnosis. — The diagnosis of brain abscess is based upon the history of injury, aural or nasal disease, remote suppuration, upon the general symptoms of sepsis, upon the presence of headache, vomiting, slow pulse, normal or subnormal and irregular tempera- ture, a local tenderness of the scalp and rise of temperature over Fig. 204.— Showing the Points where the Trephine is Usually Applied and the Re- lations OP the Sinus. The divisions on the lines indicate quarter-inches CLanceO. the seat of the lesion, hebetude, delirium, optic neuritis, rapid wast- ing, and diminution of chlorides in the urine. The diagnosis of the location of the abscess is based upon the history of its cause, whether from iiijury, ear disease, emboli from the lungs, or nasal disease ; also upon the presence of hemiplegia, local convulsions, tenderness and rise of temperature of a certain area of the scalp. As brain abscesses are apt to affect latent regions like the temporal and frontal lobes, local diagnosis is usually diffi- cult. The diagnosis must be made from tumors of the brain, men- ingitis, and jjhlebitis of the sinuses. The differential points are given under the heads of the diseases mentioned. The presence of leucocytosis helps in distinguishing the presence of suppuration. The jjror/nosis of the disease is absolutely unfavorable unless some surgical interference is resorted to. The few rare cases of spontaneous evacuation of the abscess would not lead to any prac- tical modification of this statement. DISEASES OF THE BRAIN. 413 Treatment. — The actual treatment of a brain abscess after it has developed is, as already stated, exclusively a surgical one. The successes so far have not been very great, but they have been suffi- cient to justify operation and to furnish greater hope for the future, when a more exact diagnosis can be made and a Avider surgical ex- perience has been obtained. The accompanying figure shows the points to be located in trephining for abscess from ear disease. Something is due to the patient in the way of prevention, especially in cases of persons who have chronic aural or nasal disease with carious processes. These should be carefully watched and treated. ACUTK EXUDATIVK ExCEPHALITIS OF THE GkAY MaTTER (Polio-Encephalitis) . Acute exudative polio-encephalitis is a disease which affects the gray matter forming the cranial nerve nuclei. It has two forms, polio-encephalitis superior, and inferior. Acute polio-encephalitis inferior is a disease which is strictly analogous in course to acute jiolio-myelitis. The special symptoms simply depend upon the peculiar location of the disease. They con- sist of an acute glosso-labio-laryngeal palsy, and are referred to under the description of bulbar paralysis. Acute polio-encephalitis superior is a disease in wliich the nuclei of the nerves supplying the eye muscles are involved ; it is also a disease analogous to polio-myelitis anterior, and has been described under the head of ophthalmoplegia. Acute cortical i)olio-encephalitis of children is a disease which, according to Striimiiell, involves the gray matter of the convexity of one of the cerebral hemispheres. It also is supposed to be strictly analogous to an inflamiiiatif)n of the anterior horns of the spinal cord. The real existence of this disease is still doubtful. Acute Exudativk En( kphamtis with ]h,MoiiUJiA(;K (IIk.mou- i:iiA(;ic Excei'HA litis). This is a form of encephalitis affecting diffusely various areas of the brain and characterized by intense congestion with capillary hemorrhages follow«'d by inflammation, never ending in suppuration and sometimes terminating in ])artial or complete recovery. Ef'iolofli/. — One of the principal exciting causes of this disease is probably the infection of influenza, but it also occurs in connec- tion with other infectious fevers, such as typhoid, tyjilnis, and ejti- demic cerebro-spinal meningitis. Tt has been known to follow malignant endocarditis and it occurs in connection with the inui- 414 DISEASES OF THE NERVOUS SYSTEM. peral state. I have seen a number of cases occurring as a result of acute alcoholism, although it is not impossible that there is a coin- cident infection. In about one out of ten autopsies on the brain of persons who have died from acute alcoholism, I have found large foci of hemorrhagic softening with evidence of inflammatory reac- tion about it. The disease occurs also after sunstroke. Acute hemorrhagic encephalitis, when due to infection, occurs most fre- quently in the young, that is to say, in persons under twenty, and more often in females than in males. Probably the increased sus- ceptibility of the young to the infectious fevers is the explanation of this. Si/niptotiis. — The disease begins rather suddenly and without notable premonitory symptoms. The patient is seized by head- ache followed by fever sometimes reaching 105^ F. This may be associated with vertigo, vomiting, photophobia, and delirium. The symptoms of irritation disappear and are followed by a condition of semicoma or stupor. The patient can generally be partly aroused, and he does not have the stiff neck or the small pupils of menin- gitis. The respirations are shallow and frequent, the pulse is rapid and feeble. As the disease progresses, the deep reflexes are diminished and later the sphincters may be involved. After the patient has lain in a semicomatose condition for several days, he may become less stupid and more irritable and restless; or after two or three weeks of comparative stupor he may begin gradually to improve and, in a few weeks mora, convalescence takes place. In some cases an epileptic convulsion may occur in the early part of the disease. Again, as the disease develops, aphasia and paralysis of the arm or leg, or hemiplegia, may appear. In accord- ance with the location of the inflammation, the patient may have disturbances in the motor sphere, or he may have hemianopsia, hemiataxia, or disturbance of the cranial nerves, such as nystagmus, or eye palsy, or difficulty in speech and deglutition. An optic neu- ritis may also occur. Course and Prognosis. — The disease is always serious but is not by any means always fatal. It may in its milder form run a course of two or three weeks, the patient gradually coming out of his stupor and making a slow recovery. In other cases the coma con- tinues to deepen and the patient dies of exhaustion, and in still other cases the disease passes into a chronic state in which he lingers for Aveeks and even months. Diarjnosw. — The disease in the young is probably more often mistaken for meningitis. It is to be differentiated from this by the sudden onset with coma, the absence of projectile vomiting, pin- DISEASES OF THE BRAIN. -il5 hole pupils, stiff neck, hyperaesthesia, and rigidity of tlie limbs. The presence of hemiplegia or local paralysis, or the occurrence of an epileptoid attack, "would point to encephalitis. The diagnosis from meningitis, however, cannot always be made. The previous occurrence of an attack of grippe in the young, or of exposure to the siui or acute alcoholism in the adult, M'ould lead to the probability of an encephalitis, provided the symptoms of meniugeal irritation could be excluded. Tuberculous meningitis can be excluded usually by the presence of premonitory symptoms and the absence of any tuberculous focus in the lungs or intestines. By the help of lumbar puncture fluid can be withdrawn from the spinal sac, and examina- tion of it might be of service in excluding at least tuberculous men- ingitis or a serous meningitis. Pathological Anatoiiuj. — The pathological process underlying this disease consists of an acute inflammation with intense conges- tion and numerous small hemorrhages and capillary emboli. There is some hemorrhagic exudation as well as infiltration of leucocytes, with a certain amount of softening of the cerebral tissue in the neighborhood. The parts most frequently affected are the semi- ovale, the temporal lobes, the base of tlie brain, and the corpus striatum. In four cases which I have examined, the process Avas in the temporal lobes, the parietal lob\de, the mid-brain, and the corpus striatum. If the process is a mild one, the hemorrhage and exudate are absorbed, and the injured brain tissue is gradually re- ■ placed by connective and neuroglia tissue. In this way small foci of sclerotic tissue are formed and the jiatient may afterward suft'er from symptoms due to this condition. In the severer cases the soft- ening becomes more extensive, larger hemorrhages occur, and in one case I have seen a massive apoplexy as the terminal stage. Trmtmmt. — The patient slujuld be kept quietly in bed and should be given an active jmrge. Calomel is usually cnqdoycd, but crt)ton oil has seemed to me to be nuich more eflicient as an eliniinative and counter-irritant. The kidneys should be kept active, an ice cap placed upon the head, and leeches placed at the back of the neek. The tieatnuMit alter tliis can bo only that of sedation and support. If the patient is stuporous, and has a high fever, small doses of aconite should be given. If he is asthenic, he should receiv(> strych- nine. Of course, the nourishment should be carefully attended to. and, if ho stiffers pain, he slmuhl have mor])hine. Chloral anl bromide seem to be the most efficient agents for relieving the reO- lessness and insomnia. 410 DISEASES OF THE N"ERVOUS SYSTEM. Multiple Sclerosis. ^[ultiple sclerosis is a chronic and progressive malady charac- terized b}' some paralysis, usually in the form of paraplegia, by coarse tremor, disturbances of speech, nystagmus, apoplectiform attacks, and various other cerebral and spinal symptoms depending upon the seat of the lesion. It is due to the development of sclerotic patches in the different parts of the brain and cord, which patches are for the most part the result of a neuroglia proliferation. The disease is probably an inflammatory rather than a degenerative one. It affects the spinal cord as well as the brain. Etlolofji/. — It occurs rather more frequently in the male sex and is a disease of the first half of life. Multiple sclerosis is in fact one of the few chronic nervous disorders of organic origin develop- ing at this time. Most cases begin between the age of twenty and thirty. Cases have, however, been observed in infants and chil- dren, but the trouble in its typical form does not appear in the de- clining years of life. The sufferers have often inherited a feeble power of resistance on the part of the central nervous system. But the disease is not directly hereditary. There can be no doubt that the most important of all of the few causes of multiple sclerosis is infection. This is so true that it may be called a post-infectious disease. The infectious disorders which are followed by sclerosis are typhoid fever, pneumonia, malaria, and the eruptive fevers. Among these malaria and typhoid are the more important. It has been known to follow also diphtheria, whooping-cough, erysipelas, dysentery, cholera, and even rheumatism. Besides infection, trauma and shock are rarer causes, and a malady somewhat resembling multiple sclerosis may follow sunstroke. Syphilis is rarely a cause. Sijtnptoms. — The disease begins insidiously. A. comparatively short time after recovery from malaria or some acute fever, the patient begins to suffer from weakness of the lower limbs with stiff- ness and some degree of numbness. The bladder is also a little weak, and it is difficult to retain the urine. In fine, the symptoms are very much like those of the onset of myelitis. Very soon the patient notices some unsteadiness in the gait, due not alone to weak- ness in the legs but to a certain degree of ataxia. He finds also that his hands are trembling and that this tremor increases upon voluntary motion. It is the type of tremor known as " intentional." He has at this time also some indistinctness in speech, it being difficult for him to enunciate long words. These come out in a slow, sylJah'io utterance, as it is called, each syllable being spoken sepa- rately. He may have also a little trouble in swallowing. By this DISEASES OF THE BRAIJf. 417 time he has had some sensation of numbness in the limbs, and some pains occasionally in the joints and extremities, but the sensory troubles are not very marked. If he is examined by a physician three or four months after the beginning of the malady, it will be found that the gait is stiff and awkward, the patient walking somewhat like a drunken man ; or, in other cases, it may simply be the stiff, weak gait of moderate paraplegia. The Romberg symptom Avill be found to be present to some extent. The knee jerks are exaggerated and ankle clonus may be present. The hands are unsteady, and the movements are characterized by a jerky tremor, which may be so great that the patient has difficulty in dressing and feeding himself. This tremor disappears almost entirely if the patient lies flat upon his back. If he sits up, however, it may be seen perhaps in the muscles cf the neck, causing the head to be oscillated, and constant, more or less regular tremor in the arms is present. The speech is thick and slow, and often almost unintelligible in the severer cases. Examination of the eyes shows a nystagmus, perhaps, only when the eyes are turned to one side, but often the jerky movements are seen, even when the pa- tient is told to look directly at an object. The tongue is protruded in a jerky way, and attempts at swallowing are often awkward. If a glass of water is handed him, the patient seizes it, but in carrying it to his mouth he agitates it so violently that the fliiid is spilled and perhaps the tumbler drops from his hands. Examination of the muscular system shows some weakness of the legs or possibly some degree of hemiplegia. There is, however, no marked atrophy of the limbs, and no change of any moment in the electrical reac- tions. Examination of the cutaneous sense may show some little tactile anaesthesia in the limbs, but this is not always present. There is a certain amount of ataxia, which is not so much due to the muscular amesthesia as to inability to control and co-ordinate the movements. There is no loss of sense of weight, or of press\ire. Of the nerves of special sense the eye is most frequently involved. The patient may have some diplopia from paralysis of one of the eye muscles. The pupils react to light and accommodation. Ex- amination of the fundus of the eye shows a certain amount of atrophy of the optic disc in the temporal half, a characteristic con- dition in this disease. In later stages this may go on to complete and general atrophy of the nerve. On account of this involvement of the optic nerve, the patient sjiffers from contraction of the visual field, scintillating scotomata, ami weakness of vision. Sometimes lu* develojjs the above symptoms to only a moderate extent a short time after the infectious fever. He then gradually improves and gets nearly well. Some traces of the malady, liow 418 DISEASES OF THE NERVOUS SYSTEM. ever, still linger. After a number of years it begins to develop again, and it then progresses steadily. Thus an examination of the history of a case in which the disease apparently began well along in adult life will show that the beginning of the trouble dated back before the time of adolescence. While the disease is running the course just described, the pa- tient sometimes suffers from attacks of vertigo, and occasionally from sudden seizures resembling apoplexy, and even epileptiform attacks may occur. The mind is usually not much affected. There may be some slight dulness of the intellect, some hebetude, or even a slight amount of melancholia. In certain cases the patients are subject to attacks of impulsive laughing; that is to say, without any sufficient cause they suddenly break out in exaggerated laugh- ter, from which they quickly recover themselves. These attacks may be frequently repeated. The progress of the affection in very variable. It sometimes goes steadily on without remissions, reaching finally in one or two years a chronic stage, in which the patient remains for several years without much change. At other times the progress of the disease is hastened by repeated exacerbations, accompanied by apoplectiform or hemiplegic attacks. In still other cases the amelioration con- tinues and remains jDermanent, and a practical cure takes place. The various symptoms of the disease are classified as cerebral, cerebellar, and spinal. The cerebro-cerebellar symptoms consist iu modifications of speech, attacks of vertigo and apoplectiform sei- zures, hemiplegia, intention tremor, mental changes, optic atrophy, and spasmodic laughing or crying. There is sometimes also a cer- tain amount of deafness and perversion of taste and smell. Finally, lesions in the brain may give rise to a cerebellar ataxia, due to the development of the disease in the cerebellum. Under the head of spinal symptoms are included the spasmodic paraplegia, with some bladder and sexual weakness, and a slight amount of sensory trouble. There may be also some weakness of the arms. Occasionally there are noted some trophic troubles, such as splitting of the nails and atrophy of the muscles. Aborted Types ok " Formes Frustes " of Multiple Scle- rosis. — In some cases the nodules of sclerosis are so limited in number and so peculiarly placed that they give rise to very atypical forms of the disease. Perhaps the most common one is that in which the disease takes the type of ?i progressive spastic paraph'ijiu . The patient suffers from weakness of the lower limbs, accompanied b}' stiffness, cramps, exaggerated reflexes, and disturbances in the bladder and rectal functions. Amesthesias, pain, and the girdle DISEASES OF THE BRAIX, 419 symptom may develoj). In addition to this, however, a close exam- ination will show some evidence of disease of the optic nerves and perhaps disturbances of the eye muscles. The patient will have nystagmus, diplopia, or other visual disorders. There will also be some attacks of vertigo or of epileptoid convulsions. The combi- nation of the eye symptoms with the progressive paraplegia will often reveal the true character of the disease. Fatlwlo(jy. — Grayish nodules are found distributed through the brain and spinal cord. They vary in size from a millimetre to two or Fio. 2()5. Fig. SOU. Figs. 2()i> and ~(t6. — ^Iit.tiple Cerebro-Spinai. Sclerosis (Cliarcot). three centimetres in diameter (one-twenty-hfth to one inch). They are of firmer consistence than is the surrounding brain substance, but are not quite so hard as is ordinary connective tissue. They consist microscopically of fibrous tissue which does not seem to be connected with the walls of the blood-vessels, as a rule. Very often the axis cylinders of iterves can be seen passing through the h'sion. The nodules are foiuul most frequently iu the white matter of tlie brain, more es])ecially in the pons, internal capsule, and centrum ovale (Figs. 205, 206). They rarely begin primarily in the gray matter, but may invade it secondarily. The roots of the peripheral, especially of the cranial, nerves occasionally contain or are sur- rounded by these sclerotic masses. In the spinal cord they may 420 DISEASES OF THE NERVOUS SYSTEM. extend up and down the gray and white matter for a considerable distance, or they may involve the whole cord at a certain level, turn- ing it into a fibrous mass. The blood-vessels surrounding and in connection with these diseased^areas show some evidences of thick- ening and increased vascularity, but no true inflammatory process. The primary pathological change in multiple sclerosis is as yet un- known ; many things point to its starting originally from small emboli or thrombi which lead to minute softenings, with a secondary repara- tive and sclerotic process. The fact that the disease follows infec- tive fevers makes such an origin of it seem probable. On the other hand, pathological anatomy does not yet bear out this view, and it is possible that the disease begins by a primary degeneration affect- ing first the myelin sheaths of the nerve fibres, this being followed Fig. :i07. — SpinaIj Sclerosis. J, K, L, M, sclerotic foci; A, anterior, B, posterior horn (Blocq) by a neuroglia and connective-tissue proliferation which ends in the formation of the small islands of sclerosis. An important path- ological peculiarity of the process is that, while it destroys the myelin sheaths of the nerves, the axis cylinders remain intact for a long time, and consequently conduction of nerve impulses takes place imperfectly, directly through the nodular masses. Course and Duration. — The disease runs a very irregular course. Its prodromal stage is long and remissions of considerable length occur. The disease may last from five to fifteen years, the average duration being five or six years. Death sometimes occurs from mvolvement of the nerves of the medulla, but more often from weakness and exhaustion or some intercurrent malady. Diagnosis. — The diagnosis in typical cases is not very difficult; but as, on the other hand, typical cases are not common, the dis- ease has always to be studied with great care before certainty can be reached. The diagnosis is based upon the slow development oi" DISEASES OF THE BRAIN. 4:21 the disease, with attacks of vertigo, weakness, and uncertainty in gait; also upon the paralysis of the extremities with intention tremor, ataxia, rigidity, and contractures; upon the disturbances of vision, nystagmus, and the speech troubles. The presence of headache, attacks of vertigo, apoplectiform attacks, and the pecu- liar mental condition often furnish help. The age of the patient and the cause should also be taken into consideration. The dis- ease must be distinguished from Friedreich's ataxia, spastic spinal paralysis, locomotor ataxia, dementia paralytica, bulbar paralysis, paralysis agitans, chronic meningitis, and hysteria. The points already given and those furnished under the heads of these different diseases must be utilized in making these distinctions. The method of exclusion may be used with advantage in reaching the diagnosis of this protean malady. Frognosls. — The prognosis, while not favorable as regards the ultimate cure, is somewhat favorable as regards the remission and improvement, and the disease on the whole is not so severe as is locomotor ataxia or the other degenerative disorders. Treatment, — In the treatment the same measures recommended for other chronic diseases of the nervous system must be em- ployed. Hygienic measures, electricity^ and hydrotherapy have some therapeutic value. Internally the use of large doses of iodide of potassium, the hypodermic injection of arsenic, the administra- tion of nitrate of silver and of quinine and other tonics are advised. A very regular, systematic, and quiet mode of life, combined with the use of iodide of potassium and bichloride of mercury, has pro- duced the best results in my experience, even in cases which gave no history of syphilitic infection. THE APOPLEXIES. Apoplexy is a clinical term used to indicate a condition charac- terized by sudden paralysis, usually attended with loss of conscious- ness, and due to the breaking or blocking up of a blood-vessel in the brain. Apoplexy is a general term. Tarticidar forms are describftl in accordance with the cause of the apoplexy. These are: 1. Intracranial hemorrhage, from rupt\ire of a blood-vessel (Hemorrhagic a])oplexy). 2. Acute cerebral softening, from embolism or thrombosis (Em- bolic or thrombotic apoplexy). 422 DISEASES OF THE XERVOUS SYSTEM. Apoplexy from Intracranial Hemorrhage (Cerebral Hem- orrhage, Hemiplegia). There are four groups of blood-vessels in the brain, those of the dura mater, those of the pia mater, and those supplying the basal ganglia and white matter. Besides this, we may consider the pons, medulla, and cerebellum, which are supplied chiefly by branches of the vertebrals as a separate group, subject to some- what different mechanical conditions. Corresponding to this we have: 1. Dural or pachy meningeal hemorrhages. 2. Pial or subarachnoid hemorrhages. 3. Central liemorrhages. 4. Hemorrhages in the medulla, pons, and cerebellum. It is the central hemorrhages (No. 3), due to rupture of the blood- Yessels going to the great basal ganglia, internal capsule, and white matter, that constitute the great majority of cerebral hemorrhages seen by the physician. It is this class that I have particularly in mind in the following description. Etiology. — At the time of birth and during infancy there is a slight tendency to intracranial hemorrhage owing to the accidents and injuries of labor. After this period the liability is very small, but slowly increases up to the age of forty, when predisposition specially begins. Four-lifths of all cases occur after forty, and the tendency to hemorrhages increases in each decade up to eightj^, when it diminishes absolutely and relatively.* Males are slightly more predisposed than females (five to four). Eather more cases occur in cold weather, at high altitudes, in the tem- perate zone, and among civilized races. Heredity has an un- doubted though not great influence in predisposing to cerebral arterial disease. Infective fevers and marasmic states are predis- posing causes. Chronic kidney disease is present in one-third of the cases. Chronic alcoholism, syphilis, and gout are powerful predisposing causes. Kheumatism is less important. Heart dis- ease, fatty and atheromatous arteries, arteritis, and miliary aneu- risms may be regarded as more than simply predisposing — they * Among 53 cases collected by me at Bellevue Hospital, the ages were : 10 to 20, 4 ; 21 to 30, 6 ; 31 to 40, 10 ; 41 to 50, 11 ; 51 to 60, 7 ; 61 to 70, 10 ; 71 to 80. 5. The right side was affected in 23 cases ; the left in 25 cases. The location was : Pachymeningeal, 7 ; ])ial and cortical, 8 ; ventricular, 23 ; corpus striatum and vicinity, 7 ; optic tlialamus, 2 ; corpora quadrigemina, 1 ; pons, 1 ; cerebellum, 3. DISEASES OF THE IJKAIX. 423 are determining causes. Leucocytha^mia, scurvy, and purpura are conditions which also ])articularly tend to cause hemorrhage. The so-called apoplectic habit — short thick neck and high shoulders and florid face— has really some importance in the better classes. Congenital anomalies, such as a narrow thoracic aorta or inherited deficiency in the strength of the walls of the blood-vessels, also play a part. Any sadden physical exertion, such as straining at stool, the excitement at coitus or of a pas- sion, eating a large meal and drinking a great deal of fluid, es- pecially alcohol, taking a cold bath, all may lead to rupture of an artery. The sijiiqitoms are the prodromal, those of the attack and acute stage, and those of the chronic stage. Prodromal symptoms are rare except in syphilitic cases. When present the patient suffers from dizziness, numbness of the hand and foot on one side, and a failure of memoiy for words. He may have " full" feelings or even pain in the head and bad dreams at night. Nosebleed and irregular heart action sometimes occur. The attack always comes on suddenly and may be accompanied (1) by convulsions and coma, (2) by coma alone, or (3) it may come with- out loss of consciousness. 1. Initial convulsions are rare and generally mean a meningeal hemorrhage. When present they are unilateral or partial, as a rule, but may be general. 2. The common mode of onset is with coma. The patient, without warning, suddenly becomes dizzy, loses consciousness, and falls. The face is flushed, the pulse hard and rather slow, the breathing is labored and stertorous, the cheek on one side puffs out with each expiration, the eyes are partly closed, the eyeballs fixed or deviated to the paralyzed side, the pupils are contracted and rigid, the skin is bathed in sweat, the limbs are relaxed, but some evidence of hemiplegia is present; the urine may be retained or it and the fa'ces involuntarily evacuated. The urine is usually of rather high specifit^ gravity and often contains albumin, even when there is no renal disease. The tem- perature in severe cases may fall below normal during the first twelve hours, even to Of) ' F., but this is not the rule. It is the rule, however, for the temperature in a few lnmrs to be A° <>r 1° higher on the paralyzed than on the sound side. If tli«> case is ra])idly fatal coma continues, resijiration often assumes a Clieyne- Stokes character, the ]uilse becomes faster, the temperature gradually rises, and usually reaches 102 or 103' F., until Just before death, when it may sink again. Swallowing and speech become difficult, hypostatic pneumonia sets in, and the patient 42i DISEASES OF THE XERTOUS SYSTEM. dies in from two to four daj^s. In slower fatal cases the patient regains consciousness partially and then enters a condition of stupor or mild delirium. He is restless and suffers from head- ache. The temperature may continue normal for a time, but is usually higher on the aifected side. At tlie end of two or three weeks it rises higher, pneumonia develops, the patient becomes unconscious, and death ensues. In the favorable cases, which constitute the majority, coma, if present, gradually passes away in from one to six hours, leaving the patient's mind somewhat weak and confused and his speech disturbed, or more rarely the intelligence may not be at all disturbed. During the first few days or weeks after the attack the physician finds that the prominent symptom is the hemiplegia. This affects the arm and leg most and the face least. Only the lower two branches of the facial nerve are involved, and the patient can shut the eyes. The tongue, if protruded, turns to the paratyzed side; the uvula is turned in various ways and its position is of no significance. There is often some evidence of cutaneous anaesthesia of the para- lyzed side, and less often hemianopsia and disturbances of hearing occur. In right-sided hemiplegia the patient, after recovering consciousness, is often unable to talk or to understand what is said. Examination shows that he has a motor or sensory aphasia (vide Aphasia). The deviation of the eyes and head to one side usually disappears in a day or two. Occasionally there is a temporary ptosis. The pupils at first are contracted, that on the paralj'zed side the more so; this condition disappears with returning con- sciousness. The paralysis of the arm and leg is flaccid at first, and the limb falls heavily when lifted ; the reflexes are lessened or abol- ished. Sometimes, however, rigidity sets in at once. This symptom occurs when blood has broken into the ventricles, and also in some meningeal hemorrhages. The skin reflexes are abolished or nearly so on the affected side. The usual course of the temperature is for it to rise on the sec- ond and third day to 100° F. or 102° F., being ^° to 1° higher on the paralyzed side. In a few days it gradually falls, so that by the eighth to the tenth day it is normal. If the temperature continues to rise after the fourth or fifth day, it is a sign of an extension or inflammatory reaction of the hemor- rhage. Hence the thermometer furnishes a very important criterion of the seriousness of the case. DISEASES OF THE BRAIX. U5 The varying course of the apoplexy is shown in the following diagram : Health line. Attack. 3. Chronic stage. 4 to S weeks. Improvement. '•._ 1. Death. 2 to 4 days. 2. Death. S to 4 weeks. The Chronic Star/e, Hemiplegia. — At the end of a month, if fever and symptoms of cerebral irritation have subsided, the chronic stage may be said to begin. The hemiplegia has improved, the pa- tient can move the leg and arm a little, sensory symptoms liave lessened, the mind is clear, headache has disappeared. Improve- ment continues, though more slowly, for several months or even one or two years. During this time the patient is " a hemiplegic" (Fig. 208). The hemiplegia affects the arm more than the leg, and the face least of all. The distal segments of the limbs, the feet and hands, are affected more than those near the trunk. The muscles that act Vjilaterally, such as those of respiration, phonation, and facial ex- pression, are but slightly involved. The paralysis is not strictly a hemiplegia, for the muscles on the sound side are somewhat weak- ened, as tests will show. In severe cases, especially in old people, even the visceral muscles, especially those of the bladder, are weakened. At the onset of the attack there is sometimes a tem- porary "initial" rigidity of the muscles on the paralyzed side, or an " early" rigidity may develop in one or two days. There always develops at about the beginning of the second week a "late" rigidity. This, which at first is slight, gradually in- creases, and finally contractures affect the i)aralyzed limbs. The superficial reflexes, which at first were absent, reappear; the ten- don reflexes become much exaggerated, and clonus can be obtaimd in the leg and arm. Tlie sound side shares to a small extent in these conditions. Tlie contractures affect the extensors of the foot more than the flexors, and bring the to(^ down and the heel u]). The leg is held nearly extendc'd, and the limb in walking is swung around, the toe scra])iiig th(! ground. The shoulder is addncted, the forearm flexed, and the fingers are tightly shut into the pabn by the 426 DISEASES OF THE NERVOUS SYSTEM, overaction of the flexors (Fig. 208). The facial muscles show a slight contraction and drawing to the affected side. The muscles on the paralyzed side do not waste. In infantile hemiplegia, however, the affected limbs grow less than those on the sound side. The paralyzed limbs may be the seat of peculiar disorders of movement. These consist of Associated movements. Tremor. Ataxia. Choreic movements. Continuous or athetoid move- ments (Fig. 209). Spastic movements and cramps. Such movements, aside from those that are spastic, are rarely seen in the hemiplegia of adults. T h e electrical irritability may be at first slightly increased or diminished, but the change is small in amount and never reaches the degenerative stage. Hemianaesthesia, if present at first, disappears to a great extent, leaving only residua about the feet and hands. ParcBsthesiai are common. In rare cases the patient suffers great pain in the arm and leg. This pain is generally of a burning character and very obstinate and distressing. Cramping pains in the legs and arms are common in the severer cases. During the first few weeks after the onset joint inflammations and bedsores may attack the affected side. The temperature of the hemiplegic side is usually a very little higher than that of the sound side. Vasomotor disturbances, sweating, skin eruptions, and increased growth of hair are some of the rarer symptoms. The mental condition is more or less affected. The patient becomes irritable, cries easily, and is in general more emotional. Fig. 208.— a Case of Chronic HE.MiPLEiiiA WITH Contractures FROM Cerebral IIemor- RHARE (Ciirsclimann^ . DISEASES OI- THE HKAJX. 4-27 The memory is impaired, and the jtower of concentrating the'atten- tiou and carrying on work is less. Sometimes a progressive mental deterioration sets in and epilepsy or insanity develops. The mental disturbance is greater in old people and depends somewhat on the size of the hemorrhage. Those forms which produce serious aphasia especially limit and lessen mental activity. Mk.ningeal Apoplexy. — Aside from the apoplexies due to rup- ture of the central arteries and involvement of the basal ganglia just described, there are a minor number in which the meningeal ar- FiG. 2(;!J.- Showing Athktuiu 3Iovemexts of Hands (Curschiiiaiin). teries, the cerebellar, or some branch of the basilar are affected; hence we have meningeal, cerebellar, and pons hemorrhages. Hemorrhages from the vessels of the dura mater are usually due to a ruptuie of the iniddle meningeal artery or vein or some of its ])ranches, and this is especially true in such hemorrhages as are the result of injuries to the liead. The causes are injuries to the head, including obstetrical injuries, alcoliolism, and insanity. In dural hemorrhages the result vf Iwinl Injuries, the clot is sometimes intradural, lying iu the arachnoid si)ace, and sometimes ejtidural, lying l)etween the bone and the dural membrane The extradural liemorrhages are perhaps a little more common. In over one-half of these there is an interval of consi-iousness lasting from a few ln)urs t(j two months, but usually only a few hours, between the accident and the time when distinctive cerebral symptoms de- velop. Then the ])atient gradually becomes dull, somnolent, and finally comatose. In about one-half the cases tliis interval of con- sciousness between the accident ami the development of hemijdegia 428 DISEASES OF THE NERVOUS SYSTEM. is present. Along with tlie gradual or rather sudden loss of con- sciousness there develops a hemiplegia upon the side opposite the clot. This is usually not complete, though it may become so. An- aesthesia is rarely present. The reflexes are generally somewhat exaggerated, and there may be considerable rigidity. Spasmodic movements of some kind occur in nearly half the extradural cases and in more than half of the intradural. These spasmodic move- ments may involve the whole of the affected side, or may simply affect the eyes and the facial muscles. They consist of irregular twitchings. The pupils are usually somewhat contracted, more so upon the paralyzed side. When there is a dilated pupil on the side of the lesion and a small pupil on the opposite side, it is known as the Hutchinson 2')npil, and means a severe brain compression involv- ing the third nerve at the base. The'eyes are generally both turned toward the affected side and away from the lesion. The pulse is slow and full; the respiration is rarely stertorous, though it may sometimes be so, and Cheyne-Stokes respiration may be present. In these cases the clot is very large and the compression great. Aphasia may be present if the clot is upon the left side. The tem- perature may be raised one or two degrees, or it may be normal. The progress of the disease is usually steadily fatal unless surgic>al interference is undertaken. The coma deepens, the respiration be- comes stertorous and then embarrassed, the pulse gets rapid and weak, and the patient dies. With surgical interference (since 1886), between two-thirds and three-fourths of the cases are saved (Scudder and Lund). Dural hemorrhages occurring idlopathicallij are due sometimes to the rupture of a meningeal artery, and sometimes to rupture of the veins of the pia mater. This idiopathic hemorrhage is rare in ordinary practice, but is not specially so in insane asylums or in large city hospitals. This is because the two great causes of this type of hemorrhage are insanity and alcoholism. General paresis is the form of insanity with which it is oftenest associated. In the case of alcoholics, it is probable that injuries from blows are an ex- citing factor in the production of the hemorrhage, these occurring while the patient is in a state of intoxication. The symptoms of idiopathic hemorrhage are extremely variable, owing to the compli- cating influences of the insanity and alcohol. The patient after suffering from headaches or vertigo becomes s.uddenly comatose and shows marked evidences of hemiplegia and' even of anaesthesia. Rigidity of the paralyzed side is often present, and sometimes spas- modic movements are observed. On the other hand, at times the paralysis can hardly be observed, and the patient is in a semicoma- DISEASES OF THE BRAIN. 429 tose state, has a muttering delirium, and presents the general aspect of a person suffering from the cedema or " wet-brain" of alcoholics. In dural hemorrhages occurring in paresis, the patient usually with- out warning becomes unconscious, and he often has some convulsive symptoms and a hemiplegia develops. In these cases there is often a rapid improvement, and the patient gets partly well, usually ex- periencing other attacks later. Pi.Aii APOLEXY occurs vciy rarely, and the most frequent cause is trauma associated perhaps with syphilis and alcoholism. In many instances very slight localizing symptoms occur, and no abso- lute diagnosis can be made. If the hemorrhage, however, is in the motor area of the cortex, local spasmodic movements and some hemi- plegia are observed. The most characteristic sj^mptoms are the sudden incomplete hemiplegia, involving, perhaps, mainly an arm or a leg, associated with local spasmodic movements, resembling Jacksonian epilepsy. Poxs Apoplexy. — This is accompanied by initial loss of con- sciousness and sometimes with spasmodic, jerking movements of the limbs, more particularly of the legs. Some rigidity on both sides of the body may be present. The facial or ocular nerves may be involved, and speech, articulation, and swallowing may be affected. The pupils are often contracted almost to a pin point, and the respi- ration is slow. The teinperature almost always rises, and may reach as high as lOS"" or 104^ F. There may be some disturbance in sensation and some hemiplegia. These hemorrhages are usually fatal. Ckkebellar Apoplexy. — Hemorrhage into the cerebellum oc- curs in one or two per cent of all fatal cases. Its recognition is very difficult. There is sometimes a prelimmary period of severe head- ache, lasting several days. In other cases the patient at once falls into a state of profound coma, with stertorous respiration. Vomit- ing sometimes occurs. There may be some hemiplegia, and if so this is on the side of the lesion, owing tathis pressure on the motor tract. Distinct evidences of hemiplegia, however, are not always observed. The condition of the pidse and arterial system is very much like that of ordinary apoplexy, but the respiratory system is usually more seriously affected. Disturbances in the movements of the eyes and in swallowing, and in fact all those symptoms which show a pressure or irritation duo to blood oozing into the fourth ventricle may be present. Death is almost sure to occur, and is in- evitable if the hemorrhage, as is so often the case, breaks through and roaches the fourth ventricle. Fathologijund 3Io)'bid ^Inafomi/. — Spontaneous intracranial hem- 430 DISEASES OF THE NERVOUS SYSTEM. orrhage is always due to the presence of diseased blood-vessels in the brain. This diseased condition consists of: 1. A degenerative arteritis which results in producing small aneurisms. 2. A fatty degeneration of the vessel walls. 3. Be- sides this, in most cases the larger blood-vessels are atheromatous. 1. The arteritis produces small or miliary aneurisms which affect only the smaller arteries, especially those of the central group. They may be fusiform or sacculated in shape ; they range in size from one-fourth to one millimetre ( yi^ to -^-^ in.) in diameter. They are usually not very numerous, but there may be as many as a hundred in the brain. They are the results, not of inflammation, but of a degeneration which affects first an area in the internal coat; this causes local weakness and consequent dilatation; secondarily there is a periarteritis. These aneurisms occur almost exclusively during the degenerative period of life. 2. Fatty degeneration of the walls of the small cerebral arteries occurs in purpura, scurvy, leucocythaemia, marasmic conditions, and post-infective states, especially in early life, and is the com- mon cause of hemorrhage at that time. 3. Atheroma affects the larger vessels only. It is indirectly a cause of hemorrhage by lessening the elasticity of the vessel wall. Atheroma is present in from one-eighth to one-fifth of all cases. Hypertrophy of the heart is a factor in causing hemorrhage, and such hypertrophy exists in about forty per cent of cases. Emboli lodged in the cerebral arteries may cause hemorrhage by suddenly stopping the arterial circulation and raising the blood pressure. Hemorrhages are found by far the oftenest (twenty per cent) in the caudate and lenticular nuclei and adjacent parts. The lenticular and lenticulo-striate branches of the middle cerebral are oftenest affected ; next the branches of the anterior cerebral to the caudate nu- cleus and the ventriculo-optic branches of the middle cerebral. The branches of the posterior cerebral break more rarely. The parts affected in hemorrhage, in order of frequency, are about as follows : Caudate and lenticular nuclei. Meninges and cortex. Centrum ovale. Optic thalamus. Pons, cerebellum, medulla. Cortex hemorrhages are generally small and may be subarach- noid or may break through into the arachnoid cavity. Ventricular hemorrhages are almost always secondary to a rupture into the neighborhood of the basal ganglia. Pons hemorrhages occur usu- ally in the median line. Cerebellar hemorrhages are oftenest due DISEASES OF THE BRAIX. 431 to rupture of the superior cerebellar artery. Tliey usually cleave their way externally and break into the fourth ventricle. Dural hemorrhages are due to rupture of the meningeal veins and arteries and of the vessels in newly organized clots. They lie in the arach- noid cavity and flatten the convolutions. The reparative changes after a hemorrhage take the following course: 1st, Coagulation of the blood, which in a few days begins L.S. Art O.E. Fig. ~10.— Showing the Different Areas Commonly Involved in Cerebral Hejior RHAGE. Art. L.S., lenticulo-striate artery; Art. L. O. , lenticular optic; Art. O. £., e.\- teriiiil optic. to soften and become absorbed, 2d. Formation of a iibiinous wall about the clot. This occurs from the seventh to the ninth day. 3d. Formation of a cyst with tiaiispaient fluid contents, and per- haps fibrous trabecuUe running through it, tweutietlx to tliirtietli day. 4th. Contraction of the cyst wall, which begins by the fortieth day. 5th. Secondary degenerations begin from the tenth to the fourteenth day. Plif/.'iioh)//!/. — The blood press\n-o of the cerebral arteries is equal to about 155 mm. of mercury. Tht> resistance or sujqiort furnished by the surrounding tissue is ecjual to about 10 iiiiii. of mercury. 432 DISEASES OF THE NERVOUS SYSTEM. Hence there is a special liability to rupture of intracranial vessels. The middle cerebrals are most often affected, because they are in the most direct line from the heart and are nearest to that organ. The pressure lessens as the arteries subdivide and get farther away fron. the h^art (Mendel). The diafjnosis of hemorrhagic apoplexy must be made from alco- holic coma, urffimic coma, opium coma, epilepsy and hysteria; acute softening from embolism and thrombosis. From alcoholic coma the diagnosis is made by the odor of the breath, the incomplete coma, the equal pupils, the absence of low or unequal temperature. From uremic coma by the absence of albumin and casts in the urine, though their presence does not surely indicate ursemia; by the unequal pupils, the temperature, the absence of hemiplegia and of the physiognomy peculiar to cases of chronic Bright' s disease. From opium poisoning by the history, the stomach contents, the presence of equal and contracted pupils, the slow respirations, the temperature, and the absence of paralysis. From epilepsy by the history of the onset wdth epileptic cry, the dilated and equal pupils, the biting of the tongue, the absence of hemiplegia, the rather rapid return of consciousness. Hysterical attacks present little semblance to that of apoplexy; hysterical hemiplegia is characterized by its flaccidity, by its not involving the face, and by the presence of the anaesthesias and other hysterical stigmata. In embolic softening the earlier age of the patient, the presence of decided valvular heart disease, the parturient condition, the slighter degree and shorter duration of coma, the absence of seri- ous disturbance of temperature, the onset first of paralysis and then of convulsive movements and coma — all lead to a presumption in favor of embolism. The presence, on the other hand, of a congested face, tense pulse, and throbbing carotids favors the existence of a hemorrhage. From thrombotic softening diagnosis is more difficult. The oc- currence of prodromata, consisting of slight seizures quickly recov- ered from, the slighter degree of coma, the advanced age, hard atheromatous arteries, evidence of anaemia and asthenia, weak or fatty heart, the absence of stertorous respiration, flushed face, and unequal temperature not much lowered or raised, the slight ])upil- lary disturbance, and absence of conviilsions point to thrombotic softening. Evidence of a lesion in the pons or cerebellum suggests liemorrhage, while evidence of lesion in the medulla points almost surely to softening. DISEASES OF THE BRAIN. 433 The chances in any case between the ages of thirty and htty, if there is no heart disease, are six to one in favor of hemorrhage. Fro'jnosis. — The majority of cases get over the first attack. They are very liable to have another within one to five years. The minority recover from this. Few survive a third attack. The prognosis of the attack itself depends on the severity of the coma and paralysis, the disturbance of temperature and of respiration, the evidence of rupture into the ventricles, the development of de- cubitus, the continuance of loss of control over the bowels and bladder. If profound coma continues four da3's there is little hope; if fever develops and continues steadily, or if there is initial sub- normal temperature, the prognosis is grave. If the patient passes the first week with little or no fever and consciousness has returned, the prognosis is good. The presence of renal disease and of alcoholism is bad. Devel- opment of slight delirium which continues is unfavorable. Cerebellar and pons hemorrhages are very fatal, meningeal slightly less so. The prognosis of the chronic stage has been given under symp- toms. Improvement continues rather rapidly for three months, then very slowly. Improvement may continue for one or two years. Oomjilete recovery is very rare. The great danger after middle age is recuirence of the attack. Treatment of fhn Attml;. — The patient should be laid in a hori- zontal position and kept quiet. Ice should be ai)plied to the head and hot bottles at the feet. The feet and legs should be swathed in cloths wrung out in hot Avater containing mustard, a cupful to a pail of water. A laxative should be given, either one or two drops of croton oil or a quarter of a grain of elaterium. If there is evidence of intense cerebral congestion, the pulse being very full and hard and the heart beating strongly, bleeding eight to ten ounces is justifiable. Ordinarily it is better to give a drop of tinc- ture of aconite every twenty minut(\s lor two or three hours. Pres- sure on the carotid ot the sound side and even ligature of it have been recommended, but there is no experience yet to justify either. Administration of bromide of sodium and enemata of ergot have been advised, but are of doubtful value. After the first twelve hours, treatment must be symptomatic. Should delirium and other evidence of mental irritation a]t])ear, large blisters nuist be aj^plied at the back of the neck and an elaterium ])urge given if the patient is not too weak. The use of iodide of potassium or mercury is not 434 DISEASES OF THE NERVOUS SYSTEM. indicated unless the case is distinctly syphilitic. The passage of a galvanic current through the brain cannot possibly do any good. Great care should now be taken that the patient does not develop pneumonia. The mouth and pharynx should be cleansed antisepti- cally, and the patient should not be allowed to remain in one posi- tion. If there is sufficient evidence of a meningeal or cortical clot, trephining should be seriously considered. At the end of three or four weeks the faradic battery may be used carefully on the affected limbs. A seance of fifteen minutes daily for four to six weeks should be given, then treatment should be suspended for a fortnight, to be begun again and kept up syste- matically for a year if need be. Massage may be alternated with the electricity. When contractures develop the stabile galvanic current may be tried, though it does little good. Static sparks, however, are helpful; lukewarm baths should be tried and meas- ures used to produce hyperextension of the affected parts. Internally during this time the patient is to be given courses of iodide of potassium, tonics, and laxatives if needed. The patient shoald be made to live a quiet life, preferably in a warm, equable climate. The kidneys should be kept active and arterial tension low. For these purposes nitroglycerin should be given and at times small doses of chloral, and the diet should be simple and rather non-nitrogenous. Strychnine in very small doses (gr, yu-tt) sometimes helps the contractures; so also do the bromides and physostigma. Acute Softexixg of the Braix (Embolism, Thrombosis) . Acute softening is a condition caused by the plugging of a blood- vessel with an embolus or thrombus, and is characterized by a sud- den apoplectic seizure; the symptoms eventually running a course like those of cerebral hemorrhage. Etlolofjij. — -Embolism occurs rather more often in women, throm- bosis in men. Embolism is rare in children ; it occurs oftenest be- tween the ages of twenty and fifty, thrombosis betweeen the ages of fifty and seventy. The most important predisposing factors in embolism are acute or recurrent endocarditis, infectious fevers, pro- found anaemia, pregnancy, and blood dyscrasias; in thrombosis, syphilitic, lead, or gouty arteritis, fatty heart, and blood dyscrasias. The same causes which lead to the arterial disease which produces cerebral hemorrhage also predispose to thrombosis, though in the latter condition atheroma plays the important part. Si/mptoms. — In embolism there are rarely any premonitory symptoms ; the onset is sudden ; it may begin with some convulsive twitchings, then follow hemiplegia and temporaiy loss of conscious- DISEASES OF THE BRAIN. 435 ness. Coma, however, is rarer than in hemorrhage, and if present is usually shorter. There is rarely vomiting, nor do we find the hard, pulsating arteries, flushed face, and severely stertorous breath- ing. The initial temperature changes are slight, but in a few days fever may develop. In thrombosis premonitory symptoms are frequent. In syphi- litic cases there are headaches and cranial-nerve palsies. In other cases vertigo, temporary aphasia, transient hemiplegia, numbness of the hand and foot, and drowsiness may be present. The onset is more gradual; the hemiplegia slowly develops, taking several hours, perhaps, for its completion ; meanwhile the patient gradually becomes comatose. The attack sometimes is rather sudden, with no loss of consciousness, and it may occur in sleep. The tempera- ture often has a slight initial fall, followed by a rise, just as in nemorrnage. In both embolism and thrombosis the hemiplegia tends to improve very much in a few days or weeks unless the ves- sel obliterated is a large one. Embolism is rather more apt to affect the left side of the brain, though the difference is not great. The middle cerebrals are most frequently affected (seventeen out of twenty-seven cases). Softenings affect the vertebrals, basilar, and posterior cerebral arteries more often relatively than do hemor- rhages; then the initial symptoms may not present the character of hemiplegia, but of a bulbar paralysis. Acute softening may kill within twenty-four hours, but, as a rule, the patient survives the onset, and if he dips it is not for several weeks. After the a<-ute stage is over the patient passes into the chronic stage, which re- sembles in nearly all respects that of hemorrhage. After an acute softening, however, it is believed that there are more spastic symp- toms and a greater tendency to mobile spasm. In embolism, owing to the j'outh and freedom from arterial disease, the mind is less affected ; while in thrombosis the contrary is the case. Pdthnloijif. — The embolic; pbig cuts off the blood supply from a certain area of brain tissue. In twenty-four hours this begins to soften. If the area is in the cortex it becomes red (red softening); if in the white and less vascular i)art, it is usually white with a few red ]>unctate si)otK. The red softening gradually becomes yellow (yellow softening). The dead tissue softens and is absorbed, leav- ing a cicatrix or cyst. If the end)olus contains infective microl>es there may be a local en('e])lialitis and abscess. In thrombosis there are usually evidences of extensive athe- roma or syphilitic arteritis. Tn those instances in which the throm- bosis is caused by the blood state and a weak heart, little arterial change occurs. Atheroma aftVcts chiefly tiie internal carotids an Diplegia, Little's Disease. The brain palsies of early life show themselves in the form of {1) hemiplegias; (2) diplegias or double hemiplegias, in which both sides of the body are involved; and (3) paraplegias, in which the lower limbs are chiefly or entirely involved. In these palsies, as in the same troubles of adult life, the loss of motor power is always accompanied by a rigidity and by some contractures and exag- geration of reflexes, in this respect distinguishing these paralyses from those of spinal origin. The seat of lesion in these cases is in the hemispheres of the brain, and it is the central motor neurons which are involved; that is to say, that part of the direct motor tract which extends from the brain cortex down to the spinal cord as far as the anterior horns. The brain palsies of children are therefore disorders of the cortico-s])inal neurons, while the si)inal palsies of children are disorders of the neuro-s])inal neurons. Etioloiji). — The disease occurs rather oftener in males than in females, though the difference is slight. The vast majority oci-ur in the first three years of life; about one-third of them are congeni- tal. Injuries to the mother during the time of pregnancy, possibly diseases and emotional disturbances at this time, are factors in })ro- ducing the congenital cases. Those cases that occur at the time of birth are due to tedious labor, the use of forceps, and other injuries at the time of parturition. After birtli, the causes are those which lead to the production of intracranial hemorrhages, eml)t>lism, and thrombosis; these being injuries and the infectious fevers. Of the latter, jmeumonia, whooping-cough, measles, and scarlet fever are the most prominent. Sy])hiUs is a rare cause; cerebro-spinal men- in.f/'tis and e])ile]»tic convulsions are also occasional cruises. S>iiiijiti>niiifi>lii(jii. — Tlie disorder in about one-fourth of the cases 438 DISEASES OF THE XERVOUS SYSTEM. begins with a convulsion, which may be unilateral, but is usually general in character, and may last for several hours. At the same time a febrile process develops, and this continues for several days. When these acute symptoms have subsided, or before this, it is noticed that the child is paralyzed upon one side, the paralysis in- volving the arm, leg, and face, as in adult hemiplegia, or perhaps in- volving both sides. This paralysis undergoes gradual improvement, the face recovering earliest and most, the leg next, and the arm least. As the child develops it is found that the paralyzed side fails to grow as fast as the other, and there may be from one-half to one inch or two inches of shorteuing in the arm or leg. The circumference of the limbs is less, the surface somewhat colder, and some vasomotor disturbance may be present. With the progress of the case a rigid- ity of the affected limbs develops ; the heel becomes drawn up, so that there is talipes equino-varus or equino-valgus. The flexors of the forearm and of the wrist and fingers contract, as do also the ad- ductors of the thighs. In general it will be found that there is a contraction of the flexors and adductors of the affected limbs. With this rigidity and the contractures there are exaggeration of reflexes and clonus in most cases. In the disordered limbs the peculiar mo- bile spasms develop. These consist of athetoid, choreic, and ataxic movements, also sometimes tremors and associated movements. The choreic and athetoid movements are the most common (Fig. 209). Along with the appearance of these symptoms it is noticed that there are disturbances in the mental condition of the child. It is usually backward in development, this backwardness ranging from simply feeble-mindedness to complete idiocy. Taking all cases, there is about an equal division between feeble-mindedness, imbecility, and idiocy (Sachs). Perhaps a little over one-fourth of the subjects have a fair intelligence. There is usually slowness in learning to talk, and in a small proportion of cases there is a de- cided aphasia. Such condition is rather more frequent with right hemiplegia than with left hemiplegia, though the rule is not an ab- solute one. In connection with the mental defect there may develop many of the peculiar moral traits associated with idiocy and low de- grees of intelligence. Epilepsy very frequently complicates the dis- ease; nearly one-half of the subjects suffer from this trouble. This epilepsy is in most cases general in character ; in a few cases it takes the Jacksonian type, in a small number pe^^/i mal alone is noted. Examination of this class of sufferers reveals, aside from the paralysis described, various evidences of defective development. These are known as stigmata of degeneration; though they cannot be classed strictly among such, since they are acquired stigmata in DISEASES OF THE BRAIX. 439 most cases, rather thau marks which are the result of primary de- ficiency in development. These stigmata consist of a microcephalic or a macrocephalic sknll, cranial and facial asymmetry, progna- thism, imperfectly developed teeth, and a high palatal arch. It has been found that, as a rule, in cases of cerebral hemiplegias of child- hood the patient eventually has a slight flattening of the skull on the side of the lesion (Fisher and Peterson). Finally, in a few cases there may be found defects in the special senses, such as im- perfect hearing, deafness, deaf-mutism, and defects in vision such as hemianopsia, and perhaps imperfections in smell and taste. An£esthesia is never observed. The symptoms in the cerebral palsies of children, having passed the acute stage and having become somewhat ameliorated, enter into a chronic stage. This chronic stage begins within a few months after birth or after the onset of the disease. Xo great change occurs in the paralyses as the child grows older until he reaches the time of puberty, though there is a slight improvement in most cases. After the time of puberty, if the mental condition of the child is good, the physical symptoms are apt to improve considerably. Mnrhid Anatovii/. — The primary changes that lead to the cere- bral palsies of children are : 1st, simple agenesis or lack of brain development, producing localized atrophy of the cerebrum and the condition known as j)or('nci'phalus (true porencephalus is a condi- tion in which, owing to a congenital defect in nutrition, a cavity or depression exists in the cerebral hemisi)hores, this cavity reaching generally into the lateral ventricle; true porencephalus is found in about one-fourth of the cases, though no definite statistics can be given, owing to the different inter])retations given to this term); 2d, liemorrhage, which is probably the most fretpient of the single causes; 3d, embolism; 4th, tlirombosis; oth, meningo-encephalitis and perhaps polio-encephalitis; Gth, a diffuse cortical sclerosis. Many other terms are used to describe the pathological conditions found at the basis of tlie brain palsies of children, but the prin- cipal causes of all are undoubtedly, as has been described, liemor- rhages, embolism and thrombosis, and a defective development or agenesis. It is i)rol)abl«' that in tlie h('mij)h'gics tlic original lesion is generally a central hemorrhage, less often a meningeal hemor- rhage. After this, probably the most frequent condition is a por- encephalus from some intra-uterine accident, which may have been defective nutrition causing ana'inia and softening, or liemorrhage, or thrombosis. Polio-encej)halitis or inflammation of the cortex of the brain of the kind similar to ])olio-myelitis is alleged to be a cause in some cases by Striimpell, but this has not yet been proven. In 440 DISEASES OF THE NERVOUS SYSTEM. double hemiplegias or diplegias of cliildren the cause is in the vast majority of eases a meningeal hemorrhage due to some injury or disturbance at the time of labor. In other cases of diplegia the le- sion is a double porencephalus, which may be either the result of an intra-uterine hemorrhage or simply a defective development. In the paraplegias the lesion is probably very much the same as in the di- plegias, that is to say. either a meningeal hemorrhage or a brain agenesis. Occasionally a diffuse sclerosis has been found in these Fig. -11.— Atrophied 13uai;j with Sclerosis and a Cyst, from a Case of InfantilB Cerebral Hemiplkgia. cases. Not infrequently, as the result of hemorrhages, there develop cysts which fill up the atrophied areas of the brain (Fig. 211 ). It is dif&cult to present accurately and definitely the relations between the pathological change and the clinical result, but it may be shown with some degree of correctness in the following table. Original Lesions. Later Pathological Coudition. Clinical Result. Hemorrhage. Embolism. Throml)osis. Agenesis. I Atrophy. 1 Lobar sclerosis. ^ Cysts. 1 Porencephaly. j ^licroccphaly. f Hemiplegia. Diplegia. J Paraplegia. 1 Sensory defects. 1 Mental defects. [^Epilepsy, etc. DISEASES OF THE BRAIN". 441 Diplegia or Birth Palsies. — That form of the brain palsies of childhood characterized by double hemiplegias or diplegias has certain special characters which lead to its being often classed apart. These diplegias in almost all cases are congenital and are due either to injuries at the time of birth or to some disorders of intra-uterine life. There may be convulsions or a prolonged state of asphyxia at Fig. 212. Fio. 213. Figs. 212 am> 213.— Cbbebrai. Diplegia with CoxTnACTiRES and Talipks. FIet. 209, stand- injf; FiK- ~J0, suspemli'il liy nniis the time of birth. After recovery from this no special trouble is noticed with the chikl by the mother for some weeks or months, when it will be found that it does not use its arms or legs. Other convulsions develop, and eventually the features of a double hemi- plegia with mental impairment and epilepsy are observed (Figs. I'll', L'l.'i). In these cases the mental defect is miu-h more decided than in the h('mi])h'gias; indeed, fi'W of the.se cases ever show any good amount of intelligence. Epilepsy is extremely comnum. The anatomical lesion in the cases is, as already stated, citlnT a menin- geal hemorrhage which has pressed upon and injureil the cortieaJ 442 DISEASES OF THE XERVOUS SYSTEM. motor areas in each hemisphere, or it is a congenital porencephalic defect. Spastic Cerebral Paraplegia, Little's Disease. — In a few cases the brain lesion is such that there results little disturbance to the arms or face; the paralysis is largely confined to the lower extremities. The mental condition is often very good, and there is no epilepsy. As the child gets older great improvement in the use of the limbs may occur. There are, however, rigidity and contrac- tures of the limbs, exaggerated reflexes and spasms of the flexors and the adductors, so that the child's legs cross each other and in- terfere in its feeble attempts at walking. The disease is thought to be due to a developmental defect in the motor tracts, and it is pos- sible that in some cases only the spinal cord is affected. Diagnosis. — The clinical diagnosis of cerebral palsies is to be made from the spinal palsies. The latter are distinguished by the fact that in the paralyses of spinal origin there is no rigidity or ex- aggeration of reflexes, and there are electrical degenerative reactions of the muscles and decided wasting of the limbs with shortening. The mode of onset in cerebral palsies and their distribution in the form of hemiplegias in which the face is involved also indicate the seat of the lesion. The pathological diagnosis is by no means an easy one. Cerebral palsies occurring at the time of birth and ac- companied at that time by general convulsions or asphyxia may be considered to be due to meningeal hemorrhage, especially if the delivery of the child has been brought about by the use of forceps or if the labor has been long and tedious. Diplegias and paraple- gias which are congenital are probably due to true porencephalus, provided there was no difficulty at the time of labor and there were no convulsions or other serious phenomena after it. Cerebral pal- sies occurring after birth in the first, second, or third year of life are apt to be due to hemorrhage, and less often to embolism or thrombosis. Hemiplegias developing after infectious fevers are likely to be due to hemorrhage. In diagnosticating the pathological lesion in such cases it must always be remembered that hemor- rhage is much more frequent than embolism, and that thrombosis as a factor has not yet been very clearly established. Course and Prognosis. — In all types of the disease the course is chronic and perfect cure is hardly possible, although in the slighter forms of hemiplegia nearly all traces of the paralysis may be ab- sent. In the hemiplegic form the patient often reaches adult life, and if his intelligence is not defective and he has no epilepsy the motor trouble improves a great deal and he may live a long and use- ful life. If epilepsy and mental defect are present, there ensues eventually a further mental deterioration, and such subjects rarely DISEASES OF THE BRAIN. i-to live mucli beyond tlie period of adolescence, or if they do they pass into the asylums for the idiotic and epileptic. The diplegic and paraplegic cases have a much worse prognosis both as to duration of life and as to improvement in symptoms, except occasionally the type described above as cerebral spastic paraplegia or Little's dis- ease. The degree of intelligence and the absence of epilepsy are the two factors which measiire the seriousness of these cases, as they do those of the hemiplegias. As regards the significance of individual symptoms, the post-hemiplegic movements have a bad import ; the presence of a microcephalic head or of decided marks of degenera- tion is unfavorable. Treatment. — The treatment, so far as the paralysis is concerned, is largely mechanical. The patient is benefited by occasional courses of electrical treatment which stimulate somewhat the nutrition und functions of the muscles. Massage and stretching of the coutrac- tured tendons and limbs also are helpful in ray experience. The orthopaedic surgeon is able to render valuable assistance by occa- sional overstretching the contractured limbs and placing them in splints. Tenotomy may also be resorted to with advantage, as 1 have had occasion to see. The child should be encouraged above all, however, to use the limb as much as possible. He should be taught gymnastic exercises; running, walking, and bicycle riding are all measures which give great help. When the child's intelli- gence is good and there is little or no epilepsy, a great deal can be expected in the way of improvement as the child grows older. So far as the epilepsy is concerned, it should be treated on the same principles as idiopathic epilepsy, except that great care should be had in the use of the bromides; a thorough test must be made in order to determine how much of this drug will suppress the fits, and then its use must be graduated in the future in accordance with the knowledge thus obtained. The mental defects of the child can be helped only by proper training of the body and careful education of the mind. The question of operative interference in these cases has of late excited much attention. A 2'>'i<»'i^ it would not seem as though surgical interference could do good in relieving conditions in which there is destroyed or atrophic tissue. Still the subject must be dejilt with empirically, and there have been some results which show that a])parently a relief is obt;iined in a few cases by trephining the skull or by Lannelonguc's operation of craniectomy. If there is no microcephalus, if the case is one of hemiplegia with imbecility and epilepsy, the surgeon should simply make an ex- ploratory opening. If he then finds any evidenros of comju-ession from the presence of a (^yst, this nuiy be very cautiously opened. 444 DISEASES OF THE NERVOUS SYSTEM. If there is microcepliahis, the linear craniectomy is the operation which is indicated. In all cases, in operating on children it has been found that it is imperative that the operation be made as short as possible, and that as little be done at any single operation as is consistent with the indications. CHAPTEH XX. TUMOES OF THE BRAIN— SYPHILIS. The kinds of tumor found in the brain are tubercle, syphiloma, glioma, and sarcoma, "which are the common forms; myxoma, car- cinoma, fibroma, osteoma, cholesteatoma, lipoma, psammoma, neu- roma; vascular tumors including aneurisms ; echinococcus, audcysti- cercus. In fact, all forms of new growths are found in the brain ; but the infectious granulomata, tubercle and gumma, and the sarcomatous type of tumors are the most common. As compared with other organic diseases of the central nervous system, brain tumors are rare. Etlolofjij. — Brain tumors affect males oftener than females, the ratio being about as two to one (644 : 320) . Sarcomata alone seem to affect females about as often as males. Brain tumors occur with about equal frequency throughout all ages of life up to about fifty ; one third occur under the age of twenty (Gowers). During childhood tumors are about equally distributed throughout all ages (Starr). One-half of all the tumors of childhood are tubercidous; after this come gliomata and sarcomata. The gumma, glioma, and sarcoma begin to be more frequent after the age of twenty. Sarcoma and especially cancer occur in the middle and later ages of life; but brain tumors of any kind are extremely rare after the age of sixty. To sum up in tabular form, the relative frequency of the different kinds of tumors with regard to age is shown in the following: Childhood, tubercle, parasites. Early life, ..... gumma, glioma, parasites. Earl\' and middle life. . . sareoma, glioma, and gumma. Middle and late life, . . . sarcoma, gumma, cancer. Heredity has a slight influence in predisposing to brain tumors. Blows on tlie head and other forms of injury to the cranium are exciting causes in a small proportion of cases. Si/wj)tinns. — The symptoms of brain tumors vary extremely in accordance with the location, the kind of tumor, the rapidity i)f growth, and the age of the ])atient. The general course of a case of brain tumor in an adult is somewhat as follows: The patient first notices a headache which is intense and persistent, and 44(3 DISEASES OF THE NERVOUS SYSTEM. which has exacerbations of frightful severity. With the headache or between the attacks vomiting occurs, which is often not accom« panied by any nausea. Sensations of vertigo, annoying pares- thesias, and convulsive movements affecting one or more extremities develop, and there may even be general convulsions. The patient finds that his eyesight is weak and progressively deteriorates. The mind becomes more or less disturbed, the mental processes are dull and slow, a feeling of hebetude and incapacity to attempt any mental exertion is present. As the disease progresses the intense pains and vomiting produce weakness and emaciation. Paralyses of various kinds develop. Blindness may ensue. Convulsions of a local or general character become more frequent, and finally the patient becomes bedridden and helpless. The course of the disease is not a steady one, there being often slight remissions, or there may be periods when progress seems to be arrested. After a period of time varying from one to four or five years death occurs from exhaustion or some intercurrent malady. The symptoms thus very briefly outlined are divided into gen- eral and focal. The general si/injjtonis are : Headache, Vertigo, Vomiting, Optic neuritis, Mental defects. Besides these there may be general convulsions and speech dis- turbances. Headache occurs in from one-half to two-thirds of the cases ; it is very severe and the pains are of a boring or lancinating character; they are so horrible that they often lead the patient to think of sui- cide. The pains are sometimes periodical, occurring every night or every other day, and suggest by their perodicity a malarial character. They are located sometimes in the brow or in the occiput, while sometimes they are diffused all over the head; they are rather more frequent than otherwise in the neighborhood of the tumor. They are more frequent with cerebellar tumors than with those located any- where else. Pains are also frequent with tumors of the mid-brain and of the cerebral hemispheres. They are less frequent with tu- mors situated in the peduncles and at the base of the brain. The pains are due to the increased intracranial pressure and to irritation of the membranes of the brain by the encroachment upon them of the new growth. Headache occurs in about the same proportion in children and adults, and it does not seem to bear much relation to the kind of tumor, although the pains are generally less with the TUMOKS OF THE BKAIX — SYPHILIS. 447 gliomata, and they are more frequent with rapidly growing tumors whatever their character. With the paius there is often a local tenderness of the scalp and cranium which may be elicited by per- cussion, and in most cases there is greater tenderness in that part of the cranium lying over the tumor. Vomiting is a symptom which is almost as frequent as head- ache. The vomiting is often of a projectile character and not ac- companied by much nausea. Vomiting occurs, as does headache, more frequently with cerebellar tumors. It is associated with rap- idly growing tumors such as syphilitic or tuberculous neoplasms. Vertigo is a general symptom which occurs in from one-third to one-half of the cases. The vertigo may be slight, such as is often felt ivoni ordinary causes. Occasionally it is very severe and ac- companied by forced movements. The severer forms and those associated with forced movements occur with tumors of the cerebel- lum and the parts closely connected with it. Optic neuritis is one of the most frequent and important of all the general symptoms of brain tumor; it occurs at some period of the disease in at least four-fifths of the cases, more frequently in cerebellar tumors and in those of the mid-brain and great basal ganglia. It is rare in tumors of the medulla. It is less frequent and nuuked in the slow-growing tumors. The neuritis may run a somewhat rapid course and then improve a great deal or even for a time disappear; but ordinarily the course is progressive and it ends eventually in an atrophy of the optic nerve. Hence the examina- tion of the eyes in brain tumors should be made a number of times in order to note the progress of the trouble. Primary atrophy of the optic nerve does not occur in brain tumors. Tlie inflammation almost always affects both nerves, but it may begin with one and subsequently affect the other. Mental defects are almost always present in tumors of the brain. These defects consist in a slowness of the mental processes, a condi- tion of hebetudt', a tendency to attacks of somnolence, and sometimes a peculiar cliildishness and silliness or peculiar mental irritability. The memory is also usually somewhat weakened and tlie power of attention lessened. Such psychical defects are more fretpient witli tumors of the frontal lobes and more frequent also with large tumors. General convulsions occur in about one-fourth of the cases and more frequently when the tumors are situated in the cerebral liemi- spheres and cortex. There may be also apoplectiform attacks, from which the patient recovers in the course of a few days or weeks. More rarel}" there is a genuine a]ioplexy fro"! tbf bursting of a blood-vessel in the neigliborlvood of the tumor. 448 DISEASES OF THE NERVOUS SYSTEM. The speech disturbances are most marked in tumors which affect the pons and medulla and the origin of the cranial nerves. Such speech disturbances, when characteristic, are shown by a confluent articulation; that is to say, the patient runs the syllables together. The cranial temperature in brain tumors is in most cases some- what raised as compared with the normal (Gray, Mills, and Lloyd). The elevation may be several degrees above the normal. The nor- mal average scalp temperatures (Gray) are from 92° to 94.5° F., being somewhat higher over the frontal and parietal than over the occipital regions. In brain tumors the temperature has been found raised to 9o'^, 96", and 98°. The value of thermometric observa- tions, however, in the symptomatology of brain tumors is somewhat doubtful, owing to the variability in the normal temperature and the difficulty of getting accurate records. Focal Si/mjjtoins. — Having by a study of general symptoms arrived at a fairly certain diagnosis as to the presence of a tumor, it is necessary to corroborate the diagnosis and to localize the lesion by an examination of the symptoms which are the result of irrita- tion or destruction of certain particular parts of the brain; these are called the focal symptoms. For purposes of special or local diagnosis we divide the brain into the following parts or areas (Knapp) ; 1. The prefrontal, which includes all that part lying in front of a line that extends from the upper end of the ascending branch of the fissure of Sylvius directly up at right angles to a horizontal line betAveen the frontal and occipital poles of the brain (see Fig. 211). This region includes probably centres for the move- ment of the head, and eyes, but it is chiefly concerned with the higher intellectual j)rocesses; its under surface lies on the orbital plate of 'the frontal bone and upon the right olfactory lobes. 2. The central region, which is bounded in front by the vertical line just described, behind by a line passing down from the anterior end of the parietal fissure to the fissure of Sylvius, and above by a line that bounds posteriorly the postcentral convolution. 3. The parie- tal lobe. 4. The occipital lobe. 5. The temporal or temporo-sphe- noidal lobe. 6. The corpus callosum. 7. The great basal gan- glia and capsules. 8. The corpora quadrigemina, deep marrow, and pineal gland. 9. The crura cerebri. 10. The pons and medulla. 11. The cerebellum. 12. The basal surface of the brain. The boundaries of most of these areas are indicated better by the figure than by a description. They correspond to some extent with the cerebral lobes, but not entirely so, since the frontal and parietal lobes divide between them the central area. 1. Tumors of the prefrontal area. Tumors in this area often TUMORS OF THE BRAIX — SYPHILIS. 449 show no particular localizing symptoms, and this part of the brain is consequently put down as a latent one ; nevertheless, in a good proportion of cases tumors here produce peculiar mental disturb- ances that, taken in conjunction with the general symptoms, enable us to make a local diagnosis. The symptoms are peculiar mental hebetude, childishness, irritability, often a kind of silliness and emotional weakness, a tendency to laugh aud cry and to get angry at trifling causes. The entire character and temperament of the man are sometimes changed. Besides this, owing to implication of Localized spasms and epilepsy with sensory aurse; local palsies, sliirlit ansesthesia, motor aphasia, airraphia. Mental dulnesg, trritabiUty, child- aljnes.s, lack of jKiwer of atten- linii; later, motor epi.-in or paraly- t.1.-. anosmia, eye symptoms, hys- teria. Vt'onl deafnes deafoesH, liysten DO symptoms. Muscular anaesthesia, a|)raxia, oeiilo-motor sy 111 i>t o ms. word blindness. With deep lesions, an- ajsthesia. H e ra i u II opdn word bliiiduusa soul b liiidiiess. With deep lesions, aniesthesia- ere bei la r ataxia, vertigo. \oiiiitiiiK, fo'ced movements, «*eipital headache; ter, bulluir symiv toms. Crossed |«ralysis o( ton^rue anil limliH ; ijiilbar |uil.iy. Fio. -11.— Showing the F>>c.\l Symptoms op Brain Ti-Mons. the olfactory nerve, there may be loss of the sense of smell on one or both sides ; implication of the optic nerves will cause hemianopsia and optic neuritis. If the tumor involves the orbit there will be paralys«^s of the ocular muscles and protrusion of the globe of the C3e. If the tumor grows backward there is gradual invasion of motor centres with irritation, showing itself by spasms, convulsions, and later by paralyses. 2. Tumors of the central region. It is in this area that wo are often able to make the closest and most accurate diagnosis of the localization of new growths, owuig to their involvement of the differ- ent motor centres. Tlirough this involvement these centres are at first irritated, with tlio result of ]n"oducing local spasms or Jackso- 29 450 DISEASES OF THE NERVOUS SYSTEM. niau epilepsy. Such spasms are often preceded by sensory symp- toms or aura^. As the tumor grows the area of involvement becomes larger, spasms become more diffused, and general convirlsions may finally appear, with hemiplegia. The motor disturbances are not infrequently accompanied by sensory disorders. These may be simply feelings of numbness or prickling, Avhich either are perma- nent or simply precede spasms, or there may be hemianaesthesia of a moderate degree to pain, touch, and temperature. The mus- cular sense also may be somewhat involved. In cases of slight sensory involvement the capacity for localizing sensations seems to be most implicated. Besides the symptoms mentioned, there may also be motor aphasia and agraphia. The exact localization must be worked out with the help of the figures and descriptions given under anatomy. 3. Tumors of the parietal area. The symptoms produced by tu- mors in this, area may be very slight. The most characteristic are disturbances of muscular sense, which occur when the supramargi- nal gyrus is affected, and word blindness, which occurs when the angular gyrus and inferior lobule are affected. When the tumor is higher up near the longitudinal fissure, the muscles of the lower limbs may be involved, and if the tumor encroaches upon the central area spasms and paralyses of various muscular groups ensue. The cortical representation of the third nerve is thought to be in the neighborhood of the angular gyrus, and some cases have been re- ported in which paralysis of this nerve resulted from tumors in that area. 4. Occipital lobes. Tumors in this region, if situated in the cuneus and first occipital convolution, produce homonymous hemi- anopsia. If the tumor involves the other parts of the occipital lobe and the cuneus is not seriously involved, there may be a condition known as soul blindness or incapacity to understand the nature of the things which one sees. If the tumor extends up chiefly toward the angular gyrus, there may be word blindness, along with some hemianopsia. If the tumor extends farther forward into the parie- tal lobe, there may be hemianaesthesia, hemiataxia, and perhaps a little hemiplegia owing to involvement of the fibres of the internal capsule. 5. Temporal area. The temporal or temporo-sphenoidal area on the right side is very nearly a latent one. On the left side tumors involving the posterior part of the first and upper posterior part of the second temporal convolution produce word deafness. Tumors in either lobe when large and extending well down toward the base may produce attacks of vertigo or forced movements, owing TUMORS OF THE BRAIX — SYPHILIS. 451 probably to irritation of the internal ear. Tumors that involve the hippocampal convolution and the uncus may produce perhaps some disturbances in the senses of smell and taste. 6. Tumors of the corpus callosum. Tumors situated In this area are very rare. Their symptoms have been thought to be somewhat characteristic; but in the writer's experience they corre- spond closely with tiimors situated in the third ventricle and lateral ventricles of the brain; in other words, tumors which, beginning in the central parts of the brain, gradually extend outward toward the periphery. The symptoms credited to tumors of the corpus callo- sum are, first, the general synipoms of brain tiunor, to which there are superadded a gradually developing hemiplegia with later a para- plegia. At the same time there is a great deal of mental dulness, stupidity, and drowsiness; the patient often sits for hours mute, refusing to speak, or lies in a half-somnolent condition. There are no paralyses of the oculomotor nerves or of the other cranial nerves. There is no anaesthesia. The disease gradually progresses and the patient dies in coma. 7. Tumors of the great basal ganglia and the capsule (the optico- striate region). The general symptoms of tumors of this region resemble in many respects those of tumors of the corpus callosum. The stupidity, however, may be less marked. There is usually a progressive hemiplegia which may be accompanied by anaesthesia and sometimes by choreic movements, if the tumor involves the optic thalamus and adjacent part of the capsule. Tumors of the caiulate nucleus alone and of the lenticular nucleus alone seem to give rise to no special symptoms, and these regions are regarded as latent. Tumors of the anterior thr»^e-fourths of the optic thalamus alone nuiy cause no special symptoms, bub in some cases there oc- cur peculiar choreic or athetoid movements. These, however, are probably due to irritation of the fibres of the internal capsule. If the tumor involves the posterior part of the optic thalamus and ad- jacent areas, there will be a hemianopsia, which may be distinguished from the hemianopsia due to lesions in the occipital lobe by the presence of the Jwrntojilc, jmi'ilfxi'H mnfnoi ; that is to say, a ray of light thrown in \i\H>n the insensitive part of the retina will not pro- duce a refiex contraction of tlie pu[iil. 8. Tumors of the corpora quadrigemina, deep marrow, and pineal gland. The characteristic symptoms, as shown by Noth- nagel, of tumors of this region arc inco-ordination, forceil move- ments, and oculo-motor palsies. Together with tliese tliere may be hemianopsia or blindness due to destruction of the primary optic- centres. It is possible that some degreee of deafness or hemideaf- 452 DISEASES OF THE NERVOUS SYSTEM. ness may be produced by the involvement of the posterior tubercles of the corpora quadrigemina. 9. Tumors of the crus. Tumors of the crura cerebri are ex- tremely rare. When present, they cause hemiplegia and perhaps a hemiauEBsthesia, with j)aralysis of the third nerve upon the same side as the lesion; la other words, a crossed paralysis (Fig. 215, M), 10. Tumors of the pons and medulla. Tumors in this area nec- FiG. ~15.— Showing the Mechanism op Crossed Paralysis. Lesion at M causes paralysis of third nerve, lesiou at J" paralysis of fifth nerve with hemiplegia of opposite side. (After Van Gehuch ten.) essaril}' produce very varying symptoms in accordance with their size and location. If the tumor is in the pons it will cause, if situ- ated high up, a palsy of the third nerve on one side and hemiplegia on the opposite side. If lower down there may be a palsy of the fifth nerve on one side and hemiplegia on the other side (Fig. 215, F). If the tumor is extensive it may produce not only a hemiplegia, but a hemianaesthesia. If situated somewhat superficially and on the lat- eral edge of the pons involving the peduncles, there will be forced movements of the bodj^, either toward or from the seat of the lesion. rmroRS of the bkaix — syphilis. 453 Tf the tumor is in the medulla it will produce hemiplegia and hemi- anaisthesia, with paralysis of the hypoglossal nei've or perhaps some other cranial nerves upon the same side (Fig. 215, Jl). If large and involving both sides of tlie medulla, there may be the general symp- toms of a progressive bulbar paralysis. One peculiarity of tumors situated in the pons is that they sometimes produce a conjugate deviation of the eyes which is away from the side of the lesion. In this respect the symptoms differ from conjugate deviation produced by lesion in the cerebral hemispheres, in which the head and eyes are turned toward the side of the lesion. 11. The general symptoms of tumors of the cerebellum are, as we have already said, more pronounced than those of tumors of other regions; we more frequently have headache, vomiting, vertigo, and optic neuritis from neoplasms here. If the tumor is situated in the Literal lobes of the cerebellum, no localizing symptoms develop initil the tumor becomes very large so that it presses upon the medulla or other adjacent regions, "When the timior is in the middle lobe a pe- culiar ataxia develops, known as cerebellar ataxia. The gait of the patient is a reeling one like that of a drunken man, or in walking lie takes short steps and spreads his legs as if in fear of falling. This has been called the titubating gait. Besides this, severe forced movements may occur which usually throw him sideways or perhaps forward, very rarely backward. Secondary symptoms from pressure on the medulla often develop in tumors of the middle lobe, such symptoms being glycosuria and disturbance of the functions of the cranial nerves. Late in the disease hemiplegia and paraplegia and bulbar symptoms nuay develop from extreme pressure. There may be also hydrocephalus due to pressure on the veins of Galen and obstruction of the return flow of blood from the central arteries of the brain. 12. Tumors of tl»e base of the brain. Tumors situated in the anterior fossa prodiice symptoms very much like those described under the head of tumors of the prefrontal area, but there is neces- sarily destruction of the olfactory lobe and there is more ajjt to be involvement of the optic and oeulo-motor nerves and of the tissues of the orbit. Tumors of the middle fossa. Tumors sometimes involve the hypophysis. Such condition lias been found in cases of acromegaly ; Vint on the other hand a number of tumors of this region liave been described in which none of the symptoms of acromegaly Avere pres- ent. Tumors of this region and of the interpeduncular space pro- duce symptoms such as would naturally result from jiressure on the optic chiasm, and it is mainly llu' I'arly lu-esence of optic neuritis 454 DISEASES OF THE NERVOUS SYSTEM. and of peculiar forms of hemianopsia which differentiates lesions in this area from those in the anterior fossa. Multiple tumors. About one-seventh of all brain tumors are multiple. Hence in making a diagnosis of the localization of tu- mors this fact must be borne in mind. The tumors which are most frequently multiple are tubercle, cancer, and melanotic growths. Patholo(j)j. — Tubercle is the form of tumor found oftenest in chil- dren and is altogether the most frequent of brain tumors. It is more often located in the cerebellum, but may appear in the pons or other parts of the brain. It may be a single or, as it is then called, a solitary tubercle, or there may be a multiple growth. The tumor is irregularly round in shape and varies in diameter from one and a half to two inches. It has a grayish-yellow appearance exter- nally ; internally, a yellowish or cheesy look. It is not vascular, but is often surrounded by softened or inflamed tissue. There may be an associated meningitis. The tumors, when solitary, usually start from the central parts of the brain, but they also develop on the meninges of the convexity, particularly in the parietal region, and sometimes they develop also at the base. Tubercle always arises from infection by the tubercle bacilli, which are carried by the blood to the brain. The tumors develop usually from some in- fectious focus, starting in a blood-vessel of the pia mater. Micro- scopically the tumor shows the ordinary appearances of tuberculous growths. It contains in its periphery many round cells, nuclei, and giant cells. In the centre there is usually an amorphous substance, the product of degeneration and the breaking do^vn of the ordinary substance of the tumor. The characteristics of the growth are the presence of the round cells and giant cells, the caseation and soft- ening of the centre, and the absence of vascularization, with the presence of the bacilli. Syphiloma or gumma. Gummatous tumors of the brain are usually associated with syphilitic meningitis or some other form of cerebral syphilis, such as endarteritis, and perhaps inflammation of the cranial nerve roots. Syphilitic growths are usually found upon the brain surface, oftenest on the base, next upon the con- vexity of the frontal and central convolutions. The process appears either in the form of a somewhat distinct tumor or in the form of an irregular thickened exudate lying upon the surface of the brain and forming what is called gummj' meningitis. The gummata may at- tain great size. They start usually from the pia mater and are due, as in the case of tubercle, to the irritative action of some infective organism. The gumma is irregular in shape; it has a somewhat thick grayish periphery and often a yellowish centre, the appear- TUMORS OF THE BltAIX — SYPHILIS. 455 ances differing with the age of the tumor. Microscopically it is found to consist of small round cells and spindle cells with various broken-down nerve-tissue elements. It presents in the interior the evidence of cheesy degeneration, somewhat like that in tubercle, but less marked. There is a peculiar development of fibrous tissue in the syphilitic growths which distinguishes them somewhat. Besides this, the blood-vessels are numerous in the periphery and show evidences of endarteritis and peri-arteritis. The distinctions between gumma and tubercle are the less amount of cheesy degeneration in the centre of the former, its more irregular appearance, the presence of arteritis and vascularization, the absence of giant cells and of tubercle bacilli. Actinomycosis is a form of infectious tumor which sometimes extends from the face and neck into the brain, leading to indamma- tory processes, however, rather than to true tumors. Xo other neo- plasms of infectious origin attack the brain unless glioma be found to be of that nature. Glioma may occur in any part of the brain, but is most fre- quently found in the cerebrum. It is the onl}' tumor which is pe- culiar to the nervous centres, being developed from the neuroglia tissue Avhich forms the supporting structure of these centres. Gli- oma originates in the white matter of the nerve centre and not from the membranes or fibrous structures. It may grow to a very large size and is the form of brain tumor which becomes the largest. Gliomatous tumors measure from three to eight or more centimetres in diameter. In appearance the glioma can be scarcely distinguished from the brain substance itself, but usually looks like either j)ale or congested gray matter, or it may liave a yelh)\vish or gelatinous ;ip- pearance. The tumor is very vascular and it may show the results of hemorrhages. The central part sometimes breaks down, forming cavities or cysts. The tumor may grow very rapidly, infiltrating the normal tissue. In these cases there is hardly any definite bcmn- dary between the tumor and tlie normal tissue. In other cases the tumor grows slowly, but rarely if ever becomes encapsuled. Micro- scojjically it is found to consist of small cells with delicate iil)r()us prolongations, these being the glia cells. The tumor is very vascu- lar and its whole appearance is suggestive of an infiamniatory juoc- ess rather than a new growth; the inflammatory ]»r(»cess being one in which the neuroglia tissue reads to the inflammatory irrit;nit. Gliomata may undergo certain changes, ('.araplegia MJtli K|)inal pains fuse, disseminated, or localized and involvement of sphincters. nieningo-myelitis. 4(52 DISEASES OF THE NERVOUS SYSTEM. III. — Si'ixAL Syphilis. Paraplegia with pains, Brown- Meningo-myelitis, gumma, localized Sequard paralysis. softenings from obliterative ar- Spastic paraplegia and ataxia. teritis. IV. — Syphilis of Neiives. Cranial-nerve palsies, caudu-equina Root neuritis, gummatous neuritis, symptoms, local palsies of periph- eral nerves. V. — Post-Syphilitic Degenerative Processes. Locomotor ataxia ; general paresis. Taking up these different forms of nerve syphilis in order, I will give some further details with regard to each of them. I. Syphilis of the brain in its most common form shows itself by a gradual development of severe and persistent headache. This is usually associated with vertigo, sometimes with nausea and vom- iting. After the headache has developed and has lasted for a time, or even without much delay, there comes on sometimes an attack of hemiplegia. Preceding the hemiplegia, or in some cases without the hemiplegia, there are paralyses of the cranial nerves, more es- pecially of the nerves of the eye. Optic neuritis is somewhat fre- quent. There may be, before any paralyses develop, attacks of epileptic convulsions, either general or partial. Without any paral- yses or with simply cranial-nerve paralyses there may develop at- tacks of somnolence and coma. Even if such attacks do not appear the patient often shows a mental irritability and weakness, a slow- ness of the reasoning process, and incapacity to fix the attention such as is observed in connection with brain tumors, only with nerve syphilis these symptoms are not usually so marked. Polyuria and polydipsia are symptoms which are occasionally met with. It will be seen that the syphilitic poison produces very various mani- festations when it attacks the brain. The characteristic features are this variability in the symptoms and their remittent character. Elaborate systems of clinical classification might be made out of these various groups, but it will be sufficient for the present pur- pose to call attention to the fact that the intense headaches, optic neuritis, cranial-nerve palsies, attacks of somnolence and coma, and hemiplegia associated with some of the foregoing symptoms are characteristic of most of the forms. The reason for the peculiar symptoms in brain syphilis is manifest when it is knoAvn that the lesion most commonly found underlying them is a gummatous men- ingitis which has a special predilection for the base of the brain. TUMORS OF THE BRAIX — SYPHILIS. 463 In particular it seems to attack the interpeduncular space and the neighborhood of the optic chiasm and the surface of the pons Varolii. This gummatous meningitis consists of a syphilitic inflammatory ex- udate which surrounds, presses upon, and injures cranial nerves, attacks the arteries of the base, producing an obliterating arteritis and consequent softenings, with the hemiplegia which is so often a manifestation of the disease. Much less frequently the inflamma- tory process attacks the convexity, and then it assumes the form of a gummatous patch which produces cortical irritation with head- aches, mental disturbances, and convulsions. II. The next form of nervous syphilis is the cerebro-spinal. In this we have almost exactly the same conditions and symptoms so far as the brain is concerned; but in addition there are symjitoms due to more or less diffuse syphilitic inflammation of the pia mater of the spinal cord. The syphilitic process often extends into the spinal cord, producing an obliteration of the arteries and softening with the symptoms of a transverse or a central myelitis. Thus we have combined the symptoms of cerebral syphilis and paraplegia with, as a rule, considerable pain in the back, produced by the involvement of the meninges. III. The third type of syphilis is the spinal form. The symp- toms in spinal syphilis are usually those of a transverse myelitis, involving, in the Avriter's experience, most often the lower part of the dorsal and upper part of the lumbar cord. This myelitis usu- ally comes on rather slowly with the ordinary symptoms of a chronic or subacute transverse myelitis, there being a progressive paraplegia with spasticity of the legs and a good deal of pain. The condition is known as sypliilitic spinal paralysis. It is probable that syphilis is a much more frequent factor in the production of so-called transverse myelitis than is usually supposed. The anatomical proc- ess underlying it is that of a meningitis which passes along the septa into the substance of the cord, involves the arteries of the cord, and produces a more or less complete softening of the part. Tlie only truly inflammatory process, therefore, is that which is jtroduced in the meninges, connective tissiies, and arteries. The anatomical changes in the cord substance are mainly those of soft- ening with reactive inflammation. Sjiinal syphilis may show itself also by the devt'lopnient of gummatous nodules which grow from the meninges, press upon the cord, and produce the symptoms of a s])inal tumor. Spinal syphilis may also develop itself in three or four dit- ferent foci, producing the symptomatology of disseminated myelitis. IV. Syphilis of the nerves. Syphilis rarely affects the ])eriph- 464 DISEASES OF THE NERVOUS SYSTEM. eral nerves; there are, however, occasional deposits of sypliilitic exudate producing the ordinary symptoms of irritation and com- pression of nerves. There is said to be a form of multiple neuritis produced by syphilis, but its actual existence has not yet been abso- lutely demonstrated. Syphilis has been known to attack the roots of the cranial nerves, producing a root neuritis ; and it is very apt to attack the roots of the spinal nerves when the spinal membranes are involved. V. The post-syphilitic degenerative processes are locomotor ataxia and general paresis. Occasionally it happens that the syph- ilitic deposits in the spinal cord may produce lesions somewhat like those of locomotor ataxia, and in this case there will be a train of sj'mptoms which also resemble this disease. In true locomotor ataxia, however, the process is a degenerative not an exudative one. The syphilitic poison seems so to aifect the nervous centres as to predispose them to the peculiar degeneration characteristic of tabes. Syphilis may also produce a chi-onic meningo-eucephalitis which will manifest itself by symptoms resembling to a considerable extent general paralysis ; but it is very generally conceded that true gen- eral paresis is not a syphilitic disorder. Syphilis, however, seems to predispose to it, just as it does to locomotor ataxia. Hereditarij SijphUls. — Inherited syphilis will lead to anatomical changes and clinical manifestations resembling in all respects those of acquired syphilis. Inherited syphilis, in other words, may pro- duce headaches, cranial-nerve palsies, hemiplegia, epilepsy, mental disorders, and paraplegia. The disease probably is the cause of a considerable proportion of the cases of chronic hydrocephalus and of many of the cases of so-called tuberculous meningitis. The peciili- arities of hereditary syphilis show themselves rather more in diffuse symptoms such as would be attributed to a meningitis of the con- vexity; in other words, convulsions and mental weakness are rather more frequent, while hemiplegia and cranial-nerve palsies are com- paratively rare. Hereditary syphilis also very rarely indeed attacks the spinal cord, although it is not unlikely that it is a factor in the production of some of the hereditary diseases of that organ. He- reditary S3^philis develops at any time from birth to the eighteenth year, but most coinmonly under the age of live years. Pathologij. — I have already given some indications of the patho- logical changes produced by syphilis. The disease affects the ner- vous system (1) b}^ producing a meningitis with infiltration, (2) by producing gummatous masses, (3) by producing an inflammation of the arteries, and (4) by so influencing the nervous system as to lead to the development of degenerative diseases. Of all these forms of TUMORS OF THE BRAIX — SYPHILIS. 405 anatomical change it is the arteries that are most often affected, and particular!}" the arteries at the base of the Ijrain. Syphilitic meningitis is characterized by the jjroliferation of round cells and the preponderance of an exudate which has a ten- dency to infiltrate into the nervous tissues. The anatomical char- acteristics of the syphilitic gumma must be studied in special text- books. The inflammation of the arteries attacks first the exteinal coat and adventitia, producing there an enormous multiplication ol round cells. The external coat becomes weakened, and as a result there develops beneath it, between the intima and the elastic layer, another exudate which constitutes what is known as endarteritis. In syphilitic arteritis, therefore, there is both a peri-arteritis and an endarteritis; the former being usually the primary and most essen- tial process. The endarteritis, however, as it develops gradually produces an occlusion of the arteries. This cuts off the circulation of the blood and leads to softening of the part. There is also a development of a hyaline degeneration in the arteries, which some regard as a very essential part of the anatomical change. Diagnosis. — The diagnosis of iiervous syphilis is based upon the history of an infection, the irregularity and fugacity of the symp- toms, the intense headaches, the presence of an optic neuritis, the age of the patient, and the results of treatment. In estimating the importance of the history of infection, it should be remembered that the third year after infection is the serious one for the development in particular of those symptoms produced by obliterating arteritis. In hereditary syphilis the presence of the Hutchinson teeth, the hazy cornea, and deafness or other ear trouble help us in diagnosis. The headache of syphilis is rather characteristic. It may attack any part of the head, but is usually unilateral or irregular, or again it may be bilateral in its distribution. The pain is very intense and 6(»metimes exhibits a certain periodicity. It is usually worse at night. It is apt to last continuously for from five days to three or four weeks. Headache of this character, followed by the paralysis of one or more cranial nerves or by an attack of hemiplegia, is ex- tremely suggestive of syphilis. Oj)tic n«nuitis is very liable to occur when the disease shows other evidences of being situated at the base of the brain. This optic neuritis is associated with contraction of the visual field, and a characteristic feature of tliis contraction is that it varies a great deal from week to week. The sex and age of the patient may be taken into consideration in weighing the evidi-nce, and finally the prompt effects of the use of iodide of potassium should have very decided weight. 30 466 DISEASES OF THE NERVOUS SYSTEM. PrfKjnosis. — It is very difficult to give definite facts regarding the prognosis of sypliilis. Uuquestiouably tlie outlook is luucli more favorable than it is for any other organic disease of tlie nervous system. When the syphilitic ])rocess has not produced so much arterial disease as to lead to obliteration of vessels and softening, a very great degree of improvement and even a recovery may be ex- pected. So far as injuries to the nerves or nerve roots go, we can gen- erally expect a great improvement or cure. Lesions of the convex- ity are usually amenable to treatment. Syphilitic hemiplegia has a not much better prognosis than hemiplegia from other causes. Syph- ilitic myelitis has a not very good prognosis, but it is better than that of myelitis due to trauma. Nervous syphilis may last from one to three or four years. The effects of the disease may, if nerve tissue is destroyed, last a lifetime. Treatment. — -As regards the prophylaxis, it is important that persons who have become infected by syphilis should be treated with iodide of. potassium in the second as well as the third stage of the disease. After the first year at least, the patient should not neglect to take a certain amount of iodide of potassium four times a year, each course of treatment lasting six weeks. The patient should be warned against indulging in alcohol, against all excesses, mental as well as physical. A laborious life full of worry and anx- iety, in which tlie patient attempts to help himself along with stim- idauts, is surely provocative of nervous syphilis. The treatment of the disease when it has appeared consists mainly in the administration of iodide of potasium or sodium. This should be given in beginning doses of ten grains three times a day and increased gradually until the maximum amount which the pa- tient can bear is taken. This maximum is usually between three and four hundred grains a day. In some cases it is important to give more than this — as much, that is to say, as two hundred grains three times a day, and it is the general experience of American neurologists that results can be obtained by these large doses which cannot be obtained by smaller ones. In my own experience I have known a patient to take five hundred grains three times a day for a considerable time without harm, and indeed with benefit. Usually, however, such extraordinary doses are rarely needed. It is found that, as a rule, patients tolerate large doses of iodide quite as well as smaller ones, and sometimes the iodism produced by small doses disappears when large doses are given. The drug is best adminis- tered largely diluted with water or with Vichy or in milk, and taken after meals. Some persons bear it better before meals. It is oc- TLMORS OF THE BRAIX — SYPHILIS. 467 easionally advisable to combine meiciiiy with the iodide. This may be given in the form of the bichloride or by an inunction. Other drugs which are of value are the ordinary tonics, such as iron, quinine, and the bitters and mineral acids. Plenty of good food, out-door air, and all those things which will improve the general health of the patient are indicated. In recent years the treatment of syphilis by hypodermic in- jections of the bichloride or salicylate of mercury has been widely adopted, and apparently better results have been obtained than by inunction or by administration by the mouth. One or two grains of the salicylate mixed with a liquid petroleum oil may be given twice a Aveek. CHAPTER XXL FUNCTIONAL NERVOUS DISEASES. Functional nervous diseases are those in which no definite knoAvn anatomical change underlies the morbid phenomena. On this account it is customary to classify them on a clinical basis. We can, however, also make etiological and" pathogenic subdivisions. Applying such a method now, we have two broadly distinguished classes: the primary, or degenerative, and the secondary, or ac- quired neuroses. Such a classification is suggestive and helpful, though not perfectly correct, because several factors often enter into the cause of the same neurosis. Primary degenerative neuroses. Acquired neuroses. Primary neurasthenia, hypochondriasis. Epilepsy. Hysteria major. Hereditary chorea. General spasmodic tics. _ Myotonia and myoclonia. ' Chorea. Tetanus. Tetany, Rabies. Tremor. Neuralgia. C Neurasthenia. . Exhaustion an d J Hysteria. From infectious, au tochthonous, and- mineral poisons. shock neuroses. Acquired degenera- tive neuroses. (_ Miscellaneous. ) Exophthalmic goitre. L Occupation neuroses. Tic douloureux. Local spasmodic tics. Paralysis agitans. Vasomotor, trophic, and sleep disorders. THE DEGENERATIVE NEUROSES. Epilepsy. Idiopathic epilepsy is a chronic functional disorder character- ized by periodical seizures attended by loss of consciousness and usually by convulsions. Mental disturbances may accompany cw take the place of the convulsions. FUNCTIONAL NERVOUS DISEASES. 469 Symptomatic epilepsij is a form in which the periodic convulsive attacks are dne to gross organic changes in the brain. Jticlcsonian OY partial epilepsy is a form of symptomatic epilepsy usually, and is characterized by periodic convulsions affecting only certain groups of muscles, and often unattended by loss of con- sciousness. llystero-epilepsy is not epilepsy, but a form of hysteria. Eclampsia or acute epilepsy is the name given to a single iso- lated attack of convulsions. It is generally of the symptomatic type. Idiopathic epilepsy shows itself in three rather distinct types of attacks, viz. : that of severe attacks, called the grand mal; that of minor attacks, t\\Q pietit mal; and the rarer larvated forms char- acterized by acute mental disorder and called pjsycliical epilepsy or the psychical ejnleptic equivalent. Etiohxjy. — Predisposing causes : Heredity is the most potent of any single influence. A history of epilepsy or insanity is found in the family in about one-third of the cases and rather more on the paternal side. Alcoholism and the intermarriage of neurotic per- sons contribute powerfully to produce the convulsive tendency in children. Powerful emotions during pregnancy, accouchement in- juries, and syphilis have some influence. More cases occur in the country than the city, more in temperate climates, and more among in-bred i^aces. All American statistics (Putzel, Hamilton, Ham- mond, Starr, and myself) show a slight preponderance among males. European observers find it the other way. Aye. — The epileptic age is between ten and twenty, and still more definitely between ten and fifteen. In three-fourths of the cases the disease begins before the age of twenty ; in one-sixth of my cases before the age of five. After twenty the danger of epi- lepsy is slight, and when it occurs it is usually due to accidental causes, like syphilis, alcoholisu), or ])lumbism. Idioi)athic epilepsy, however, may develop even after sixty. The accompanying table shows graphically the relation of age to the development of epi- lepsy, chorea, and neuralgias. Ej'citiiiy Causes. — Exciting causes are not present in the majority of cases. The most important are the occurrence of rickets at the time of dentition, fright, injury to the head, sunstroke, infectious diseases, especially scarlatina, masturbation, alcoholism, and syphilis, !^[as- turbation is a real but rare cause, so also is syphilis. The so-called reflex causes are ocular and auditory irritations, worms, dyspeptic states, dental irritations, lesions involving peripheral nerves. Some American observers jmt much stress on tlie imj)ortance of ocular ir- 470 DISEASES OF THE NERVOUS SYSTEM. ritations. European writers have laid more emphasis on disease of the ear. Probably the gastro-intestinal tract and genital organs fur- nish the most important exciting irritations. True idiopathic epi- lepsy may be brought out by peripheral irritations ; more rarely there occurs only a reflex epileptiform neurosis. Sipnjitoms of the Convulsion. — The patient often feels some pre- monitory symptoms for a f^w hours or a day, consisting of general malaise, irritability, or giddiness. The attack begins in about half Percenlage of total cases 60% SOX 40 X 30% 20% 10 7c up to end of 5V>- 6*^ to 7 th to 15'^ 16'.^ 20*^ 21*-* to to 4o*^ to, 5P.' to 60*-^ 6P.f to r '' ,- -^ / A / \ r u ^ k \ \ 1 1/ / V, :^ ^ ^^ .^.^^ Fig. 217.— Table showing Percentage of Cases of Epilepsy, Chorea, and Neu- ralgia Occurring at Each Half-Decade and (after Twenty) Each Decade. Double line, epilepsy; dotted line, chorea; single line, neuralgia. the cases with a peculiar sensation called the aura. Often also a loud cry is uttered and the patient falls unconscious to the ground. The face is pale, the eyes are open and turned up and to one side, and the pupils dilated. The head is drawn back or to one side, and the -whole body is in a state of rigidity or tonic spasm. The arms are slightly drawn out from the trunk, the forearms and wrists flexed, the fingers clinclied or flexed in other ways, the legs and feet extended. This tonic stage lasts for fifteen or twenty seconds ; the face becomes congested and then livid from compression of the veins of the neck and stoppage of respiration. Gradually jerky movements of the face and limbs begin and the stage of clonic spasm sets in. The trunk and limbs are now alternately flexed and FUIfCTIONAL NERVOUS DISEASES. 4Tl extended with violent shock-like contractions, the fax^ial and eye muscles twitch, saliva collects in the mouth, and as the tongue is often bitten it becomes stained with blood. The movements are sometimes so violent that the patient is thrown about the bed or floor, and occasionally a limb is dislocated, usually the shoulder. The urine often, and the faeces occasionally, are passed. The tem- perature is raised ^^ or 1^ F., rarely more. The pulse, feeble at first, becomes frequent and tense, and then, as the attack subsides, becomes feeble again. The clonic spasm lasts from one-half to one or two minutes. It subsides gradually, and the patient sinks into a stupor, from which he can be roused with difficulty. This stupor is succeeded by a heavy sleep of several hours and a feeling of hebe- tude which lasts all day. Vomiting sometimes occurs as a terminal symptom. Immediately after the attack there is a temporary ex- haustive paralysis, Avith loss of knee jerk. The pupils contract again and often oscillate. There may be a slight amount of tran- sient albuminuria or glycosuria. The earthy phosphates are found increased ; urea is not. There is a distinct lessening of haemoglobin in the blood (Fere) and of htematoblasts. Sometimes the attack is followed by others, and for hours the patient passes from one con- vulsion into another. This condition is called status ejjilepticus. It usually lasts less than twelve hours, but may last for one or more days and until finally death occurs from exhaustion. It de- velops only in the severer types. Si/mjjtoms of the Minor Attacks. — In the minor attacks (petit mal) the patient suddenly stops in anything in which he is en- gaged, the features become fixed, the eyes open, the face is pale, the pupils are dilated, often slight twitching of the facial muscles or of the limbs occurs, and consciousness is lost. In a few seconds the attack is over, and the patient, who does not fall, resumes his work or conversation, being unconscious of what has occurred, ex- cept that lie has had a " S])ell." Often there is a warning sensation or aura. This is felt as giddiness, sense of fear, numb sensations of the extremities, flashes of light or blindness, or choking sensa- tions. There may be a cry uttered. The minor attacks are in rarer cases accompanied by sudden forced movements; the patient runs a few steps, or turns round, or makes some automatic movements. This is called ^//v<<'//rA/re ejiilcpsy. Si/mptnnis of the Psiji'hlcal Attachs. — Sometimes the minor at- tacks are followed by outbursts of numiacal excitement or by sud- den violent automatic movements, and in these states the patient may commit crimes of violence. In rare cases the patient passes into a somnambulic state, during which he performs accustomed 472 DISEASES OF THE NERVOUS SYSTEM. acts, such as driving and walking, automatically and naturally (somnambulic epilepsy). This form of epilepsy may come on with- out a preliminary minor attack, and then it is to be considered a "psychical epileptic equivalent." Minor attacks may end in convulsions of a co-ordinate type in which the patient jumps, kicks, throws the arms about as in hys- terical attacks. These are called hysteroid convulsions. The seizure may consist of only a short touic stage and a few twitchings of the limbs, the whole lasting but a few seconds. This is called an ahorth-e attack. Under the influence of medication, the severe seizures are often reduced to abortive forms. Jacksonian ov 2Ja^'tlcil epil&psy is a form of the disease charac- terized by convulsive attacks affecting only a single group of mus- cles or a limb, and generally not accomj)anied by loss of consciou.s- ness. Jacksonian epilepsy is always symptomatic of some focal lesion affecting the cortical motor area of the brain. This may be a tumor, inflammation, or injury. This form of seizure is particu- larly significant of a slowly growing brain tumor or syphilis. The aura usually consists of a sensation of numbness, prickling or of a breeze beginning in the hand or leg and passing up to the head, when consciousness is lost. Still oftener there is a peculiar sensa- tion starting in the epigastrium and passing upward. More rarely there are special-sense aurse, such as flashes of light, noises, or voices and peculiar tastes or smells. Besides these there occur feelings of giddiness, dreamy states, peculiar sensations in the head, and indescribable general sensations. The auree may be divided into : Visceral — epigastric, laryngeal, cardiac. Cutaneous sensations. Special senses — flashes of light, etc. Psychical — emotions, dreamy states, etc. Cephalic — giddiness, etc. The aura is thought to indicate the seat of the first discharge of nerve force, and its study is of most importance in connection with symptomatic epilepsies, as will be shown later, liclatlre frequeyicy of the different kinds of attacks. The severe attacks are the most frequent, next come combinations of severe and minor attacks, and next minor attacks alone, while the psychical forms are the rarest. Fre'iiiennj of the Attacks. — The severe attacks may come on only once or twice a year, and this commonly occurs during the develop- ment of the disease. The frequency gradually increases until they occur every month, or two or three times a month. Sometimes the FUNCTIONAL NERVOUS DISEASES. 4:73 fits occur in groups of four or five every month or two. In very bad cases convulsions occur every day. The jjctit-mal attacks are more frequent and usually occur daily. Time of Attacks. — The moon and the seasons have no influence. More attacks occur during waking hours than during sleep; but two-thii-ds of the attacks occur between 8 A.ai. and 8 p.m. Many patients have their attacks early in the morning just after awaken- ing {^matutinal epilepsy). Many attacks occur between 3 and 5 A. 31., when the temperature of the body and the vital powers are at the lowest. State of Patient betiveen Attacks. — Epileptic patients often feel better for a time after the convulsion is over. They not rarely suffer from severe neuralgic headaches ; the appetite is capricious, often in children it is voracious, but in older cases there may be anorexia; the bowels are usually constipated; the pulse is small, soft, and frequent in the young, later it is often slow. Mental Conditmi. — A gradual mental deterioration occurs in the great majority of epileptics, but it is slight in some and not very great in others. It shows itself by feebleness of memory, irrita- bility of temper, selfishness, incapacity to concentrate the mind or to carry out a purpose. In children great mischievousness and lack of moral sense, with vicious impulses, may appear. The mental deterioration is dependent on those underlying factors which cause the disease. It is apparently in some cases due to the excessive number of the fits. This is not necessarilj'^ the case, nor it is gen- erally true that it occurs more often with ^e^/i tnal. It is more marked in cases beginning very early in life, but this is true only when there are decided marks of physical and mental degeneration pres- ent. A certain rather small percentage of epileptics become either demented or insane. True epilepsy is not compatible with extraordi- nary intellectual endowments. Caesar, Napoleon, Peter the Great, and other geniuses may have had some symptomatic fits, but not idiopathic epilepsy. riii/sirnl Condition. — Epileptics are rather undersized and of not very robust constitution (Fere). They always present some of the marks of degeneration, physical, ])hysiological, or mental. Such marks or stigmata are about ten times more frequent than in healthy persons. The physical stigmata are (Fere) short stature, cranial asymmetry (in 71 percent), short parietal or frontal arc, and triangu- lar skull ; in women high prominent forehead ; bad teeth badly placed, high palatal arch; facial asymmetry; prominence of occi]iut and liMUurian hypo])hysis; differences in color, size, position, and shape of pupils; astigmatism (in 7") per cent of cases); badly shaped 474 DISEASES OF THE NERVOUS SYSTEM. and placed ears ; misplaced crowu of scalp j low vital capacity ; small genitals, atrophic uterus j greater development of left side; long fingers. Cranial deformities of pronounced type occur in epileptics associated with idiocy, hemiplegia, and brain defects of early origin. Sometimes, apparently from a premature ossification of sutures, there are the peculiar shapes of the skull known as scaphocephaly, or steeple skull, and plagiocephaly, or obliquely deformed skull. The physiological marks of deterioration are a lessened muscular strength (as 35 to 50), habit choreas, a rather imperfect eye with excessive amount of astigmatism and fimctional muscular weakness. There is a lessened vital capacity, weak and slow digestion, and mm Pio. 218.— Diffuse Neuroglia Sclerosis OF THE Cortex in Epilepsy. Fig. 219.— Same, Enlarged CChaslin). sexual atrophy or irritability. The excretion of phosphoric acid is below normal as compared with urea. The psychical stigmata are mental feebleness, moral insensibility, irritability, wayward and vicious impulses, lack of will power, and sexual aberrations. Tathology. — The body of the epileptic shows sometimes skin eruptions and ulcers, the result of treatment. There are often evi- dences of local injuries and fractures due to falls. The organs may show vices of conformation. The uterus is frequently infantile or sharply flexed. Deformation of the occipital bone or the atlas so as to produce narrowing of the upper spinal canal has been noticed. The brain may be unduly large or small, but there is nothing con- stant in this, nor is there an abnormal difference in the weight of the two hemispheres. The convolutions show many anomalies, but there is in them nothing specific. On the whole the convolutional type is a simple one. The pathological cliange found most con- stantly in epilepsy is an induration or sclerosis (gliosis). This FUNCTIONAL NERVOUS DISEASES. 475 affects the cornu ammonis rather often (4 to 10 per cent), more rarely the olivary bodies or cerebellum. Besitk's this, small patches of induration occur in the gray matter in various parts of the cor- tex. Chaslin finds a diffuse increase of neuroglia tissue throughout the brain, more marked when the case is older Fig. 2i9). Others have foimd an increase in the neuroglia cells (Kingsbury). In old cases there is often a chronic leptomeningitis, and vascular changes due to the frequent congestions of the brain take place. These con- sist in varicose and fusiform dilatation of vessels, with evidence of small hemorrhages. Slight degenerative changes in the nerve fibres are also observed. Bevan Lewis finds in epileptics with insanity a fatty degenera- tion of the nuclei of the " angular cells " of the second layer of the cortex. In the severer and later stages of the disease this nuclear degeneration is increased so that vacuoles are formed. The cells of the deeper layers are also affected, but to a less extent. The change, though not peculiar to epilepsy, is more extensive and pro- nounced in this disease. To sum up : The anatomical basis of idiopathic epilepsy consists in a degeneration of the cortical cells. Also a proliferation and increase in the neuroglia tissue, this occurring most markedly in various islets or special areas of the cortex. The blood-vessels and connective tissue are involved only secondarily and later. PJujsiohgij. — The epileptic fits are due to sudden discharges of nerve force. The seat of the discharge is the cortex of the brain. The discharging cells are, in the severe seizures, the large motor cells, the function of which is to store up and discharge nerve force. They are under control of the sensory cells (angular cells) of the second layer, Avhich have an inhibitory power. These being dis- eased, their control is weakened and the motor cells " explode" peri- odically. In sensory and psychical epilepsy the same mechanism exists. The more highly organized cells with large nuclei of the second layer are congenitally or otherwise weak and diseased; the cells below them are not maintained in stable equilibrium and hence periodically break down and "discharge." The dlagvnsis is based on the character of the attacks and has to be made fron\ hysterical and various toxic and symptomatic convul- sions. The aura, the scream, the quick loss of consciousness, the di- lated pupils, the tonic convulsion, the bitten tongue, the emptied bladder, are all characteristic. The hysterical patient sometimes, but rarely, loses consciousness, the epile])tic almost always. Hys- terical patients do not hurt themselves in falling or bite their 476 DISEASES OF THE NERVOUS SYSTEM, tongue, aud their muscular movements, while irregular and violent in character, are yet co-ordinate, i.e., they throw themselves about, kick, strike, etc. Their attacks often are produced by emotion and are ended by some powerful mental or physical impression. The slight rise of temperature in epileptics rarely occurs in hysterics. Fetit mal and epileptic vertigo are distinguished by the sudden lapse of consciousness and by the sudden pallor and fixation of the eyes, dilatation of the pupils, and slight twitchings of the face. Xocturnal convulsions are usuallj' epileptic. Eclampsia, or acute symptomatic and reflex convulsions, cannot always be distinguished from epilepsy. The history of the case, the irregular and often prolonged character of the fit, may enable one to make the diagnosis. Course and Frognosis. — Epilepsy shortens life to some extent; most subjects do not live beyond the age of forty or tifty. About ten per cent become demented or insane. Five or ten per cent get ■well. The remainder reach a certain stage of severity in their dis- ease and continue in it for years. This severity depends on the treatment, the nature of the attacks, and the extent of degenera- tion which the organism shows. While unquestionably treatment cures or suppresses the disease in some cases, it disappears sponta- neously in others. The prognosis of ^;e^ii mal is worse than that of grand mal; that of the two combined is worse still, yet not hope- less. The psychical form of epilepsy is the least amenable to treat- ment. Epileptic insanity and dementia are incurable. Death oc- curs rarely in the attacks except in terminal stages. Yet the status epileptlcHS is always a source of danger. Epileptics are said rather frequently to suffer from phthisis. This is, however, a matter of infection and can be prevented. It should be remembered that epileptics who have only a moderate number of attacks, six to fifteen yearly, can get along comfortably for years, doing their work and enjoying a fair share of the duties and pleasures of life. Finally, the following prognostic rules may be laid down : The prognosis is better in males, better if there is a hereditary history, better if the fits are nocturnal or diurnal alone, better in grand mal, better if fits occur infrequently, better if they begin after twenty, and better if due to extrinsic causes. The prognosis is very bad in post-hemiplegic epilepsy and epilepsy due to organic disease. Treatment. — The first and essential rule of treatment is to take cases early and treat them vigorously from the s.tart. Children who have had a few convulsions during the first three or five years of life should be treated as if they might develop epilepsy between the FUNCTIONAL NERVOUS DISEASES. 47? ages of ten and fifteen or earlier. The recurrence of a fit between the ages of five and ten should excite appi-ehension and call for the most diligent treatment. Another rule is that when epilepsy is recognized in children the case should be treated constantly for at least three years after all attacks have ceased. Constitutional Treatment. — Along with the evolution of epilepsy there is probably a progressive diffuse neuroglia sclerosis of the brain. Whether this is primary or secondary, it is at least proper to use those measures which apparently affect this neuroglia pro- liferation. Mercury, arsenic, and perhaps iodide of potassium are drugs Avhich we have good reason for believing affect this. Besides this, we should use measures that increase vasomotor tone and strengthen and steady the circulation. Nothing does this better than water. Epileptics should be given showers, douches, cold sponge baths, or wetpacks according to their needs and oppor- tunities. They should also drink water freely. Again, the nervous system is greatly steadied and quieted by mental occupation that interests one. Nothing is more unfortunate than the idleness often inforced on epileptics. I have seen the disease absolutely checked by having a boy learn a trade that he liked. The next most important indication is diet, the prevention of intestinal decomposition. In j^f'tdt wal particularly an absolutely non-irritating diet, such as milk, meat, and bread, will quickly les- sen or stop the attacks. Meats can be taken in moderation if eaten slowly. As a rule it is a little safer to keep meat out of children's diet for a time ; but in adults it is not necessary, though it should be given in moderation. Removal of irritating causes. Malaria if present promotes the convulsive tendency; so also do lead and acohol; tobacco does not do this, but its use is better stopped, as it is liable to weaken vas- cular tone and impair digestion. Syphilis causes epilepsy only through ])roducing organic changes. The rheumatic, gouty, and so-called tuberculous diatheses do not stand in any close relation to epilepsy. The condition known as lithainiia, however, in which there are insufficient oxidation and ex- cretion of products of tissue waste, needs attention. Hence the use of bicarbonate of potassium, salicylate of sodium, the alkaline min- eral waters, aiul a restricted diet are not rarely indicated. The imixjrtance of reflex irritations has been much overesti- mated. Still they must be considered. The most serious are those arising from the gastro-intestinal tract, the sexual organs, and the eyes. Phimosis if present nuist be relieved, and masturbation or sexual excesses stopped if possible. It is admitted now that re- 478 DISEASES OF THE NERVOUS SYSTEM. moval of the ovaries, even if diseased, never cures true epilepsy, though it may help hysterical convulsions. Astigmatism and hypermetropia should be corrected; also ocular msufficiencies if these are pronounced. Proper attention to the frequent constipation and dyspepsia is of course necessary. The use of hot water is often serviceable, a glass being sipped slowly before the morning and evening meals. This helps also to carry off the bromides and wash out the system generally. Still further to promote this, a purge should be given every fortnight or month. Out-door life and active physical exer- cise are indorsed by Hippocrates. They do not have any specific influence unless associated with some employment. Specific treatment. The drugs which have obtained and held a reputation as anti-epileptics are not numerous. They are the bro- mides, chloral, chloral-amide, belladonna, zinc, nitroglycerin, anti- febrin, and antipyrin. Of less value are digitalis, cannabis in- dica, borax, valerian, and ergot. As adjuvant drugs we have quinine, strychnine, iron, the phosphates, arsenic, silver, the alkalies and iodides. The most valuable of the specific drugs are the bromides. All bromides act alike in this disease. If one does not cure an- other will not. Occasionally, changing or mixing reduces the attacks for a time and benefits the stomach. The best bromides are those of potassium, sodium, strontium, ammonium, and hydrogen (hydro- bromic acid) . Pure bromine may be used. Bromide of potassium is the most trustworthy. Bromide of so- dium is more agreeable to the taste, less irritating to the stomach and milder in its effects, but is eventually just as depressing as other forms. Bromide of ammonium has a brief stimulant effect on the circulation. Bromide of strontium has no advantages that I can discover. Bromide of gold is of no use. Hydrobromic acid is useful in those cases in which there are indigestion and phosphaturia and an alkali is contraindicated. It produces acne less readily than the alkaline bromides. Bromides should be given in daily doses of 3 i., increased grad- ually until the attacks are suppressed or the dose reaches 3 iv. to 5 i. daily. Few patients can tolerate more than this latter dose. Thorough bromidization should be always tried if necessary to stop the fits, and it may be occasionally repeated. But bromidization is sometimes injurious, even making the disease worse, and it must always be employed with caution. When the fits are suppressed the bromides should be reduced, but never entirely stopped for at least two years after the last fit. In most cases, and especially in nocturnal epilepsy, an extra large dose of bromide or bromide and FUKCTIOXAL NERVOUS DISEASES. 479 chloral should be given at night. It is very important that the bro- mides should be chemically pure (most samples are not), that their use should be continued a very long time, and that their depressing effects shoidd be offset by tonics and all possible roborant measures. Bromides lessen the fits in from eighty to eighty-five per cent of cases. They do no good or do actual harm, as regards frequency of attacks, in from five to ten per cent of cases. Bromides do no actual good to the patient in a much larger proportion of cases. To prevent bromide acne, arsenic, calcium sulphide, baths, and diuretics are the best measures. To prevent bromidization, one should adopt all possible roborant measures ; use salt-water baths and regular physical exercise ; give black coffee, caffeine, cocaine, mineral acids, strychnine, bitter tonics, cod-liver oil. In all cases the patient should dilute the drug, preferably with carbonic-acid water or Vichy, in the propor- tion of six ouuces of water to a scruple of the drug. A few drops of phosphoric acid may be added to this. The continuous administration of an alkaline bromide in an alka- line water sometimes affects the bladder, and then the bromide can be given dissolved in hydrobromic acid. The best substitutes for the bromides, when these do no good or do harm, are belladonna, zinc, strychnine, glonoin, borax, and anti- pyrin. The best non-specific adjuvants (drugs) to the bromides are po- tassium iodide (in syjjhilitic epilepsy), carbonate and sodium sali- cylate (in lithsemic and rheumatic states), carbonate of ammonium, the hypophosphites, arsenic, iron, and quinine. One of the best specific adjuvants to the bromides, as Seguin has shown, is chloral hydrate. By adding five or six grains of this to a mixture the bromide dose can be reduced one-half and the fits still be controlled. Chloral-amide has a similar effect. Both these drugs will sometimes affect the eyes and stomach unfavorably. Other ex- cellent adjuvants are salicylate of sodium and antipyrin. Children bear nearly as large doses of bromide as adults. The remedies that are especially useful in 2>''f'tt wol are, after the bromides, antipyrin, bromide of camphor, belladonna, glonoin, can- nal)is indica, cod-liver oil, ergot, counter-irritation at the back of the neck, and cold spinal douches. For epile[)sy in children, besides the bromides it is sometimes advisable to emi)loy milk diet, rest, and oxide of zinc. In hemiplegia and in .Tacksonian epilepsy the actual cautery ap- plied over the scalp is beneficial. Uretliane occasionally acts well also, but it is of no use in ordinary epilejisy and it may produce 480 DISEASES OF THE NERVOUS SYSTEM. albuminuria if given in large doses. Strychnine is sometimes use- ful. Kaising the head of the bed or making the patient sleep in a chair at night are measures that may be tried. For hysterical and erethitic cases, with or in place of bromides give a diet of milk and vegetables, and try tvirpentine, valerian, or zinc. Belladonna is usually contraindicated. Counter-irritation by means of blisters, issues, and setons at the back of the neck is of doubtfid value. For the status epilepticus give large enemata of chloral and use emetics and purges. Venesection is often efficacious, morphine is dangerous, chloroform is only palliative, and nitrite of amyl is of little value. To prevent impending attacks the best remedy is nitrite of amyl, which may be carried in a phial filled with cotton. Inhalation of chloroform or ammonia, the internal administration of ammonia, spirits of lavender, or alcohol, a sternutatory, and pressure on the carotids — all are measures which sometimes stop the attack. Alterative and habit-breaking drugs, such as mercury, iodide of potassium, arsenic, and antimony, are useful in epilepsy, especially in acquired forms due to lead, alcohol, and syphilis. Bromides stop the fits oftener if given early in the disease, if given to young children, and if given in cases that develop after twenty-one. Injuries to the head which have caused a fracture or a contusion of the brain are the most frequent traumatic irritants. Whenever epilepsy can be distinctly traced to a blow on the head the question of trephining should be brought up. If there is a history of frac- ture, or present evidence of fracture, or even evidence of severe head injury, trephining is justifiable. The more marked the evidence of a degenerative constitution and the less marked the evidence of real brain injury, the less ho])efnl the prognosis. On the whole, surgery can do little for acquired and nothing for idiopathic epilepsy. CHAPTER XXII. HYSTEEIA. Hysteria is a chronic functional disorder characterized by ner- vous crises of an emotional, convulsive, or other nature and by an interparoxysmal state in which certain marks or stigmata are pres- ent. Hysteria is essentially a psychosis, and the dominant symp- toms are attributable to disorder of the cortical areas of the brain. Its components are the paroxysms, or *' crises " as they are called, on the one hand, and the peculiar symptoms of an interparoxysmEd state on the other hand. The disease is to be regarded as a definite one, having a certain, as yet unknown, pathological basis underly- ing it. The use of the -word should be much more restricted and definite than has hitherto been the fashion. There are two forms of the disease, hysteria major and hysteria minor. Etlolofjij. — Of the predisposing causes heredity is the most im- portant. In about seventy-five per cent there is a history of hys- teria or some neurosis or psychosis in the parents. The disease is transmitted more often by the mother. Heredity is particularly apt to be important in the hysteria of children; it is a much smaller factor in hysteria of adult males. A hereditary history of rheu- matism, gout, and tuberculosis is of very doubtful importance. Hysteria is a disease of early adult life, most cases occurring be- tween tlie ages of from fifteen to twenty-five in females; it occurs later in males. Hysteria attacks children between the ages of eight and fifteen, chiefly between eleven and fourteen. The disease af- fects women more than mem in the proportion of four to one, vary- ing much with rac<', climate, and occupation. Hysteria occurs in all (^lasses of life, but r;ither less frequently in the middle classes than among the poor and the very rich. Mule hysteria is more fre- quent in the poorer classes who are subjected to the exciting influ- ences of alcoholism, poverty, injuries, etc. Hysteria is certaiidy much less fre(|uent in its severer forms in this country than in some parts of Europe, particularly France. In my experience it is much less frequent than epilei)sy in the northern and eastern parts of this ••ountry. It occurs, however, quite frequently in the negroes and also in the Latin races of this country. Bad methods of education 31 482 DISEASES OF THE NEEVOUS SYSTEM, anci bad family training imdoubtedly tend to promote the develop- ment of the disease. The most important single exciting factor is powerful emotion, particularly fear. Other emotions of an allied character — excite- ment, sorrow, anxiety — may bring on attacks. The disease can be developed by imitation. Injuries combined usually with mental shock are fruitful causes of producing hysteria. The infectious fevers, syphilis, diffuse hemorrhages, the poisons — lead, alcohol, mercury, and tobacco — the administration of ether, mental and bodily and sexual excesses, are all important agents in developing the disease. Symptoms. — The symptoms of hysteria are best described under two general heads : first, those of hysteria minor or the hysterical condition, and second, those of hysteria major. 1. Hysteria minor is characterized by the interparoxysmal con- dition of emotional weakness, nervousness, hypersesthesia and pains, and by crises of an emotional character. In hysteria minor there are no permanent objective marks like anaesthesia and paralysis, and no decided convulsive seizures. The patient, who is almost al- ways a girl or young woman, gradually develops an undue sensitive- ness, the mind is depressed, and she gets easily alarmed. She has feelings of nervousness and lacks control over the emotions, she laughs and cries very easily and yields to every impulse. She suf- fers from headaches, which are usually vertical and often severe and chronic, and from spinal jpains. She sleeps as a rule rather badly and often has disagreeable dreams. She has, under any little ex- citement, sensations of tickling, fulness or choking in the throat, forming the' condition known as globus. Excitement also brings on attacks of trembling or chilly feelings which come and go. There is more rarely a considerable amount of vasomotor instability, as shown by flushings and by coldness of the extremities. She has with more or less frequency distinct crises of an emo- tional character, during which she laughs or cries without apparent cause, or at least to an extent beyond her control. She may have attacks of vomiting or headache, or of intense mental excitement amounting almost to delirium. In some cases the patient has som- nambulic attacks at night, or she may have under a little excitement attacks of cerebral automatism during which she involuntarily does things that she is entirely imconscious of Avhen she comes out of the attack. The crises are followed by a copious discharge of very light urine. Hysteria minor is closely allied to a condition of neuras- thenia or of simple nervousness. It is associated with neurasthenia oftentimes, and is to Vje distinguished from it chiefly by the peculiar HYSTERIA. 4.'-l3 psychical state, the hypersesthesia, and t)ie crises "which have been described. Even in hysteria minor there is a degree of that pecu- liar mental condition which will be described later and which is known as suggestibility. Hysteria minor is a disease which belongs especially to childhood and early womanhood. It is very apt to become ameliorated and disappear a little later in life or under the intluence of proper treatment, but it may continue or pass into the major form. 2. Hysteria major is characterized by interparoxysmal mani- festations of anaesthesia, paralyses, contractures, tremors, peculiar mental conditions, and by paroxysms of an emotional, convnlsive, or other serious nature. Hysteria major is what is usually meant when one speaks of hysteria; it includes also hystero-epilepsy. The onset may be gradual, but not infrequently it follows some shock, the first symptom being a convulsion, a paralysis, or some emotional outburst. The sijiiiptoins of the crises are the most striking and will be de- scribed first. The most common of the paroxysms of hysteria are emotional outbui'sts of crying or laughing; after this come motor disturbances in the shape of convulsions of various types or of hemi- plegia or other type of paralysis. Besides this we have attacks of severe pain, forming neuralgic crises; attacks of nausea, gastral- gia, and vomiting, forming gastric crises; much more rarely there are prolonged attacks of hysterical coughing, hiccoughing, sneezing, or rapid breathing. The hysterical seizure may also take the form of attacks of trance and lethargy, catalepsy, amnesia, and cerebral automatism. The emotional crises are characterized by appearing without any good cause; the patient laughs without reason, and the laughing continues and is quite beyond her power of control. In the same way, and rather more frequently, crying attacks or attacks of furi- ous anger and excitement come on. Associated with these outbursts there is almtjst always a peculiar sensation of something in the throat. It is described sometimes as being a ball or pressure or a squeezing sensation. It is called h3'sterical globus, and is due usu- ally to a paresthesia of the nerves of the throat and larynx, but occasionally there is also a muscular spasm of those parts. Fol- lowing the crises there is a profuse discharge of pale, limpid urine. Hysterical convulsions have two rather well-defined types. One of thein is that which comes on also in hysteria minor and is the ordinary form of hysterical convulsions; the other is a much more severe disturbance in every way and is known as a hvstero-e])ile])tio or hysteroid attack. In the hysterical convulsion the patient, undet 4S4 DISEASES OF THE NERVOUS SYSTEM. the influence of some excitement, injury, or acute gastric disturb- ance, rather suddenly falls down and begins to go through various irregular movements of the body, such as thrashing with the arms, kicking with the legs, throwing the head from side to side, rolling about on the bed or floor. In the more distinctively convulsive seizure the hands and arms and fingers are flexed, the legs and feet are ex- tended, the eyes are generally closed, the eyeballs often converged or moved about irregularly, the pupils dilated. There is some les- sening of sensation over the body and of the conjunctivae. The pa- tient often utters noises or screams at intervals. She may bite her lips, but does not bite the tongue, nor does she ever hurt herself in her various contortions. The attack may last for half an hour to several hours, unless some measures are taken to break it up. In other forms of hysterical convulsion there is simply a general shak- ing or trepidation of the body as though the patient had a chill; in other cases, again the main type of movement is that of opisthot- onos, the patient rising up upon the head and heels and arching the body as in tetanus. Again the attack may consist simply of a little rigidity of the body, or of a series of rhythmical movements of the head or trunk or limbs, the patient sitting up and oscillating the head or swaying the trunk or moving the arms, uttering at the same time incoherent words. In still other cases the patient sim- ply falls down and lies unconscious like a person sleeping for a few minutes or even an hour. In children the attacks may be asso- ciated with peculiar noises and movements in imitation of animals, such as the growling of a dog or the mewing of a cat. This condi- tion is called therio-mimicry. In some instances the attack may be accompanied by or may end in a condition of mental excitement approaching delirium. The patients while suffering from these seizures generally appreciate what is going on about them, and Avill often respond to some stern order for them to cease or will be brought to a state of quietude by pressure upon some part of the body which provokes pain. In women in particular, pressure over the ovaries or epigastrium will abort the attack; the application of cold water or an emetic will do the same. After a hysterical crisis, or sudden shock, the patient may be found to have a paralysis of arras or legs or one side of the body. Tlie Si/mptoms of the Interjjaroxijsmal State. — Between the crises the patient may be in a fair condition of general health, but usually presents certain definite chronic manifestations of the disease. The most characteristic are sensory symptoms, paralyses, and contrac- tures. Sensory symptoms. These consist of cutaneous and mucous HYSTERIA. 485 hyperaesthesia and anaesthesia and anaesthetic disturbances of the sjjecial senses. Cutaneous anaesthesia occurs in three forms: the common form is that of heniianaesthesia involving one-half of the body ; next in frequency is the segmental anaesthesia involving an arm or a leg or part of the face or head ; rarest of all the forms is a dis- seminated anaesthesia occurring in the form of patches. These various modes of distribution are shown in the accompanying figures. The anaesthesia is a pain anaesthesia chiefly. The tactile and thermic sensations are less markedly affected. The anaesthesia is in some rare cases transferable by means of magnets or electrical irritants or by suggestion. The anaesthesia can also be lessened or removed tempo- rarily by the application of magnets or coins or pieces of metal. For example, if a silver coin is fastened upon the anaesthetic area, in the course of a few minutes or a few hours there will be a zone of normal sensation under and around the coin. Sometimes the temperature of the skin upon the anaesthetic part is lowered 3^ or 4^ F., and upon pricking the skin blood does not flow. The anaesthesia is oftener upon the left side in tlie proportion of three to one. Hysterical anaes- thesias are not accompanied by subjective sensations as are organic aniesthesias. The skin reflex is usually abolished. Anaesthesia of some kind occurs in a very large proportion of chronic forms of hysteria major. They are rare, however, in children, and are rarer in women than in men, in the author's experience. Anaes- thesia of the mucous membranes is present chiefly in hemianaes- thesia; it then involves the mucoxis membrane of the mouth and throat, and to a less extent that of the nose and glottis. Hemi- anaesthesia is usually accompanied by some hemiplegia and often by some tremor. Segmental anaesthesia is also often accompanied by some degree of paralysis of the part. Visual an esthesias. One of the most common of the perma- nent stignuita of hysteria is an anaestlietic condition ot the retina. The result of this is the i)roduction of a concentric limitation of llie visual field and a disturbance in the color sense. Com])lete ] or attacks of amnesia and cerebral automatism. 4114 DISEASES OF THE NERVOUS SYSTEM. As these conditions all occur in other diseases than hysteria, they ■will be described elsewhere in connection with the siibject of the disorders of sleep and of consciousness. Hysterical persons occasionally are attacked with violent and persistent hiccoughing or sneezing. Sometimes also there come on attacks of extremely rapid breathing or hysterical polypnoea, during which the respirations run up to iifty or seventy a minute. A hysterical cough sometimes occurs; it lasts for a longtime. CEso- phageal spasm with consequent dysphagia is another one of the somewhat rare phenomena of hysteria. PatJiologij. — There is no known anatomical change at the basis of hysteria. We do not find the marks of degeneration as we do in certain forms of insanity and epilepsy. Diagnosis. — Physicians recognize three different phases of hys- teria — a hysterical temperament, hysteria minor, and hysteria major. The hysterical temperament is something with which all women and many men are naturally endowed. It is a condition, not a disease, and does not call for description or elucidation here. Hysteria minor is the hysterical temperament plus certain stigmata and the crises. One should not make the diagnosis of hysteria minor unless he can find these factors. The stigmata we have already enumerated, also the peculiar and varied forms in which the crises show themselves. In hysteria major we have a much greater preponderance of the stigmata and much severer forms of the crises, these being largely of a motor type. Hysteria simu- lates many organic diseases, and it is often difficult to distinguish surely the real from the spurious thing. The essential character- istics of hysterical forms of disease are the peculiar emotional con- dition of the patient, the past history of hysterical crises, the pres- ence of the stigmata of hysteria such as anaesthesias, limitation of the visual field, paralyses, and contractures. The variability of the symptoms, their susceptibility to influence under suggestion and rigorous moral measures, the absence of serious disturbance of nutrition, the sex and age, and the cause should also have weight in guiding us to our decision. Diafjnosis of special forms of hysterical manifestations. Hys- terical paralysis is characterized by the fact that there is no marked degree of wasting of the muscles, no electrical reactions of degene- ration, the deep reflexes are preserved or exaggerated, and other marks of hysteria are present. Hysterical anaesthesia can gener- ally be lessened over certain areas by the application of the mag- net or can be made temporarily to disappear; it is peculiarly dis- tributed in the way described under symptoms and is associated HYSTERIA. 405 with anaesthesias of the special senses. Hysterical contractures sometimes cease during sleep and always under deep narcosis, and the use of an anaesthetic may clear up the case. They usually follow a fit, an injury, cr an operation. They are somewhat in- creased on attempts to overcome them by force; they are usually associated with paralysis and anaesthesia and other hysterical symptoms. Hysterical convulsions. These differ from convulsions of epi- lepsy in the way best indicated by the following table; Hysterical Convulsion. Epileptic ConvuUian. Brought on by emotion or injury ; no The opposite in all these particulars, aura ; no initial cry ; movements co-ordinate ; tongue not bitten, and patient never injures herself. Dur- ation perhaps several hours with intermissions ; consciousness gen- erally preserved. Micturition and defecation do not occur. No rise of temperature ; may be stopped artificially. The hystero-epileptic attacks are so characteristic that a mis- take coukl not be made. FriKjnosh. — The prognosis of hysteria in children is good. They generally get well, though in some cases there is a recur- rence later in life. In hysteria minor of young adults the prog- nosis varies with the severity of the disease and with the physical strength, mental endowment, and social environment of the patient. Mild forms of hysteria under proper treatment usually get well. The severer forms are often intractable even ruider the best treat- ment. AVhen a severe form of hysteria occurs in a person of fee- ble frame who is surrounded with a sympathetic family, the task of rescuing her from her disorder is a very arduous one. Trau- matic forms of hysteria which are not infrequently associated with some actual physical injury arc^ sonu'timcs ditticult to cure. Hys- teria which is associated with some organic disease, such as a severe pelvic disorder or an organic affection of the central nervous sys- tem, has a bad prognosis. Hysteria in the male is generally cur- able, but it requires vigorous treatment, and spontaneous cure is by no means likely to happen. Tvciitmi'ut. — The treatment of hysteria may be divided into the mental, mechanical, dietetic, and medicinal. By all odds the most important factor in the treatment of hys- teria is the mental treatment, and the most important measure t j 41)6 DISEASES OF THE NERVOUS SYSTEM. be taken is the isolation of the patient. She should be placed where she will not be surrounded by sympathetic friends; where her life will be a regular one ; where some occupation may be given which will engross her attention, interest her mind, and call into play her physical activities. In the major forms of hysteria asso- ciated with anorexia, emaciation, anaemia, and possibly pelvic dis- orders, the "rest cure" as elaborated and carried out by Weir Mitchell forms by all odds the most successful means of treatment. In many cases of less severe character a partial rest cure in which the patient is separated from her family but is not placed under such severe restrictions may be all that is needed. In the case of children removal from home is often advisable, and the discipline of Avell-conducted schools is a most excellent measure. The mechanical means used in hysteria are hydrotherapy, elec- tricity, massage, and exercise. Of these measures hydrotheraphy and electricity take the first rank. In hydrotherapy the douche or jet to the back, the shower and cold plunge, and the half-bath are the most efficacious. The technique of their use is given else- where. In the electrical treatment the static and faradic currents give the best results. The static sparks often relieve contractures and lessen or remove the anaesthesias, and both forms of electricity seem to have a generally beneficial tonic effect. Massage is of some value in promoting nutrition and it also has a favorable seda- tive effect on many cases. Exercise, particularly of an active kind such as stimulates the mind and interests one, is a measure of ex- treme value and one which has perhaps not been sufficiently appre- ciated. The use of the bicycle, playing tennis, and horseback- riding are measures which cannot be too strongly recommended to hysterical women; in fact, it is probable that some cases which are submitted to the rest-cure treatment might do better by an entirely opposite kind of procedure. The drugs which can be recommended in hysteria are not nu- merous and their power is limited. Valerianate of zinc, turpentine, asafoetida, tincture of sumbul, iron, and the bromides are the most important of the nervines. In hysterical children a capsule con- taining two grains of valerianate of zinc and one of sulphate of qui- nine is often efficacious. Gowers places more reliance upon the oil of turpentine in doses which should be increased to the point of strangury. Pitres recommends the Avearing of colored glasses m order to keep off hysterical attacks. Some experimentation is necessary in order to see which color is most suited to the case. In the treatment of hysterical convulsions the most efficient measure is the administration of an emetic, and this can be best HYSTERIA. lit? done by giving Lypodermically one-twelfth of a grain of apouior- phine. Convulsions can be stopped sometimes by throwing water in the face or on the epigastrium; by firm and somewhat long- continued pressure over the ovaries; by the administration of vale- rian, aromatic spirits of ammonia, or compound spirits of ether. Thk Si'AsMoJuc Tics (Tru Coxvulsif). Spasmodic tic is a disease to which the name of chorea is often, but incDrrectl}', given. It is a very chronic disorder, and shows itself in the form of quick, electric-like spasms of certain groups of muscles or single muscles. The spasmodic movements are violent, and several rapid contractions succeed each other, after which there is a period of rest. The spasm has a tendency to become localized in certain nerves, especially the facial [vilinlr tie), or even in a single branch or twig, as that to the orbicularis, the zygoniaticus, the dia- phragm, or the tensor tympani. Spasmodic tic sometimes involves the muscles of expiration and the larynx, and then it has been wrongly called chorea of tJie lat-ijnx. Stuttering is a form of t'u'. The convulsive movements may take a wide range and affect a number of groups of muscles, producing quick, violent move- ments of the body. They are sometimes accompanied by explo- sive disturbances of speech. In these cases the patient at the time of the convulsi\ e movement utters some obscene or profane words {i-ojivohiJhi), or involuntarily repeats the last words of the sentence spoken to him {echolaiiu) , or spasmodically imitates a gesture made to him {pr/ioldni'sls), or involuntarily exclaims the thought ui)per- most in his mind, perhaps revealing some secret against his will (^tiG lie jJ'iii^ee). The peculiar disorder of the Maine "jumpers," characterized by sudden violent movements on being touched or startled, Js a form of tic. So also are the similar troubles known as httali, oc- curring in Malay, and vn/rladiit, occurring in Siberia and Kam- chatka. Most of the si)ecial forms of spasmodic tic (mimic tic, wiyncck, etc.) have been described elsewhere. Sijasiiiodlc tic witii eopnildliii affects children between the ages of six and sixteen years, and hy iuererene(> tlie masculine si-x. There is almost always a neurotic family history, and the children are nervous. The disease begins with attacks of violent and irregular move- ments, affecting generally the head, fac(% and upi)er extremities first, then involving the whole body. The movements can be con- 32 498 DISEASES OF THE NERVOUS SYSTEM. trolled i'or a time by the will, only to break out with increased violence later. They cease entirely during sleep, which is gener- ally profound. After having suffered from the disease for a time, the patient will, with the attacks, utter inarticulate cries, or he may begin to repeat or echo the words that he overhears. All this is done auto- matically and suddenly, with the accompaniment of grimaces and muscular contortions. The special peculiarity of the disease is the sudden interjection by the patient of obscene words and expressions (coprolalia) . The disorder is chronic, lasting for years. It is best treated by isolation, tonics, and ordinary antispasmodics. Thoisex's Disease (Myotoxia Coxgexita). This is a hereditary family disease characterized by the devel- opment of tonic cramps when the patient attempts voluntary move- ments. The disorder is very rare. Etiology. — Congenital myotony is practically always hereditary and runs in families. It affects males by preference and develops at the time of adolescence. Symptoms. — The patient notices that on trying to rise or walk his legs are seized with a painless cramp, which in a few seconds relaxes, but comes on again when the muscular movements have been repeated. If he closes his hands tightly a cramp occurs and he cannot relax the grip. If he shuts his eyes he cannot open them for a moment. The muscles of mastication may be affected, but the extremities are the parts most involved. The involuntary muscles are spared. The cramps are increased by cold and ner- vousness; they are lessened by muscular exercise. The muscles are somewhat hypertrophied, and the patient may present the ap- pearance of a very strong man. The actual strength is fair, but less than would seem. The general health may be good, but the patients sometimes show the signs of low vitality in weak diges- tion, feeble sexual power, and susceptibility to cold. The electrical excitability of the nerves is normal, that of the muscles is increased, and there is produced a contraction tetanus by both currents. In addition Erb describes a peculiar reaction produced by a strong stabile galvanic current. It consists in the appearance of wave-like muscular movements passing from cathode to anode. This was not preset t in my case or Jacoby's. The mechanical excitability of the mut.cles is also increased. Fatltoloyy. — The disease is pi'obably a primary muscular dys trophy. There may be, however, a peculiar defect in innervation, resulting from a congenital anomaly of the motor tracts. The muscular fibres are found to be hypertrophied, the striations indis- tinct, and the nuclei increased. HYSTERIA, 499 The diagnosis is easily made by the characteristic tonic cramps. The uro(jnosis is bad as regards cure, but the disorder does net- shorten life. Treatment. — Dr. Thomsen, who first described the disease, states that active muscular exercise benefits patients. !No specific measures are known. Congenital Paramyotonia. Paramyotonia is the name given to a form of myotonia in which the symptoms deviate somewhat from the typical ones that appear in Thomseu's disease. Paramyotonia occurs symptomatically, con- genitally, and in a peculiar clinical form known as ataxic. We have, therefore, symptomatic, congenital, and ataxic forms. Symptomatic paramyotonia is noted most characteristically in a certain form of paralysis agitans. Here the patient, when at- tempting to walk or to rise from the sitting posture, is suddenly seized with an apparent rigidity of the muscles which prevents him from stirring. The myotonic condition appears also in spastic paralyses of spinal and cerebral origin. Congenital paramyotonia is a family affection, resembling in this respect Thomsen' s disease. The muscular rigidity is brought on not by voluntary movements, but by exposure to cold and often very slight degrees of cold. The tonic spasm is a long one and lasts for from a quarter of an hour to several hours. It affects the arms more than the legs. The facial muscles are prone to be- come rigid. The attacks are followed by some muscular weakness. In congenital paramyotonia the trouble is undoubtedly a primaiy disturbance of the muscles; in other words, a myopathy. Ataxic paramyotonia is the name given to a disorder character- ized by transient spasms like those of Thomsen's disease, associ- ated with distinct ataxia and also with weakness and some anaesthe- sia (Gowers). This disease is probably located in the spinal cord and should perhaps be considered one of the forms of symptomatic paramyotonia. Xo special treatment can be given for either of the two latter forms of disease, of which very few examples have been observed. Akinesia Algeka (Pain Palsy). Akinesia algera is the name given by Moebius to a peculiar foim of paralysis which occurs in psyi-liopatliic persons and is due to the fact that intense pains are produced by every muscular movement. The result is that the patient lies helplessly in bed, afraid to stir hand or foot. The disease occurs only in persons who have a very unstable nervous system and generally in those who have a para- noiac tendency. It occurs in adults only. Pain paralysis comes ou gradually and affects eventually all the muscles of the extremi- ties and body. There are no objective disturbances such as atro- phy, electrical degenerations, and anoBsthesias. The muscles and skin, however, are somewhat tender to the touch. The disease 500 DISEASES OF THE NERVOUS SYSTEM. lasts a long time. The patient sometimes improves, in other cases insanity ensues. The disease is essentially a form of insanity, a pathophobia, and is allied to the disorder known as mysophobia. The paralysis is the result of pain hallucination, and the i)atient is afraid to move the arm or leg on acccount of this hallucination, just as the mysophobic patient is afraid to touch anything on account of the fear of contamination. The prognosis is bad, and so far treatment has accomplished little or nothing. (IIAPTEK XXIII. THE ACQUIRED NEUEOSES. Chouea (St. Vitus' Dance). Under this name various spasmodic disorders have beea described. They are to be classed as follows : I. Common chorea, or Sydenham's chorea. II. Hereditary chorea, or Huntington's chorea. III. The convulsive tics. IV. Hysterical chorea, includhig so-called chorea major. V. Various local endemic choreas, such as the electric chorea of Dubini and the electric chorea of Bergeron. Chorea of Sydenham. This is the common type of chorea, and is the disease ordinarily meant when the term chorea is used. It is a subacute disorder characterized by irregular jerking and inco-ordiuate movements. The disease is a common one, forming about one-fifth of the nervous diseases of children. iiY/'Voyy.— Most cases occur between the ages of five and fifteen (see cliart, p. 470). It is very rare under five. A few cases occur after twenty, and even up to old ag<^, when a senile chorea is some- times observed. It affects girls more than boys in the ratio of about 2.5 to 1. In adult life the disproportion is less marked. It is relatively rare in the negro race, especially in thos3 of puro blood (Mitchell). In this country it is more common in children of German, Hebrew, and Portuguese races. It occui's in all climates. Most cases develop in the spring months, next in the autumn, next in winter, and last in summer. TJie seasonal influence varies in different localities. In I'hiladel- phia more cases occur relatively in the spring. In New York ther&. is an almost equal increase in the autumn. School attendance has- sonu'tliing to do with these variations. Choreic attacks appear Ui be related to increase in storms (Lewis). The disease is more fre- quent in cities, and probably in the poorer classes. Hereditary in- fluence is slight, but it exists. In a small percentage of cases one.* 502 DISEASES OF THE NERVOUS SYSTEM. parent has had chorea, epilepsy, insanity, or a decided neuropathic constitution. A phthisical or a gouty history in parents is also not rare. The chief exciting causes are injury and fright, mental worry, and rheumatism. Fright or some emotional disturbance is a cause in about one-fifth of the cases. Acute rheumatism is given as a cause in very varying proportions, ranging from five to twenty-five per cent. In this country it ranges from fifteen to twenty per cent (Sinkler, Starr, Sachs, and personal observations). Endocarditis is developed in the course of chorea in a slightly larger proportion of cases. This may exist without any manifestations of rheumatism. Pregnancy is a cause of chorea generally in primiparee and always in young wjmen under twenty -five. Chorea sometimes follows infec- tious fevers, especially measles, scarlatina, and whooping-cough. It has been caused in rare cases by reflex irritation from an injury, from nasal disease, and from sexual disorders. Overstudy and the worry of examinations are factors in causing chorea in predisposed and badly nourished children. Intestinal irritations, such as worms, may excite chorea. Malaria also may aggravate, if it does not pro- duce it. Hamilton describes a form of chorea caused by tobacco- poisoning. Anaemia and malnutrition underlie most cases. Si/mptoms. — The disease may begin suddenly, but usually it de- velops slowly, and it is not till one or two weeks that the symptoms are decidedly prominent. It usually begins with irregular twitch- ing of the hand or face on one side. The child winks, grimaces, and drops things from its hand. The foot and leg become affected later and the child stumbles in walking. In two or three weeks the opposite side is involved, but usually less than the one originally affected. In three or four weeks the disease reaches its height. The patient's movements are then almost continuous. The hands can hardly be used and the child has to be fed and dressed; even walking is awkward and difficult. Speech is indistinct and confused from the irregular movements of the lips and tongue. The muscles of respiration may be involved so that the rhythm is uneven. It is asserted that the heart's action is affected also; but this is unlikely. The choreic movements usually occur both when the muscles are at rest and during volitional acts. In some cases the disease is chiefly characterized by inco-ordinate moveinents when purposeful acts are attempted. In other cases voluntary movements can be readily performed, and the muscles twitch only when the limbs are at rest. The movements cease, as a rale, during sleep. But the child sometimes sleeps badly on account of the movements. In se- vere cases attacks of mental excitement and even delirium come on THE ACQUIRED NEUROSES. 503 for several successive nights, and this may be so marked a feature as to form what is called chorea insaniens, or maniacal chorea. Apart from such phenomena, the mind in chorea is usually dulled, the temper irritable, and the child much harder to manage. The appetite is poor and capricious, the tongue coated, and the bowels are often constipated. The nutrition fails a little ; there are antemia and a tendency to loss of flesh. The eyes present nothing abnormal. Hypermetropia, astig- matism, and muscular insufficiencies exist, but not much more than in other nervous children. The child is often worse in the morning and improves toward night. Excitement and physical exertion make the movements worse. There is rarely any pain and never ansesthesia or tender- ness. The muscles are weak but not actually paralyzed. The deep reflexes are somewhat lessened and the knee jerk may be abolished. The electrical irritability of the muscles is, as a rule, increased, but there are no qualitative changes. Nocturnal enuresis occasionally occurs. The urine contains an excess of urea and phosphates, and at the height of the attack the specific gravity may be increased. Forms. — Maniacal chorea is characterized by great mental ex- citement — especially at night, delirium, with hallucinations and de- lusions. After one or two weeks the excitement lessens and the pa- tient becomes dull and apathetic. Such cases usually occur in adult women, and they are sometimes fatal. Paralytic chorea, hx this form one arm becomes rather suddenly weak and jjowerless. A few twitching movements are observed. This for]u occurs only in children and runs the same course as the spasmodic type. Chorea of adult life and senile chorea. The disease when it oc- curs in the second half of life attacks men rather oftener than wo- men ; it is not related to rheumatism. There is usually a neurotic family history and even a hereditary history of chorea. The attack is usually caused by emotional disturbances. It runs much the same course as juvenile chorea, but it rather more apt to become chronic. When it occurs in old men it is called s^'vUe chorea. This type is not to be confounded with hereditary or Ihmtington's chorea. Duration — Jic/a/jses. — The disease in this country lasts about ton or twelve weeks, ranging, however, from six weeks to six' months. There may be great improvement followed by a relapse, and in this remittent manner tlio disease may last for j-ears. If it last more than six montlis it should ho called rhr»itir. Relapses occur in about one-thiid of the cases and rather oftener in girls. Relapses occur ofteuest within a year of the first attack and much oD-t DISEASES OF THE XERVOUS SYSTEM, ofteuer iu the spring. After three years relapses practically cease. The number of relapses is usually but one, but the disease may recur eight or nine times. Relapses rarely occur iu adults except iu the chorea of pregnancy. Pathology. — -The seat of the lesions in chorea is the gray matter of the cortex and its meninges, the pyramidal tract, basal gan- glia, and the spinal cord. The lesions are in acute cases of the Fig. 226. — Perivascular Dilatations in the White Matter of the Convolutions of a Very Chronic and Severe Case of Chorea. nature of intense hypersemia, with dilatation of vessels, small hem- orrhages, and spots of softening. There are infiltration of the peri- vascular spaces Avith round cells and swelling and proliferation of the intima of the small arteries. In chronic cases the evidence of active vascular irritation is less, but there are perivascular dilata- tions and increase of connective tissue (Fig. 226). The process suggests a low grade or an initial stage of inflammation. The cause of this is probably either an infective micro-organism or a humoral irritation similar to that causing the rheumatic symptoms THE ACQUIRED NEUROSES. 505 and the heart lesions. Iii a considerable per cent of cases (ninety per cent — Osier), especially in those of long duration, there are fibrinous deposits on the walls of the heart. The hyperaemic proc- ess may not be confined to the meninges and motor areas of the brain and cord, but it is only from the disease in these parts that the symptoms of chorea arise. The presence of points of irritation in the cortex and its meninges and in the deeper parts excites irreg- ular discharges of nerve force and produces the choreic movements. The interruption of the voluntary nerve impulses by diseased foci makes these movements irregular. The apparently special involve- ment of the lenticular nuclei may explain some of the inco-ordina- tion. In paralytic chorea the pyramidal tract is probably more se- riously injured by some single large focus of congestion, exudation, or heiuorrhage. Indeed, I have seen a true hemiplegia develop in the midst of an attack. In maniacal cliorea the meninges and ccitex are more involved. Dlajjuosia. — The disease is easily recognized by the peculiar twitching movements. It is necessary only to distinguish the dif- ferent forms. It must be distinguished from convulsive tic, electric chorea of Dubini, hysterical spasms which include uiyoclonus, sal- tatory chorea, and chorea, major. The distinctions are not difiicult and are given in connection with the descriptions of these disorders. Frof/nosls. — As regards life the prognosis is very favorable. In this country death from chorea hardly ever occurs in children. It is more fatal in adults. In England the mortality from chorea is about two per cent. Nearly all non-fatal cases eventually get well. Treatment. — The most important single factor in treatment is rest. The child should not be allowed to take violent exercise or to have any excitement. In most cases he should be taken from school, and in bad cases he should be kept in bed. Cold sponging or the ether spray daily along the back is useful. Nourishing food and iron are indicated. As specific remedies, arsenic still heads the list. It should be given in doses of tt|v. of Fowler's solution t.i.d., increased b}' one or two drops daily to fifteen or twenty drops or even more. If this causes nausea and gastric pain or headache, the dose should be stop])ed for a day and then resumed, if possible, where it was left off. Sometimes the sulphide of arsenic is better tolerated than the arsenite. Next to arsenic come antii)yrin (gr. v.), antifebrin (gr. iij.), exalgin (gr. iij.), the doses to be carefully increased if needed. Tincture of cimicifnga sometimes helps when arsenic fails. The bromide or valerianate of zinc is also an excellent remedy, especially when there is a liysterical element. The bromides and chloral arc 5U6 DISEASES OF THE XEEVOUS SYSTEM. useful adjuvants in promoting sleep. Chloral alone is said to be curative if given in doses sufficient to prolong sleep greatly (Bastian). Exalgin given cautiously with iron, in doses increased to fifteen grains a day, is often very useful. Hyoscine hydrobromate iu doses of gr. jljj- is occasionally eflicacious. Among other drugs of less value are the salicylates, cypropedium, lobeline, physostigmine, and tartar emetic. In chronic and obstinate cases hypodermic injections of Fowler's solution should be tried. Galvanization of the brain and spine is also useful. Change of air sometimes breaks up an attack. Hereditary chorea was first descrioed by a Long Island phy- sician, Dr. Waters, in 1842, later by Drs. Gorman and Lyon, and in 1872 by Dr. Huntington. The American cases have been ob- served chiefly in New York, Connecticut, New Jersey, and Penn- sylvania. Cases have been reported also from Germany, France, and England. The disease rarely begins before thirty or after fift}' ; it occurs about equally in males and females. It is always directly hereditary, either through father or mother, usually the latter. It begins without known cause by twitehings in the face; the movements then extend to the arms and legs. It is attended by progressive mental deterioration, by a tendency to melan- cholia, and finally ends in dementia. Its course is chronic and usu- ally very slow, lasting ten or twenty years. Post mortem, chronic pachymeningitis and leptomeningitis with degenerative changes in the cortex have been found. Electric Chorea is a name sometimes and wrongly given to very violent forms of ordinary chorea of Sydenham. The term was first applied by Dubini to a peculiar and progressively fatal spas- modic affection which has been observed almost solely in Italy, and which is perhaps of a podagrous or malignant malarial origin. M. Bergeron in 1880 also described an " electric chorea " in which the patients are attacked b}^ sudden rhythmical spasms. This latter disease has a uniformly favorable course. Neither of these dis- eases resembles true chorea, nor do they have the character of the tics. The term electric chorea, therefore, is one that shordd be used, if at all, only with a qualifying explanation. Habit Chorea {Tic Coordine). — There are many persons who go through life with some trick of speech, of gesture, or some pecu- liar grimace. It may be only a shrug of the shoulder, a twitching of the eyes, or a sniff. These various movements are tics of the co-ordinate kind. The spasmodic motion is of itself normal, but is inappropriate and misapplied. Such movements are often seen in children. They sometimes represent abortive attacks of chorea, and sometimes they are the residuum of old attacks. In many cases they are chronic convu]- THE ACQUIRED XEUEOSES. 507 sives tics from the start and have little relationship to Sydenham's chorea. The condition is to be treated both by moral and medi- cinal measures. Oscillatory spasms and nodding spasms have been described else- where. Frocursive Chorea^ or Dancinfj Cliorea. — Laycock has described as a separate kind of chorea a rhythmical or trochaic form, which he says affects children, principally girls, and shows itself in spas- modic rhythmical contractions or in sudden rotating or procursive movements of the body. This has been called chorea procursive, or chorea festinans, by other writers. In many cases it is accompanied by vertigo, when the condition of the patient is similar to that of a person who has been whirling around a number of times. Such cases always have decidedly hysterical characters, although these procursive attacks may complicate ordinary chorea. Chorea laajor is a manifestation of hysteria, and has been de- scribed under that head. It is not a chorea at all. Paramyoclonus Multiplex (Myocloxus Multiplex, Convul- sive Tremok, ^Ivospasia). Myoclonus multiplex is a rare disease allied in nature to the convulsive tics and characterized by attacks of quick clonic spasms affecting the trunk and sometimes the extremities also. The dis- ease occurs most often in adult males. It is caused usually by fright, injury, or some violent emotion. A condition resembling it is produced by removal of the thyroid. Aery different forms of spasm have been descril)ed under the name myoclonus multiplex, hut there are two groups of cases Avhich may be distinguished. One is of hysterical type, the other belongs to the convulsive tics, and in its typical form myoclonus is to be classed with this latter form of spasmodic disorder. In the hysterical form the patient without warning is seized with sudden and lightning-like contrac- tions of the trunk and hip muscles, which cause his body to be al- ternately flexed and extended so violently that lie is often thrown from the chair or couch on whicli he is lying. Tlu^ arms and legs may be also involved, ami the attaek takes on the characteristics of a general trenujr in which tlie wliole Inxly shakes. The attack then ceases and tlie ])aticnt has a rest for liours or days. In the true or choreiform type the disease comes on more slowly, with sliarp choreic-like twitchings, and the patient presents something of the aspect of chronic diorea. The facial muscles may be affected, but not those of the eyes. The s])asniodic nu)vements are bilateral, altlujugh they sometimes begin on one side The convulsions differ from those of hysteria in tliat they affect groups of muscles that have not the same physiological function and ]»roduce movements which cannot be easily imitated voluntarily. Still this distinction is not a sharp one. The jtaticnts are generally neurasthenic. They ■.y.\ 508 DISEASES OF THE NERVOUS SYSTEM. have no paralyses, no anaesthesias, very few pains, and their Ijotlily nutrition is not seriously inii)aire(l. The pathology and pathological anatomy are unknown. The diagnosis is based on the peculiar character of the spasm, on the fact that the trunk muscles are involved, and that the spasms are bilateral. The disease usually lasts but a few months in the hysterical form, but it may extend over a number of years. The J) !■()// u OS is is fairly good. The treatment consists of tonics and the use of cliloral and hyos- cine. Galvanism seems to be very efficient. Atropine and hyos- cine are indicated, and hydrotherapy may also be advantageously employed. Thyroid extract has been of benefit. Saltatoiiv Si'ASM. This is a curious and rare form of disease characterized by con- vulsive movements of the legs brought out by touching the feet to the floor. It occurs in both sexes and at all ages, but usually in those of a neurasthenic and hysterical temperament. The phe- nomena of the disease are exhibited Avhen the patient attempts to stand. The minute that the feet touch the floor violent contractions occur in the muscles of the calves and hips, sometimes in the whole body ; these cause the patient to jump, and the movements may be so severe as to throw him down. The seizures are brought on only by the exciting effects of the weight of the body on the feet. Sal- tatory spasm is probably a form of h3'Sterical spasm. It has been described chiefly by the older writers, and its symptomatology and pathology have not been carefully worked out. Tetanus. Tetanus is an acute or subacute infectious disease characterized by violent tonic spasms with remissions and exacerbations. It is called idiopathic when no open wound is found and traumatic Avhen such condition is present. When it attacks infants it is called tet- anus neonatorum; when the jaws alone are involved it is called lockjaw, or trismus. A form which affects the face and throat is called head or cephalic tetanus. Etiolofjij.- — It has a special predilection for newborn children in some countries (West Indies) and to a less extent for puerperal wo- men. It affect males more than females. After the first month of life there is practical immunity till after the tenth year. It then increases in frequency up to forty. It is much more frequent in dark races and in some tropical climates (West Indies, South and Central AinericaV THE ACQUIRED XEUROSES. OO'.I Si/iiijitniiis. —The disease sets in from five to fifteen days after infection. It begins with feelings of stiffness in the neck and throat and sometimes with chill}- feelings. Gradually tonic spasms develop which involve the trunk muscles, causing opisthotonos and other forms of rigid spasm. Trismus, or lockjaw, also occurs. The spasms are attended with intense pain. Sometimes there is a rise of tem- perature and this may be very high. The disease lasts from two to five weeks. There is evidence of irritation and congestion of the spinal cord and injured nerves, but no special anatomical changes are found. A specific bacillus producing a tetanizing poison has been discovered. The d'uifjnosls is based on the characteristic history and the pe- culiar spasms. In strychnine posioning there is no initial trismus or epigastric pain. In rabies there is also no trismus but a respira- tory spasm on attempts to swallow. The^v/'oy/^o.s/.s is bad. About eighty per cent of traumatic and sixty per cent of idiopathic cases die. The treatment consists of complete rest and quiet in a dark room and the administration of chloral, bromide, juorphine, and pliyso- stigma. Successful results from injection of blood serum of an animal which has had the disease are reported. A tetanus antitoxin has also been tried with some success, and this has even been injected into the subdural cavity of the brain, but the results are not yet very satisfactory. Tetaxv (Tetanilla). Tetany is a subacute or chronic spasmodic disorder characterized by intermittent or persistent timic contractions beginning in the extremities and associated with parcesthesiie and hyperexcitability of the motor and sensory nerves. FJlohxiii. — The disease is very rare in tliis country, but relatively common in Europe, especially in Austria. It occurs w^ith frequency during the second, third, and fourth years of life and again at the time of puberty. Its rate of frecpiency then slowly declines and it is V(>ry rare after fifty. It affects nudes much oftener than females up to the ago of twenty; after that the difference disappears. It o-cars mostly in the working classes. In infants rickets is often noted. The exciting causes are exhausting influences like diarrhnea, lactation, sepsis, fatigue, mental sliock, and fevers; also exposure to cold and wet. Alcoliolism, dilatation of the stomacli, and intes- tinal entozoa ;iro also causes. It may be produced artificially by extirpation of the thyroid gland. The disease sometimes appears as an epidemic. Sijiiiptnins. — Tetany begins sometimes suddenly with symmetrical 510 DISEASES OF THE NERVOUS SYSTEM. tonic contractions of the hands ; at other times there are at first sen- sations of numbness, prickling or pain in the extremities, with mal- aise and perhaps nausea; then spasms begin. The attacks affect first and most the upper extremities. The flexors of the forearm and hand are usually involved; the fingers are flexed at the meta- carpo-phalangeal joint and extended at the other joints, and the thumb is adducted, producing the "accoucheur's hand." The fore- arm may be flexed and the upper arm adducted. The knees and feet are extended, the toes flexed, and the foot is inverted. In severe cases the muscles of the abdomen, chest, neck, and face are in- volved. Opisthotonos and dyspnoea may result. The muscles of the face and eyes develop contractions, and trismus sometimes occurs late in the disease. The muscles of the larynx, oesophagus, and bladder may be affected. Fibrillary tremors are observed in the contracted muscles. The attacks aie accompanied by paraesthesias and cramp-like pains. There may be some abolition of sensation in the skin of the parts affected during attacks. The cramps last from a few minutes to hours or daj's. They occur during day and night and may wake the patient from sleep. Fever is sometimes present in epidemic cases. The disease has a tendency to recur- rence. While it lasts, both during and between the attacks peculiar phenomena are observed as follows : 1st. Increased Mechanical Irr'dahUiti/ of Motor Nerves. — The motor nerves show an abnormal irritability, so that on striking the motor point a sharp muscular contraction is brought out. When pressure or a blow is made on the face over or near the exit of the facial nerve from its foramen, contractions of the facial muscles occur, especially those of the lips. This is called the " facial phe- nomenon." By i^ressiug on the artery and nerve of a limb a tetanic attack can be produced in the muscles supplied. It is prob- able that it is the pressure on the nerve alone which causes the phenomenon which is called "Trousseau's symptom." 2d. Tlce electrical irritability of the nuiscles and nerves is in- creased, especially to the galvanic current. Thus a negative-pole closure contraction (CaCC) is brought out by a very weak current; and if a little stronger it causes a tonic contraction or cathode-closure tetanus (CaCTe). The positive-pole opening contraction (AnOC) may be tetanic, i.e., AnOTe, and there may be even a cathode- opening tetanus (CaOTe), a phenomenon not seen in any other dis- ease. According to Gowers there may be a reversal of the polar formula, so that a positive-pole closure contraction occurs earlier than a negative (AnCC>CaCG). This is certainly rare. 3d. An increase of irritability of the sensory nerves is shown by pressing upon them, when sensations of prickling and formication appear along their course. There is an increase also in the elec- trical sensibility, shown by appreciation of very Aveak galvanic cur- rents. The auditory nerve reacts to the galvanic current in about fifteen per cent of normal cases, and then only to strong current? THE ACQUIRED NEUROSES. 511 and to only a partial extent; but in tetany it reacts in nearly all cases, and with comparatively weak ciirrents (2 to 5 or 6 ma.) on anode closure, anode fixed, and anode opening (AnC Klang, AnDKl, AnOKl) (Chvostek). The piienomena of hyperexcitability above described \a.rj con- siderably and rapidly during the course of the disease, and are not always present. Tijpes of the Disease. — The disease varies in intensity and dura- tion. This variation depends much upon the cause, and there have been made a number of types of the disease based on the etiology. Thus we have : 1. Epidemic or rheumatic tetany. 2. Asthenic tetany due to lactation, diarrhoea, exhausting dis- eases, etc. 3. Thyroid tetany, due to removal of the thyroid gland. 4. Eellex tetany from gastric dilatation and intestinal worms. 5. Latent forms of tetany in which the phenomena of hyper- excitability and parsesthesia occur with very slight if any contrac- tions, and no Trousseau symptom. Infantile tetany should perhaps be separated from other forms. Symptomatic tetany from brain disease is also spoken of. When the spasms are continuous the disease lasts but a few weeks; when they are intermittent it may continue for months. Epidemic cases last but a few weeks. The disease may be said in general to last from a few weeks to a few months. Patients are liable to a recurrence on retui-n of the exciting cause. Pathol oij If. — The phenomena of the disease indicate a congested and irritative condition of the gray matter of the spinal cord. The cause of this state is evidently in some cases (epidemic tetany) an infectious poison ; in other cases mucin in tlio blood (thyroid tetany), and in other cases it may be a rheumatic or some other toxic influ- ence. Ergot is known to produce symptoms resembling tetany. In infantile tetany the irritation is apparently cortical and due to meningitis or to rickets and the reflex irritation of disordered bowels. It is doubtful if any reflex influence can be invoked in adults. Tetany is a functional disease and the symptomatic ex- pression of a central irritation. This irritation may be of diff^erent kinds, hence tetany h;is a claim to be called a distinct disease sim- ply on clinical grounds. It has no such definite pathology as chorea or epilepsy. In the very few autopsies which have been made no definite organic lesion lias been found. Dinrjiwsls. — The disease is usually easily recognized by the char- acter of the spasms, their symmetricul nature, their course, and the phenomena of hyjjerexcitability of the nuiscles and nerves. Trous- seau's symptom is found in no other disease. The " facial plie- nomenon," the peculiar electrical and mechanical irritability of the muscles and nerves, are very rare in other conditions. The sensory irritability, and especnally that of the acoustic nerve, is also charac- teristic. From tetanus the disease is distinguished by the intermit- 512 DISEASES OF THE NERVOUS STSTEM. teucy of the contractions, their feebler character, the fact that they begin in the extremities and extend to the trunk, and by the absence of trismus, at least until late in the disease. Treatment. — The cause should be removed if possible, lactation stopped, diarrhoea and indigestion corrected, worms expelled, rickets if present attended to. Rest, nourishing food, and tonics are indi- cated. Symptomatically, bromide of potassium in doses of 3 iss. to 3 ij. daily with chloral furnishes the surest relief. Hyoscine in doses of gr. ^^i-^ may be tried. Inhalation of chloroform or injec- tions of morphine are needed in severe cases. In nocturnal tetany Gowers advises digitalis. Lukewarm baths may be of service; so also may ice bags to the spine. If electricity is used only the weak galvanic current should be employed. CHAPTER XXIV. l^ECJEASTHENIA (NERVOUS EXHAUSTION, BEARD'S DISEASE). Neurasthexia may be defined as a chronic functional nervous disorder which is characterized by au excessive nervous weakness and nervous irritability, so that the patient is exhausted by slight causes and reacts morbidly to slight irritations. There are evidences that the neuropathic constitution existed in all ages, but coherent descriptions of clinical types like the neuras- thenia of modern days are not found in literature imtil the present century. The credit of calling attention to this condition most in- sistently, most acutely, and most successfully is due to Dr. Geo. M. Beard. He showed that a large class of symptoms which had been previously referred to hypochondriacal fancy, to disease of the stom- ach, disease of the uterus, perverted conditions of the liver and urinary excretions, were really and fundamentally dependent upon a morbid weakness of the nerve centres, and the result of his writ- ings and the propaganda which he started is that now practically all medical men of experience agree that there is a morbid condition of which the underlying cause is a nervous irritation or defect. Etiology. — Some doubt has been thrown over the question of the excessive nervousness of the civilized nations of the present time. It is not a nuitter which can be fairly settled by statistics or the pe- rusal of historical documents, but, on the wliole, the evidence is, to my mind, conclusive that the human race docs now suffer relatively more from nervous irritability and exhaustion, in its various types, than it did in the past. This I infer partly from the fact that the l)redisposing and exciting causes of lU'urasthenia are more largely present now than they used to be The tendency of people to city rather than rural life is perhaps one of the strongest points in favor of this view, since we know it is in our urban population that neu- rasthenia breeds best. A larger proportion of persons now also use their brains in the struggle for existence and live upon a higher mental plane, with all tlie danger which that implies. The eigh- teenth-century writers attributed all the functional disord»'rs then known, under the teiins "va])ors, " **s]>leen," " hyjjocjiondiia," "liysteria," to three tilings — luxurious living, sedentary life, and 33 514 DISEASES OF THE NERVOUS SYSTEM. the unsanitaxy conditions of great and populous cities. They said nothing about the effects of overwork, continual anxiety, and mental strain, and one certainly does not gain from reading the English medical literature of this period that there was any such excess of work and worry among the people. Without going into any further argument upon this point, I shall admit, as an offset to this, the more widespread knowledge of how to live and how to ward off disease, so that it is at least probable that even if neurasthenia is more prevalent now, and has been steadily increasing, this will not necessarily always continue to be the case. At the present time we know that neurasthenia is found more frequently among the highly cultivated races. I have seen it in negroes, but it is extremely rare, while hysteria and insanity are fairly common. I believe that Americans deserve to an extent the reputation Avhich they have of suffering greatly from neurasthenia. This is particularly the case in the Northern and Central States, on the Colorado plateau, in parts of California, and in the great cities of the East. Neurasthenia is said to be quite prevalent in Eussia, and it is generally observed that it affects particularly often the Hebrew race. In this country we see it quite often in the Irish, but almost as often in the English, and rather less frequently in my experience in the Germans. Neurasthenia prevails rather more in dry temperate climates, but it is by no means infrequent in the tropical regions, and is to be found in the West Indies and in the republics of South and Central America in its classical forms. Neurasthenia is found rather more often in men than in women, but the difference is not great. * Among 828 neurasthenics whose histories were analyzed by Hosslin, there were 604 men and 224 women, but this does not give the proper ratios if we include all grades of society. The neurasthenic age ranges from eighteen to fifty-five, but the larger proportion of cases is met with between the jeavs of twenty and fifty. Occasionally symptoms resembling neurasthenia may be seen in children of the age of twelve or thirteen, and occasionally also there develops a kind of senile neurasthenia, which is, how- ever, often associated Avith hypochondriasis, and some definite degenerative changes in the nervous or vascular system. * Among 100 consecutive personal cases there were 53 women, 47 men. Ages : fifteen to twenty-five, 25 ; twenty-six to thirty -five, 38 ; thirty -six to forty -five, 25; forty-six to fifty -five, 20; fifty-six to sixty-five, 2. There are relatively more cases in the adolescence of man and in the later period of life of women. Nativity: United States, 59 ; Ireland, 29; Germany, 12; ethers, 9. Xi:URASTHENlA. 515 In men neurasthenia occurs more often in the sina:le; in women the relation is somewhat reversed, so that, taking both classes, the married and the unmarried are about equal. Neurasthenia does not much affect the people of the coimtry and small towns, though it does exist there. In great cities the number of neurasthenic women, among the wives of laborers and artisans, is rather large, and this is the natural result of the strain of living with husbands who are dissipated, and of rearing large families of children in the close quarters of a tenement house. The disease is relatively more frequent in the educated classes. Hereditary influence plays a very considerable part in the de- velopment of neurasthenia. We can usually find that there is a his- tory of migraine or some nervous irritability upon one side or the other. A distinct history of the major neuroses or of severe mental diseases is rare, but there is no doubt that a very large proportion of neurasthenics come into the world with an oversensitive and weakened nervous system. They may be strong enough to undergo the ordinary strain of life, but break down under some specially exciting cause. The exciting causes of neurasthenia are very various, but they can most of them be classed under the head of excessive mental strain or shock, sexual abuse, and the influences of exhausting fe- vers, of chronic infections like syphilis, and of poisoning with al- cohol and tobacco or tea and coffee. In the larger proportion of cases of men, the trouble if it develops during adolescence is brought on by overwork at school and in college, combined with neglect of sleep and carelessness in diet. Frequently the abuses of the sexual function, of tobacco, or of athletics are the exciting causes. The practice of masturbation is one of the things for which neu- rasthenics very often keenly reproach themselves and over which much hypochondriacal brooding develops. Excesses of this kind, liowever, are usually a sign of a degenerate or unbalanced nervous system rather than a cause. The actual harm done is greatly exag- gerated, however strongly this practice is to be reprobated. Exces- sive and luinatural indulgences, such as sodomy, etc., tend to weaken the nervous system and are causal factors of neurasthenia. Bad methods of eduf-ation and in particular excessive st\idy are thought to predispose to nervous cxliaustion. This is usually' seen in ambi- tious college students, or in young men who an! forcing their way under great disadvantages through professional schools and into, professional practice. Young women, who are excessively devoted to study and yet cannot refrain from social indulgences, sometimes; break down wifli nervous exhaustion. The studies and training of 518 DISEASES OF THE NERVOUS SYSTEM. he has a sense of weakness or even pain in the back of the neck. He has also peculiar parsesthesise of the hands and limbs ; they feel numb or asleep at times. Peculiar chilly sensations creep up the back or legs. He less often has attacks of dizziness ; spots come before the eyes and buzzing sounds are heard in the ears and head. Headache occurs in perhaps one-half of the cases, the headache being usually' either frontal or occipital. It is often very persistent, and in fact a chronic headache, not due to tumor or meningitis or sypiilis, is almost invariably of neurasthenic origin. This neuras- thenic headache is usually diurnal only, coming on in the morning when the patient wakes up, and lasting a good part of the day. It does not often keep hun awake at night. In this point it is distin- guished from the headaches of syphilis and of meningitis or of tu- mors. Women suffer from these headaches, and from pains in gen- eral, more often than men. They in particular have much pain in the back of the neck and along the spine. This keeps them from walking or being upon their feet, and it may develop into a form of neurasthenia known as " spinal irritation." The special senses are not very seriously affected. The patients can often see quite well, but their eyes soon tire ; the effect of watch- ing a play fatigues them. They cannot read a book long because it makes the ej^es smart or produces some headache. Examination of the neurasthenic's eye frequently shows the existence of some re- fractive error, most frequently astigmatism and hypermetropia; de- fects in the ocular nuiscles, and especial!}' weakness of the internal recti, often occur. Patients have frequently complained to me of a defect in visual memory. They see a thing or face but do not remember it again as readily as they used to. There is no limita- tion of the visual field in true neurasthenia uncomplicated by or- ganic disease, but there is a morbid susceptibility to fatigue, par- ticularly of the periphery of the vision, so that, after long testing, objects in the periphery become less distinct, and a sort of artificial limitation of the field may be produced. In some cases an object which is brought from without into and across the visual field is seen in wider range than an object which is placed in the centre of vision and carried gradually out toward the periphery. This is the reverse of the normal condition, and is known as " Foerster's shift- ing type." Peculiarities of accommodation, a slight drooping of the lids, inequality of the pupils, and excessive mobility of the iris have been noted in neurasthenia. As I have alreadly stated, neurasthenics sometimes siiffer from tinnitus, which is very distressing and aggravates every other ner- vous symptom, but this usually occurs only in connection with ac- XEURASTHENIA. olD tual disease of the middle ear, or in old people with degenerative changes in the cerebral blood-vessels. An excessive sensibility to noises, and even the pleasant sounds, like those of music, may be present. Neurasthenics sometimes cannot bear even the most en- chanting melodies. A similar morbid sensibility to taste and smell may be present. But these are matters of minor moment, and are much more often seen in hysteria or in a hystero-neurasthenia. There is no doubt in my mind that in neurasthenics the general muscular and nervous strength is lessened, and although the patient may not have lost flesh, and may not appear particularly weak, he tires quickly on ordinary exertion, and the tests of the dj'namometer show a lessened response. A fine tremor of the hands is often present, and when the eyes are tightly closed there will be a quiv- ering of the lids, and in very acute and exaggerated cases twitch- ings of the muscles of the face and tongue, almost like those in gen- eral paresis. This rarely occurs, however, unless the patient has, in addition to the neurasthenia, a considerable amount of toxaemia from alcohol, tobacco, or tea. The reflexes are exaggerated very greatlj'. In many cases a blow upon the leg, anywhere from the patella to the middle of the shinbone, will bring out a prompt reaction, and similarly a blow struck on the thigh anywhere from the patella up half-way along the thigh, will produce a knee jerk. And blows upon the motor points promptly bring out responsive contractions. The cutaneous reflexes are also exaggerated. These things vary considerably, how- ever, in different cases, and are more marked in the younger patients and those of a neuropathic constitvition. The sexual function is irritable and weak. There is a considerable disturbance of the heart function in neurasthenia. The most frequent condition is an acceleration of the pulse beat from very slight cause, due to a weakening of the inhibi- tion of the heart. A pressure over some painful point in the body will sometimes bring up the pulse from 80 or 90 to over 100, and it will remain there for one or two minutes. This is called "Rumpf's symptom." Arrhythmia and palpitation of the heart are less frequently observed. It is my belief that cardiac weakness is an imi)ortant condition in many forms of neurasthenia and undci- lies sometimes a good many of the other symptoms. This is partic- ularly true of the neuraslhcnias of more advanced life. The cardia.'! disturbances are more frequent in women, in yo\nig people, ami im neurasthenia associated with the use of tobacco and tea. A great deal of empliasis has been laid U]ton the vasomotor dis- turl)an('('s of neurasthenia, and a large nuiuber of neurasthenic syntp- o20 DISEASES OF THE NEKVOUS STSTEil. toms have been ascribed to a weakening of the vasomotor centre. As a result of this the patient siilfers Irom cold hands and feet, from flushing of the face alternating with pallor, from dermographic skin, and from those symptoms which we usually attribute to cere- bral congestion, such as a sense of fulness in the head, headache, spots before the eye, dizziness, and noises in the head. Sphygmo- grams of the puls<3 show a lowering of arterial tension, and perhaps still more a great variability in the tension of arteries. The condition of the urine has been studied very closely in con- nection with this subject. In fact many of the symptoms which we now call *' neurasthenic" were described by Dr. Prout and Dr. Gold- ing Bird eariy in the century and were held by these gentlemen to be due to oxaluria. This was a condition characterized by flatulent d^'Spepsia, melancholia, and nervous irritability, and was thought to be due to defective metabolism, resulting in the production of an excess of oxalic acid. More recent studies have shown that oxaluria is only one of the manifestations of lithsemia, and tiiat while it is significant, as was then supposed, of defective nutritive changes, these are more dependent on a neurasthenic state than primarily upon dyspepsia and metabolic disorder. There are, according to Herter, few cases of neurasthenia which do not show in the urine or faeces some indication of defective metabolism. " The faeces often contain excessive amounts of urobilin or some related substance. The urine is usually concentrated and of small volume (600 to 1000 c.c. in twenty-four hours). Frequently there is an excessive excre- tion of phosphoric acid (P^O J and an alteration in the quantitative relation of urea and uric acid. In health the relation of the uric acid to the m-ea excreted varies between 1 to 45 and 1 to 60 in adidts. In neurasthenia (as well as some other conditions) the re- lation is often 1 to 40, 1 to 35, or 1 to 30. Indican is often present in pathological quantities, especially in cases of sexual neurasthenia. Oxalate of lime is often present in excess in the urine" (" Diag- nosis of Nervous Diseases," p. 547). In rare cases one finds in neurasthenics a temporary albuminuria; I have observed it only once in one hundred cases, which is about the average. This albuminuria is not associated with the presence of casts or other evidence of kidney disease, and it is apparently due to a paresis of the vasomotor nerves of the kidneys. Transitory glycosuria is more often found. This glycosuria is usually associ- ated with a heavj' urine and evidences of lithaemia. Some authors (Hosslin, Dercum) state that there is an excess of uric acid very uniformly in neurasthenia, and that this uric acid results from a breaking-up of the nuclein of the cells. It has been ingeniously NEURASTHENIA. 521 suggested, therefore, that since the nuclei of nerve cells become smaller and irregular in shape when the cell is exhausted, it is from this source that the uric-acid excess comes. All observation, how- ever, shows that excessive use of nervous tissue leads to an exces- sive excretion of phosphoric acid rather than of the urates. My experience in studying the urine of neurasthenia is that in the younger cases, with a strong neuropathic taint, it is variable in specific gravity, but, on the whole, rather low ; and that the daily amount, as Dr. Herter states, is below the average. It is of a low specific gravity also in nem-asthenia occurring after middle life, when the arterial changes of that period begin to set in. In early adult life the urine is more often foimd to be condensed, as others have observed, and to contain the products of defective metabolism. The urine thus shows either a weakened and slowed-up nitrogenous metabolism or a perverted metabolism. The important things to determine, then, in examining the urine, after excluding such evi- dences of serious change as albumin and sugar, are: the specific gravity and the daily amount, the amount of phosphates, the amount of urates and uric acid and their relation to each other, and finally, the presence of indican or other products of perverted nutrition and digestion. I do not find indican very often, and practically never in the light urines. The digestion of neurasthenics is often more or less affected, and a large proportion of them are probably treated mainly for their stomach conditions. I do not, however, usually find cases of seri- ous and genuine gastric disturbance. In the majority, under proper treatment and proper diet, the tongue soon cleans off, and the pa- tient complains relatively little of the stomach, though his nervous symptoms continue. The neurasthenic, it is true, has alwa3's a feeble digestion, and has to take great care of what he eats and drinks, but when he is put upon the kind of diet that he should take the stomach gives relatively little trouble. This is especially true of the younger cases. The common form of dyspepsia is one which is associated with acidity, flatulence, some epigastric uneasiness, and lithaliuus is usually bikiteral and even. If one eye is alone or Biore affected it is the right. The ex- ophthalraus varies much in degree. It is not usually very great, but may be so excessive as to prevent closing of the lids and to expose the insertions of the recti. The eyeball may be slightly enlarged (one-tenth). The pupils are normal and vision is not impaired, though myopia occasionally occurs. The fundus and visual field are normal. Paralysis of some of the eye muscles is a rare com- plication. Weakness of the internal recti and exophoria are fre- quent. The lids show certain peculiarities. One of these, known as Von Graefe^s sijmptoiii, consists in the inability of the lid to follow the downward movemei.t of the eyeball. When the patient is told to follow the movement of the finger vertically downwarc^ "*•> k il Fig. 227.— Exophthalmic Goitre with and without Exophthalmus. the eyeball moves steadily, but tlie lid catches, as it were, and re- fuses to follow or does so in a jerky manner. Another symptom, known as Stellwac/s syhiptoin, is a considerable retraction of the lids, especially the upper one. Both this and Von Graefe's symp- tom are due to a common tendency of the lids to retract — due per- haps to overactiou of the muscle of Miiller. A tremor of the lids sometimes occurs. Course. — The disease progresses slowly. After a year or two it often becomes stationary for a long time. Cases of gradual spon- taneous recovery occur. The natural duration of most recoverable cases is two or four years. In those which do not recover the dis- ease lasts live, ten, or more years. Eventnully the patient emaci- EXOPHTHALMIC GOJTKE. 541 ales, tiie heart becomes weaker, albuminuria and dropsy a[)pear, diarrhoea sets iu, and the patient dies of exhaustion or is carried off by phthisis or some intercurrent disease. Other cases, having im- proved up to a certain point, remain in this state for years. Complications. — Mental derangement occasionally occurs in the later stages of the disease. Hysterical crises, epileptic attacks, choreic movements, paralysis of the ocular muscles, muscular atrophy, paralysis agitans, Addison's disease, diabetes, locomotor ataxia, and local oedema have all been observed. With the excep- tion of hysterical attacks these complications are rare. Abortive Fonns. — This name is applied to cases in which only a part of the distinctive symptoms develop. Tachycardia always exists; with it are tremor and moist skin, lessened electrical resist- ance and nervousness. Or tachycardia and goitre may alone be present. Fathohgical Anatomij. — Post-mortem examination of this gland shows that it undergoes a true hypertrophy with increase of vascularity and of the glandular structure. The rational infer- ence is that in life there is an increase in the secretions from tliis structure. After the hypertrophy has reached a certain stage, the glandular epithelium degenerates and breaks down, forming large acini filled Avith the colloid secretion. In the nerve centres the changes which have been found are small hemorrhages in the medulla and degenerated nerve cells. In one case of about a year's standing, I found a veiy marked piginentation and vacuolization of the cells of the vagus and glosso-pharyngeal nuclei. In another case of six months' standing, no marked. changes could be seen in these areas, but there was a spot of softening at the junction of the puns and the cerebral peduncle. This was ante mortem and had led to crossed paralysis just a few days before death. In other cases congestion and small hemorrhages in the medulla liave been found. The heart is dilated and enlarged; endocarditis is sometimes present, oftener not; the arteries are dilated. ratJioJofjij. — Some writers now consider this disease primarily one duo to a disordered function of the thyroid gland. From my own observation I an; led to the conclusion that liasedow's dis- ease is primarily one of nervous origin, but that the thyroid dis- ease leads to excessive secretion, causing the prin(ii)al symptoms. The nervous tissues re(piiie for their proper nourishment and natural functioning a certain supply of the secretion of the thy- roid gland. If this is excessive, there is a state of nervousness and erethism, such as we see in liasedow's disease, and if it is di- minished there develo])s a hebetude and depression of nerve fuiu- 542 DISEASES OF THE NERVOUS SYSTEM. tioii, such as we find in myxcedema. Under the influence of shock and powerful emotion or prolonged strain, there is a certain power- ful demand upon the product of the thyroid gland by the nerve centres. The thyroid juice is thrown out in great amount, and in persons of unstable organism a morbid impetus is given to the activ- ity of the gland. It continues to grow and throw out its juice ; the overexerted nervous system makes continually more demand upon it, thus acting in a vicious circle. So, while the symptoms of the dis- ease, the nervousness, the insomnia, and t?ie vasomotor disturbances are due to the hypersecretion of thyroid, the primary disturbance is one in the nerve centres. If these can be kept quiet long enough, the demand on their part for this excess of thyroid juice gradually ceases and the patient gets well. This is the rationale of the pro- longed rest and the use of the bromides and tonics, which are the only things which do much good in the treatment of the disease. As to the special cause of the different symptoms, it may be as- sumed that the original enlargement of the thyroid is a vasomotor par- esis of its vessels. It is a kind of erection of the organ, due to the sudden demand put upon it by emotional strain and exhausting work. The exophthalmus is also due chiefly to paralysis of the orbital ves- sels. A tonic spasm of the muscle of Mtiller is thought to help in producing this symptom. This muscle consists of unstriated fibres originating in the membranous lining of the orbit and inserted into the lids. It is rudimentary in man, and its influence in causing protrusion of the globe must be very small. The deposit of retro- bulbar fat is a secondary phenomena. The rapid heart beat is probably due to impairment of the inhibitory fibres of the spinal accessory. Froffnosis, — About one-fifth of the cases get well or practically well. Probably over half the cases, if they can be properly treated, reach a fairly comfortable condition of improvement. The cases in which symptoms come on quickly have the most favorable progno- sis. In those with marked exophthalmus and goitre the prognosis is not so good. The duration of the disease in recovering cases is from two to eight years. Diagnosis. — The disease can be distinguished by the persistent tachycardia, with goitre or exophthalmus, and in its early stage by the tachycardia with tremor, moist skin, sensations of heat, ner- vousness, insomnia, lessened respiratory expansion, and electrical re- sistance. A symptomatic Graves' disease may sometimes be caused by a goitre pressing on the vagus or symjDathetic and causing irreg- ular heart beat and perhaps exophthalmus. In these cases the his- tory of a long-standing goitre exists, the heart's action is irregular. EXOPHTHALMIC GOITRE. 543 tlie exoplithaliuus is usually partial and oue-sided. In abortive forms it is necessary to have tachycardia and at least one other of the four major symptoms to make a diagnosis. Treat til ent. — ^Eest is the most important single thing. The pa- tient should be put to bed or kept on the back for one or more months. Freedom from excitement and worry must be enjoined. Ko especial diet is needed, nor do climatic influences or baths or mineral waters have much effect. Some cases are said to be im- proved, however, by removal to heights of one to three thousand feet. In most cases a sea voyage is the better change if one is made. The drugs used are ninnerous. The most efficient are tincture of strophanthus in doses of fifteen to forty drops daily ; iodide of potassium or the syrup of hydriodic acid ; arsenic and bromide of potassium used together; quinine, mineral acids, and iron, used to- gether. Dilute phosphoric acid is often very useful. Other rem- edies are tincture of aconite in ni v. or aconitia in gr. ^^ doses, tinc- ture of belladonna increased to the limit of tolerance, tincture of cactus grandiflorus in iTl x. to xx. and tincture of veratrum viride, TT[ X. to XXX. dose, and the picrato of ammonium, gr. i. to ij. t.i.d. Of these drugs, strophanthus, aconite, the iodides, bromides, and iron have served me best. Digitalis is of doubtful value.* Electricity possesses some utility. It should be given, if pos- sible, two or three times daily in the form of galvanism and in doses of two to six milliamperes for ten minutes. The technique is as follows: positive pole on back of neck, negative drawn along course of vagi in the neck ; each side two minutes. Same Avith positive pole placed subaurally one minute; negative pole over thyroid two minutes, negative over cardiac region one minute, jjositive pole over eyes, negative over thyroid one minute, two milliamperes. The faradic current may be used for general tonic effects or combined locally with the galvanic. The patient should lie down during treatment and remain quiet for an hour later. For the palpitations, sulphate of sparteine or strophanthus with Hoffniann's anodyne may be used. The ice bag placed over the heart and neck is helpful and may be used systematically. Tonic hydrotherapy is often useful, but should be carefully employed. Surgical treatment until late years has been unsuccessful. Recently many ceases have been reported in which cure has been produced by partial removal of the thyroid gland. This measure is yet in * Some writers now lay great stress on the direct treatment of the thyroid gliuid by nibbiiiuj upon if djiily tlic ointmcut of the red iodide of mercury; or by paiiitiug it with iodiuo. 544 DISEASES OF THE NERVOUS SYSTEM. an experimental stage. Ti'eatnient of the nose has been said to cause disappearance of symptoms, but its utility is very doubtful. Respiratory exercises by which the patient is taught to increase his chest expansion do some good. Mild compression of the lids at night seems to help the exophthalmus, and slight and steady com- pression of the thyroid gland sometimes reduces its size a little. CHAPTER XXV. PKOFESSIONAL NEUROSES, OCCUPATION NEUROSES (WRITERS' CRAMP AND ALLIED AFFECTIONS). Writers' cramp is a chronic fimctional neurosis characterized by spasmodic, tremulous, inco-ordinate or paralytic disturbance when the act of writing is attempted, and associated with feelings of fatigue and pain. Etiology. — It is a disease of the present century, and has been par- ticularly noted since the introduction of steel pens about the year 1820. A neuropathic constitution is often present, and sometimes there is a hereditary history. Men are much more subject to the disease than women. The most susceptible age is between twenty- five and forty. It rarely occurs after fifty or before twenty. Clerks and professional writers are naturally much more subject to the dis- ease. Excessive worry, intemperance, and all debilitating influences predispose to it. The chief exciting cause is excessive writing. But this is not all. The writing that is done under strain or a de- sire to finish a set task is the harmful thing. The style of writing is also an important factor. Writing done in a cramped posture with movements of the finger alone or with the little finger or wrist resting on the table is most injurious. Free-hand writing done from the shoulder according to the American system is least harm- ful. Shaded or heavy writing with sharp steel pens is also pro- ductive of harm. Copying is much more harmful than composing. Authors seldom have writers' cramp. Albuminuria, lead poison- ing, exposure to wet and cold, and local injuries are sometimes exciting causes. Sijnijitoins. — Writers' cramp very rarely attacks a person sud- denly. The patient first notices a certain amount of stiffness occur- ring at times in the fingers, or the pen is carried with some uncer- tainty and jerky movements are made. He feels a sensation of fatigue in the hand and arm, and this may amount to an actual tired puin. The first symptoms may last for months or even years. :?5 54:lj DISEASES OF THE NERYOUS SYSTEM. The haud is rested as much as possible} new pens or penholders and new modes of holding it are tried. Often the patient, fearing the onset of the cramp, and as its result loss of employment, be- comes anxious, worried, and mentally depressed. Sometimes the trouble is worse when beginning a daily task, and it gradually wears off in a few hours. At other times exactly the reverse is the case. When the disease has reached its highest stage, writing becomes al- most or entirely impossible. The moment the pen is taken in the haud and an attempt at using it made, spasmodic contractions of some of the fingers, or even of the arm, occur, the pen flies in any direction, and it is impossible to control or co-ordinate the move- ments. The rnle is tint although writing cannot be done, all other complex movements are performed as well as ever. Thus the suf- ferer from writers' cramp may be able to play the piano, or paint, or thread a needle, or use the hand in any complex movements. This limitation, hoAvever, is not always present. Telegraphers, who use to some extent the same muscles as in writing, and who also often have to do a great deal of writing, are liable to suffer from both writers' and telegraphers' cramp at the same time. No evidences of actual paralysis are present in the affected muscles, and there is rarely anaesthesia, but the arm aches and is sometimes tender. Sensations of numbness and prickling are present: in rare cases vasomotor disturbances are observed; associated muscular movements of the other arm or of the neck or face sometimes occur. The hand may tremble on attempting to write or fall almost para- lyzed when the pen is taken. The various symptoms occur with different degrees of promi- nence, so that the disease has been classed under the heads of (1) the spastic, (2) the neuralgic or sensory, (3) the tremulous, and (4) the paralytic forms. These forms are, however, often more or less mixed. 1. The spastic form is undoubtedly the most common, and it has given to the disease its name. Cramp of some muscle or mus- cles is present in over half of the cases. The muscles of the thumb and first three fingers are oftenest affected, and in some cases the flexors, in some the extensors, are chiefly involved. In telegraph- ers' cramp it is the extensors, but in writers' cramp the flexors, that are mainly attacked. The thumb or forefinger or the little finger alone may suffer from the spasms. The pronators and supinators are quite often involved. The spasm is usually a tonic one. With the spasm there is also inco-ordination so far as writing movements are concerned, and this fact is quite as important in producing the bad writing as the spasm. PfiOFESSlONAL LEUKOSES, OCCUPATIOX NEUROSES. 547 2. The neuralgic form resembles the spastic plus sensations of fatigue and pain, which are quite severe and are brought on by writing. There may be tenderness along the arm also. 3. The tremulous type, though rare, is very characteristic when present. The patient when attempting to write develops a tremu- lous movement of his hand and arm. This ceases when his attempts to write cease. The tremor usually affects most the fingers used in pen jjrehension, but it also spreads to the forearm and may even in- volve the entire extremity. An oscillatory or lateral tremor, due to involvement of the pronators and supinators, has been observed. The tremor is of the character known as "intention tremor," such as is observed in disseminated sclerosis. It is shorter in range and more rapid than the tremor of that disease. 4. The paralytic form, or that type in which muscular feeble- ness is the dominant symptom, is said to be rare by Gowers, and this accords with my experience. German writers speak of it as common. In the typical paralytic form the patient, as soon as he begins to write, feels an overpowering sense of weakness and fatigue in the fingers and arm. The fingers themselves loosen their grip and the pen may drop from the hand. Powerful impulses of the will and change in the mode of holding the pen enable the sufferer to continue, but the arm aches and finally is absolutely painful, and weakness and fatigue compel the writer to desist. Sometimes the paretic condition is succeeded by the spastic. Many of the cases of paralytic writers' cramp are not true examples of the neurosis, but are rather cases of neuritis of a rheumatic or other type. General Symjjtoms. — Writers' cramp is essentially a motor neu- rosis, and its leading symptom is the impairment of a motor func- tion. Other symptoms, however, both general and local, are al- Avays associated with it. These are mainly (1) psychical and (2) sensory, more rarely (3) vasomotor and (4) tro))hic. 1. Psychical symptoms. The patient is often nervous, emo- tional, and mentally depressed at times. He suffers from insom- nia and vertigo. Patients are generally unwilling to admit that there is any other trouble than the local one, and only careful ex- amination may bring evidence of constitutional trouble. There are cases of purely mental writers' cramp. 2. Sensory troubles. These consist of pains, sense of fatigue, feelings of numbness, jirickling, i)r('ssure, weight, tension, constric- tion, etc. Hypertesthesia, and more rarely auaisthesia, are also ob- servefl. The most common sensory symptom is that of aching and fatigue, and this is usually cojifint'd to the arm, and oftonest runs along the course of the radial and median nerves. The cervical ver- 548 DISEASES OF THE XERVOUS SYSTEM. tebrae may be tender, and sometimes patients have a headache in the parietal region of the side opposite the affected ami. 3. Vasomotor, trophic, and secretory disturbances. The condi- tion known as dif/itl wortici has been observed, coming on paroxys- mally. It is a symptom which the general neurasthenic state helps to produce. When the nerves are involved decided vascular changes may occur, such as passive congestion of the hand and arm, with swelling and turgescence of the fingers, and a sensation of throb- bing. In bad cases the fingers will look as if they had chilblains. Local sweating, dryness of the skin, and cracking of the nails, all are conditions which may follow impairment of writing power from neuritic causes. Electrical Reactions. — The results of observations upon the elec- trical reactions of the affected parts are somewhat contradictory. Ordinary tests will, as a rule, reveal very little change. Sometimes there is a quantitative increase, sometimes a decrease, of irritability to both forms of current. The increase occurs in the earlier stages, the decrease in the later. An increase or modification of electro- muscular sensibility has been noted. The electrical examinations, therefore, are only of value in excluding a neuritis or possibly in determining the stage of the disease. Pathologij. — Keuritis is undoubtedly present in some forms of writers' cramp, so called. It is not present, however, so far as ex- ternal tests go, in the typical neurosis. Nor are there any post-mor- tem observations throwing light on the anatomy of the disease. We must believe, therefore, that it is a neurosis having no appreciable anatomical basis. The act of writing is a very complicated one, calling into play numerous sets of delicately innervated muscles. These muscles are employed: 1, in pen prehension ; 2, in pen movement; 3, in hold- ing the arm and wrist tense. 1. The muscles employed in pen prehension are the two outer lumbricales, two outer interossei, the adductor muscles of the thumb, the flexor longus pollicis ; to some extent the deep and superficial, short and long flexors, and the extensors of the thumb. These are supplied mostly by the ulnar (interossei, adductor pollicis, inner heads of deep flexor of fingers, and inner head of short flexor of thumb). The rest of the muscles are supplied by the median. 2. In moving the pen, if the writing is done mainly by finger and not by arm movements, the muscles brought into play are the flexor longus pollicis, extensor secundi internodii pollicis, flexor pro- fundus digitorum, extensor communis digitorum, and to some ex- tent the interossei. The m\isculo-spiral and ulnar nerves innervate PROFESSIOSTAL NEUROSES, OCCUPATION' XEUKOSES. 540 these groups about equally. In moving the pen by the "American" or free-hand method there is a very slight play of the above mus- cles, while most of the pen movement is done by the muscles of the upper arm and shoulder, viz., the teres major, pectorales, latissimus dorsi, biceps, and triceps. The spinal centres for these muscles are distributed along the fifth, sixth, and seventh cervical segments of the cord. The cells are larger and situated more superficially in the anterior gray horns. 3. Besides these movements involved in pen prehension and in the letter making, a certain amount of muscular tension is exercised in " poising" the forearm and hand and steadying the wrist. The biceps and triceps, the supinators and the flexors and extensors of the hand are here brought into play. Prom the foregoing it will be seen that the muscles of pen pre- hension are most used in all but tlie free-hand style of writing, since the same groups have a double duty, that of clasping and of moving the instrument. "While writers' cramp is often complicated with some neurotic distiirbance leading to symptoms in the affected arm of pain, paral- ysis, tenderness over nerves, vasomotor disturbances, etc., there can be no doubt that the lesion in typical cases is central, and involves the psycho-reflex centres and indirect motor and sensory paths. Little more can be said of the pathology than that it is an " ex- haustion neurosis." The same is true of all the other forms of oc- cupation neuroses, and nothing need be said upon this point regard- ing them when they come to be considered. The diof/iiosis of well-marked cases of writers' cramp presents no difficulty. In the earlier stages, however, it may be confounded with a large number of disorders, viz., i)ost-hemi})legic chorea, he- miataxia, progressive muscular atrophy, progressive locomotor ataxia, various forms of tremor, lead paralysis, rheumatoid arthritis, neu- ritis, cerebral and nerve tumors, and tenosynovitis. In many of these cases it is only necessary to bear in mind the history of the disease in order at once to reach a safe conclusion as to its nature. If there is a great deal of pain in the arm, with tenderness along the course of the nerves; if there is decided change in the electrical reactions; if there are sensations of tingling, numbness, etc.; and if the ])atient sliows an absolute loss of power in the various groups of muscles, with some incapacity for doing otlicr acts besides the one with which he is specially concerned, then the trouble is un- doubtedly peripheral and due largely to an underlying neuritis. Tli(i ])r()gnosis in tliese cases is much more favorable. If, on the OoO DISEASES OF THE NERVOUS SYSTEM. Other haud, the disorder comes on in persons who have done an ex- cessive amount of writing; if it is associated with nerve strain; if the electrical reactions are but slightly changed, the sensory symp- toms slight, and the motor inco-ordination is marked, limited to the special class of work, and not accompanied with absolute paresis, the disorder is central and needs both a different treatment and prognosis. It is these cases that form writers' cramp proper, al- though no doubt neuritic and central forms are associated, or the former may run into the latter. Course and Duration. — Writers' cramp is a chronic disease. It begins insidiously and attacks one group of muscles after another as each is brought into play by new methods of writing. If the left hand is used, that, too, is liable to become affected. The course varies, however; for a time progress maybe arrested or improve- ment set in. When the disease becomes well established it will most often last a lifetime. Pr'ognosis. — The prognosis is unfavorable, yet not so much so as was once thought. Undoubted cases of complete recovery have been reported, even under unfavorable conditions. The prognosis is much more favorable if the patient begins treatment early and before marked spastic symptoms are present. It is more favorable in the neuralgic forms. Some patients who suffer from a mild form of the trouble manage, by the help of instruments or special pens, to do their work for years. The more acute the disease and the more evidently peripheral and neuritic its origin, the better the prognosis. In over one-fourth of the cases, patients who use their sound arm wall not be affected in it. The facts stated regarding the cause, physiology, and general symptomatology of writers' cramp apply to the other forms of occu- pation neuroses. A few special details, however, wall be given re- garding these. The most common and important are musicians' cramp and telegraphers' cramp, ILisicians' Cramp. — Under this head we include pianists' cramp, violinists' cramp, flutists' cramp, and the cramp of clari- onet players. Pianists' cramp occurs usually in young women who are study- ing to become professionals or who are especially hard Avorking and ambitious. The absurd " Stuttgart method" of teaching the piano, in which the motions are confined as much as possible to the fin- gers, predisposes especially to this disease. The symptoms are those of fatigue, pain, and Aveakness. The pains are of an aching char- acter. They are felt in the forearm especially, but extend up the arm and between the shoulders. Spasmodic symptoms are rare. The right hand is oftener affected, but both hands eventually be* come involved. PROFESSIOXAL NEUROSES, OCCUPATIOX NEUROSES. 551 ViollnisTs' cramp may attack the right hand which holds the bow or the left hand which fingers the strings, but more often the left hand is affected. Clarionet ijlayers sometimes suffer from cramp of the tongue and of the laryngeal muscles. Flvte ylaijers suffer not very infrequently from slight laryngeal spasms. A similar trouble affects elocutionists. The term mogo- phonia is api^lied to this type. TdeyrapJiers^ cramp affects especially those operators using the Morse system, which is still the one most widely in vogue. Con- trary to the opinions of previous writers, Dr. Lewis believes that this neurosis is not a rare one and is destined to become more fre- quent. In this city the cramp is not rare, the proportion being about one in every two hundred. The technical name among operators for the cramp is "loss of the grip," In telegraphing, the extensors of the wrist and fingers are called most into play, and hence are most and earliest affected. The symptoms come on very slowly, the thumb and index finger being first affected. The victim finds that he cannot depress the key on account of spasm in these muscles, and he finds most difiiculty in making the dot characters, such as h (. . . .), or p ( ), or z ( ). When the flexors are most affected the key is depressed with undue force and a dash is made instead of a dot. Sufferers from the " loss of grip " generally have writers' cramp also. While spasm is usually pres- ent, the disease may show itself simply in pain, paresis, and in- capacity to co-ordinate the muscles. In sewimj-spasm, which affects tailors, seamstresses, and shoe- makers, clonic and tonic spasms attack the muscles of the hands on attempting to use them in the regular work. Tailors who sit cross-legged sometimes suffer from a peculiar spasm on as- suming this position. It is possible, however, that these are cases of tetany, and not the functional neurosis under considera- tion. Suiiths' sjtasvi, or ^'' iKpliasfic hcmiph'r/'Ki^^ appears to have been observed only by Duchenneand Dr. Frank Smith. It occurs in per- sons engaged in pen-blade manufacturing, saw straightening, razor- blade striking, scissors making, file forging, etc. In doing this work they have to use a light or heavy hammer, with which strokes are delivered veiy rapidly and carefull}-. After a time spasmodic move- ments occur in the arm used, and the arm falls i)Owerless. As in the cases reported, there are generally hemiiilei^nc symptoms, and also neuralgias, vertigo, and other cerebral troubles, the disease cannot be a pure "occupation" neurosis. L>r!orrs' s/)as7n has been observed in veterinary surgeons l.y Di. Samuel Wilkes. Jiliflers* njxiiim is an extremely rare affection, which was first described by Basedow and seems to occur in milkmaids, never in milkmen. Cifjamiakers* cramp is very rare 55"^ DISEASES OF THE XERTOUS SYSTEM. Watchmahers' cromp and photographers^ cramp are also to be regarded merely as pathological cniriosities. Ballet-Dancers' Cramp. — Under this name certaia painful and paralytic troubles occurring in ballet dancers, especially premieres danseoses, have been described by Schtdtz, Onimus, and Kraiis- 8old. It does not appear that the trouble is really a co-ordinative functional one, but is rather neuralgic or the result of local strain upon the parts. Tlie list of professional neuroses is made to include, besides those above given, cramps and co-ordinative troubles affecting arti- ficial-flower makers, billiard players, dentists, hide dressers, elec- trical-instrument makers, stampers, turners, sewing-machine girls, money counters, weavers, painters, and pedestrians. Prophylaxis and Treatment. — The iatroduction of typewriters, gold pens, and improved penholders has prevented somewhat the increase of WTiters' cramp. Stenographers rarely have it unless they write in long hand. Persons who have to write a great deal should use large cork or rubber penholders and gold or quill pens with smooth paper. The best style of writing is that done from the shoulder, but this is a method that bookkeepers and those who have to keep accounts cannot easily adopt. The vertical system of writing which is now being widely taught is to be preferred. !Many nervous persons have a bad habit of gripping the pen very tightly and pressing down on the paper with excessive force. Fatigue soon re- sults and painful sensations develop in the arm. Proper attention should be paid to the position of the paper written upon, the height of the desk, the light, and the sleeves of the coat or dress. The paper should be laid at an oblique angle to the edge of the desk, and not at a right angle as many writing-teachers are accustomed to direct. As some cases of " cramp" are undoubtedly cerebral, it is very unwise to attempt any extraordinary exploits in writing or to work with the ambition to put the writing-capacity to the utmost test. Cramp is often dated from days when such extra work is done. When the cramp is folly developed, the most essential thing is rest, and it is generally best to advise the patient to change his oc- cupation at once. Some rest, however, may be secured by getting a new form of penholder, holding the pen in a different way, using the unaffected arm, or using some form of mechanical appliance. The mechanical appliances are splints, rubber bands aroimd the wrist, and various instruments contrived to prevent spasm and throw the work of writing on new and larger groupis of muscles. Instruments for writers* cramp are very numerous. Those that are of some value are 3Iathieu's, Nussbaum's, ar J some modifica* PEOFEStlOXAL XEUROSES, OCCUPATIOX XEUROSES. 553 titm of Cazenave's (see Figs. 228. 229 ) . All the various instrxuneiits have been of service, or have even been curative in some special cases, but not too much must be expected of them. As a rule they are only palliative. A cheap instrument that may prove satisfactory is that of 3Iathieu. In the medical treatment of writers' cramp, two important agents are massage and electricity. By massage only very mediocre results were obtained untQ greater attention vras drawn to it by Mr. J. "Wolff, a writing-mas- ter of Frankfort-on-the-Main. This gentleman has cured many cases, though not all that he has treated (Berger), and he has secured many testimonials for his method. The treatment, as de- scribed by Schott (G. W. Jac-oby i, consists of a system of gym- nastics and massage. The gymnastics consist of movements per- FiG. SB.— MatbixC^ IxsTsrvKST Fte. 2S9.— KrssaAni's IxarrKrviocT. roB WansBs' Cbaxp. formed by the patient alone and movements executed with ibe co-operation of the operator. The first are performed by the pa- tient during from twenty to thirty minutes, rarely for forty -five minutes. These movements consist of gymnastics of the fingers; extension, flexion, abduction, and adduction being performed, and the thumb being exercised separately. After this the four motions are executed at the wrist-joint, then extension and flexion of the forearm, and ultimately the arms themselves are exercised in the same manner and are to be lifted over the head. Each single ex- ercise is to be performed from six to twelve times. After each mo- tion a pause is to be observed. The opposed movements are to be carried out in the same manner, except that the operator must care- fully resist their execution as though he were endeavoring to force the patient to perform a motion just the reverse of his intentions. Regularity of pressure is to be observed in this, so that the same amount of force is always used and so that the pressure does not 554 DISEASES OF THE NERVOUS SYSTEM. vary iu intensity from moment to moment. The time to be devoted to these opposed movements should be the same as that for the un- opposed ones. According to the intensity of the affection, the exer- cises must be repeated two or three times daily. The massage it- self consists of two parts — nerve and muscle massage. The nerve massage is effleurage along the course of the nerve trunks, the me- dian, ulnar, and radial, going upward to the axillary and cervical plexuses. This effleurage lasts about ten minutes. Following this is the muscle massage. This consists of petrissage, beginning with the hand and ending at the shoulder. The duration is the same as that of the last movement. One sitting a day has always proved sufficient. Wolff, in addition, uses " a peculiar method of writing instruction" and employs rubber bands and rings in his manipula- tions. It must be added that one hears very little of the Wolff method at the present time. Electricity ranks second to massage in the treatment of occupa- tion neuroses. The high-tension faradic current with long coil has done good service in some of my cases. The galvanic current has been helpful also. It should be given daily. The anode is placed over the cervical spine and the cathode over the various muscular groups affected. A stabile current of five to ten milliamperes for from ten to fifteen minutes is given. Lotions containing muriate of ammonium, liniments, hot and cold douches, the cautery, all have been recommended in professional neuroses. Tenotomy was once employed, but has been abandoned. Very little can be expected of drugs. The most trustworthy are atropine, strychnine, cannabis indica, the iodides and bromides, and cod-liver oil. It should be remembered that sometimes the disease is almost purely cerebral, and then an antineurasthenic treatment is called for. But in other cases, when the disorder is largely pe- ripheral, the usual treatment for a low grade of myoneuritis must be employed. CHAPTER XXVI. PAEALYSI8 AGITANS (SHAKING PALSY, PARKINSON'S DISEASE) . Paralysis agitaus is a chronic progressive disease, characterized by tremor, muscular rigidity and weakness, and by a peculiar atti- tude and gait, together with sensations of heat, pain, and restless- ness. Etiolofjij. — It occurs oftenest between the ages of fifty and sixty, then between sixty and seventy and forty and fifty. In very rare instances it occurs in early life, but the genuine disease does not occur before puberty. Males are affected much oftener than females (five to three in seventy-eight American cases). It occurs in all classes of life, but oftener among those who incur exposures and en- dure hard labor. It is not a disease of vice and is not the result of alcoholism, syphilis, or sexual excess. Prolonged overwork and anxiety in middle life are very often predisposing causes. Heredity is a rare factor, but I have known h^^reditary family tremor to end in paralysis agitans. It appears to have some relation to rheuma- tism and especially to rheumatoid arthritis. It occurs oftenest in this city among the Irish, Gt-rman, and Polish races (twenty Irish, thn-teen Germans and Russians, the last mostly Hebrews). The apparent exciting causes in the majority of cases are ex- posure to wet and cold, fright, injury, and acute mental suffering. An attack of rheumatism, a siulden severe muscular strain, and fevers are rare causes. The actual exciting cause is probably al- ways an infection, just as in multiple sclerosis, paralysis agitans being the senescent counterpart of that disease, Sijnqttiniis. — The disease is sometimes ushered in with an acute illness, or an attack of sciatica. It then develops slowly with some aching pains in the arm and a slight tremor in the fingers of one hand, oftener the left. This gradually extends and involves the foot of the same side, theri the other side beconu's affected. The neck, face, and tongue are rarely attacked, and then to a small extent. After or with the tremor there comes on a stiffness in the arms and legs, and indeed of the whole bodj-. "With this there is a general con- tracturing and shortening of all the flexor groups; so that the head and body are bent forward, the fingers are straight but are flexed 55(3 DISEASES OF THE NERVOUS SYSTEM. as a whole on tlie metacarpus, the forearms flexed on the arm, the trunk is flexed forward on the thighs, and the knees are slightly bent. The attitude gives the idea of extreme senility (Fig. 230). The gait is slow, the steps are short and shuffling; the patient has trouble in starting, stopping, and turning corners, owing to the slowness in initiating new movements in the voluntary muscles. When once started he may be unable to stop and has to nm along. The speech early becomes affected. The voice is high-pitched, weak, and piping, or senile in quality. There is a slowness in getting out words or in starting a sentence, though after it is begun the words come rapidly. The condition is analogous to the hestitation in the gait. Along with the other symptoms there are often, though not always, sensations of heat, burning, fever, and rarely of coldness. These sensations are felt most in the feet, legs, or arms diffusely. Often there is a general feeling of rest- lessness and nervousness. Aching pains and a sense of fatigue occur; neuralgic pains are more rare. There are always a peculiar redness and flush in the faces of the pa- tients. Sometimes they sweat pro- fusely. The temperature in the axilla is normal, on the skin it is sometimes increased (Peterson). The appetite is excellent, often abnormally great, and digestion is good. Visceral complications are rare. Muscular weakness comes on early; it slowly increases, but complete muscular paral- ysis does not occur. The disease ends in rigidity, which makes the patient as helpless as if paralyzed, but the muscles preserve consid- erable functional power to the last. The deep reflexes are present and not, as a rule, exaggerated ; but exaggeration and even clonus occur in a small percentage of cases. As the disease progresses the tremor increases in extent, and continues without remission during all the waking hours; the limbs get more rigid; the patient becomes Fia. 230.— Attitude in Paralysis Agitans (Curschmann). PARALYSIS AGITAXS. 557 bedriddeu and is finally carried off by exhaustion or some iuter- 3ui-reut illness (Fig. 231). It will be seen that the dominant symptoms in paralysis agitans ire: Tremor. liigidity, progressively increasing. Muscular weakness. Sensory and vasomotor disturbances. Further details must be given regarding these symptoms: The tremor is at first rather fine, but later is coarse. It ranges From about 6 vibrations per second to 3.7. The average rai)idity is i or 5 per second, Avhich is about cue-half the normal muscular 1. 2. 3. 4. FiQ. 231.— ATTiTrnB and Gait in Paralysis Aoitans. rhythm. But the chief characteristic of the tremor is that it con- tinues when the hand or limb is at rest, while voluntary motion causes it to cease. As the hand rests on the knee it shakes; as it is QKjved the tremor stops. When held straight out there is no shak- ing for a moment, but it soon begins. A glass of water is carried safely to the lips. The patient can control the tremor for a mo- ment, especially in the early stages of the disease. These facts about the tremor apply in ninety per cent of cases, but there are patients whose ti'cmor is slight when the limb is at rest and is in- creased on voluntary effort. The hands are affected in a character- istic way. Tlie fingers and tlnimb are sliglitly fiexed and liehl about in the writing-position; the tremor moves the fingers and thumb as a whole, and they vibrato so tliat tlio one pats the other gently. Ronietimes the tremor is one of alternate supination and pionation of the forearm. Tlie neck and face muscles are not usually or ev 558 DISEASES OF THE XERVOUS SYSTEM. tensively involved, the shaking of the head being generally the re- sult of the general bodily tremor. Sometimes one sees a tremor of the lips or neck muscles. The tongue and eye muscles are practi- cally never involved. BigicUtij. — The rigidity conies on early, and may be the first and even the only prominent symptom. It affects chiefly the Fia. 232. —Terminal Stage of Paralysis Agitans, showing rigidity and contractures. flexors of the arms, head and trunk, and legs, producing a char- acteristic senile position. In rare cases the extensors of the neck are affected and the head is drawn back. Cramps occur, and there is always a sense of stiffness. The muscular movements are slow, especially the initiation of a movement. Once started, a motion may be quickly done. The gait is peculiar: the steps are short and shuffling; the patient may have difficulty in starting, but once started he goes along very well ; or while walking there may be a sud- PARALYSIS AGITAXS. 559 den running forward. This is called " festination." Rarely there is a tendency to nm backward or sideways. The facial muscles are stif- fened and little used, so that the face has a peculiar expressionless look. The patient is often emotional, but the mind is not seriously affected. The urine is usually about normal, but contains an excess of phosphates. There may be polyuria and less often glycosuria. Forms. — The unusual types of paralysis agitans are the hemi- plegic or the monoplegic, the rigid type, and the retrocollic type. The only one of importance is the rigid type, in which there is practically no tremor. Course and TJuration. — The disease slowly but steadily pro- gresses until a full development of symptoms occurs, when it may Fio. Si3.— Anterior JIohn of Sri.N.u. Cukij, showiii}; dilated veins. remain stationary. It takes about two years for the whole body to be affected, though this varies much. It lasts from three to twelve years or even more. In three cases of mine death occurred in three, six, and eleven years. Death is due to exhaustion and may be ac- com))ani('d by mild delirium and fever. The dhiiinosls must, be made from senile tremor, multiple scle- rosis, post-hemiplegio tremor, and wryneck affecting the extensors bilaterally (retrocollic spasm). Senile tremor occurs in the very old ami affi'cts the head first and most. In multiple sclerosis the tremor is more jerky and is a tremor of motion; there are nystagmus, syl- labic speech, and often apoplectiform attacks, eye trouble, and paralyses. Post-hemiplegic tremor is accompanied by a history of hemi- 5<;o DISEASES OF THE XERVOUS SYSTEM. plegia; there are paralysis and exaggerated reflexes and the disease is unilateral, la retrocollic spasm only the neck muscles aud fiou- 7 I i ' <^W" ^^% \-^,, «^^w-'.v: ','.■• '*^-s 1/^ ,■■">■ V\" 1 1^ >5='« : ■^ /u %- ^f 1\ \ 1 ^ ^_ 1 Fio. 234.— Cells of the Anterior Horn of the Spinal Cord. The rl?ht row from a case of paralysis agitans, showing atrophy aud pif^ineulatioii, the left row trom a nor.'iial case. talis are involved. The absence of exaggerated reflexes, the pecu- liar voice, gait, and attitude, and the sensations of heat and nervous ness often help greatly in the diagnosis. PARALYSIS AGITAXS. 5G1 The 2^ i'o[/nos is is favorable as regards life; unfavorable as regards cure; and not very good as to bringing about a cessation of progress in the symptoms. The progress of the malady, however, can be delayed. Fatholoylcal Anatomy and Patholofjij. — The post-mortem changes are not very marked, and are seen mostly in the spinal cord and medulla. There are congestion and dilatation of vessels in the gray matter, a diffuse increase of interstitial tissue, atrophy and pig- mentation of cells (Figs. 233 and 234). The j)rocess is suggestive of a chronic interstitial inflammation with cell degeneration. It is probably a post-infectious process, with a toxin behind it. The cerebro-spinal motor neuron is the most at fault; and it seems as if the connections between its end brushes and the motor cells of the spinal cord were interfered with. Hence the peculiar " hold- ups," the rigidity and tremor of the disease. Paralysis agitans is certainly not merely a premature senilit}", as some have taught. Trtatinent. — The most important measure is rest, mental and physical, Avith plenty of fresh air. X(} special diet is indicated. Lukewarm baths and mild massage are agreeable and helpful. I know of no climatic cure. The galvanic current produces temporary relief; it shouhl be given daily. Ilyoscine hydrobromate, first used by Charcot and introduced into this country by Seguin, is of much temporary value in relieving the tremor (gr. -pL- increased). Codeine and morphine give the best permanent results. Quinine and min- eral acids are of much service in relieving the vasomotor and sensory symptoms. I have used bromide of uranium (gr. -g'g-) with some ap- parently good results. Arsenic, Indian hemp, tinct. veratrum viride, ^alicin, and salicyate of sodium rank next in value. Kitrate of silver, L'onium, curare, bromides, atropine, phosphorus, cod-liver oil, iron, md picrotoxin have all been recommended. Bromide often helps the insomma and restlessness. Extract of pituitary gland in doses il gr. XXX. to xl. daily (piiets the system also. .Suspension is of some use in a minority of cases not too much idvanced. The mind in paralysis agitans is sometimes in an emo- tional, almost hysterical, condition, and jiatients are easily made Detter for a time by some psychical influence. Hypnotism by means )f fascination is said to be of use, but it has failed in my experience. 36 CHAPTER XXVII. TROPHIC AND VASOMOTOR DISORDERS. Progressive facial HEMi^rROPHY is a disease characterized by a progressive wasting of one side of the face. Etlologij. — It begins oftenest in the young between the ages of ten and twenty. Pemales are more affected. ''^ There is in rare cases a hereditary history. Injury and infectious fevers sometimes start up the trouble. The left side is oftener attacked. Synqjioins. — The disease begins very gradually and shows itself Fig. 235.— Facial Hemiatrophy, Early Stare, shovWngr alopecia and osseous depressions. first in patches. The skin gets thinner, there is loss of pigment, hairs fall out, and the areas may have a yellowish appearance. Sometimes the periosteum and bone are affected, and shallow de- pressions are formed which may be anaesthetic (Fig. 235). The sub- cutaneous tissue IS most involved, the muscles suffer least, and there are no changes in electrical reaction. The muscles of mastication are usually spared. The bone undergoes general atrophy and the lower jaw may be reduced to two-thirds the normal size. The se- cretion of sebum ceases, but that of sweat may be increased. The * About 100 cases have been reported. Among 5 seen by myself, 3 were in females, 2 in males. The disease in all cases, so far as could be found, began between the tenth and twentieth years/ THROPIC AXD VASOMOTOR DISORDERS. 503 temperature falls. There are a sinking in of tlie eye, narrowing of the lid, and dilatation of the pupil. There is sometimes pain and rarely anaesthesia. The tongue and other parts of the body may be involved. Spasmodic movem.ents of the muscles of mastication have been noted (B. Sachs). Scleroderma sometimes appears on the face or hands. The disease progresses rather rapidly at first, but finally comes to a standstill. It does not shorten life. Pathology. — There has been found a degenerative neuritis in- volving the fibres of the trigeminus ; its descending root and the substantia nigra were atrophied (Mendel). The diagnosis is easy. Hemiplegia with atrophy in children, congenital asymmetry, and atrophy from gross lesions of the nerve are distinguished by their stationary character or the pres- ence of severe pain. Treatment. — There is no treatment known to be of service. Tonics, iodides, and electricity may be tried. Derciun has suggested resecting the trigeminal nerve. Progressi^'e Facial Hemihypeb- TROPHY is an extremely rare condition, only eleven cases having been reported. It is usually congenital in origin, but may develop in connection with giantism, as in a case of my own (Fig. 236 j. Fkj. ZV<. — Facial Hemi- hypertrophy occurring is A Giant. Acromegaly (Marie's Disease). Acromegaly is a chronic dystrophy characterized by gradual en- largement of the hands, feet, head, and thorax, and by a dorso-cer- vical kyphosis. Though the disease was first described only ten years ago by P. Marie, the number of cases reported is rapidly increasing, and if one includes various abortive types it is not extremely rare. KtioliKjij. — It affects the two sexes nearly alike. It begins be- tween the ages of eighteen and twenty-six; recently a congenital case has been reported. No hereditary influence or definite exciting cause is known. The patients are sometimes naturally endowed with large extremities. Si/inptoins. — The disease begins with a gradual enlargement of the hands, feet, ai.d head. In women there is amenorrlKya, in men sexual weakness; slight rheumatic pains, headaches, malaise, men- tal hebetude, ana'inia, and geneial weakness are present. The skin is dry and there is polyuria. o64 DISEASES or THE XEia'OUS SYSTEM. Til 3 hypertrophy affects the soft parts as well as bones. lu these latter there are periosteal thickening and hyperplasia, with the result of producing increase in width more than length. The arms are not much involved, nor is the shoidder girdle, except the clav- icle. The lower jaw is much more involved than the cranium. The tongue, lips, and nose are enormously hypertrophied (Fig. 2.'->7). The thorax is enlarged antero-posteriorly and flattened. There is sometimes dulness over the sternum due to persistence of the thymus. The pelvis may be enlarged, but the hip and leg bones are geuer- FiG. ;;:;;.- FnK l' :galy (Curschman). ally spared. The hands and feet undergo enormous hypertrophy (Fig. 238 j. The following are some of the measurements in the case that has come under my observation, reported by Adler, and in cases reported by Osborne and Packard : Length of luuul. Length of foot. Cranial circumference, . Circumference of tliorax, 7.6 to 8| inches. U.?tol2i " ■24 to 261 " 44 The Vision is sometimes impaired and there may be hemianopsia. The muscles may be at first hypertrophied, later atrophied. There are no paralyses and rarely any anaesthesia'. The disease runs a A^ery chronic course, lasting ten or twenty years. Fatholfxjij. — There has been found an enlargement of the pitu- TROPHIC AND VASOMOTOR DTSORDHRS. oGo itiiiy body in nearly all cases, and it is probable that the disease is due to disorder of its function. The attempts to place the disease in relation with a persistent thymus, sclerotic changes of the sym- pathetic, and disease of the thyroid, all of which conditions have been found, are unsuccessful. The disease must be regarded as a perver- sion of nutrition due to defective action of the pituitary gland. The cllafjiwsls must be made from congenital enlargements, from so-called giant growth which affects single members, and from oste- FlG. :i;ih.— NoRMAt, IlASr) ANU HaND IN ACROMEGALY. itia deformans. In the latter disease it is the shafts of the long bones and the cranium, not the face, which are involved. Fneumoijenic ustrn-nrtltriipntli ij is the name given by Marie to a disease associated with ]tulmonarv and iileuritic disease, and charac- terized by enlargement of the extremities and ])eculiar deformities of the terminal phalanges. The enlargements are not uniform. The tongue, is not affected. The wrist and ankle bones are hyper- trophit'cl, the linger-tijjs are bulbous and si)ade shajted. J'rnrjiinsis. —Acromegaly is incurable, but it has been arrested, or at least lias ceased to progress, and it may not greatly shorten life. Tredtment . — Cases liave been reported in which iodide of potas- sium and arsenic have arrested the disease. In general, the treat- ment is only sym])tomatic, but feeding with jiituitary gland in large doses (gr. .\1. ) should be tried. 5GG DISEASES OF THE KEUVOUS SYSTEM. MyXCEDEMA. Myxoedema is a disease of the thyroid gland, but its symptoms are so largely nervous that a brief description of it is justified here. It is a chronic disorder, due, as a rule, to an interstitial thyroiditis, and characterized by a solid oedema of the subcutaneous tissue, diy skin, loss of hair, subnormal temperature, mental dulness, and even ir! sani ty and idiocy. It lias two forms — the congenital and infantile Fig. 239.— a Case of Myxedema in a Man aged Forty-Four Years (Murray). — causing a condition known as cretinism ; and an adult form con- stituting myxoedema proper. It occurs most often between the ages of thirt}- and fifty, and oftener in women (seven to one). It is seen oftenest in temperate climates. Hereditary influence, alcoholism, and syphilis are not predisposing factors ; lead poisoning may be a cause. It begins slowly. The patient is languid and dull, and is un- usually sensitive to cold. Voluntary movements are slow; the weight increases and a solid cedema which does not dent on pressure develops in the face and extremities. The skin gets dr}^ and rough, the hair begins to fall, the temperature is subnormal, 1° to 2° F. TROPHIC AXD VASOMOTOR DISORDERS. 507 Mentally the patient is dull, forgetful, depressed, and in one-fiftli of the cases melancholia, mania, or dementia develops. The mus- cles are weak, the gait is slow, the voice hoarse and monotonous. There is considerable auaimia and the heart is weak. The pulse is slow and the arterial tension low. Albuminuria is present in twenty per cent of cases, and hemorrhages may occur. The pallor, cedema, loss of hair, and mental hebetude give to the face a characteristic expression (Fig. 239). The disease may run a course of six or seven years, the patient dying of cardiac weakness or some intercurreiit malady. The disorder is due in most cases to a chronic interstitial thy- roiditis which usually causes atrophy of the gland. It may be produced by artificial removal of the thyroid. The result of this is a defective action of the thyroid, and a consequent poisoning of the system and deposit of mucin in the subcutaneous tissue espe- cially. The diagnosis is based upon the peculiar physiognomy due to the cedema pallor; the loss of hair, subnormal temj)erature, mental hebetude, and atrophied thyroid. The prognosis is good if treatment is instituted. The treatment consists in the administration of the thyroid ex- tract in daily doses ranging from five to forty grains or even more. Tlie results are most brilliant, and humanity owes nmch to Dr. George K. Murray, who first instituted it. Gketixism. Cretinism is a form of myxcedema due to absence, atrophy, or de- fective function of the thyroid gland, occurring congenitally or dur* ^ ii^'^ Via. ^0.— A CRETtN Dwarf, aobo Twknty (Xeszynsky). fag infantile life. The disease occurs endemically in parts of En* ro])e, but only sporadically and happily witli great rarity in America. 568 DISEASES OF THE XERVOL'S SYSTEM. HereditaiT and family influences are at work in endemic but not in sporadic cretinism. It develops either directly after or in the first three years of life, and shows itself in a stunted growth both of brain and body, most cretins being idiotic dwarfs. The general symptoms are much like those of myxoedema in adults plus the retarded growth of mind and body. The deposits of solid oedema cause peculiar deformities and lead to a characteristic ]ihysioguomy. FiQ. 211.— Sporadic Cretinism in a Patient aged Twenty-eight; Height, 341^ Inched (Murray). The mind is dull and placid, the muscles are weak, the abdomen is protuberant, the hands and feet are broad and thick; the patients are anaemic, the temperature is subnormal. The arrested bodily growth is such that on reaching adult age the stature ma.j be only twenty -eight to thirty -three inches (Fig. 241). Cretins tisually die young, but some survive to the age of thirty or forty. TROPHIC AND VASOMOTOR DISORDERS, 56'J The treatment is tlie same as that of myxedema. Here, too, if the case is seen before adolescence, brilliant results can be obtained. Axgio-Xeurotic Oedema (Circumscribed Qt^dema). Angio-neurotic oedema is a functional disorder characterized by the rather rapid appearance of circumscribed swellings upon differ- ent parts of the body, these swellings being due to disturbances of vasomotor innervation and not of an inflammatory character. The disease occurs oftenest in early adult life, the average age being from twenty to thirty, but it has been observed in young children and even m the aged. It occurs oftener in males than in females, except in this country, where the reverse ratio exists. Hereditary influence plays a part in some cases ; the disease has been known to run in families. It occurs oftener in winter and oftener in the early morning hours. Exhausting occupations predispose to it. The ex- citing causes are sudden exposure to cold, slight traumatisms, fright, anxiety, grief, and the ingestion of certain kinds of food such as apples or fish. A peculiar form of this oedema seems to develop in connection with menstruation. Sijmj)toms. — The disease appears without much if any warning. In a few minutes 6r hours there develops a circumscribed swelling upon the face or arms or hands. This swelling varies in diameter from one-half inch to two or three inches. It may be dark reddish or rosy or it mr.y be pale and waxy. It does not easily pit on pres- sure. There is sometimes a local rise, sometimes a fall in tempera- ture. It is accompanied by sensations of tension and stiffness, scald- ing, burning, and sometimes itching, but there is no actual pain. The swelling is usually single, but it may be multiple. It is located most often upon the face, next upon the extremities, particularly the hands ; nex'j on the body, then in the larynx and throat, and then on the genitals. The swellings last from a few hours to two or three days. Between the attacks the patient feels well. They are apt to return at intervals of three or four weeks to several months. Sometimes they are brought out only by certain peculiar exciting causes, such as indigestion or mental anxieties or emotional disturb- ances. When the disease attacks the larynx or throat, serious symptojns of dyspiuea and suffocation may appear; surgical inter- ference may even be called for, and death has been known to re- sult. It has been thought that neurotic oedema may sometimes at- tack the stomach, producing symptoms of nausea, vomiting, and great gastro-intestiiud distress, and an a<'ute neuroti(r cedema possibly some- timer, attacks the lungs. This, liowever, is unlikely, since the vaso- motcr innervation of the pulmonary ])lood-vessels is a very stable one. 570 DISEASES OF THE NERVOUS SYSTEM. The pathology of the disease is not known, except that it is un- questionably a disorder due primarily to disturbance in nerve inner- vation. The nerves affected are, farvhermore, undoubtedly vaso- motor nerves. The cederaa is precisely similar to that which is associated with attacks of tic douloureux and migraine. Diagnosis. — The symptoms of the disease are so peculiar that they are easily recognized. The spontaneous appearance of the oedema, its recurrence at certain intervals, and the absence of pain and evidences of inflammation are sufiScient usually to enable us to recognize it. The giant urticaria is a disease resembling neurotic oedema and probably closely allied to it. The blue and the white oedema of hysterics differs in being persistent and associated with paralyses, ansesthesias, and conti'actures. The prognosis, so far as cure is concerned, is not very good. The attacks, however, can be ameliorated, and the disease itself is not serious as regards life and the enjoyment of a fair degree of general health. The treatment consists in the adoption of such measures as will give tone and stability to the nervous system ; the use of cold baths, exercise, and massage is indicated. Internally laineral acids and strychnine may be of some value. Cascara, nux vomica, the salicy- lates, arsenic, quinine, and atropine are all drugs Av^hich have been recommended. CHAPTER XXVIIL THE DISORDERS OF SLEEP. Insomnia, Hypnotism, Mokbid Somnolence, Catalepsy, Tkance, Lethargy, the Sleeping Sickness. Sle?:p is a coiiclitioii iu which consciousness is normally lost ana in which the whole body, but particularly the brain, enjoys func- tional rest, while constructive and nutritive activity goes on. PJii/sioIofjij. — The most conspicuous phenomenon of sleep is the subsidence of the higher cerebral f imctions ; yet other organs, nota- bly the muscular system, also take part iu the restiug-process. The brain during sleep is slightly anaemic, the deficiency in blood being a part of, but not the cause of, the phenomenon. The remote cause of sleep is inherent in the nervous tissue itself, Avhich follows the great rhythmical law, common to all living tissue, of rise and fall in its irritability. It is probable that the immediate cause of drow- siness is the exhaustiiin of the irritability of the cortical cells and the benumbing of them by the circulation of waste products m the bhjod. Many facts in the history of the pathology of the brain point to the existence of a sleep centre, which, being especially acted upon, tends to inhibit the consciousness and draw the mind into a somnolent state. As sleep is only a function, we cannot speak of its diseases, but only of its disorders, and these really form but a part of the dis- eases of the brain or of general diseases. It is a matter of conven ience, however, to discuss some of these separately. Classification. — Custom has established the use of certain terms for the various disorders of sleei*, and such terms must be for the most part adhered to. It will be proper, however, for the sake of completeness, to arrange the various disturbances we are to discuss in accordance with the modern methods of studying the pathological changes of bodily functions. We pro})ose, therefore, the following elassifi(^ation, which indicates the various depressions, exaltations, and i)erv('rsions of the fiuictions of sleep: 1. Stat(; of normal sleep Jfi/iinosis. Soninus. II. Stjvteaof absence of sleep. Ahyp- Insonuiia. iiosis. 572 DISEASES OF THE NERVOUS SYSTEM. III. States of perverted or artificial Dreams, nightmare, night terrors. sleep. Parahypnosis. sleep-drunkenness, somnambulism, hypnotism. rV". States of excessive or frequent Morbid somnolence, paroxysmal drowsiness and sleep. Hyper- sleep, epileptic sleeping-attacks, hypnosis. trance sleep, lethargy, sleeping- sickness of Africa. I. Normal sleep varies much iu accordauce with age, sex, the individual, and, to a slight extent, with occupation, race, and eli- mate. The infant sleeps fourteen or sixteen hours out of the twenty- four, the adult needs about eight hours, while the aged live health- fully with but six. Women need half an hour or an hour more than men. A few persons, generally men, need nine, ten, or even twelve hours of sleep daily ; others require only six. Brain workers, as a class, take less sleep than laborers. Sleep is sounder and longer in cold climates and among northern races. II. Insomnia is a term given to conditions in which persons simply suffer from insufficient and restless sleep or from entire ab- sence of sleep for a long time. Such conditions result from a great variety of causes. It is my purpose to discuss only those forms iu which the trouble is functional or nutritional, leaving out of consid- eration the symptomatic insomnia of organic brain disease and that occurring as the result of painful diseases. An entire absence of the capacity to sleep occurs most often and typically at the onset or in the course of insanity. It is here a prominent and most distressing symptom. The length of time dur- ing which a person can live without any sleep is about the same as that during which he can go without food, viz., three weeks. Many hysterical, neurasthenic, or incipiently insane individuals will assert that they have not slept for weeks, but careful examination shows that they have at least been in a drowsy, somnolent condition, which is, in a measure, physiologically equivalent to sleep. Etiology. — The cases in which persons can get only a troubled rest of a few hours are much more numerous. It is a disorder of the third, fourth, and fifth decades of life. Women are less liable to suffer from it than men, and the laboring classes less than those engaged in business or professional pursuits. A frequent symptom of neurasthenia is an imperfect, and especially an unresting, sleep. In gout and in the so-called latent gout, or litheemia, insomnia is a frequent symptom. One of the few nervous symptoms of secondary syphilis is insomnia. Insomnia may develop as a bad nervous habit in persons who are neglectful of themselves. It occurs sometimes as an hereditary neurosis. I am acquainted with a family in which, for four generations, one or more of the members have suffered from THE DISORDERS OF SLEEP. 573 chronic insomnia thioughout life. In anaemia and chlorosis there is often insomnia at night, combined with somnolence during the daytime. Disease of the heart and arteries may lead to insomnia, and under this head come the eases which occur in Bright' s disease with tense arteries and ancemic brains. Disorders of the stomach lead to disturbed sleep oftener than to complete insomnia, and the liver, when inactive, causes somnolence rather than the contrary. The poison of malaria and the toxic agents of fever must be added to the list of causes of imperfect sleep. It will be seen that the causes of chronic functional insomnia may be classed under the following heads : 1. Neurasthenic and vasomotor, including hereditary and habit insomnia. 2. Vascular and cardiac, including heart disease, arterial fibrosis, and general amemia. 3. Auto-toxic or diathetic, including lithaemia, gout, and uraemia. 4. Toxic, including syphilis, lead, malaria, tobacco, and various drugs, such as coffee, tea, and cocoa. In many cases there exists a combination of these causes. Symptoms. — The forms and degrees of insomnia vary greatly. In children it is accompanied usually by much mental and physi- cal disturbance. The patient is restless, excited, talkative, or quer- ulous and irritable. The insomnic child is more ill than the insom- nic adult. In neurasthenic insomnia there is a tumidt of thoughts wliich prevent sleep, or sleep is superficial, unresting, and inter- rupted by dreams. In many cases of insanity insomnia is char- acterized by great motor restlessness. In old people insomnia is generally of the quiet kind. Treat iimnt. — As insomnia in all its phases is often a symptom of some general disorder, treatment of a curative kind must be directed to this. Antemia, lithajmia, uraemia, malaria, and the other toxic iiiHuences nuist be removed by remedies adapted to these conditions. Hut besides constitutional treatment there is a symptomatic treat- ment wliicli will be discussed here, premising, however, that while bhcre are numy sleep-producing medicines there w/v? vn good Jnnjs for uisoiinii'fi. The older physicians in treating sleeplessness, used to depend largely on hyoscyamus, campiior, ojjiun), and the fetid drugs, such as asafa'tida, nmsk, and valerian. Ilyoscyanuis is still used. It is to be given in large doses, such as five or ten grains of the extract, ov even more, and from ten to twenty drops of tlie fluid extract. The hydrobromate of hyoscine, in doses of gr. -j-J-^- to gr. -yV O' 574 DISEASES OF THE NERVOUS SYSTEM. more, is one of the best forms. Hyoseineis indicated in the insom- Dia of the insane, especially in forms accompanied by motor ac- tivity. Chloral hydrate still holds its o^vti as one of the surest of hypnotics. The dangers involved in its use have been somewhat exaggerated, though they are sufficiently real. Doses of gr. x. and gr. XV. are often quite large enough, but in alcoholic insomnia it may be given in twice the above amounts, guarded with ammonia and digitalis. Not a few persons find that chloral has bad effects. The patient awakes with a dull, heavy sensation in the head, slight headache, or gastric disturbance. The various bromides are efficient and safe hypnotics if properly used. The immediate effect of them is simply sedative, and sleep is not produced unless very large doses are given. Some persons are even kept awake by average doses (gr. xv. to xx.). In insom- nia, therefore, bromides are best prescribed in doses of gr. xv. three times a day. By the second evening sleep is generally secured. Tiie bromide habit is rarely formed, and is in itself not so seriously injurious as the choloral or opium habit. The bromides alone are hardly strong enough hypnotics for alcoholic insomnia or the insom- nia of insanity. I have found them to fail in the insomnia of the aged. Paraldehyde ranks close to chloral in its value as a hypnotic. In some persons it disturbs the stomach, but not in all, and it may be used as a hypnotic for months without its power being impaired. It is a disagreeable drug, and there is nothing, so far as I know, that palliates its offensiveness. I prefer, however, to prescribe it in 3 i. doses poured upon a teaspoonful of powdered sugar. Doses of 3 ss. are sufficient to cause sleep in many cases, and collapse may be caused by 3 ij. given to weak patients. Urethane, in doses of a scruple or more, is a mild and agreeable hypnotic, but not so certain as paraldehyde. Amylene hydrate is a hypnotic of properties similar to those of paraldehyde, but less disagreeable. It is given in doses of about one drachm. Lupulin in large doses, gr. x. to gr. XX., is a good hypnotic. Suiphonal in doses of gr. x. to gr. xxx. given two or four hours before retiring is one of the best hypnotics. Chloral-amide is more agreeable and safer than chloral, though it acts practically in the same way. The dose is 3 i. to 3 ij. Trional in doses of gr. xv. is rather better than suiphonal. Among the antispasmodics are several drugs which occasionally answer well in the insomnia due to nervous irritability. A drachm of the fluid extract of valerian or of spirits of lavender, for example, may be prescribed. In some forms of insomnias — perhaps best in those due to fever, or pain, or some rheumatic or gouty trouble— antipyrin in twenty-grain doses acts well. It is known that in THE DISOKDERS OF SLEEP. 0<0 many cases of mild types of insomnia a dose of whiskey, brandy, or beer will put the patient to sleep. Besides drugs, there are many hygienic or mechanical measures to which the physician may successfully resort — listening to monot- onous noises, reading dull or hea\^ books, counting, or keeping be- fore the fancy some blank or wearying picture — " A flock of sheep that leisurely pass by One after one ; the sound of rain and bees Murmuring ; the fall of rivers, winds and seas, Smooth fields, white sheets of water, and pure skies. " Mechanical remedies have nearly all for their purpose the withdrawal of the blood from the brain to the skin and abdominal viscera. Hot footbaths or warm general baths, cold douches do^vn the spine, beating the limbs with rubber hammers, brisk exercise, a light meal, massage, all are at times efficient hypnotics. Persons who suffer from insomnia should sleep in cold rooms, the head should not be too high or very low, and in most cases they are better without late suppers, even though these be light. Mental work should be laid aside several hours before retiring, and the evening devoted to quiet conversation and reading or amusements that do not actively excite the nerves. Many persons live in good health though they sleep in the day and stay awake at night. Journalists and editors, whose work obliges them to go to bed in the early morning, often continue for years without impairment of physical vigor. Despite this, it is true that the best time for sleep is at night, and that the old maxim, " Early to bed," is a sound one. Yet it is not the early bird that gets the worm so much as the bird that has slept well. The human system requires a certain amount of sleep and should have it. The industrious and ambitious often try to train themselves to shorter hours, but though they may succeed for a time, nature will not be cheated out of her due and health suffers in the end. It is a widespread custom in some countries to take a short nap in the daytime, and the custom is a good one. America has not adopted it, but might do so with benefit to the health of her brain-working class. jNIany from childhood up do not get a suffi- cient amount of sleep. III. Pekversioxs axd Disturbances of Sleep. — Sleep is said to reach its deepest stage in front one to two hours after it begins. There is then after this a gradual lessening of the depth of sleep. Probably there are great variations in this rule, for many persons seem in soundest slumber several hour:; after falling asleep. But, at any rate, there are lighter stages of sleep at its inception and 576 DISEASES OF THE NERVOUS SYSTEM. toward its end. These are the favorite times for dreams, and at this period also there develop the peculiar phenomena of sleep drunkenness. Dreamsy Nightiiiave. — When sleep is perfect and profound, dreams afterwat'd remembered do not occur. Dreaming is, there- fore, a morbid symptom, although often of trivial significance, es- pecially if it occurs at about the time of natural waking, when slum- ber is, in its physiological course, passing into the lighter stages. In sleep, no matter how light, the action of the regulating centre which directs thought, controls emotion, and exhibits itself in volition is suspended; the psychical mechanism, if excited to action at all, works without purpose, like a rudderless ship at sea. Ideas and emotions succeed each other by the laws of association, but are not properly correlated, and judgment and logical reasoning are gone. As a rule, dreams are made up of somewhat ordinary ideas and fancies incoherently associated, and shifting too rapidly to call up much feeling. When from some point in the body painful sensory excitations do produce disagreeable images, emotions of a most vio- lent kind may be felt. In the earlier stages of civilization, among primitive people, dreams were comparatively rare. When they did come with vivid- ness they were regarded with iniportance, and often were considered visitations of spirits. Civilized man dreams more, but he has learned to treat his fancies with corresponding indifference. The attempts of scientific men to formulate laws regarding them have been pro- ductive of small results. Some diseases, however, cause, as a rule, dreams of a more or less peculiar kind. Thus heart disease is accompanied by dreams of injpending death. Previous to at- tacks of cerebral hemorrhage patients, have dreamed of experienc- ing some frightful calamity or of being cut in two. Intermittent fever is often announced by persistent dreams of a terrifying char- acter. Hammond has collected a large number of what he terms prodromic dreams, all going to show that before recognizable signs of disease are present morbid dreams of various kinds may occur. Albers says: "Frightful dreams are signs of cerebral congestion. Dreams about fire are, in women, a sign of impending hemorrhage. Dreams about blood and red objects are signs of inflammatory con- ditions. Dreams of distorted forms are frequentl}' a sign of abdom- inal obstructions and diseases of the liver." Niglitmare is a disorder incident to the hypohypnotic state, or that of incomplete sleep. It is one of those minor ills that are nearly always symptomatic of an irritation in some part of the body. The usual causes of it are some digestive disturbance (re- PLATE III. NERVOUS DISEASES Dana COMPOSITE PHOTOGRAPH SHOWING RELATIONS OF CRANIAL SURFACE TO THE FISSURES AND CONVOLUTIONS (Aitc Fraser). THE DISORDERS OF SLEEP. Oit pletion) and cardiac disease. Persons of a nervous temperament are more subject to it; and there are individuals whom it makes suifer all their lives. The popular belief that sleeping on the back favors it is, m general, a correct one. When nightmare occurs in cardiac disease a certain position, semirecumbent or on the right side, must be maintained, or the painful fancies will awaken the patient. Healthy people can get sound sleep whether lying upon the back, the side, or the stomach; but light sleepers, and those with sensi- tive abdominal viscera, generally find that the position on the right fiide is the most comfortable and less provocative of unpleasant dreams. Prolonged mental or physical strain, excitement, and worry predispose to nightmare, Farinaceous foods, excessive use of strong liquors, coffee, and tobacco, all have a similar tendency. Xightmare occurs also in anaemia and malaria, and it may, in fine, be excited by morbid conditions in any part of the body. It sometimes occurs about the menstrual period in women. Its most common feature is a sense of suffocation or impending death. Favor nocturnus, or night-terrors, is a sleep disorder peculiar to children. It is allied to nightmare on the one hand and sleep-drunk- enness on the other. It differs from the former condition in that the child continues to suffer from the distressing fancies for some time after he is awake. Kight-terrors occur usually one or two hours after sleep has begun. The child wakes up screaming with fright, and perhaps runs about the room or seeks its parents for protection against some imagined harm. The disorder occurs in weakly, anaemic, nervous, or rheumatic children. It is due some- times to litliaeniia, or, as the older writers put it, rheumatism or gout of the brain. Digestive disturbances, worms, dentition, he- reditary syphilis, mental strain, fright, and excitement are placed among the causes. It sometimes appears to be a paroxysmal neu- rosis allied to epilepsy. The disorder is usually harmless and the prognosis favorable. Soniiiofr/ifiti, or sleep-drunkenness (^ScJiInftrunhcii), is a condi- tion of incomplete sleep in wliicli a part of tlie faculties is abnor- mally excited while tlie other is buried in repose. It is a kind of acted nightmare. The person affected is incoherent, excited, and often viokMit. He experiences the delusion of some impending danger, and while \inder it acts of violence have been committed. Tlie condition is one of medico-legal importance, therefore, and has been discussed by writers on that science (\Vharton and Still^j. Minor degrees of it are often noticed in chihlren and in adults who are roused from a very profound sleep. It at times becomes a haUiU, 37 578 DISEASES OF THE NERVOUS SYSTEM. and a most annoying or dangerous one. The disorder in its severe form is fortunately very rare. The treatment of morbid dreams, nightmare, and pavor noc- turnus must be directed to a removal of the causes. Tonics, cardiac stimulants, laxatives, antirheumatics, attention to diet, are called for according to the condition of the patient. Change in surround- ings is often necessary. Among symptomatic remedies the bromides are the best, except m lithsemia, when alkalies and salicylates may prove more serviceable. In somnolentia the patient should be pre- vented from getting into too profound sleep. He may be awakened once or twice during the night, or take a nap in the da3-time. The head in sleeping should be raised high and the body not too heavily covered. Somnambulism. — Somnambulism is a condition similar to h^^p- notism or the mesmeric state. In it volition is abolished and the mind acts automatically under the dominance of some single idea. It is an acted dream. Sight, hearing, and nearly all the avenues of sense are closed. The sleej)walker avoids obstacles and performs ordinary acts automatically, like an absent-minded man, which in reality he is. All those mechanisms which have been trained by constant repetition to act automatically, like that which preserves equilibrium, are active, and their powers may even be heightened, so that the somnambulist may walk along roofs or on dangerous roads and thread intricate passages without harm. The automatism of the somnambulist may continue for hours, until a journey has been performed or a task completed. He may carry out with success familiar mathematical calculations, write a letter, or work upon a picture, but he only follows along the lines established by constant iteration in his waking moments. He can originate nothing new. He is roused from his state with difficulty, and when out of it he remembers nothing of what has occurred. Somnambulism usually arises from overeating. Sleeping with the head too low is another cause. Violent emotions act indirectly by disturbing digestion. The habit being once established, how- ever, attacks occur without apparent cause. The disorder occurs oftenest in young people about the age of puberty, and it then at- tacks the sexes alike. Later in life women are more often affected. The disease is fostered sometimes at school by the attentions of the schoolmates. In most cases a condition of morbid sensitiveness un- derlies it. The patients are neurotic. Hereditary somnambulism has been observed. Its attacks have alternated with those of cata- lepsy. They are likely, after a time, to become periodical, occur- ring every week, fortnight, or month. The somnambulic state may THE DISORDERS OF SLEEP. 579 come upon a person in the daytime. It is tlien regarded as spon- taneous trance, or hypnotism. It is not the case, however, that persons "svho are easily hypnotized are usually somnambulists, though the reverse may be true. Somnambulism is a term that should include not only sleep walking but sleep talking. The treatment of somnambulism is very much like that for sleep drunkenness. The patient's surroundings must be investigated, and unfavorable influences, such as may occur at school or from injudicious nurses, be removed. He should be prevented from sleeping too soundly, the head should be raised, the clothing light, the diet regulated. Eemedies like iron, quinine, phosphorus, and cod-liver oil may be given. When the patient is discovered in the somnambulistic state he should not be awakened, or at least not until he is safely bar-k in bed. HvpxoTisM, Tkaxck, Mesmerism. — Major lajpnotisvi is a mor- bid mental state artificially produced and characterized by (1) per- version or suspension of consciousness ; (2) abeyance of volition ; (3) a condition of suggestibility leading the patient to yield readily to commands or external sense impressions; and (4) intense concen- tration of the mental faculties upon some idea or feeling. JUliiinr lim^aotlsm is a state closely bordering on normal sleep in which there is a lowering of consciousness and a condition of sug- gestibility. The proportion of persons of all ages found by Beannis to be hyp- notizable was about eightepn or twenty per hundred. Children up to the age of fourteen are very susceptible. After the age of fifty-five susceptibility lessens. Men are almost as easily affected as women; but persons of a docile mind and those trained to some degree of mental discipline and capacity for submission, such as soldiers and artisans, are more sensitive. In this country the percentage of hyp- notizable subjects is less than it is in Europe. Hysterical and in- sane persons are not very susceptible. Those who have been mes- merized once are more easily affected afterward, and may even pass into the state involuntarily. Metliods. — There are two ways of inducing hypnotism, the fixa- tion method and the suggestive method. The former and older plan, devised by Braid, is to make the patient fix his eyes for five to ten minutes on some bright object at a distance of six or eight inches from the eyes and a little above the horizontal plane of vision. A modification of this is the fascination method of Luys, by which the patienu is made to fix his eyes on revolving mirrors. In the " suggestive method" devised by Li^bault and Bernhoim 580 DISEASES OF THE XERVOUS SYSTEM. the subject is placed in a chair in front of the operator. The oper- ator then talks to the subject in a hrm and confident voice, assuring iim that he will go to sleep in a short time, telling him to make no resistance, that his sleeping will be natural, that nothing will be done to worry or fatigue him, that he will dream pleasant dreams, that he will wake up feeling better; then that he is feeling drowsy, his eyes are heavy, objects look confused, the lids are falling, they are closed — in a moment more the patient goes off to sleep. This requires some little time — five to fifteen minutes. It may fail the £rst time and succeed the second. Hypnotic states may be self-induced by rigorously fixing the at- tention upon some object. The ecstatic states of the saints and the nirvana of the Buddhists are forms of hypnotism; so also are the trance states in which some clairvoyants and spiritualistic preachers place themselves ; this same curious phenomenon is at the bottom of the so-called "mind-healing" science, and it enters into rational therapeutics and orthodox religion. The capacity of the human mind for hypnotism or semihypnotic states is, therefore, a most curious and important fact. Sijinptoms of the Major Form. — The person who has been hypno- tized at first sits or lies cjuietly in the position he has assumed during the manipulations of the operator. Ko notable physiological changes occur, as, for example, in the pulse, respiration, temperature, pupils, skin, etc. Some increase in the cerebral blood supi)ly, however, is said to be present. The patient Avill now respond automatically to any outside command or will be dominated by any idea which is suggested to him. He will talk, or walk, or run, or gesticulate, assume ex- pressions of fright, anger, or joy, entirely in accordance with the command given. Apart from these commands he is entirely dead to the outside world. He hears, sees, smells, tastes, and feels nothing. He can be burned, cut, or injured without showing any signs of feeling. At a suggestion he may be made cataleptic, som- nambulic, or paralytic. This state is termed somnamhuUstic trance. If left to himself, he gradually sinks into a deep sleep, from which he can with difficulty be roused. After a time, rarely more than one or two hours, he awakes as from ordinary slumber. This latter state is called trance coma, or letliarrjic hi/pnotism. The attempts of the Charcot school to divide hypnotic phenomena into three forms, the somnambulic, cataleptic, and lethargic, are hardly successful. Sensitive subjects can be thrown at once into lethargy, catalepsy, or somnambulic states at the command of the operator. The phenomena of hypnotism depend upon the wonderful sen- sitiveness and quickness of the subject in responding invoMntarily, THE DISORDERS OF SLEEP. 581 with all his nervous energy, to outside suggestion. Dishonest per- sons may learn the latter trick and thus simulate the hypnotic state. Travelling mesmerizers utilize such persons largely; hence no confi- dence can be placed in the phenomena exhibited by them. Minor hypnotism is produced by the "suggestive method" of hypnotizing. By this latter plan patients are thrown into various degrees of the hypnotic state from slight drowsiness to lethargy, but they are not somnambulic, and do not become cataleptic or anaesthetic. Patients naturally come out of the mesmeric state through the channel of deep sleep or lethargy. Ordinarily they are dehyjj- notized by word of command, or by a pass of the hand, or any impression which the patient expects to be used for the purpose. Hypnotized persons have been observed to have a diminution in tbe spinal reflexes and a muscular hyperexcitability. They some- times show a most extraordinary exaltation of visual, auditory, or other special sense. Patholof/i/. — The underlying changes of the hypnotic condition are unknown and will probably long remain so. Hypnotism is no doubt associated with changes in the vascularity of different parts of the brain and with rapid breaking down of nerve tissue. Ani- mals constantly subjected to hypnotic influence become demented (Harting, INIilne-Edwards). The state of major hypnotism is prob- ably pathological. It is a neurosis. Minor hypnotic states are but slightly removed from the normal, and their production is not injurious. Diiii/nos'is. — As hypnotic states maj'' be imitated and as injuries or crimes may be done in this state, it is very important to be able accurately to distinguish it. Since the phenomena are all subjective this is very difficult. The methods of value are these : 1. Careful examination of the general phenomena by experts while the sub- ject is in the alleged hypnotic state. 2. Testing the muscular hyper- excitability by percussing motor points. 3. Tests of alleged anaes- thesia by sudden burning, or pinching, or injuring the subject. 4. Tests of the tetanic muscular rigidity by the revolving tambour. In the, hypnotic state the hand may be extended and held with per- fect steadiness, while in conscious states a tremor soon appears. 6. Tests with glasses and other apparatus may be made to determine alleged anffisthesire of tlu; sjiecial senses. T/if'i'npeutirs. — The practice of using major hypnotization is in- jurious, tending to exhaust the nervous force and weaken the will. It should be done only with the greatest care. Its utility' in thera- peutics I greatly doubt. It may relieve symptoms in the hysterical 582 DISEASES OF THE NEKVOUS SYSTEM. for a time, but it cannot be of permanent benefit and is likely td lead to actual harm. The induction of minor hypnotic states by suggestion is not harmful if carefully and moderately employed. Its practical re- sults, however, are not great, and the method is tedious, uncertain, and sometimes ridiculous. It has its value in pedagogy, among children, in neurasthenia and in morbid habits. The general popu- larization of hypnotism by means of mind cures. Christian science, etc., accomplishes its results at the expense of mental demoraliza- tion; and faith-healing institutes are pernicious elements in society. Morbid Drowsiness. — This is a very common symptom, which may be due to any one of the following causes: 1. Old age, when there is a weakened heart or diseased arteries, with cerebral mal- nutrition. 2. The diseased vascular conditions which precede cere- bral hemorrhage. 3. The cerebral malnutrition occurring before or during certain forms of insanity. 4. Various toxa3mi8e, e.^., malarial, ursemic, cholsemic, and syphilitic. 5. Dyspepsia and gastric repletion. 6. Diabetes. 7. Obesity. 8. Insolation. 9. Cerebral anaemia. 10. Exhausting diseases. 11. Concussion of the brain. 12. Climatic conditions, cold, etc. A very common cause of drowsiness is dyspepsia attended by some torpidity of the liver, the condition popularly known as " bil- iousness." Another frequent cause is mialarial infection, which perhaps acts indirectly by impairing the functional activity of the liver. Drowsiness from these causes oftenest conies on in the after- noon. Anaemia is attended by drowsiness during the day, while there is often insomnia at night. Syphilis is more likely to cause insomnia, but in its third stags somnolent conditions may be pro- duced which are of serious significance. Drowsiness occurs from the effects of severe cold. It sometimes develops when persons change their surroundings, especially on going to the seashore, for low levels and a high degree of atmospheric pressure seem to pro- mote sleep. The drowsy state that sometimes follows concussion of the brain is a familiar phenomenon. Some persons, no doubt, acquire the habit of drowsiness. At first the trouble may have been induced by indigestion, "biliousness," or malarial infection, but it persists after the cause is removed. Such persons can hardly sit through a lecture, a church service, or any exercise requiring quiet and attention. As the morbid drowsiness here described is only symptomatic, its treatment need not be discussed. Such rem- edies as coca, coffee, tea, atropine, glonoin, do not produce results equal to expectations. Morhklly Beep Sleep. — Certain persons, when they sleep, pass THE DISORDERS OF SLEEP. r,Ro into an almost lethargic slumber. Persons who sleep in this way often sleep a longer time than normal. They are awakened with difficulty, and then suffer with headache or disagreeable sensations throughout the day. The symptom may be a prodromaof insanity. Instances in which persons retire at the usual hour, but can with great difficulty be roused in time for the ordinary duties of the day, are not rare. Some of these are illustrations of the vice of indo- lence, but in other cases there is an absolute need of nine, ten, or even fourteen hoiirs of sleep. This disorder of sleep is most liable to occur in the young and in those of nervous temperament. It often seems to be a congeni- tal condition, for which nothing can be done. In other cases it results from overfeeding and indolent habits. Treatment is much the same as that indicated for sleep-drunkenness and somnam- bulism. Paroxijsmal Sleep, Narcolepsy, Sleep Epilepsy. — It sometimes happens that persons suffer from sudden attacks of unconquerable drowsiness; they fall off into slumber despite every effort of the will. These are more than drowy sensations, for sleep, or a state resembling it, cannot be kept off. Some of these cases are of a purely nervous character, i.e., the trouble is not due to a hmnoral poison or to organic disease, but to a paroxysmal change in the ner- vous centres of a vascular or chemical character, causing sleep. It may be that the patient is epileptic and the sleep seizure takes the place of the ordinary epileptic spasms. Cases of epileptic sleej), or narcolepsy, and allied forms are not of frequent occurrence. Females are rather more often affected than males, and the susceptible age is from fifteen to forty. Tlie disorder is brought on sometimes by fright, overstrain, and humoral poisons acting on a predisposed nervous system. The course is chronic and relief is not always obtained. It should be rfinembercd that syphilis, malaria, or anaemia, and indi- gestion may be elements in the trouble which are important, if not fundamental. Bromides in small doses are often useful factors in treatment. Change of 0(M'upation, of mode of life, or of climate may be essential to a cure. Catahpay, Tniiici', L'tharyy. — Most of the so-called cases of prolonged sleep, lasting for days or weeks, are cases of spontane- ously develo[)«'d mesmeric sleep in liysterical women, or cases of in- cipent insanity (katatonia or stui)orous melancholia). The phe- nomena in these cases may take the form of catalepsy, with waxy rigidity of the liMi])s, or hflinrtjy. In catalej^tic states the limbs may be placed in various positions and will remain there for several 584 DISEASES OF THE NERVOrS SYSTEM. minutes (Fig. 242). In lethargy or trance states the patient raaj be plunged into a deep and prolonged unconsciousness, lasting irom one day to several years. These are the " sleeping girls" of the newspapers. Others are persons of a too ready susceptibility to mesmeric suggestion, who get into a morbid habit of going into mesmeric sleep spontaneously. In these states there may be a low- ering of bodily temperature, slowing of respiratory and heart ac- tion, and excessive sluggishness of the action of the bowels. The patients can hear and may respond to suggestions, but they are ap- parently insensible to painful impressions and do not appear to smell, taste, hear, or see. The eyes are closed and turned upward, and the Fig. 24:i. —a Case of Catalepsy. pupils contracted as in normal sleep. Many variations, however, occur in the physiological phenomena of these states. The duration of the attacks of trance lethargy is from a few hours to ten years. Ordinarily, however, profound trance sleep lasts not more than a few days, Avhile those cases in which the sleep is from mesmeric suggestion lasts but a few hours. The katatonic patients after a few weeks or months gradually awake, become excited, and then pass into a condition of dementia or into catalepsy again. Morbid Sleep fkom Okganic Disease. — Prolonged and ex- cessive sleep occurs as tlie result of syphilis of the brain, brain tu- mors, and the degenerative changes in old age and insanity. Mor- bid somnolence and stupor are not very frequent in cerebral syphilis, but are quite characteristic. The patient in some cases lies or sits all day in a semisoporous state ; in other cases he walks about, but con- tinually sleeps at his task. This state of partial sleep may pass off or end in complete stupor (Wood). It does not necessarily signify a THE DISORDERS OF SLEEP. 585 serious issue, even though it last for weeks. Somnolence or sleep is a rare symptom in cases of cerebral tujnors other than syphilitic. Conditions of drowsiness or stupor have been noted especially in tumors of the basal ganglia and third ventricle. Organic diseases of the brain tend to produce conditions of men- tal Aveakness, hebetude, or comatose states, rather than anything allied to sleep. The Sleepixg - Sickness, Sleeping - Dropsy, Maladie du SoMMEiL. — This is a peculiar disorder, apparently infectious in character, which occurs among the negroes of the western coast of Africa. The disease has been transported to other regions, but is endemic only in Africa. It begins gradually with some headache and malaise. Soon there is felt a drowsiness after meals. This increases until the patient lies for nearly the whole time in a stupor. When awake he is dull and apathetic. There seems to be no fever, and the temperature may even be subnormal ; the pulse, too, is not rapid; the skin is dry, the tongue moist but coated, the bowels are regular. The eyes become congested and prominent. The cervical glands are enlarged. The disease ends in coma and finally death. Recovery rarely occurs. Sometimes the course of the disease is more violent, and toward tlie end tliere are epileptic convulsions and muscular tremors. Autopsies have revealed no definite patho- logical changes. Accidents OF Sleep. — Owing to the fact that sleep is a resting state of the organism, and that many of its functions are lowered, or their cerebral control lessened, peculiar crises, or physiological and pathological disturbances of nervous equilibrium, occur. At- tacks of gout, of asthma, and of pulmonary hemorrhage are most liable to occur during the early morning hours. Deaths and sui- cides occur oftener in the forenoon, but births oftener at night. Epileptic and eclamptic attacks occur a\ ith nnich frequency at night. Involuntary emissions of spermatic fluid, orgasmic crises, and in- continence of urine are among the pathological incidents of sleep. DisouDKHs OK THK rK.EDOKMiTirM. — Suddcn attacks of start- ing of the whole body, shock-like in character, accomjianied by peculiar feeling in the head or occiput, not infrequently attack persons as they are dropping oft' to sleep. They are of slight sig- nificance. CHAPTEK XXTX. CRANIO-CEKEBRAL TOPOGRAPHY. The object of cranio-cerebial topography is to map out upon the scalp the uuderlying fissures, convolutionSj and other parts of the bi ain. As this is for purposes of surgical operations, the mapping is done upon the shaved aseptic scalp with a soft anilin pencil dipped in strong carbolic solution (1 to 4), or with a brush and car- bolized tincture of iodine. The only instruments needed are a steel tape measure and an instrument of nickel-plated soft iron. This consists of a flat strip 25 cm. long and 1 cm. wide. From its middle there branches a second strip 10 cm. long making an angle of G7° with the longer strip. * Practically, the principal points to be de- termined are the position of the longitudinal, Eolandic, Sylvian, and parieto-occipital fissures and the lower outline of the brain. The measurements are based chiefly upon the known relations of certain landmarks on the skull to the parts beneath. These landmarks are the glabella, bregma, lambda, stephanion, asterion, and pterion, which are points at the junction of the various sutures with each other and with certain ridges or protuberances. Their position is shown in the cut (Fig. 240) except that of the glabella or prominence just above the nasofrontal suture. The inion is identical with the occipital protuberance. The following rules are based upon the observations of Heftier, Thane, Reid, Horsley, Fraser, and myself : I. The longitudinal fissure. This corresponds with the naso- occiptal arc. II. The fissure of Rolando. Measure the distance from the glabella to the inion; find 55.7 per cent of this distance, and the figures obtained will indicate the distance of the upper end of the fissure of Rolando from the glabella. It should be about 48 mm. behind the bregma in male adults, 45 mm. in women, 30 to 42 mm. in infants and yoimg children respectively. The fissure runs downward and forward for a distance of about 10 cm. measured on the scalp, the real length being about 8.5 cm. * Special instruments called cyrtometers have been devised by Wilson and Horsley, but are not nficessarv. CRAXIO-CEREBRAL TOPOGRAPHY. 587 The fissure makes an angle of about 67' with the anterior part of the longitudinal fissure. This direction is determined by tlie in- strument above described or by the eyrtometer. The lower third of it is more vertical, and the lower end is 25 to 30 mm. behind the coronal suture. A line from the stephanion to the upper part of the asterion should about pass through it. The fissure is shorter in children. III. The fissure of Sylvius runs nearly horizontally, and lies either under or a little above the uppermost part of the parieto- Sfjuamous suture. This suture, the external orbital process, and the parietal eminence are the guiding landmarks by help of which the Pio. ;i43. — SnowiNa the Position of the Koky Points on thk CRAimTM, thh SUTIMIES, AND THE PRINCIPAL UNDERLYING FiSSURES, ALSO THK BaSAL OUTLLNE OF THK Brain. surgeon can often operate without marking down lines on the scalp. In children the fissure is sometimes higher and more oblique. To outline it, draw a vertical line from the stephanion to the midille of the zygoma. Draw a horizontal line from the external anguhir process to the highest part of the squamous suture; con- tinue this back, gradually curving it up till it reaches the parietal eminence. The junction of the two lines will be at the beginning of the fissure of Sylvius. The vertical hno indicates nearly the po- sition of the ascending or vertical branch of tlie fissure, which is, however, directed a little more forward, and is about 2.5 cm. (1 inch) in length. The posterior part of the line indicates the posi- tion of the posterior brnncli of the fissure. Keiil's method of find- ing the fissure of Sylvius is to " draw a lino from a point 1^ inches 588 DISEASES OF THE NERVOUS SI STEM. behind the external angular process to a j)oint f inch below the parietal eminence. The ascending branch starts from a point f inch back from the anterior end of this line, and 2 inches (5 cm.) back of the external angular process." IV. To outline the parieto-occipital fissure, find the lambda, mark a point 3 mm. anterior to it, draw a line through this at right angles to the longitudinal fissure, extending about 2.5 cm. (1 inch) on each side of the median line. This marks the position of the fissure. If the lambda cannot be felt, its position may be found by measuring the naso-occipital arc and taking 22.8 per cent of it. This indicates the distance of the lambda from the inion or external occipital protuberance. The average distance in male adults is 7.42 cm. {2^ inches). It is greater in women than in men by a little over a millimetre. V. To outline the frontal lobes : The anterior end of the frontal lobes reaches to a point determined by the thickness of the frontal bone. This ranges from 2 to 8 or more mm. (yV to ^ inch). The floor of the anterior fossa reaches in front to a level a little above the supra-orbital margin (16 mm., -J inch — Heftier). It slopes down and backward, its posterior limit being indicated by the lower end of the coronal suture. VI. To outline the temporal lobe and the lower border of the cerebrum : The temporal lobe is limited above by the fissure of Syl- vius, below by the contour line of the lower border of the cerebrum. This latter corresponds to a line drawn from a point slightly (about 12 mm.) above the zygoma and the external auditory meatus to the asterion, and continued on along the superior occipital curve to the inion. The anterior border of the lobe corresponds to the posterior border of the orbital process of the malar bone. The temporal lobe is about 4 cm. (1| inches) wide at the external auditory meatus. A trephine, as Bergmann states, placed half an inch above the meatus would enter the lower part of the lobe. The middle of the lobe is in a vertical line from the posterior border of the mastoid process. A line from the upper end of the fissure of Rolando to the point of the process Avould pass through this impor- tant sensory area (Fig. 243; see also p. 412). VII. To find the position of the central ganglia, viz., corpus striatum and optic thalamus, draw a line from the upper end of the fissure of Rolando to the asterion, practically a vertical line. This limits the optic thalamus posteriorly. A vertical line parallel to ^e first, a little in front of the beginning of the fissure of Sylvius, (imits the corpus striatum anteriorly. A horizontal plane 45 mm. m inches) below the surface of the scalp at the bregma limits CEAXIO-CEREBRAL TOPOGRAPHY. 589 th" gauglia superiorly. The ganglia lie about 35 tnm. (lA inches) below the superior convex surface of the brain (Fere). VIII. To reach the lateral ventricles : A number of routes may be taken. The lateral is recommended by Keen. Mark a point 1\ inches behind the external auditory meatus and 1^ inches above a base line made by drawing a line through the lower border of the orbit and the external auditory meatus. Trephine at this point and plunge the director into the braiu in the direction or a Fig. 244.— tjiiowixG THE Rklative Position (iv tuk Fissures a.\d Coktic.u. Centres of TUE Bralv. point 2.V to 3 inches vertically above the opposite external meatus. The ventricle lies at a depth of 2 to 2} inches (5 to 5.7 cm.). Mr. Alec Fraser has devised a way of mapping out the fissure.-, by means of a series of composite photographs, so taken as to show the relation of the underlying parts to certain tapes tacked uix)n the skull. One of his figures is reproduced here (Plate III.). In applying tliis method the surgeon tacks the tapes on the shaved scalp. Then looking at the diagram, he finds where the point in the brain is that he wishes to reach and notes its relation to tlie median lateral or circumferential tajios. Then as the circum- ference of the illustrated head is to the circumference of the lining one, so is tlic position ttl the area on the tapes in the illustratcil 5^»0 DISEASES OF THE XEKVOUS SYSTEM. head to the desu-ed position of the same area in the living one. The illustration is a composite of several adult heads varying in circumference from 20 ^ to 23^ inches. The tapes are divided into inches and half-inches. The primaiy tape is the circumferential passing horizontally round the vault of the head (on the shaven scalp) from the root of the nose (glabella) to the maximum occipital point, which is about one inch above the iuion. The tape which thus entirely surrounds the head is divided into four equal parts. The points where the division is made aie at the anterior and posterior poles and midway on each lateral half of the tape. From these lateral mid-points a tape is run vertically over the top of the head, and other tapes are run anteriorly and poste- riorly half-way between the point where the transverse tape crosses the sagittal suture and the anterior and posterior poles. Another longitudinal tape is run from the anterior to the posterior pole half* way between the sagittal suture and the circumferential tape. CHAPTEIi XXX. ON NEUKOLOGICAL THERAPEUTICS. It has seemed best to describe, iii a separate chapter, some of the technical details of the treatment of nervous diseases. Hydrotherapy. The APPARATUS needed for applying water in therapeutics con- sists of a room at least sixteen by twenty feet, well ventilated, with waterproof floor and walls. The floor must be made so that it will drain away the water flowing upon it. The room should contain a stationary bathtub, a shower or rain batli, an apparatus for giving hot and cold douches at various jjressures, a hot box in which a patient can take a hot bath with the head ex{)osed, a few foot baths, ice bags and ice caps. The most important point in detail is the douche apparatus, which should be supplied with all the improve- ments for regulating the heat, pressure, and impact of the stream. The stationary bathtub should be of the largest possible size, rather shallow, and i)laced low down so that patients can move their limbs easily anil get exercise while in it. Among the accessories may be a "vaporium," devised by Dr. Percy Wilde for local application of heat or cold. It consists of a double copper cover, made in two sizes, one suitable for a single limb, the other for both ex- tremities, the abdomen, or thorax. Boiling water is poured into the upper part (at 7>), and permitted to escape by two outlet pipes (C) at tlic b(jttoni. This apparatus has bet>n greatly elaborated re- cently, so that temperatures of over 200^ F. are reached and applied locally. Wliile all the foregoing things are needed in an institution and shoidd bo placed in every hosi)ital and asylum, most of the liydro- therapeutic procedures can be carried out fairly well with a stationary tub and a sliower above it. A cheap hot box with a hole in the top and a lump fi)r heating below can be easily added if needed. The common forms of hydrotherapy prescribed by myself are the hot 592 DISEASES OF THE NERVOUS SYSTEM. box and Charcot or Scottish douches, the cold sitz bath, the drip sheet, and wet pack. Special Applications of Hydrotherapy — Epilepsy. — Most patients should be made to take cold showers or sponge baths with a vigorous rub-off daily in the morning. Once a week they should take a hot bath. A cold plunge into a tub full of wat r is a good sub- stitute for the shower. Persons who have neither shower nor tub should get a foot tub and a large sponge. Standing in the tub with a basin of cold water before them, they should fill the sponge ajid let the water trickle over the head, back, and body generally. This is done for two or three minutes, then the patient rubs himself down. The foot tub may have little warm water m it at first. With delicate persons hydrotherapeutic treatment must be begun carefully. The first applications should be dry, warm flannel packs, then wet packs gradually made cold. Finally, cold drip sheets, showers, plunges, and rubbing may be used. A good method for a fairly robust person is that originally de- scribed by Fleury. This consists in giving simultaneously the rain shower and the jet. The patient standing in the shower receives a jet of water on the posterior surface of the body for fifteen seconds ; then the jet alone for fifteen seconds; finally the jet alone on the anterior surface of the body for thirty seconds. In neurasthenia of adult life in men the patient should take the cold shower or plunge daily. In addition to this or in place of it, if needed, I strongly advise the Scottish douche thrice weekly or oftener. This may be preceded by a short hot bath. In neuras- thenia of adolescence the same treatment is often indicated, but it must be applied more carefully, as many patients do not react well at first. They may require wet packs and lukewarm baths as seda- tives for a time. Nervous women almost always do better with a preliminary course of dry and Avet packs, followed later by show- ers and douches. Thus I prescribe first a hot flannel pack for one Half to one hour (see p. 64) ; next day a wet pack, using a hot sheet; next day a cooler sheet, imtil in one or two weeks the pa- tient takes a cold wet pack thrice weekly. If this, however, does not lessen irritability and quiet the patient, I prescribe a hot-air bath followed by a shower or douche. Insomnia. — The lukewarm bath at a temperature of 90" to 96^ F. is often efficacious. It should be taken at night before retiring, and should last from fifteen minutes to three-quarters of an hour. A cold cloth may be laid on the patient's head. A simpler method of inducing sleep is to make the patient thrust the feet into a basin of cold water, 40^ F. to 50" F. The legs are sponged up to the NEUROLOGICAL TIIEKAPEUTICS. o'.'3 knees. This is done fur fifteen or thirty seeonds, then the feet are taken out and briskly rubbed. The most efficacious measure often is the hot wet pack. The pack is taken like a cold pack, only the sheet is "wrung out in hot water. The patient lies upon this, and the sheet and then the blanket are folded about him. The duration is an hour or all night. In the rest-cure treatment a drip sheet is used (see Partial Rest-Cure, p. 605). Headache of a congestive character is helped by cold foot baths or cold douches to the feet; or a bath at GO^ F., which should last ten or twenty minutes and be accompanied by friction to the feet and legs. In anamic headaches the head shoidd be wrapped in thin linen bandages wrung out in very cold water and covered with a few layers of flannel. After they are removed the head is to be rubbed dry and covered with a dry cloth. In liijsterla much the same kind of treatment is indicated as in neurasthenia. When there is much excitement the wet packs are indicated. In most of the major forms a half-bath at GO" with cold affusions, or the shower, with Charcot or Scottish douche, should be given. The ordinary treatment at the ^lontefiore Home consists of: Cold affusions while standing in warm water, or a hot-air bath followed by rain bath for thirty seconds at 85"^, daily reduced imtil 60° is reached, this to be followed by a spray douche for five seconds at C5'^ or jet douche for three seconds at 65° to 55". The douche is reduced gradually to 50" or less, increasing the pressure from two pounds to thirty (Barucli). \Vlien there is spinal irritation the filiform douche may be used as a counter-irritant, or the shower at 65" to 85°. In locomotor ataxvt, different patients get relief from different forms of treatment. The very painful and hyperaesthetic cases are not in my experience much helped by hydrotherapy. One may try, however, lukewarm baths, 85° F. to 95° F., for ten to twenty minutes, with or without pine-needle extract. For leg pains, hot- air baths to the legs alone, followed by affusions at 60° to 70 ', are recommended. The extremities may also be wrapped in flannels wrung out in hot water and covered with dry cloths. Some pa- tients are greatly refreshed and helped by cool affusions, TO" to 80 , poured over the back and legs. In painful cases, relief can be ob- tained sometimes by applying the Charcot douche at a very hi.^h temperature to the back. The temperature at first is 90" F. This is gradually increased to about 160° F. The duration of ttcutment should be only al)out one minute. Sjiermotorrhdd. — Cold sitz baths may be given for from five to twenty minutes, 50' to 70', daily at bedtime. 38 594 DISEASES OF THE NERVOUS SYSTEM. Imp(>t<')icp.—\^\-\(ti cold sitz baths, daily, at 56° to 64°, for from one to five minutes. The psycliropliore, i.e., application to the prostate of cold by a rubber condom or bladder secured over a rectal irrigator an doiihle courant, is sometimes helpful. Incontinence o/ Urine.— In paresis of sphincter or detrusor, brief cold sitz baths, daily, 56° to 64°, one to five minutes, are indif^afed; also cold rain baths (50° to 60°) and douches as general tonics. In spasmus detrusorum vesicae,, on the contrary, prolonged lukewarm sitz baths daily for thirty to sixty minutes, at 70° to 90°, should be given. The Rest Treatment. This form of treatment was devised and perfected by Dr. S. Weir Mitchell and has been popularized by him and his pupils. Its value in many types of neurasthenia and hysteria, especially among women, is unquestioned. It seems more difficult to apply it to men, though it is often useful with them. Among women it answers best in my experience for young women or those this side of middle life, of not very forceful character and not very strong will. The active, keen-witted, intellectual woman who suffers from headache, brain tire, and exhaustion from slight exertion does not do so w^ell under a method which for a time ren- ders the patient entirely abulic. The essential features of the rest cure are : Isolation, diet, rest in bed, massage, electricity, and the energizing personality of a wise physician. Isolation. — The jDatient can rarely be treated successfully at home, even if the relatives are not allowed to see her. The best place is a comfortable room in a boarding-house or private hospital. A private room in a general hospital may ansAver. A special nurse is necessary, and she should be young, neat, careful, sufficiently in- telligent and tactful, but not overeducated or one who feels too keenly her social position. Decayed gentlewomen are sometimes very interesting characters, but they make poor nurses. I am afraid of nurses with an English or Irish accent. She should be a stranger to the patient, rather than one who has nursed the patient in previous illnesses. She should preferably know how to give massage, electricity, and the simpler forms of water treatment. The patient sees only the doctor and a masseuse if the nurse does not know how to give this treatment. The diet should consist as far as possible of milk. During the first two weeks this is especially important. Skim-milk is used NEUROLOGICAL THERAPEUTICS. 595 and it should be perfectly fresh. Four ounces are given at first every two hours. This amount is increased to two or four quarts a day. The milk may be treated in various ways in order to make it more palatable or digestible. The addition of a little salt or lime water, or of tea, coffee, or cocoa, or Vichy water, accomplishes this end. It may be varied with malted milk, dextrinized barley, Xcstle's food, or the milk may be mixed with barley or rice water. Two or four ounces of liquid malt may be given before the mi'k three times a day. At the end of a week a pint of beef tea is added. It is made (Mitchell) by chopping up one pound of raw beef and placing it in a bottle with one pint of water and five drops of strong hydrochloric acid. This mixture stands all night, and in the morn- ing the bottle is set in a pan of water at 110^ F. and kept two hours at about this temperature. Strain through a stout cloth and squeeze the mass till nearly dry. The resulting fluid is given in three por- tions daily. If the taste be objected to, the meat may be roasted a trifle on one side, or the ordinary commercial extracts may be used. It is better at first for the patient to be fed by the nurse. The milk and other food should be taken slowly. Rest. — It is extremely important that the patient be made to go to bed and lie flat on her back, not even sitting up to be fed. The object is not only to secure absolute rest, but to make the patient feel that she is in the hands of her physician, Avho is to manage her till she is well. The enforced quiet also adds to the desire later to to get well and regain her freedom. She is to be kept in bed for a month; then allowed to sit up for ten minutes twice a day, this time being lengthened by five or ten minutes daily. After five or six weeks she may be allowed a driv6 or a short walk. About this time one must also begin systematically to enforce walking and other exercise, and the ])atient must be taught to ignore the slight pain and fatigue that at first ensue. Miissdijc. — The system of massage recommended by Mitchell is simpler than that ordinarily used by the Sw-edish professionals, and consists jnainly of kneading and centripetal friction. It is given at least an liour after a meal and lasts at first fifteen or twenty min- utes once a day. In a few days this is increased to three-quarters of an hour and an hour. The legs are wassed first, then the abdomen, chest, and arms. The head and neck are not touched. No ointment or lubricating substance is used. Particular attention is paid to the abdomen in order to prevent constipation. After massage there should be a rest of an hoin-. After four or ci'^ht weeks Swedish movements are added to the massage. Elect t'h'ltij. — The faradic current is used with a primary coil 596 DISEASES OF THE NERVOUS SYSTEM. and a slow interrupter. In very sensitive persons a long secondary coil with fine interruptions is better. Electrodes of the " normal" size are employed and each segment of the limbs is gone over, be- ginning with the periphery. The two electrodes are placed over the muscles a few inches apart and each muscle is contracted four or six times. The question of poles may be ignored. The feet, legs, abdomen, back, and arms are gone over successively, then the fine secondary current is turned on. A large electrode, of the " indiffer- ent" size, is placed on the back of the neck, and the other electrode placed on the sole of one foot; a current is passed for seven and a half minutes ; then the electrode is shifted to the other foot and the current given for the same time. It is best for tlie physician him- self to give the electricity if possible. The duration of each seance is from three-quarters to one hour, and it is continued for six weeks. Very mild currents are used at first. The duration of the rest-cure should never be less than a month. It is usually about six or eight weeks. A typical schedule for a rest-cure patient as given by Dr. John K. Mitchell is the following: 7 A.M. — Cocoa. Cool sponge bath with rough rub and toilet for the day. 8 A.M. — Milk, breakfast. Rest an hour after. 10 A.M. — 8 oz. peptonized milk. 11 A.M. — Massage. 12 M. — Milk or soup. Reading aloud by nurse 1:30 P.M. — Dinner. Rest an hour. 3:30 P.M. — 8 oz. peptonized milk. 4 P.M. — Electricity. 6 P.M. — Supper with milk. 8 P.M. — Reading aloud by nurse one-half hour. 9 P.M. — Light rubbing by nurse with dri]) sheet. 8 oz. malt extract with meals, tonic after meals. 8 oz. peptonized milk with biscuit at bedtime and a glass of milk during the night if desired. Laxative: cascara, 10 to 30 drops p. r. n. Later Swedish move- ments are added to the massage. Additional Pleasures. — A sponge bath is given every morning. Insomnia is to be feared at the start, and for this bromide of sodium may be given in doses of gr. xxx. at 6 and 9 p.m. and gradually decreased grain by grain; or sulphonal (gr. xx. to xxx.) in hot NEUROLOGICAL THERAPEUTICS. 597 t\'ater, or trional (gr. xv.). Some form of hydrotherapy may an- swer better than di-iigs, and a favorite measure is the drip sheei,. The following are the directions for its use (Mitchell): Basin of water at 65" F. Lower the temperature day by day 3y degrees to 55° F., or to still less. Put iu the basin a sheet, let- ting the corners hang out to be taken hold of. The patient stands n one garment in comfortably hot water. Have ready a large soft XDwel and iced water. Dip the towel in this, wring it, and put it ;urban-wise about the head and back of the neck. Take off uight- Iress. Standing in front of patient, the basin and sheet behind, he maid seizes the wet sheet by two corners and thi-ows it around the patient, who holds it at the neck. A rough, smart, rapid rub from the outside applies the sheet everywhere. This takes but two minutes or less. Drop the sheet, let the patient lie down on a [ounge upon a blanket, Avrap her in it, dry thoroughly and roughly with, coarse towels placed at hand. "Wrap in a dry blanket. Re- oaove ice wrap; dry hair; put on nightdress. Bed, the feet covered svith a flannel wrap. As tonics, lactate, pyrophosphate, or subcarbonate of iron are jiven in doses of gr. xxx. daily. Small doses of strychnine, salicin Dr quinine, or dilute phosphoric acid may be useful. The partial rest-cure is indicated in the milder cases of neuras- :henia and hysteria. The following is the schedule given by Dr. WeiT Mitchell : A.M. — On awaking, cup of cocoa. Take bath. (Temperature jiven.) Lie down on lounge while using drying-towels ; or, better, DO sponged and dried by an attendant. In this process the surface ;o be rubbed red, or, if drying one's self, to use flesh brush. Bed )r lounge again. Breakfast. Before each meal take three ounces 3f malt extract; aperient at need in malt. Tonic after each meal. Detail as to breakfast diet. If eyes are g<»od, may then read seated n bed. At 10 to 11 a.m., one hour's massage. Rest one hour; nay be read to, or read if eyes are good, or knit. At this time, 11 I.M., four ounces of beef soup or eight oiuices of milk. At noou nay rise, dress slowly, resting once or twice a few minutes while Iressing, and remain up until 3 p.m. See children, attend to house- lold business; see one visitor, if desirable. From 1 to 1 :30 I'.m. nalt, etc., and lunch. Detail as to diet. At first, as a rule, let ;his meal represent dinner. Tonic, and after it to rest on a lounge, occupied as above, reading or being read to. If possible, drive )ut or use tramway, so as to get air. Walk as little as possible. In retuin from drive repeat milk or soup. About 5 p.m., electric- ity, if used at all. Rest until 7 p.m. Supper at 7 p.m. Detail as 598 DISEASES OF THE NERVOUS SYSTEM. to meal. Malt as before, with or without ai^evient, as occasion demands. Tonic. To spend evening with family as usual. Best not to use eyes at night for near view. Bed at 10 p.m. No letters to be written for two months, when most of these details have to be revised. After two months of massage it should, in these cases, as in complete rest, be used on alternate days, and by degrees given up. If the nurse or masseuse is able to teach the patient the use of Swedish movements, it is desirable that these or some definite slowly increased system of chamber gymnastics be continued for months. Finally, walking must be resumed with slow and system- -atic increase. After the second month write out a schedule of less restriction, to be followed for six months. The JSxercise Treatment of Locomotor Ataxia. — The treatment •of locomotor ataxia by means of systematic exercises for training the ataxic limbs often produces some very satisfactory results. The method was elaborated first by Dr. Frankel, and still further by Dr. Hirschberg. For the convenience of students and readers, a schedule of the exercises which I prescribe, and which are based, more or less, upon those of the authors mentioned, is appended here. The exercises are usually to be taken twice a day, and each exercise is to be done with the utmost care and precision by the patient. Exercises jar the Hands and Arms. — 1. Sit in front of a table, p'ace the hand upon it, then elevate each finger as far as possible. Then, raising the hand slightly, extend and then flex each finger and thumb as far as possible. Do this first with the right and then with the left. Eepeat once. 2. "With the hand extended on the table, abduct the thumb and then each finger separately, as far as possible. Eepeat three times. 3. Touch with the end of the thumb each finger tip separately Rid exactly. Then touch the middle of each phalanx of each of »jie four fingers with the tip of the thumb. Repeat three times. 4. Place the hand in the position of piano playing and elevate the thumb and fingers in succession, bringing them down again, as in striking the notes of the piano. Do this twenty times with the right hand, and same with the left. 6. Sit at a table with a large sheet of paper and pencil, make four dots in the four corners of the paper and one in the centre. Draw lines from corner dots to centre dot with right hand; same with left. 6. Draw another set of lines parallel to the first, with the right hand; same with left. 7. Throw ten pennies upon the paper, pick them up and place them in a single pile with the right hand; then with the left; repeat twice. NEUROLOGICAL THERAPEUTICS. 599 8. Spread the pennies about on the table, touch each one slowly and exactly with the forefinger of right hand ; then with forefinger of left. 9. Place an ordinary solitaire board on the table, with the mar- bles in the groove around the holes. Put the marbles in their places with right hand; same with left hand. Patient may, with advan- tage, practise the game for the purpose of steadying his hands. 10. Take ordinary fox-and-geese board with holes and pegs, and, beginning at one corner, place the pegs in the holes, one after the t,*her, using first the right hand, then the left. These exercises should be gone through with twice a day, and should be done slowly and carefully, with a conscious effort every time of trying to do one's best. Exercises for the Body and Lower Limbs. — 1. Sit in a chair, rise slowly to erect position, without help from cane or arms of chair. Sit down slowly in the same way. Repeat once. 2. Stand with cane, feet together, advance left foot and return it. Same with right. Repeat three times. 3. Walk ten steps with cane, slowly. Walk backward five steps wnth cane, slowly. 4. Stand without cane, feet a little spread, hands on hips. In this position flex the knees, and stoop slowly down as far as pos- siblCj rise slowly; repeat twice. 6. Stand erect, oai-i-y left foot behind, and bring it back to its place ; the same with the right. Repeat three times. 6. Walk twenty steps, as in exercise No. 3; then walk back- ward five steps. 7. Repeat exercise No. 2, without cane. 8. Stand without cane, heels together, hands on hips. Stand in this way until you can count twenty. Increase the duration eacli day by five, until you can stand in this way while one hun- dred is being counted. 9. Stand without cane, feet spread apart; raise the arms up from the sides until they meet above the head. Repeat this three times. With the arms raised above the head, carry them forward and downward, bending with the body until the tips of the fingers come as near the floor as they can be safely carried. 10. Stand without cane, feet spread apart, hands on hips; flex the trunk forward, then to the left, then backward, then to the right, making a circle with the head. Repeat this three times. 11. ])o exercise No. 9 with heels together. 12. Do exercise No. 10 with heels together. I'.i. Walk along a fixed line, such as a seam on the carpet, with cane, phicing the feet carefully on the line each time. Walk a dis- tance of at least fifteen feet. Repeat this twice. 14. Do the same without cane. 15. Stand erect with cane; describe a circle on the floor with t I.e toe of right foot. Same with toe of left. Repeat twice. Between the fifth and sixth exercises the patient should rest for •a few moments. GOO DISEASES OF THE NERVOUS SYSTEM. Lumbar Puxcture of the Spinal Cord Paracentesis of the spinal dura mater has been recommended by Quincke and Ziemssen for the treatment of meningitis with serous effusion. The relief ob- tained is usually but temporary, but the measure may be of help in diagnosis. I have tried it in a few cases with negative results, but have found that the operation is not difficult or dangerous if care- fully done. Quincke's directions concerning the operation should be followed — that is, the patient should lie on his left side with his lumbar spine flexed well forward; the needle is cautiously inserted to a depth of 5 cm. between the arches of the third and fourth or fourth and fifth lumbar vertebrae near the spinous processes. PART I[. DISEASES OF THE MIND. CHAPTER I. DEFINITIONS, CLASSIFICATION, GENERAL ETIOLOGY, GENERAL PATHOLOGY. Defixitioxs. — Insanity, medically speaking, is a serious alter- ation in the psychical functions of the brain. This leads to such departure from the normal in speech and conduct that the patient can no longer adapt himself efficiently to his environment. Insanity, legally speaking, is a condition of mental unsoundness and irresi)onsihiIity, by reason of which a person is unable to under- stand the nature of his act, or to pass a fairly rational judgment on its consequences to himself and others, and is not a free agent as far as the act is concerned. Thus the "mental unsoundness " of the law is not the same as insanity, since a person suffering for ex- ample from melancholia may be technically and Jiiedically insane, yet still be able to answer the legal test. Idio('!/y Irii/ji'ci/lti/, and fcclilc-niiiKh-diicss are different degrees of defective mental development. Idiocy is the most serious defect and feeble-mindedness the least. The exact line of demarcation is an arbitrary one. J)of>in/nt'ss is sometimes for practical purposes distinguished from insanity; it is the physiological dementia of extreme old age. Its distinction from senile dementia is an arbitrary one. Cl.vssifk^vtiox. — Mental disordeis are divided into two great groups : the major psydioses or insanities, and the minor psychoses, or psycho-neuroses. The major jisychoses include all those disor- deis which are commonly and technically regarded as insanities; tlmse in which the disorder of ihe mind is such tliat tlie i)atient lacks responsibility and capacity to care for himself. The minor psychoses include all those disorders of the mind which are not insanities, in the strict nu-aning of the term, and in which tli( patient practically is still a responsible person. These neuropsy- 602 DISEASES OF THE MIND. choses include a large part of what has been known as neurasthenia, hysteria, and the majority of a group of disorders known as neuras- thenic insanities or phrenasthenia, also many mild forms of melan- cholia, dementia, and abortive types of the major psychoses. The distinction between the major and minor psychoses is not an absolute one, and one type may be grafted upon another. Nevertheless it is of practical importance to establish the general distinction, and especially for patients to understand that a person maybe in a morbid mental condition and yet not be insane, or liable to the development of any insanity. The principal types of insanities are : A. The Functional Insanities. — 1. Dementia praecox (precocious dementia), a veiy general term which includes all the different forms of early dementias, viz. : Simple precocious dementia. The excited form — hebephrenia. The stuporous form — katatonia. The delusional form — dementia jiaranoides. 2. Paranoia. 3. Phrenasthenia, sometimes called neurasthenic insanity, or degenerative insanity. 4. Manic-depressive insanity, including the: Mania-melancholia type. Sim])le melancholia type. ]\Ielancholia of involution or chronic melancholia. 5. Toxic, exhaustion, and infectious insanities (confusional psychoses). H. The Organic Insanities. — Paralytic dementia (general par- esis) ; Epileptic dementia ; Senile dementia; Insanity from gross brain lesions, such as tumors, hemorrhages, and injuries. C. Organic Defect of Development. — Idiocy, imbecility. Besides these terms we have names to indicate symptom groups or psychical syndromes : Delirium; Maniacal excitement ; Dementia ; Confusional states; Cerebral automatism, etc. Various symptom-groups occur with hysteria, epilepsy, chorea, senility, the puerperium and the climacteric, but they do not justify ETIOLOGY. 603 forming special groups of insanities, except for purposes of conven- ience in description.* Etiology. — Sex. — Insanity occurs with about the same fre- quency' in male and female, -with a slight preponderance in favor of tlie male. Age. — It occurs most frequentl}' between the ages of thirty and forty (twenty-eight per cent), next between twenty and thirty. It is rare in childhood (five per cent under twenty) and old age (four per cent between seventy and eighty). Before twenty it occurs oftenest in the eighteenth or nineteenth year. Civilization. — Insanity is much more frequent in civilized coun- tries, ranging in frequency from one in three hundred to one in five hundred of the population. It is now slowly increasing relatively to the population, but it is most probable that this increase will be- fore long cease and the tide set in the other way through the influ- ences of a better knowledge of hoAv to live. Congenital Conditions. — The existence of a nervously unstable or neuropathic constitution is the most important of the factors that predispose to insanity. Many people have this constitution and live their lives sanely. Nevertheless, it probably always exists in those who develop functional insanities, and in many who suffer from the organic forms. This predisposition shows itself by an easy ex- haustibility of the brain, by an intemperate and excited manner of using the mind, indicating a lack of inhibition; also by its over- * Among the iusane received from April, 1903, to April, 1904, at the psy- chopatliic wards of Bellevue Hospital the distribution of types was as follows; the mania and melancholia representing various types of manic, depressive, simple, and involutional melancholia: Male. Female. Total. ]Maniii 131 57 34 60 64 201 33 94 206 179 9 20 223 136 38 86 36 36 47 99 184 203 4 14 354 Melancholia 193 Primarv and confusional 72 Paniiioia 146 Idiocy and imbecility 100 Gencnil j)aresis 237 Terminal dementia Organic and senile 79 193 Toxic 890 Dementia praecox 882 Delirium 13 Insane epilepsy 34 Total 2,193 604 DISEASES OF THE MIND. reaction to fevers, drugs, and intoxicants, by its sensitiveness to disturbances of metabolism, such as result in excess of uric acid and its allies, by a lack of social feelings, excessive self-consciousness and egoism, self-inspection, desultoriness of purpose, and abnormal sexual life, moral defects, and excessive emotionalism. Some differences in these characteristics are found according as the patient tends to develop periodical melancholia, precocious de- mentia, paranoia, or phrenasthenia. Heredity. — h.\ about twenty-live per cent of tlie insane a dis- tinct history of insanity or of some serious neurosis is found in the antecedents. This represents the influence of direct heredity. But this does not indicate the real fact as to hereditary and congenital influences. In the vast majority of persons who become insane the brain is congenitally defective or lackhig in power resistance. The original endowment of the patient mentally and cerebrally is the most important single factor in the causation of his insanity. Alcohol. — The abuse or even more than simply temperate use of alcohol is an extremely important factor in leading to degeneracy, and in producing a brain susceptible to insanity. The use of alco- hol is especially important as an indirect factor in leading to the production of weakly and neuropathic offspring, and also as a direct cause of insanity through overuse. The excessive use of alcohol often does more psychic harm to the descendants than to the indi- vidual himself. About ten per cent of cases are directly due to alcohol. Si/phUls. — Syphilis is less potent as a hereditary factor, but as a cause of paresis, which now makes up ten per cent of the insani- ties, it ranks among the important producers of mental disease. Climate. — Insanity occurs with nearly equal frequency in warm and cold climates, the civilization being about the same; rather more cases occur in summer than in winter, but insanity is little in- fluenced by the weather and not at all by the moon. Race. — There is no very great difference in insanity among the different races, except in so far as they are subject to different con- ditions of living. Certain races have more insanity because they have been subjected to more trying conditions of life. Even savage and backward races, if put under civilized conditions, develop in- sanity ; thus the negro when he gets in urban communities shows his full proportion. Education. — Education as a whole is a beneficent influence in lessening insanity ; just as are wealth and social prosperity. But both education and wealth can be made the means of developing psychoses and degenerative constitutions. GENERAL PATHOLOGY, 605 XJrhnn Life. — There is rather more insanity in urban than in rural populations, and tliere would be still more if the cities did not draw the good blood of the country to itself. Urban life, certainly of itself, is more productive of insanity than rural life. Occupation. — Certain callings furnish relatively more insane than others. Among the educated classes it is no doubt artistic pursuits, including the dramatic. Among the mechanic and artisan class it is railroad men and engineers, workers in the dangerous industries, such as lead, aniline dyes, and mercury. According to Berkley the lower the social stratum the greater the i)ercentage of psyclioses. According to Hill tlie professional class is relatively most sus- ce))tible, and farmers, including farmers' wives, are among the least. The direct and aecessonj causes of insanity are nmny. They are syphilis, alcohol, narcotic drugs, severe mental strain, depressing emotions, shocks, trauma, operations, severe infectious sicknesses, autotoxaemias, and certain organic diseast^s of the l)rain. General Patholo(;v. — Tlie insanities fall into two principal groups: the one of functional and developmental origin, the other of organic origin ; but these groups shade into each other. The two types are represented by a developmental insanity, like paranoia, and by an organic insanity, like general ])aresis. The developmental insanities liave no known anatomical base. Such lesions as are found are secondary. Tliere is, however, something wrong or de- fective in tlie arrangement and make-up of the brain neurones, or of their vascular and lymph supply. In some cases, like the non-de- menting insanities, such as phrenasthenia, or paranoia, the trouble is iierha]is an absence or misitlacenient of certain association tracts, so that normal responses and inhibitions do not come from the ordi- nary stinnili. In other cases the neurone is short-lived, or, to use the word coined by Gowers, there is an "abiotrophy." Certain neurone groups become i)rematurely senescent and die at the age of twf'iitv-Hvc instfud of seventy years. This ('(dulition underlies the ]irec()C'ious dementias. Again, the troulile may be in defects of vascular supply or in the lymph channels. As a result the brain neurones are not nourished siitticiently, or the i)roducts of tissue wa.ste clog the lymphatics and the cells become ))oisoned, just as occurs in the later toxic in- sanities. Still further, the insane may have defective excreting organs. Tlie ])roducts of digestion are imperfectly neutralized by the liver or carried off by the ahsoibents, or the kidney may not excrete fr«'ely the products of tissue waste. There are certain glands of the body, 606 DISEASES OF THE MIND. like the thyroid, and perhaps the adrenals, which may act a part even in inciting the developmental insanities. But, after all, it is the too easy exhaustibility of the neurones which seems to be the most serious trouble. Whether this be due to the intrinsic weakness of the cell or of the vascular and lymphatic systems is not known. The anatomical changes of the organic and specifically toxic insanities will be described later. CHAPTER II. GENERAL PSYCHOLOGY. For a sound knowledge of neurology one must know anatomy ; but for a sound understanding of mental disorders we must know, and, as far as possible, agree upon i)sychology and psychological terms. Neurology is based on a knowledge of structure and the significance of its changes ; but psychiatry is almost purely a clinical science, and its acquirement depends on an understanding of symp- toms. The symptoms being due to a perversion of the normal ac- tivities of the mind, it follows that a knowledge of the normal is necessary. A great deal of confusion in description and classifica- tion has resulted from the difference among writers in their stand- point toward psychology. Hence I make no excuse for giving some account of the elementary facts of this science. The works, espe- cially of James, Baldwin, Marshall, Stout, Scripture, Calkins, and Cattell, are to be credited here. In the physiology of tlie nervous system we find three groups of l)henomena: those connected with the sensory and other ingoing impulses to the nerve centres; those connected with the motor and other outgoing impulses from the nerve centres to tlie different mus- cles, viscera, and glands; and the reflex and other intermediate and associative functions, wliicli result in combining tlie first and the second. Ill y^ijcholnyij we have to deal with the phenomena which belong to the third group, that is to say, those of recording, associating, and coordinating the attVrent and efferent impulses. The work of the mind lies between the sensation started by an ingoing impulse and the motion produced l)y an outgoing impiiLse. .\11 that goes on, for example, between a visual stimulus ami the resulting voluntary act belongs to jjsycliology. Such visual stimulus gives to us a conscious sensation which is elaborated into a pt'if;ei)t, and further into an idea. It leads to associations which arouse desire, and result in ])urp()seful acts. The difference between the instantaneous reaction or "jump" of a marble as it is dropped on a stone and the vo- litional reaction of the brain to a sensation when a marble is dropped on the hand, is accomplished because of the infinitely more complex processes possible to occur between the receipt of a stimulus by the 608 DISEASES OF THE MIND. sensory nerve and the coordinated movement of the hand which follows. Some of the phenomena of the mind are grouped especially about the ingoing, some about tlie outgoing, and some about the intermediate processes. Thus we have on the ingoing side sensation and perception. In the associative and coordinating sphere : ideation, judgment, memory, association of thought, feeling, sentiment, and emotion. On the outgoing side : instinctive acts, automatic acts, and voli- tional acts. Associated with all these phenomena is co/isciousness. Consciousness is the name given to that quality of the mental state through which a person becomes aware of himself as one dis- tinguished from the rest of the world. It is the distinctive charac- teristic of mental life. This conscious state, or state of " aware- ness," constantly changes, and each state represents but a moment of time. It accompanies all our volitional acts, but there is a large amount of mental activity that goes on unconsciously. Sensations are simple conscious states aroused by the excitation of a sense organ or other afferent stimulus. Pure sensations from the outside world are rarely experienced, because they are at once grouped with other mental and previously recorded impressions into percepts. When sensations are referred to an external object they are called special ; when referred to the body they are called gen- eral. Ferceptlon. — On seeing or feeling an object we instantly asso- ciate the sensation with previously recorded impressions. In doing this we perform th-e act of perceiving, and the result is called a percept. Thus we see a round, yellow object, and immediately associate it with previous experiences, which tell us that it is rather rough to touch and of peculiar odor and taste, and we perceive that it is an orange. Thus the process of perception is the grouping of a sensation with previously recorded impressions, the result being that we recognize a particular object which in perception is always Ift'fore ns in space. An idea is the reproduction, with a more or less adequate image, of an object that is not present to the senses. A percept, on the other hand, or ^perception, as tlie term is sometimes used, is a rep- resentation in the mind of an object that is present before us in space. We perceive the orange ; we have an idea of what an orange is. In the building up of an idea we group together or associate our various sensory and perceptive experiences until we finally get this special notion or idea, which comes to our mind without having GENERAL PSYCHOLOGY. 609 le object itself before us. The term " apperception " is used by jiiie, but its meaning is generally a vague one to most minds, and i is not a term needed in the descriptions of morbid psychology. A concept is an abstract or univei'sal idea, recognized apart from [ly special or particular qualities ; the word is used with various leanings, however. By associating various ideas together in a certain regular way > that there comes from them something new, we reach a judgment, id this process of associating ideas to an effective end is called masoning. Reasoning then is a process which leads to some new ict and differs from a casual association of ideas, such as occurs I re very or in tlie ordinary play of association by suggestion, as hen a gray horse suggests the presence of a red-haired girl, or hen the smell of gas suggests a leak in the jjipe. Sometimes in le association of ideas in speech we proceed from one inference to lother, or one thing is suggested by another, until we reach a point I the discussion which may be simply the climax of a stor^-, or the cposition of a point of view, or description of some past event, rhen the associations thus lead to some definite point or idea, we )eak of it as the "goal idea," and in most rational speech or de- :ription tliere is tliis goal idea. Judgments are conclusions readied y' the processes of association. These may be elaborate and con- ;ious, or simple and very largely subconscious processes. Tlius any conclusions and opinions develop in the mind almost uncon- liously or througli sliglit suggestion. Memory and Orientation. — The activities of tlie mind are de- indent on the power it possesses to retain and revive impressions; lat is to say, its power to remember and recollect. Tliis faculty : the psycliic cells is called memory. It means that all stinuili ■nt to the brain make some kind of impression on the central nerve ssue, which impression can be revived at future times by other iggestions and stimuli. This jjrocess of record and revival is a )rm of association, and memory revival means the reestablishing : an association (Marshall). Memory forms ])art in most conscious 5ychic life. Tlie mind cannot work without its constant help, lougli the memory may be good, and yet the mind works badly, he feeling of identity or personality is dependent on memory, [emory is usually divided into the power of learning or memoriz- ig and the ])ower of reviving or recollecting. The knowledge of our relation to the external world, our ai)])re- ation of time and space — in other words, our anise of orientation — dependent on the memory. T/ie J/isfinct.'<. — Those things which wi' do, say, or feel auttimati- 610 DISEASES OF THE MIND. cally as the result of inherited liabits and experiences are said tc be instinctive. Man does comparatively few purely inherited in- stinctive acts. As an infant the instinct for food leads to emotional expression and coordinated efforts. There is an instinctive love oi life and fear of danger which control us to an extent ; the family affections and sexual feelings are largely spontaneous and instinc- tive ; the feelings of right and wrong seem also to he largely in- herited, and conduct is controlled more by instinctive feeling than h^ conscious ethical motives. The feeling for beauty is often instinc- tive. In most of these cases the instinctive feeling is automatic, but the feeling and conduct resulting are modified often by train- ing and experience or by other artificial motives. We may divide the instinctive feelings into the somatic, i.e.. those i^ertaining to the body, such as love of life, fear of deatli. sexual and hunger instincts; the ethical, those pertaining to con- duct and the family and social duties; the aesthetic, those whicl] relate to appreciation of beauty in nature and art. In the insane there is often a disturbance in all these spheres. The patient loses his sense of what is right, loses his love of ])ar- ents and child and wife ; he cares no more for what is beautiful auc is no longer repelled by what is ugly or base. When the sense oi what is right is lost the patient lies, steals, is cruel, and perhaps has no family affection; he is then said to suffer from a moral inr becility. A certain degree of this is present in constitutional crimi- nals ; but the most decided forms are found in certain children whc seem born moral monsters. Acquired insanities seldom do more than dull or extinguish in part the instincts. Feeling or affect is not a separate function of the mind, but is £ quality of the different mental states ; that is to say, every menta state is accompanied by some kind of feeling, either pleasurabh or painful, or has some quality that can be regarded as *'affec five." It may not necessarily be distinctly disagreeable, but ma^ pertain to some subjective sensation, like hunger or thirst, or som« simple desire of action. In all cases feeling only qualifies or give! a certain character to the mental state. Emotion is that distinctive feeling which is aroused by som( definite cause and leads to some expression of its existence. Th( sentime7its are the higher types of emotion connected with som( ideal object, like duty, ambition, beauty. Emotion includes feeling or affect and something more. A person may have a simple pleas arable feeling. It becomes more than this when the sight of a lon^ absent friend arouses keenness of joy and acts expressive of this state. GENERAL PSYCHOLOGY. OH The volition or will is teohuically the conscious realization of the Wrongest and therefore deciding feeling. It is usually accompanied )y a motor act, although a person after consideration may reach a lonclusion and not act on it until later. The process of volition Qay comprehend both the formation of a definite judgment or )reference and the expression of it in action. We see an ai)i)le and , stone. The idea after comparison comes to us that the apple is Qore desirable than the stone. The desire for the apple and the ntellectual and emotional i)reference for it over the stone sets to srork tlie impulse to take it, and a volitional act is performed. The volition function is not therefore simply or only voluntary .ction, but includes the whole conscious process that led to this act. n this process we are made to feel that we have a power within us- hat can reach any of several judgments and lead us to any one of everal choices. This leads us to believe we have a free will and .re res])onsible for our acts ; and society holds men responsible on he basis of tliis view. We accept it as long as we feel that there is he ordinarily free play of association and inhibition, so that the iecision or choice comes about without any artificial or abnormal iiterference. When an act is done without conscious preference or desire, or II response to an impulse coming upon one from subconsciousness, t is an involuntary or impulsive act. Acts which are the expres- ion and result of habit and wliich are done without our having any iiemorable consciousness of them are called automatic. Many acts ,re brought about by imitation and suggestion, and these art' oftea lone with so little conscious volition that they belong almost to iu- voluntary or complicated reflex actions. CHAPTER III. GENERAL SYMPTOMS AND SYMPTOM GROUPS. The functions of the mind, as described in the foregoing chap- ""ter, undergo morbid alteration in the psychoses. These alterations form the symptoms of insanity. Various technical terms are given to these symptoms. Disorders of Perception. — An illusion is a disorder of sensa- "tion and perception in which the object is perceived as something else than what it is. Thus a feather blown along the floor is taker for a mouse; a chair is mistaken for a person, or a noise is inter- preted as a spoken word. An hallucination is a disorder of sensation and perception, iu "which something is perceived which is not really present. Thus a person thinks he sees a person standing before him, or that an animal is in the room, or that there are insects crawling on th€ wall or coming through the ceiling, or he hears a noise or smells a smell when neither exists. This perception, however, does not lead him to believe that these tilings are real. He sees a man befort him or hears a voice, but he knows there is no man or actual voice. Illusions and hallucinations may, and often do, run into delu- sions ; thus the moment a person who has an hallucination that lit sees a person in front of him believes that such a person really is there, the hallucination becomes a delusion. Illusions and halluci- nations are usually disorders of the perception of hearing or sight, and are aural or visual. There may, however, be hallucinations oJ smell, taste, and of conditions pertaining to the skin, or muscles, oi viscera. A characteristic of hallucinations and illusions is that the^? are extremely vivid and impressive to the patient. Disorders of Judgment. — A delusion is a condition in whicli the i)atient has a false belief or judgment incompatible with abeliei which he should have held, considering his education and social surroundings. Delusions are divided into two types, the systematized and the unsystematized. In the systematized delusion the patient has onlj one or a few delusions which he logically works out from his false premises. In unsystematized delusions, the patient has a varietj^ GENERAL SYMPTOMS AND SYMPTOM GROUPS, 013 of delusions which have no relation to each other, and which are fleeting, foolish, and incoherent. Delusions are indicative of a deep- seated disturbance of the mind, involving, as a rule, not only the processes of thought and association, but those of sensation aud those of feeling. They receive many names, in accordance with their character. Sometimes they centre about the person, and are connected with grandiose ideas of the person's importance. They are then called expansive delusions. Sometimes they are connected with feelings of great depression and ideas of having done some harmful act, or having somj distressing disease, and they are then known as depressive or hypochondriacal delusions. Very often they are associated with ideas of persecution, and are then called perse- cutory delusions. Disorders of Ideation- axd Associatiox of Thought. — Ideas in healthy minds occur in response to normal suggestions and suc- ceed each other in more or less orderly sequence. When this se- quence fails we get a confusion of thought. Where the process of association is weakened ideas come slowly, comprehension is imper- fect, response is difficult and belated. This is called a "retardation of thought," and it occurs in dementia and in states of mental ex- haustion and melancholia. When ideas succeed each otlier very rapidly and without much or any natuial sequence, the condition is called a " fliglit of ideas," a condition characteristic of maniacal excitement. When there is an extraordinary activity, as well as confusion in ideas and trains of thought, so much indeed that no train of thouglit really seems to complete itself and no idea is clearly real- izeil in consciousness, the state is one of delirium. In otlier words, delirium is a confused and more intense maniacal excitement. In both conditions there is a general emotional and motor excitement. Maniacal excitement must not be (ionfused with "acute mania," whicli is not a symptom, l)ut a special form of mental disease. The special disturbances of ideation and association then are: Dt'lusion, confusion, retardation of thought, difficulty of thouglit, fliglit of ideas, maniacal excitement and delirium, these being iisso- ciated as are all the other symptoms, to a less extent, with emotional disturbance. DlSMKKKKS OK OltrKNTATION AND M K.Mi »|; V. — f)isi>rlfllt(itli»l is a condition in wliich the capacity to realize ourselves and our where- abouts is defective. It occurs in the clouding of consciousness, in dementia, and in other forms of mental disturbance. When there is loss of orientation of the person, we may have disorders of per* sonality. 614 DISEASES OF THE MIND. Weakness of memorij is shown both in inability to learn new things and in an inability to retain tilings which have already been learned. A great loss of memory is termed nmnesht, while a con- dition in which real memories and inventions are mixed up is called jjaraninesia. There is also a condition of memory in whicli the patient seems quite unable to recall things in the least correctly ; his memory experiences are all more or less fabrications. There is a particular form of memory disorder in Avhich the pa- tient is, to an extreme degree, unable to retain or remember, for even a moment, things presented to him. For example, he sees a friend, and a moment later forgets that lie lias seen him before that day; or he is told it is Friday, and a moment later thinks it is Monday.' This may be called a loss of attention- memory. DisTURBAxcEs OF FEELING appear very frequently and under- lie a large number of the psychoses. Wlien the affective state is pleasurably active, there is usually associated with it a correspond- ing activity in the processes of thought, and we get with exagger- ated feelings of pleasure or self-complacency some motor excite- ment. This condition of a morbid pleasurable state is sometimes spoken of as " euphoria" or " exaltation" ; if very intense as " mania. '' When the affective state is depressed so that there is a feeling of conscious suffering, the condition is known as depression or melan- cholia. The emotional condition may be simply diminished in in- tensity, so that the patient no longer feels any interest in life or in himself; his capacity both for enjoyment and for sorrow are totally lost, and there is simply emotional negation or apathy. This is often seen in exhausted conditions. The emotional state is also disturbed by specific feelings of de- pression, such as fear and anxiety. It may show a childish and a silly kind of humor, or be raised to a state of morbid intensity, in the condition known as eestasy. It may be associated with delu- sions, and we then have "expansive delusions" or "delusional melancholy " ; or it may be associated with agitation or stuporous States. Thus there occur in disorders of feeling: Apathy ; Melancholia, morbid fears, etc. ; Melancholia with stupor; Melancholia with agitation ; Euphoric and expansive states; Maniacal exaltation ; Ecstasy. general symptoms axd symptom grotps, 615 Disorders of Yolitioxal Function", or Power of Reacttox. — When a person loses the power of choice or initiative it is known as ahoidia, or paralysis of the will. Wlien the volitional activity is exaggerated so that patients continually want to be doing things, it expresses itself often in what is known commonly as " nervousness " ; or, if more exagge- rated still, in the motor excitement shown in an intoxication. When this volitional excitement is still greater so tliat patients are continually talking, planning, and doing all kinds of aimless things, or when this finally amounts to a maniacal state, in which they talk excessively, laugh and dance about, the patient is said to be under a "pressure activity." This " pressure activity " is seen not only in mania, where there is a certain kind of purposefulness, but in states in which the " pressure activity " is purposeless, the patient going through all kinds of grimaces and contortions and making senseless noises. Without actual loss of power of volition the patient may have simply a weakness of will, and with this there is often a condition of morbid suggestibility, so that the patient is easily led to do whatever is proposed to him — a condition known as suggestihilifi/. Sometimes there is a morbid persistence of an impulse that has once been started, leading the patient to posture in different ways, or to go through certain movements over and over again. This is called sterentypif. Stereotypy is shown in two ways : by a ])erson taking a certain attitude and staying there for a long time, or by going through certain regular movements, such as for hours walking up and down the room over the same course, rapping on the table, hopping and jumping, or exhibiting a certain amount of mannerism, sucli as walking with a peculiar gait, dragging one foot, or going in straight lines or circles. Frequently with the condition known as stereotypy there is an- other condition known as nrt/ufirisni. In negativism the patients tend to do just the o])i)osite from tliat which they are recpiested to do, no matter how simple or reasonable that recjuest may be. It is the ultimate insane expression of foolish and unreasoning ol)stinacy, not a resistance really due to an intellectual delusion or fear, though delusions do exist. J'rrfn'f/i'nifioii is the continual repe- tition of senseless words and phrases, and is a condition akin to 8tereotyj)y. DisfrartnltUiti/. —.Vltention is ]>art of the volitional function, and is tlie ))ower by which we are alih' to tix the mind upon given subjects. When the attention is easily distui'bed it is called a distractability, and when it is lost there is a c(»ndition of abso- (;16 DISEASES OF THE MIND. lute incapacity to fix the attention on a single process, which has received the name of aprosexia. Obsession (besetment) is a morbid mental state due to the action of an imperative idea or feeling which persistently assails and vexes the mind. This imperative or insistent idea is thrust into the mind and cannot by any process of reasoning be got rid of. The terms " obsession " and " fixed idea " are often used somewhat interchangeably. Strictly speaking, however, in obsession an idea is imposed upon one's consciousness despite the will; thus a mother becomes harassed, and even terrified, with the idea that she will kill her child, or that she may suddenly do him some harm. A fixed idea, on the other hand, is one, strictly speaking, that is legitimate and natural, and perhaps has grown out of certain rea- sonable conditions ; it becomes fixed and dominant, and it modifies the reasoning of the patient. It is of the nature of a delusion, is in fact an abortive delusion. Thus a person has an idea that he is going to have an attack of a certain illness, and there are some symptoms which justify this fear, but the idea is entirely out of proportion, in force and dominance, to the cause; or a person may have an idea of vengeance, which to a certain extent is justifiable, but which is intense and overwhelming and cannot be put out of consciousness. The term fixed idea or obsession is also applied in a rather popular way to persons who nurse and exploit certain fan- tastic views, or allow a perhaps sane idea entirely to dominate their thoughts and activities in morbid disproportion to its importance. Obsession leads to those conditions known as inorbid fears and doubts, and sometimes to morbid sensory states and impulsive acts. Obsession and fixed ideas are on the borderland of delusional con- ditions (abortive paranoia). A conijndsion is a condition in which there suddenly is forced upon the mind a desire to do a certain act, which act the patient does not want to perform but is, nevertheless, with difficulty i)re- vented from carrying out. The compulsion is accompanied by feel- ings of anxiety and attempts at resistance. Thus a patient, when shaving himself, is suddenly seized with a feeling that he must cut himself. Compulsive acts result when, as sometimes happens, the resistance is no longer possible. An imjjulshe act is one in which tlie patient does a certain act from an overwhelming impulse, wliicli he is (Conscious of, but is not able to restrain or fight against. The impulses which lead a person to these impulsive acts are known as "morbid impulses," and they are at the basis of such con- ditions as kleptomania, pyromania, dipsomania. They sometimes GENERAL SYMPTOMS AND SYMPTOM GROUPS. G17 underlie homicidal, suicidal, and perverted sexual acts. On the other hand, they may be very trivial impulses, such as to touch every lamppost, or always to put the left foot first in going out of a door. When these impulses are shown in a violent gesticulation, ejaculating inopportune words, they are calli-d j/sj/fjiic tics. DisoKDEKS OF CoxsciousxESs. — When consciousness is normal we have what is termed "clearness of consciousness." When it is lost we have imronsciousness ; and when it is imperfect the state is one of "clouding of consciousness." This is the condition in which a person becomes who is confused by excessive fatigue, by illness, or by drugs, or when he is passing into a condition of sleep or stupor. It is believed that in early childhood and in idiots, even normal consciousness is somewhat clouded. "When consciousness becomes very much dulled we have states of sUipor or lethargy; and, finally, when consciousness is lost we have states of voma^ soinnolencf, sijncope, and sh-i'p. When coordinated and apparently purposeful acts are done without the i)atient remembering them, we have states of cirehral automatism, or doulih' consclojisness. In states of excitement and ecstasy there is an abnormal intens- ity of consciousness. There are ])erversions of subconscious mental activity in many morbid mental states that have to do with the development of mor- bid impulses, obsessive ideas, and abnormal acts. SvMi'ToM (troii's. — There occur various clinical symptoms, grouped togetlier and forming what are called syndi'omes. They are seen in various forms of insanity, but do not of themselves con- stitute s[)ecial diseases. Such symptom groups an* dementia, which is a condition of general mental enfeeblement, usually ])rogressive; euphoria, wlii(;h is a state of abnormal ])leasurable feeling; melan- cholia, wliich rei)resents a symptom group, but is also the name given to a special disease. Delirium and maniacal excitement are also syndromes observed in tlie course of many of tlu' pS3-choses. Dkmkmm is a clinical term, used to express a morbid mental con- dition, cliaracterized by great mental and motor excitement, with confusion of ideas, and a rapid succession of incoherent and delu- sional ideas, usually associated with hallucinations. 'I'lie state is often ct)mplicate(l witli a febrile condition and g»'nerally ends in exhaustion. Delirium, in its very highest and nu)st intense degree, is known sometimes as "acute" delirium or "grave" delirium, and tliis form has sometinu's been de.S(*ribed as a separate disease. In t]i(> writer's o{)inion, however, it is only a symptom usu.illy of some severe infectious or toxsemic process. Anotlier sevci-e form of delirium is known ;is ilrlinnm trrtnniSy €18 DISEASES OF THE MIND. and is practically always observed as the result of the excessive use of alcohol. Delirium tremens itself, however, is usually not the direct effect of alcohol, but the result of an auto-toxsemic state, which has been brought on by starvation and alcoholic indulgence. When the delirium is less severe and marked, when the motor excitement is slight, and the mental processes are more confused and slow, it is known as a "low delirium," and this is tlie kind usually seen associated Avith infectious fevers and certain toxic and exhausted conditions. In epilepsy there sometimes occurs a somewhat mild form of delirium, which is called the "anxious delirium," while after ex- hausting exertions or severe operations, or hemorrhages, there is sometimes a "collapse delirium." The essence of all the delirious states is a great psychomotor excitement, accompanied by incoherence and confusion ; and the distinguishing point between acute delirium and acute maniacal excitement is, that in the latter there is a certain coherence of ideas, and more or less power of orientation and appreciation of surround- ings, and a certain completeness to the different delusions and ideas that arise in the mind of the patient. The clinical picture of a case of delirium is familiar to all prac- tising pliysicians. The condition generally begins rather suddenly, and the patient exhibits a wildness of action and demeanor that at once alarms those about him. He is restless and throws himself about, attempts to strike and destroy things, is altogether unappre- ciative of his surroundings, or of any of the ordinary restraints or decencies of life, and has to be promptly restrained in bed. Sleep is impossible and food is generally refused. The patient often has hallucinations of hearing or sight, and is unable to answer coherently tlie simplest questions, often responding to them with attacks of violence. Tlie condition goes on, if unrestrained, for several days, when exhaustion and perhaps collapse ensue; it is often accompanied by a rise of temperature, great sweating and congestion of the face, overaction of the heart, and neglect of the natural functions. Acute maniacal excitement is often termed simply " acute mania" or "peracute mania." Technically, however, the term " acute mania " applies to a special disease, running a course of a number of weeks or months, and marked by psychomotor excitement. Acute maniacal excitement is a condition in which the patient sliows many of the symptoms of delirium, but, as already stated, has less confusion of the mind, greater orientation, and capacity for control. The bodily excitement may 1)6 nearly as great, but it is less contin- GENERAL SYMPTOMS AND SYMPTOM GROUPS. 619 uous, and appears more spasmodically. The patient may for a time be fairly quiet and then burst out again into excitement and violence. Acute maniacal excitement is often somewhat difficult to distinguish from delirium, and the two states may mingle. It is seen in connection with the onset of paresis, of dementia prcpcor, or of manic-depressive insanity. Maniacal excitement, liowever, also occurs in the toxic psychoses, as in alcoholism and in other forms of confusional insanity in its early stages, Thk Physical Symptoms ok Insanity. These are shown in modifications of structure and of function. The modifications of structure include anatomical stigmata of de- generation and structural defects. The anatomical stigmata of degeneration usually include all con- genital defects, but many of these are simply '' marks," which indi- cate a badly put together body, and they do not interfere with nor- mal function. Thus a peculiarly shaped skull, high, narrow palate, badly set ears and teeth, and scarcity or abundance of hair, etc., are oftener found in the psychopathic than in the normal, but they do not interfere with function. On the other hand, the insane have anomalies of the cerebral arteries and of the circulatory system generally, which do interfere with normal function. It will be found that in this class as a whole also there are often defects in the kidney, liver, and glandular organs. The special anatomical stigmata of degeneration have already been described under the head of Nervous Diseases. Abnormal variations of the cephalic index are frequent among the insane. Hyperbrachycephalio skulls of 00 to 9.3, ami hypodolichocephalic skulls, with indices of 72 to 70 are often observeil (Berkeley). Microcephalic and deformed skulls are, however, mostly seen in the idi(it-iml)ecile class. Anomalies in the arteries of the base of th(^ brain an' particularly frequent in the insane. Excessive liairi- ness of th«' skin is common, but most oftt'ii appears after the psy- chosis has developed. The disorders of function include a lessened cutaneous sensibil- ity, liefects in sight and hearing, often imperfect intestinal diges- tion. Ileiirt disease and arterial sclerosis are common. The blood antl urine are often modified, but anjemia and nephritis are usually secondary conditions. Disorders of secretion are shown by ptyalism, and excessive or deficient perspiration. Tlie more characteristic physical symptoms of insanity are those shown in attitude ami expression. Examples of these are : tooth- 620 DISEASES OF THE MIND. grinding, facial grimaces and other tics, agitated movements^ anx- ious, apprehensive expression, apathetic and lifeless movements, with hanging of the head, katatonic states and strange attitudes, senseless resistance to requests or negativism, peculiar repetition of certain movements, or stereotypy ; increased brilliancy and mo- bility of the eyes in mania; ocular parallelism in melancholia j muttering, senseless laughter, and verbigeration. The Stoky ok the Max with the Pulypathk: Bkain. A/i IJlustration nf tlic I)('ri'Ioj)i)}t;nt of Mental Sijiiiptoiiis. A man, thirty-eight years of age, who had been a rather heavy drinker, suffered from a severe attack of grip. While recovering he became one evening nervous and excited. He saw tlie figures of the wall paper on his room take the shape of grinning im})S (an illusion). At times these imps seemed to leave tlie wall and dance about on his bed (a visual hallucination), sometimes sticking needles into his fingers (dermal hallucination). He thought these tilings were deceptions of his senses, but he became nervous and alarmed. He could not sleep, and assured his nurse that certain persons were sending these imps to torture or injure him (a delusion). He would stare, thrust his hands at the imaginary objects, and finally insisted on going to another room to avoid them (delusion of persecution). The next day he Avas better, but toward night be became still more excited over these same hallucinations and delusions. He began to talk rai)idly and loudly, making active movements, getting out of bed, and walking into the next room in search of hidden enemies, detectives, or police. He poured forth a succession of exclamatory sentences, with dramatic gestures, each having some idea and ex- pression of some emotion, but unrelated, and all showing a rapid flow of desultory thoughts, excited emotion, and disordered percep- tion (flight of ideas, maniacal excitement, pressure activity of the mind). His state of mind was at times exalted and his ideas were at times grandiose, and at times defiant and aggressive. He Avould answer questions with a snapping quickness of retort, sometimes wittily, sometimes insultingly, but passing at once to another topic (incoherence of ideas). Still later this maniacal state became more active, and the patient was so violent that he had to be confined in bed, where his expressions were even more incoherent, showing feel- ings of rage, expostulation, or fear due to his hallucinations and de- lusions. His ideas became finally confused to the last degree, and he did not recognize those about him or know where he was (disori- entation). He was, in fine, in a state of acute delirium. Two days later he had quieted down and his talk became more infrequent and his voice low. He muttered to himself incoherently and some times would be silent. He answered questions irrationally, or made GENERAL SYMPTOMS AXD SYMPTOM GROUPS. 621 only the sini])lest responses. He showed no knowledge of where he was, and paid little attention to external stimuli (clouding of con- sciousness and "low" delirium). Finally lie passed into a quiet state from which lie could hardly be aroused ; and if aroused would soon relapse (stupor). On coming out of this condition some days later his mind was dull, his responses to questions were slow (retar- dation of thought), Ills emotions persistently and unreasonably de- pressed. As the disease continued he remained dull and apathetic, showed little ai)])rehension of his surroundings, took his food mechanically, and would sit all day in his chair it allowed to do so. He would sometimes make curious gestures with his hands, or strike a gro- tesque attitude, and walk up and down in a certain fixed and regular way (stereotyi)y), and repeat silly jihrases over and over again (ver- bigeration). After some days of this state he gradually lapsed into a lethargy. On tiying to make liim open his eyes he resisted ; in trying to make him sit or stand or move liis limbs he resisted. Even requests made to put out his tongue were refused (negativism). A few days later his body became cataleptic and showed a waxy rigidity (katatonia). He now gradually inqnoved, and began to show some degree of general intelligence, with few or no delusions. When his mind cleared so that he was able to go out and go about, he was still list- less, apathetic, and depressed; he did not know what he wanted, could not decide as to his food or where he wished to go, or what he would like to do (aboulia). With this condition there grew a morbid apprehension of going out in the ojien air, of meeting crowds, and lie became extremely frightened at thunder or whenever a severe storm occurred. He showed an especial fear of open places, and when on the street would keep close to the walls of the houses, occasionally running into a store to quiet his alarm, for which he could give no good rea- son (morbid fear of jjlaces and of lightning). He was extremely fin- ical about his clothes, would change them four or five times a day, wondering what shirt, or socks, or .shoes he should wear, watching them for dirt, or even for some possible contagion. His dressing would occiqiy an hour or more, and his (dothes had to be arranged in a ])ecnliar fashion (doubting mania). He was taken at times with a sudden fear that he might at any time rusli at jK'ojtle and injure them, and when crossing the wat»'r on a ferryboat he would sit in the ('.ii\nn overwhelmed with a fear that he might rush to the rail and jumj) overboard (obsession ). He hail all the time a fixed idea that he was unlike other people, and that lie had .S(»me noticeable peculiarity of i»hysiogiK)my and character that he could not get away from. The.se symptoms having lasteil some months, he became rational, but showed weakness of memory (amnesia), a feeble power of atten- tion and concentration. He could net conduct his business or com- prehend ordinary problems. He was emotional and childish in Clouding sciousness Delirium. Stupor. Retardatic Tbuujrht. Melanchol Stereotypj Verbigeral Negatlvlsn Katatoniu. Aboulia. Morbid Fe Doubting Mania. Obsession. .Amnesia. 622 DISEASES OF THE MIND. conduct, neglectful of his person, and gradually sank into de- mentia. Tlie foregoing illustration is not that of a possible case, for though one person can have two or more psychoses, he can hardly have all. It is rather a composite of the mental symptoms that occur in the functional psychoses. CHAPTER IV. METHODS OF EXAMINATION AND DIAGNOSIS. Ix the examination of a patient it is best, so far as possible, to follow some fixed line, though this is often not possible, and in some cases even is not necessary. In an ordinary examination the things that are chiefly investigated are the following: The general physiognomy, attitude, and speech of the patient, which often, without much further investigation, tell the story. Thus the expression of drunken exaltation in mania, the profound dejection of melancholia, the sunken head and stupor in katatonia, the speech and tremors in paresis, and the dull and careless physi- ognomy of dementia, often at once reveal the diagnosis. The orientation of the jiatient; that is to say, the discovery of how much he is aware of his present situation, surroundings, and condition. In determining this a series of questions is usually asked regarding his past history and how he came to his present place, what symptoms he is suffering from, and what his ideas and wishes for the j-resent and future are. The existence of any delusional ideas, or any hallucinations or illusions. These points are often brought out in connection Avith questions regarding his orientation. A determination in general of liis degree of intelligence, and of his memory and judgment. His emotional condition, as to whether he is excited or de- I)re8sed, and what tiie can.ses for that condition are. An investigation into any organic or physiological disturbances. Almost all of these points can be gained by acquiring the confi- dence of tilt! patient, and getting him in various direct or indirect ways to t(dl the story of his life and present illness. If a more complete analysis of symptoms is required, a j)articular investi- gation is made alonjj^ the points just mentioned and certain otiiers. The paiticular points of such further investigation are these: First. Orientation, by whicli we determine wluit insight he Jias into his own condition, the clearness or "clouding of consciousness,'' the notion of his jiersonality, whether it has heeu changed or d()ul)led, and in general the idea ot his relations to the external world of time and space. 624 DISEASES OF THE MIND. Second. Troubles of perception, including an investigation into the existence of illusions and hallucinations and their type, whether visual, auditory, olfactory, gustatory, dermal, visceral, and motor. Third. Troubles of association, including the study of his mem- ory, of his reasoning powers and judgment, and of the existence of delusions and their character. Under this general head also we inquire into the existence of fixed ideas, obsessions, the power of attention, incoherence, and flight of ideas. Fourth. The disturbances of emotions, by which we determine the existence of indifferent, apathetic, or melancholic states, of morbidly euphoric states, of maniacal excitement, delirium, and also of the existence of morbid fears, apprehensions, impulses, pas- sions, and instincts. Fifth. The disturbances of volition, the presence or absence of aboulia, or loss of will power, of morbid automatic reaction, shown in the increased degree of suggestibility, of impulsions, catalepsy, stereotypy, and negativism. Sixth. Finally there will be the disturbances of consciousness, shown in abnormal ecstatic states, in clouding of consciousness, in weakness of the notion of personality, and of the transformation and doubling of personality. The examination and recognition of a case of insanity in the majority of cases are very simple and easy; in the minority of cases they are somewhat difficult, and in a few cases almost impossible in one examination. In the ordinarily difficult cases it will usually take about an hour to make out some distinct evidence of an abnormal mental state, for few of the insane can feign their condition so cun- ningly that some suggestion of it will not sooner or later creep out. Certain types of monomanias and of melancholia with mutism often are the most difficult to detect. It is practically a well-known fact that suggestions about religion, hypnotism, electricity, wireless telegraphy, or some idea of persecution, will often bring out the de- lusion. In the diagnosis of insanity naturally a good deal of help is to be obtained from the facts furnished as to the antecedent his- tory, and sometimes it is only by positive assurance as to the validity of these facts that a conclusion can be reached. Some help can be gained at times by a knowledge of the way in which the malady has developed. There are certain forms of insanity which practically never develop suddenly without any previous suggestion of the trouble beforehand. The physical examination of the patient will give some confirmatory evidence as to the existence of a psychosis ; thus the carelessness of appearance, the unusual growth of hair, the mutilations of the person, may all be of some help. In some de- METHODS OF EXAMIXATIOX A XI) DIAGN'OSIS. 625 mentias the evidence thus furnished is quite positive. It is only in general paresis, however, that the physical signs enable one to speak early and with absolute positiveness regarding the condition. After the existence in a patient of the fact of insanity is made out, the diagnosis of the particular type is to be considered. The recognition of the special type is helped by a knowledge of the prevalent insanities at given periods of life. At the period of adolescence (fifteen to twenty-tive) we meet chiefly functional insanities dependent on constitutionai and de- velopmental defects: 1. These are dementia praecox in its sinijde, hebephrenic, katatonic, or paranoid forms. 2. Manic-depressive insanity, chiefly in a simple melancholic or maniacal form (recurrent melancholia, recurrent mania, circular insanity). 3. Phrenasthenic or degenerative insanities. At tlie time of maturity and active life (twenty-five to forty-five) : 1. All forms of insanity, but especially paranoia. 2. General paresis and other organic insanities. 3. Toxic, infectious, and ex- haustion ty})es. At and after the climacteric : 1. C'lironic melanoliolia. of invo- lution, agitated, and hypochondriacal and (pierulent melancholias. 2. Senile insanities. 40 CHAPTER V. GENERAL PROGNOSIS AND TREATMENT. Insanity is sumetiines the result of a morbid condition inherent in the structure and function of the individual. In this case the disorder is irregularly chronic and has no very definite course. It is improved or cured only as the individual, by conserving and strengthening his constitution, manages to overcome the degenera- idve taint. Such insanities are jjaranoia and phrenasthenia. In other cases there is superimposed on a slightly or seriously degenerative constitution a serious strain, a toxaemia, or a disordered metabolism. Here the malady runs a certain more or less definite course, like a fever, ending in permanent or temporary cure. Such insanities are manic melancholia, confusional psychoses, and demen- tia })rtecox. In other cases tliere is distinct organic disease of the brain as in paresis and senile dementia. Here the course is fairly definite. Any general statement regarding prognosis is of little value since the outlook varies immensely with the type of psychosis. It is estimated that about one-half the insane get well (about one- quarter ])ernianently well), and about one-half die sooner or later in the attack. Death occurs in about six per cent, and the average age at death is about fifty- six (Hill, Pilgrim). The general treatment of the major psychoses has to be almost entirely institutional. This is not because an insane patient cannot be as Avell or better treated under private auspices, as because to do this latter requires a great deal of care and expense, much beyond the reach of most. The general opinion as to the best methods at the present time of caring for the insane is that there should be first of all in the cities and larger towns either psychopathic hospitals and dispensaries or psychopathic wards in the hospitals. In these small hospitals and special wards the acutely insane should be re- ceived, and if amenable to treatment there, retained until they are cured. If they turn out to be cases that are likely to be of long duration, they are transferred to a s( ^ond class of institutions, the State hospitals, or to some private hospital. Here proper provision for the care of cases likely to run a rather long course is made, and GENERAL PROGNOSIS AXD TREATMENT. 627 patients, the duration of whose disease is one or two or three years, ire cared for. When it has been determined that a certain malady LS absolutely incurable, the patient is transferred to a colony or hos- pital for chronic cases, where he can live an outdoor life and where means are provided for his comfort and for the utilization of such physical and mental powers as he still possesses. It IS to be hoped that in time convalescent hospitals or annexes ivill be established to complete the scheme. While it is true tliat the majority of cases of insanity are better treated in institutions than at home, this is not always the case, md not rarely patients who have only minor deviations from the lormal are better when kept in constant association with normal minds. There is as yet no speciftc medical treatment for most of the psychoses. Drugs may alleviate symptoms and possibly shorten somewhat the duration of the disease, but nearly all drug medica- tion is symptoniatic. If there is any drug which has a specific effect it is opium and its derivatives. Antitoxic medication is often used in certain confusional psy- 3hoses, and of recent years the antitoxic character of some of the functional psychoses has led to the liope that we may yet find help in medication. At present the surest antitoxic agents are the pur- gatives which unload the liver and clear out the bowel. Mineral foods, like iron and the phosphates, rank next in importance. Baths, electricity, and massage have only symptomatic value. Institutional treatment, with its auxiliaries of outdoor life and diversion, are the mainstay in the treatment. Sea-batliing, garden ind farm work are especiall}' helpful. I have often seen patients, when near their convalescence, bene- fited by taking them away from the surroundings of a psychopathic ward or hospital. The environment of the patient's family is usu- ally bad ; but to surround one insane person with many sane is some- times a very wise procedure. CHAPTER VI. THE MINOR PSYCHOSES AND PSYCHO-NEUROSES. Phrenasthexia, Hypochoxukiasis, Hysteria, Psycho- Neuroses. As already stated, the minor psychoses are not as a rule insanities in the common sense of the word, and it seems advisable to use for them some distinguishing term. Psycho-neurosis is a word which may be employed for this purpose. It includes those many cases of neurasthenia which really have essentially a psychical basis, and whicli are often mild or abortive types of simple melancholia, hypo- chondriacal melancholia and prodromal stages, sometimes aborted, of dementia prsecox or paranoia. It includes some of the traumatic and shock psycho-neuroses, and also a group of cases variously called borderland psychoses, constitutional psychopathies, neuras- thenic psychoses, and "degenerative insanity." These terms in- clude the conditions characterized by morbid impulses and fears, doul)ting manias, impulsive acts, obsessions, kleptomanias, dipso- manias, and many forms of perversion of the sexual instinct. Tliey are all dependent on a minor defect of mental stability, one that is quite compatible with sanity and responsibility. They are chronic and not dementing in tendency. The word phrenas- thenia may be used for this grouj). The Greek, fpr^v, is much more properly applied to the mind and its diseases than the 4'^7Jn which is more associated with "life," "spirit," and "soul." PIIRENASTIIEXLV. (Degenerative Insanity; Neukasthenic Insanity; Impulsive and Compulsive Insanity; Borderland Cases; Original Psychopathic Conditions.) Phrenasthenia is a chronic, non-dementing psychosis, character- ized by the occurrence of imperative ideas, by compulsive and im- pulsive acts, by morbid fears and conditions of agitating doubt. The main characteristic of phrenasthenia is a defect in the inhibi- tion, by reason of which association of ideas and the natural elabo- ration of thought and impulse to action are no longer under con- trol. The constitution which is affected by this disorder is similar to that which underlies hysteria, and with the impulsions to drink, TUE MINOR PSYCHOSES. 629 to take drugs, and to special manias, like kleptomania. In its mild form it is little more than a peculiar incapacity for self-control, and is often associated with simple neurasthenic and hysterical symp- toms. In its more severe types it approaches to the condition of systematized delusion, and it is called by some "abortive paranoia." In other eases the element of anxiety and distress is so great that there is with it a certain amount of melancholia. The phrenas- thenic syndrome, or symptom-complex, of impulsions and compul- sions, fears and doubts, fits itself ordinarily most perfectly upon a certain peculiar inherited constitution ; but this same syndrome may be seen in connection with the other psychoses or acquired degen- erative states. It may form a part of paresis for a time or ot para- noia, of senility, or even of true melancholia. Etiology. — The most frequent etiological factor is heredity; nearly one-half of my cases gave a liistory of direct or indirect men- tal disorder in the ancestry. In one case the father was a tabetic at the time of the birth of the cliild; in two cases the father had paresis. Alcoholism in the ancestry is present, but not so promi- nently as in other psychoses. The disease occurs in males and females about equally. Symptoms of the trouble may be shown in children as young as eight or nine years; more than half the cases, however, develop between the ages of Hf teen and twenty-iive ; nearly one-fourth of the cases between the ages of twenty-five and thirty, while one-eighth of the cases develop between the ages of ten and fifteen. A few cases occurred between the ages of thirty-five and forty, and it is seen again with some frequency at the time of the climacteric. The earlier the ca.se develops the more severe, as a rule, are the symptoms liable to become. Among the most frequent exciting causes may be mentioned some kind of shock by fall or accident; next after this is alcoholic excess. Among ut\wv causes I have noted infectious fevers, an attack of chorea, a stroke of lightning, car sickness, over-education, uterine prolapse, and ovariotomy. Si/iii/>foi/is. — The symj)toms develop in four different types, though these are often intermingled, and, in most cases at least-, three of the characteristic gioups of symptoms are more or less present.* * The condition of oliscssivc iitid li\tiiig mania. Obsession, Fixi-d Itha ; (J/m'ssicr I'/irriiiisf/ir)n') nmnic-depressive insanity or manic melancholia. These are all closely allied types, so much so that the term " manic-depressive i)sychosis " might also be used to include all three. '^ In non-asylum jn-actice the majority of cases observed are acute uiil c]ironi(! melancholias. In asylum practice acute mania or manic iiitdancholia, alternating or mixed, are nearly as often seen. For the general practitioner it seems well to bear this fact in mind, for lie will see and treat twenty cases of acute or chronic melancholia to one of acute mania or manic melancholia. It seems unwise to Li.se the term '' manic-dei)ressive insanity" for a large group of [•ases which never show any signs of mania, and I i)refer " acute melancholia" and "acute numia " when cases are such, and the term "manic-depressive insanity" only when there is really a com- * .My «xiicri<'ii((' is thai tlitii' arc many aciiic inclaiiclinlias arisiiit,' in mid lie and less often in early Ufe wliioli alway.s reniain nitlaiKliolia. and <'itlier LMid in pcinianent recovery or (inally take the form of chronic involutional melanI)rings into activity or violence. The mind is alert, orientation and iiemory are good, and the patient delights in what he tliinlcs are smart replies or turbulent comments. The judgment is profoundly lisordered and the mind is full of unstable and expansive delusions; nit hallucinations are rare. There is an ai)pearance of enplioria, ;ogether uilli great iiritability and tendency to outbreaks of anger, riie moral sense is disturbed and the patient maybe erotic or vulgar n si)eech. The volubility of speech and activity of thought may jhow themselves in copious letter-writing. The jjulse is rapid and full, the breathing accelerated, the appe- ;ite good, and the patient may gain weight. There is nsuall}- in- somnia, and in women the menses are suspended. The urine shows in increase in metabolism and an excess of j»hosphates. Mania sometimes takes a jun-arKfe. or delirious form, generally lue to sonie complicating alcoholism or infection or special!}' de- [)ressing previous experience. There may also be a nmnia in which the ideas are confused, and there are great disorientation and halluci- nations. This comlition is also caused by some s])ecial somatic dis- turl)ance. Sometimes there is a hypomania with milder manifes- tations of the characteristic symptoms. Attacks of mania may alternate with attacks of melancholia. In general the alterations aiul combinations of periodical mania and iiielaiuiholia take various types termed alternate, circular, mixed, ;uhI atypical. Tiie ini'hinrlniHii, wliicli alternates with or substitutes itself for mania in manic-depressive insanify, is characterized by mucli tlie same syni))toms as tliose described under tlie lu'ad of acute melan- cliolia. These cases cannot in fact often be i)ractically distinguished, nor is it necessary. The manic-melancholia, liowever, occurs early in life. There are moie marked heredity, more serious original men- tal defect, and more inofound mental disturbance, more certain and frcif. -The treatment of paranoia is altogether one of en- vironment. If tlie j)atient can be ])laced in siieli surroundings that very little excitement or strain is put upon him. if he is maile to live a simple, regular outdoor and indoor life, with such amu.se- ments ami interests as do not at all tax the brain or nervous system, lie almost invariably gets better, at least for a tinu'. In- stitutional treatment is tlierefore tlie simi)lest and usually nu>st effective way of dealing with paranoia. CHAPTEK X. CONFUSIONAL INSANITY. (Exhaustion Psychoses, Infection Psychoses, Toxic Psychoses.) Confiisional insanity is a general term which answers for a type of insanity that is usually divided into three groups. These groups consist of the exhaustion psychoses, of the infec- tion psychoses, and of the toxic and autotoxic psychoses. While such subdivision is often useful because of its etiological help, and because sometimes rather distinct clinical features develop in accordance with the special causes, yet there are certain general fundamental characters belonging to them all. These are, that in all cases the course of the malady is relatively short ; that it begins usually with some delirium or very marked confusion, and that a mental confusion at some time always dominates the scene ; that there are associated with it a great degree of hallucinatory dis- turbance and a great variety of unsystematized delusions; and that usually late in the course there is some stupor or mental enfeeble- nient. In accordance with the constitution of the individual or the character of the case the delirium varies in character, being at times hardly present, at others so acute as to prove fatal. The charac- ter of the hallucinations and of the delusions and certain peculiari- ties in memory disturbance and orientation occur in some groups more than in others. Underlying them all, however, as already stated, there are certain fundamental qualities whicli are common. The terins applied to the different groups of confusional insanity are indicated in the following grouping, showing the types and special subtypes. 1. The Exhaustion PsycJioses. — {pears to hear voices of ])eople outside. At times he may be so alarmed aiul excited that he tries to get out of bed and has to be restrained. His lack of orientation and defects of memory are great, and he will insist lie was out walking the ]tre- vious day, or that he has received visitors whom he has lu-ver seen, lie often responds Avell to direct fuid sinii)le inquiries, and at times seems fairly lucid, but soon lapses into incoherence. If (piite ill ])hysically tlie confusion and irritability are shown in a low delii- ium, which is usually worse at night. He sleejjs badly, and is at night es])ecially apt to be disturbed by his hallucinations and delu- sions. The confusion may be so great that he fails to respond sen- sibly to any inquiries, and he may beconn^ stuporous and even some- what katatoiiic— being then in a condition called "amentia," a name given by some to the exhaustion jjsychosis. There are then i)resent disorientation of person, time, and place, hallucinations and various delusions, some mental excitement at times, defect in memory, mental cloudiness, retardation of thought, and stupor. After a few weeks, or perliaps even a few days, the mind begins to clear, the delusions and hallucinations disappear, tliere is lucidity of thought and response. liut for some time the mind is weak, tliought is slow and ditticult, memory defective, and there nmy be some ai)athy and depression. In some oases, i»articularly in con- nection witli multiple neuiitis, there remain a very distinct and 654 DISEASES OF THE' MINU. chronic defect of memory and a loss of orientation. Tliis is shown particularly with reference to recent events and in the power of recording things seen or heard. The patient is shown the title of a book or a picture. It is taken away and at once he forgets that he has seen it. He does not remember whom he has just seen, or what he has just done, or w^here lie has just been. This condition may, and usually does, in its typical form (Korsakoff's psychosis) remain permanent, and renders the patient i)ractically unhtted to do his work or be at hirge without an attendant. In tlie ordinary cases, however, the ])atient gradually recovers in a few weeks or months. Choreic Insanity. — A form of insanity is associated sometimes with chorea. It is usually, however, really only an infectious psy- chosis, and is characterized by some delirium or maniacal excite- ment, followed by confusion and exhaustion. Sometimes the psy- chomotor excitement is very slight, and the patients develop only a kind of confused condition in which they do not know where they are, and have various irrelevant delusions with occasional hallucina- tions. Puerpp:ral insanity is a psychosis which occurs shortly after childbirth. It takes the form of either manic-depressive insanity or an exhaustion or toxic psychosis. Occasionally pregnancy and puerperium are the exciting causes of dementia prsecox. In ai y case tlie malady has no clinical c haracters which stamp it as a special puerperal disease. It u.sed to be more often a toxic or infectious psychosis, but puerperal insanity of this type has largely disap- peared under the influence of modern obstetric methods. The Alcoholic Psychoses. — Among the toxic insanities that associated with the excessive use of alcohol is the most common. The use of alcohol leads to a variety of morbid mental conditions, which may be grouped under the following lieads: 1st. Simi)le inebriety, or morbid alcoholic habit, which is char- acterized by a persistent indulgence in alcohol and a besottedness of mind and morals which gradually follows. 2d. Dipsomania, wdiich is a periodical psychosis, belonging to the phrenasthenic insanities, in which the patient suddenly, at va- rious periods, develops an intense desire to drink. After a pro- longed debauch of a few days or weeks he returns to his usual vocations, and does not have a recurrence for some months. The inebriety liabit or besottedness may be complicated with dijjsonuinia. 3d. There is an insanity of several weeks' duration which is a form of confusional insanity, running about the ordinary course of this psychosis. When associated with multiple neuritis it has a CONFL'SIOXAL IXSAXITY. 055 somewhat special physiognomy, and lias been given the name of the limit iith, neiiritic psi/ehosis or tlie Korsdkoff's psijcJiosis. 4th. There is an acute delirious condition, known as delirium tremmis, which is simply a form of acute i)oisoning due to prolonged use of alcohol, insufficient food, and autotoxsemia. 5th. There is a terminal condition which comes \\\\o\\ the alco- holic after many years of indulgence, which is known as nlmliollc di'inentid or alroliollr jiseiidojitn-i'sis. Dklg Ixsanitiks. — Confusional states may be caused by the use of drugs, in particular oi)ium, cocaine, chloral, and in Eastern coun- tries of hashish. Tlie victims of drug habits, however, belong as a rule to the more degenerate types of phrenasthenia, and a true con- fusional psychosis is episodical. TiiK ExHAUsTiox Psychoses. — Confusional insanity is some- times initiated by a form of acute or " collapse " delirium. After an attack of some acute disease, like rheumatism, erysipelas, intiii- enza, ]tuerperal fever, or after operations and severe hemorrhages, the patient in two or three days goes into a condition of i)r()f()iind mental disturbance, wirli maniacal excitement, flight of ideas, and active hallucimitions of all kinds. 'I'he sense of orientation is lost, tlie ])atients do not know who or where they are or recognize their friends. They often become extremely violent, tear their clothes, and try to get out of bed, refuse food, do not sleep, and neglect their person. With this sometimes develops a fel)rile condition, and the general state is one which is known as "acute delirium" or even of "grave delirium." The condition resembles a good deal that of delirium tremens, and often a diagnosis can be nmde only by knowledge of the cause and ])revious history. Amkntia. — A fonn of confusional insanity occurs after pro- found exhausting mental strain, such as results from shock or long anxious vigils with the sick. It is seen not infre(iuently in i»risoii- ers who have suddenly jtresented to them the })ossibility of a trial and an execution. Here the patients develop at first some hal- lucinations and delusions regarding their surroundings and the peo- l)le al)out them. They become dull and confused, answer questions rather at random, lose their sense of oiientation, are caieless of their ])erson, and will often sit for a hmg time motionless in their rooms, or even lie in an ai)atheti(' state in their beds. Sometimes a condition of katatouia devclo[is or a sort of stupor. This condition is more chronic than tiu' fcumer and lasts often for several months. It has been called amentia, primary dementia, and curable dementia. /'I'oi/iHisis. — The course of many confusi(»nal j»sychoses is rela- tively short; they last from six to eight weeks. In cases of very 65G DISEASES OF THE MIND. acute onset and acute delirium the course is rather shorter. In the alcoholic insanity, coming on gradually or following delirium tre- mens, the disease may last three or four months. In the multiple neuritic insanity, which is generally a form of alcoholic insanity plus neuritic inflammation, the course is about the same. The prog- nosis, in so far as the psychosis is concerned, is almost always favor* able ; if the patient survives the somatic disorder the insanity gets well. In collapse delirium and in acute delirium (grave) the prog- nosis is very serious; in fact the so-called "grave" delirium is almost uniformly fatal. In the multiple neuritic psychosis the out- look is usually serious on account of the inflammatory complication and the tendency for pneumonia to develo}). If the patient survives there is very apt to be left some permanent defect of memory. In the infection psychosis associated with chorea, cliorea iiiscaiiens, the prognosis is also serious. There is apt, after a Aveek or two, to develop a delirium, and with this a fever, leading to a fatal issue. Tlie treatment of the confusional psychoses is almost purely symptomatic, and belongs essentially to the realm of general medi- cine. The delirium has to be quieted by hyoscine or morphine, or some of the sleep-producing drugs, the bodily strength sustained by frequent feeding, and autotoxsemia prevented by a careful attention to the excretions. The use of small doses of castor oil, frequently repeated, often is helpful in this respect. CIIAPTKR XI. ORGANIC PSYCHOSES. The major psychoses which are distinctly dependent on organic changes in the brain are : Paralytic dementia. Senile dementia. Alcoholic dementia. p]pileptic dementia. Psychoses connected with gross lesions, snch as brain tumors, liemorrhage, softening, brain injuries (traumatic insanity), syjjlii- Litic exudates, abscess, nuiltiple sclerosis. Idiocw Imbecility. GENERAL PARESIS. (Gkxeral Pai;ai,vsis ok thk Ixsank — Demextia Pakalytica.) General paresis is a i)rugressive disease of the brain running a 30urse of about three years, characterized l)y al)normal mental symp- ;oms, ending in dementia, associated with ])hysieal weakness and certain characteristic physical symptoms. Etinloijij. — Paresis, as it is usually termed, is a disease of mod- M-n civilization, and, as Kratt't-Ebing states it, of syphilization. It was a medical euridsity a hundred years ago; now, it is extremely frequent in oiir asylums, in neurological (dinies, and in private prae- ;ice. It has beeoine much nu)re common of late years in this eouu- :ry. It is found in m-arly all the civilized races of Enroi>e and A.merica, but is rare in Africa and Asia. It affects even the in- ferior races living among civilized ])eople, and is found, for ex- imple, among the negroes of the United States. It is not a disea.se which is directly iidierited, but the neuro- |>athic constitution preilisposes to it, and occasionally cases are seen u early life whicli uuiy be said to be of congenital origin and are hie to syi)hilis or degeneration in the jtarent. Itoccurs nuu-h more .)ften in men than in wonu*n, the ]»ro])ortion l)eing about Atol. rhe proportion of wonu-n is slowly becoming greater. In ))rivate practice anumg the better class the nundier of wonu'U who have the 658 DISEASES OF THE MIKD. disease is very small. In luy own case the number of paretic women is about six in one liundred cases.* The excessive use of alcohol is a predisposing cause, as is also excessive mental exertion, particularly if combined with emotional strain and excitement. Sexual excesses and abuse are also predis- posing causes, but the common view, that the disease is the result of perverted sexual indulgence, is not correct. Syphilis is, no doubt, the most essential of all the predisposing causes, and paresis must be put down, with tabes dorsalis, as one of the parasyphilitic diseases, or, as I prefer to call it, one of the forms of degenerative syphilis. Statistics do not yet give more than twenty to fifty per cent of cases with undoubted histories of syphilis;! in my own experience this percentage is fifty, and the disease is so often and so distinctly traced to syphilis in a large number of cases that we must infer its relationship in the rest. Injuries, sunstroke, exposure, acute dis- eases may be put down as exciting causes, but their importance is not very great. An almost sure recipe for producing a case of paresis is this: Let a man of nervous constitution acquire syphilis between the ages of twenty and thirty, then let him work as hard as possible without vacation under great mental strain, drink a great deal of alcohol, and indulge excessively sexually. This will be pretty sure to bring on paresis in ten or fifteen years. The disease occurs most often between the ages of twenty and forty, but it is seen both earlier and later than these ages. It oc- curs oftener in married men and women. It is seen oftener in the city than in the country. Symptoms. — In its typical manifestation the disease shows two stages : one of excitement or irritation ; the second of dementia and paralysis. In place of the excitement of the first stage the patient may have a prolonged period of hypochondriasis or melancholia, or, with no preliminary stage of excitement or depression, may pass gradually into dementia, the mental and bodily feebleness going on together. The first type is the most common of all, although the opinion is growing that the ty^jes characterized by little active mental dis- * Among 85 private cases there were 78 men and 7 women (1 to 15). There was a distinct history of syphilis in 43 (nearly sixty per cent). The national- ities were: Cnited States, 49; Hebrews, 20; Irish, 11; Germans, 3; Italian, 1; Cuban, 1. Total, 85. f Among personal cases Regis found eighty per cent syphilitic. KrafTt- Ebing found, among 175, fifty-six per cent gave a history of syphilis. In 41 cases of paresis in children syphilis could be traced in 87.8 percent (Zappert). Among 24 cases in adults, 16 gave a history of syphilis (F. Mott). orptAXIc psychoses. 059 turbauce aud by more marked physical symptoms are becoming more frequent ; in other words, that paresis is becoming more a disease of the brain and spinal cord proper and less a disease of the mind, the mental spnjitoms * being almost from the first more of a pro- gressive dementia. Excited Tijpe. — In the first type of cases the patient begins by showing unusual irritability of temper ; trivial things annoy him, and his bad humor and change of disposition become noticeable in his family relations and in his business. He is fretful ; complains of being easily fatigued; loses interest in his affairs, and is unable to fix his attention for any length of time upon them. He makes, occasional mistakes of judgment, and does some extravagant or fool- ish thing in the way of purchasing or selling. This condition of irritability is followed by one of great mental exaltation. The patient becomes very happy and cheerful and confident; he feels better than he ever did before in his life. He talks excessively, and is effusive and jocose when he used to be sober and reserved. He develops great schemes for the future, he lavishes money uselessly in making presents to his family and friends, or in some extra- ordinary business venture, and imagines himself possessed of im- mense wealth or great ])Ower. He has in other words delusions of grandeur, or megalomania. This condition of exaltation is inter- rupted by outbursts of violence, especially if it leads him to indulge in drink, as is often the case. In the course of three or four months the symptoms become so marked that the family recognize the seri- ousness of his state, and he is confined in some institution where he can do himself and others no harm. Under institutional ref/ime he now becomes somewhat more quiet; his exaltation softens down. His symptoms may even remit, and for a time he becomes nearly or quite rational. But after some months he begins to show dis- tinct signs of dementia; tlie memory becomes weak, he forgets re- cent events, mislays things, makes mistakes in his accounts, is un- able to add correctly; he cannot write a h'tter coherently, or if he does there are mistakes in spelling and elisions of letters. During or before the exaltation tliere gradually ajijM'ar ]>hysical symptoms whidi are very characteristic. The jyatient's luinds ]h- come tremulous, and his handwriting is so affected that his signa- ture often cannot l)e recognized. Tln-re is distinct and (U'cided facial tremor, particularly apparent if the patient is made to close the eyes and stretch the muscles of the lips so as to show the teeth. *Ani in the descu-iption of tliese conditions. 668 DISEASES OF THE MIND. Tkaumatio 1\sy( hoses. Trauma with injury of the head may be followed by various morbid changes in the mental condition. It may be the exciting- cause of some functional psychosis to whicli the patient is predis- posed, such as dementia praecox or a melancholia. It may cause a psycho-neurosis of the type of liysteria or some impulsive insanity like a dipsomania. It may in an epileptic especially lead to a dementia, or at least to mental deterioration. r>y producing contusions and lacerations of the brain and by the shock it uuiy lead to a rather special morbid mental condition which would be classed best probably as a psycho-neurosis. ]\Iy observation coincides witli that of I^annister, who says that the patient after the accident " is in a semi-dazed state, in which he seems unable to get rid of some besetting idea often connected with the accident. He asks over and over again in regard to it, appar- ently forgetting the replies received." Sometimes the patient ap- pears at first to get over the accident, though he does not do so en- tirely. "After a longer or sliorter time secondary results begin to appear : vertigo, tinnitus, weakness of attention and memory, some- times a peculiar obstinacy and wrong-headedness, together with morbid impulses and moral deterioration." This condition rarely happens to the 3'ouiig and pure-blooded. The hysterical psychoses following head injury have already been described. INDEX. ^BDUCEXS nerve, anatom}* of the, 99 paralysis «>t the, 107 Abiotrophy, 005 Abortive paranoia, GIG Ai)oulia, 615 Abscess, cerebral, 407 Acoustic nerve, anatomy of the. ISO neuroses of the, 187 Acfiuired dementia, 652 Aerania, 390 Acrodynia, 90 Uromegaiy, 563 ^cropara'Stliesia, 153 Actinomycosis of tlie brain, 455 Acute dementia, 653 delirium, 652 mania, G4G melancholia, diagnosis, 64:! etiology, 64'.' prognosis. G43 syni|)toms. G42 Esthesiomctcr, 54 Allcet, GIO After-brain, 344 Age as a factor in the etiology of nervous di.scascs, 24 Ageusia, 195 Agoraphobia. pia. \W imentia. (>52. 055 Aminiia. 388 Amnesia. 614 hy?teiical, 489 Ampere, definition of, 68 Aniiicrenieter, 69 Amputation neuroma, 96 Amyelia, 237 Amyosthenia, liysterical, 488 Amyotiophic lateral sclerosis, 318 Amyotrophy, progressive spinal, 309 Aniemia, cerebral, 406 in hysteria, 493 meningeal. 393 pernicious, combined spinal scle- roses of, 299 spinal, 243 Anasthesia, definition of, 31. 36 hysterical, 485 muscidar, 30 trigeminal, 176 Analgesia, definition of, 36 Anatomy, general, of the nervous system, 1 Aneurisms, intracranial, 457, 459 miliary, of the brain. 430, 459 Angio-ataxia, neurosis, -paralysis, and -si»asin, definition of, 37 Angionem'otic gangrene, synunelri- cal, 205 (I'dema, 575 Angioi)athic neurasthenia. 530 Anidrosis, definition of. 37 Ankle clonus, 51 Anosmia, 161 An.xiety neurosis, 532 Anxious delirium, 617 Apha.sia, 386 auditory, 887, 389 conduction, 388, 390 cortical sensory, 388 niix«'d. 390 motor. 38S. 389 670 INDEX. Aphasia, subcortical, 890 visual 3«6, 890 Aphemia, 384, 8S.j, 388, 889 Aphonia, hysterical, 488 Aphthongia, 129 Apoplexy, cerebellar, 429 diagnosis of the varieties of, 482 dural, 438 embolic, 484 hemorrhagic, 423 meningeal, 437 pial, 439 pons, 439 spinal, 238 thrombotic, 434 Apperception, 609 Apraxia, 387 Aprosexia, 616 Arachnoid, cerebral, 366 spinal, 308 Arbor vitie of the cerebellum, 358 Arcades, interfascicular, 15 Argyll-Robertson pupil, 51, 107 in locomotor ataxia, 380 Arms, cord centres for muscles of the, 337 palsies of the, 13G spasmodic disorders of the, 136 Arteries, cerebral, 367 spinal, 339, 333 Arthropathy of locomotor ataxia, 281 pneumogenic osteo-, 565 Associated movements, 34 Association centres in the brain, 363 Association of thought, disorders of, 613 Associative functions of the brain, 377 Astereognosis, 36 Asthenopia, muscular, of the eye, 108 Astraphobia, 680 Ataxia, cerebellar, 36 definition of, 36 family, 301 Friedreich's, 300 hereditary cerebellar, 306, 327 spinal, 300 locomotor, see Locomotor Attwia motor, 36, 274 testing for, 58, 59 Ataxia, static, 36 testing for, 58 tests for, 55 Ataxiagraph, 58 Athetosis, 34 Atrophia musculorum lipomatosa, 331 Atrophies, progressive muscular, 808 Atrophy, arthritic muscular, 837 occupation muscular, 338 optic, 167 progressive nuiscular, 800 hereditary, 337 hereditary, of leg type, 314 infantile, 335 spastic form of, 318 Auditory nerve, anatomy of the, 186 neuroses of the, 166 vertigo, 190 Aura, epileptic, 473, 475 Automatism, cerebral, in hysteria, 483 Autotoxic psychoses, 653 Axis cylinder, 5, 11, 16 Axon, 5 Babinski, sign of, 47 Back, cord centres for muscles of the, 329 Bail larger, stripe of, 351. 353 Ballet-dancers' cramp, 553 Basedow's disease, 538 Baths in the treatment of nervous diseases, 62, 65, 591 Batteries, electric, 69 Beard's disease, 513 Bell's palsy, 115 Beriberi, 90 Birth palsies, 441 Blepharospasm, 115 Blindness, mind, 387 word, 387 Blood supply of the brain, 867 Blood-vessels of the peripheral nerves, 15 Borderland cases, 628 Brachial nerves, paralysis of the, 136 plexus, anatomy of the, 135 Brachycephalic, definition of, 43 Brain, abscess of tlie, 407 clironic, 409 IXDEX. 671 Brain, actinomycosis of tbe, 455 auainia of the, 4U6 anatoun- of the. 343 aneurisms of tbe, 430. 457 association centres, 362 associative function of the. 377 bilateral representation. 373 blood supply of the. 367 cancer of the, 456 central lobe. 349 centres in the, 372 centrum ovale, 377 cerebellum, 358, 378 compression symptoms, 385 convolutions of the. 346 corpora quadrigemina. 357, 378 corpora striata, 353. 377 corpus callosum. 377 corte.x of the, 346. 350 cranio-cerebral topography. 586 cutting the, 381 cysticerci of the, 457 development of the. 343 diagr.-im of the divisions of the. 2 diseases of the, 385, 405 membranes of tljo. 392 echinococcus of the, 457 eml)olism of the arteries of the, 434 fibres of the cortex. 352 fibroma of the, 456 fissures of the. 346. 347 focal symptoms. 385 frontal lolw, 347 functions of the, 372 ganglionic deposits of the. 346 glioma of the, 455 gumma of the, 454 hemorrhage in tiie, 422, 423 membrane of the. 422. 42'S. 427 hypenvmia of the, 405 intlammation of the, 407 irritation symptoms, 385 latent regions of the, 377, 379 limbic lobe, :^9 lobes of tiie. 347 l(K-ali/atioii in the. 372 Luys' Ixwly, 35H Brain, malformations of the. 390 merunges of the. 366 diseases of the. 392 hemorrhage in the. 427 miliary aneurisms of the, 430 motor tracts in the, 362 occipital lobe, 347 olfactory lobe. 350 operculum. 350 f^ptic thalami. 354 osteoma of the, 456 palsies of children. 437 parasitic growths in the. 457 parietal lobe, 347 plexuses of the cortex, 352 preserving the. 381 projection system, 362 red nucleus. 358, 378 sarcoma of the, 456 sensorimotor area. 372 sensory tracts in the, 364 softening of the, acute, 434 substantia nigra, 357 subthalamus, 358 symptoms of disease of the. 385 syphilis of the, 461 syphiloma of the, 4.">4 temporal lobe. 34^ thalamus opticus. 377 thrombosis of tlie arteries of the, 4:34 topography of the , 586 tubercle of the. 415 tumors of the. 445 focal symptoms of. 448 multiple. 454 of the Imi.sjiI ganglia and inip- sule, 451 of the base, 453 of the central area, 449 of the ccrelH'llum. 453 of the corpora (|uadrigemiua. deep marrow, and pineal gland. 451 of the corpus callosum. 451 of the cms, 452 of the occipiljil loU-s. 450 of the optic»»-striate n-gion, 451 67-2 INDEX. Brain, tumors of the parietal area, 4o0 of the pons and medulla, 452 of the prefrontal area, 448 of tlie temporal area, 450 weight of the, 380 wet, 401 Brauch-Romberg symptom, 58 Bulbar paralysis, asthenic, 316 progressive, 314 upper, 107 Bulbo-spiual paralysis, asthenic, 31G Burdach, column of, 216, 319 Caisson disease, 240 Cajal's cells, 8 Cancer of the brain, 456 of the spinal cord, 331 Caput obstipum, 123, 132 Catalepsy, 583 hysterical, 483 Cauda equina, anatomy and diseases of, 339 lesions at different levels, 341 Causes of nervous diseases, 23 Cells, Cajal's, 8 cerebral cortical, 350 Deiter's, 8 Golgi's. 8, 361 nerve, 5 neuroglia, 13 of the spinal cord, 212 Purkinje's, 359 scavenger, of Lewis, 14 spider, 13 stellate, (f the cerebellar cortex, 35!) Central nervous fibres, 13 Centres, cerebral, 372 spinal, 220 Centrosome and centrosphere of a peripheral nerve cell, 9 Centrum ovale, 377 Cephalalgia, 176 hydrotherapy in, 591 location of pain according to the cause, 179 Ceohalic index, 619 Cerebellar ataxia, liereditary, 306 Cerebellum, abscess of the, 410 Cerebellum, anatomy of the, 358 functions of the, 378 gray matter of the, 359 hemorrhage in the, 429 tumors of the, 453 white matter of the, 361 Cerebral automatism, 617 Cerebrospinal irritation, 525 meningitis, 395 multiple sclerosis, 416 aborted tj-pes of, 418 syphilis, 463 Cervical nerves, motor neuroses of the, 132, 136 sensor}' neuroses of the, 196, 197 Charcot-jNIarie type of progressive hereditary muscidar atroph}', 314 Chemistry of the nervous system, 22 Chiasm, optic, 163 Choked disc, 165 Chorea, 501 chronic, 503 dancing, 507 diagnosis, 505 duration, 503 electric, 506 etiology, 501 forms, 503 habit, 506 hereditary, 326, 506 Huntington's, 506 insaniens, 503, 656 major, 507 maniacal, 503 of the larynx, 497 paralytic, 503 ])atliolog}', 504 procursive, 507 prognosis, 505 relapses, 503 senile, 503 Sydenham's, 501 S3'm])toms, 502 treatment, 505 Choreic insanity, 654 movements, 34 Chromophilic granules of the nerve cell. 7 Chronic melancholia, 644 INDEX. 673 Chronic melancholia, etiology, 644 prognosis, 645 symptoms, 644 treatment, 645 Cigarmakers' cramp, 551 Circular insanity, 646, 647 Circumflex nerve, paralysis of the, 141 Civilization as a factor in the etiology of nervous diseases, 25 Clarionet players' crami>, 551 Clarke's column, 212, 220 Climacteric insanity, 646 Climate as a factor in the etiology of nervous diseases, 25 in the treatment of nervous dis- eases, 66 Clonus, ankle, 51 Coagulation necrosis, 29 Cocainism, 652 Coccygodynia, 205 Cold, effect of, in the treatment of nervous diseases, 63 Collapse delirium, 617, 652 Columns of the spinal cord, 210, 212, 215, 220 Coma, apoplectic, 423 trance, 53 Compulsion, 616 morbid, 632 Compulsive insanity, 028, 629 manias, 632 Concept, 609 Coufusional insanity, 652 etiology, 653 prognosis, 655 symi)toins, 653 treatment, 656 Conjugate deviation of the eyes, defi- nition of, 103 spasmodic, 110 Consciousness, 608 disorders of, 617 Contraction, paradoxical. 51 Contracture, deJinition of, 34 hysterical, 489 Convulsions, 33 (■|)i!cptic, 470. 495 hysterical, 483, 495 43 Coprolalia, 497 Cord, spinal, see Spinal Cord Corpora quadrigemina, 357, 378 tumors of the, 451 Corpus callosum, 377 tumors of the, 451 Corpus striatum, 353, 377 Cortex, cerebellar, 359 Cramps, 33 Of^fupation, 551 Cranio-cerebral topograph}', 586 Cranium, table of measurements of the, 43 Cretinism, 567 Crises in locomotor ataxia, 283 Crura cerebri, tumors of the, 452 Current, electrical, employed in the treatment of nervous dis- eases, 67, 595 primary induced, 70 secondary induced, 70 strength, definition of, 68 Cyclopia. 390, 392 Clycloplegia, 106 Cyrtometers, 586 Cysticerci of the brain, 457 Cytoplasm, 7, 22 Dead fingers, 207 in writers' cramp, 548 Deafness, nervous, 187 word, 387. 389 Degenerates. 24 Degeneration, anatomical stigmata of, 619 neuritic, complicating forms of, 94 of nerves, 80 of nervous tissue, 28 reactions of. 74 stigmata of, 41 varieties of, 29 Degenerntive insanity, 628 Deiter's cells, 8 Delires systematises, 649 Delirium. 613. 017 acute, 652 anxious, 617 collapse. 617. 652 674 INDEX. Delirium, febrile, 652 tremens, 652 Delusion, 612 Delusional insanity, 649 Dementia, acquired, 653 acute, 652 paralytica, 467 paranoides, 650 prsecox, 636 age, 636 census in psychopathic ward, 636 diagnosis, 639 etiology, 636 hebephrenic type, 637 paranoid type, 639 prognosis, 640 simple, 638 symptoms, 637 treatment, 640 variations in onset, 639 primary, 652 Dendrites, 6, 16, 17 cellulipetal impulses in the, 16, 17 Depression, 614 Development, organic defect of, 602 Diagnosis, methods of, 623 of nervous diseases, 89 electro-, 74 Diaphragm, paralysis of the, 133 Diathesis as a factor in the etiology of nervous diseases, 25 contractural, 489 Diencephalon, 3, 344 Diet employed in the rest treatment, 597 for the neuropathic, 61 Die Verriicktheit, 649 Digiti mortui, 207 in writers' cramp, 548 Diplegia, definition of, 35 hereditary cerebral, 326 infantile, 437 Diplopia, definition of, 103 Dipsomania, 654 Diseases of the mind, 601 Disorders of association of thought, 613 Disorders of consciousness, 617 of function in insane, 619 of ideation, 613 of judgment, 612 of perception, 612 of volitional function, 615 Disorientation, 613 Distractability, 615 Divers' paralysis, 240 Dizziness, 190 Dolichocephalic, definition of, 42 Dorsal nerves, anatomy of the, 147 motor neuroses of the, 147 Dotardness, 601 Doubting mania, 630 Douche, use of, in the treatment o nervous diseases, 62 Dreams, 576 Drivers' spasm, 551 Dropfoot, 151 Dropsy, sleeping, 585 Drowsiness, morbid, 583 Drug insanities, 655 Drunkenness, sleep-, 577 Duchenne- Aran's disease, 309 Dura mater, cerebral, 366 inflammation of the, 392 spinal, 208 inflammation of the, 243 Dynamometer, 45 Dysacusis, 194 Dysaesthesia, definition of, 36 Dysphagia, 121 Dystrophies, 563 hereditary, 327 juvenile, of Erb, 325 progressive muscular, 320 Ear, neuroses of the, 186 Echinococcus of the brain, 457 Echokinesis, 497 Echolalia, 497 Eclampsia, 469 nutans, 127 Ecstasy, 614 Electricity, appliances for the thera peutic use of, 69 employed in the rest treatment 595 IXDEX. 675 Electricity iu the treatment of uerv- ous diseases, 67, 595 methods of application of, 71 terms employed in relation to, 68 Electrodes, 71 Electro-diagnosis, 74 Electromotive force, definitioD of, 68 Electrotherapeutics, 77 Electrotonus, 21 Emljolism, cerebral, 434 Emotion, 610 Encephalitis, acute exudative, of the gray matter, 413 with hemorrhage, 4i;3 acute suppurative, 407 chronic sui)purative, 409 hemorrhagic, 413 Endoneurium, 10 Enteritis, mucous, 523 Enteroptosis, 528 Epilepsy, 468 abortive attack, 473 aura, 473 complicating infantile hemiple- gia, 438 course, 476 diagnosis, 475 etiology, 469 grand mal, 4C9, 476 hydrotherapy in, 593 hystero-, 469 idiopathic, 468 Jacksonian, 409, 473 laryngeal, 194 matutinal, 473 mental condition in, 473 minor attack, 473 partial, 473 pathology, 474 petit mal. 473 physical condition in, 473 l)hysio|(ig\-, 475 procursive, 471 prognosis, 476 psychical, 471, 473 severe attack, 470 sleep-, 583 somnambulic, 473 surgical treatment, «>()*? Epilepsy, symptomatic, 469 symptoms of the convulsion, 473 treatment. 476 Erl)'s juvenile dystrophy, 305 palsy. 139 Erroneous projectiou, detiuilion of, 103 Erythromelalgia, 304 Etiology of nervous diseases, 33 Examination, method of, in nervous disease, 39, 623 Exercise for the neurasthenic, 63 Exhaustion psychoses, 653, 655 Exophthalmic goitre, 538 Eye, attachment of the muscles of the, to the globe, 101 motor nerves of the, 98 muscles which move the, 101 muscular asthenopia and iusulli- ciencies of the, 108 neuroses of the, 164 si)asmodic diseases of the mus- cles of the, 110 Facial hemiatrnphy, ])rogressive. 563 hemihypertropliy, progressive, 563 nerve, anatomy and diseases of the. 111 palsies, 115 spasm, 113 Family nervous diseases. 326 Faradic medical batteries, 70 Fel)rile delirium, ()53 Feeble-mindedness. 601 Feeling, disttnbances «)f, 614 Feeling.s, instinctive, how divideti, 610 Fever, hysterical. 493 Fibres, nerve. 9. 13 P^ibrillary tn-mor, 83 Filiromii molluscum, 05 of the l)rain. 450 Fingers, dead. 307 in writers' cramj). 548 Fixed idea. 016. 031 Flechsig, oval zone of. 216 Fleece of the cerebellum. 361 G7G INDEX. Flexor response, 47 Flight of ideas, 613 Flushing, 176 Flute-players' cramp, 551 Focal symptoms of brain tumors, 448 Foerster's shifting type, 518 Folie-a-dcux, 651 Folic raisonnante, 649 Forced movements, 34 Forearm, cord centres for muscles of the, 237 Fore- brain, 343 Foot, cord centres for muscles of the, 229 Fractures, spontaneous, in locomotor ataxia, 282 Friedreich's ataxia, 300 Function, disorders of, in insane, 619 Functional insanities, 602 nervous diseases, 468 Galvanic batteries, 70 Ganglia, cerebral, 346 Gangrene, symmetrical, 205 Gasserian ganglion, area of anaesthe- sia following removal of the, 172 Gedvelst, network of, 11 Gemmules in the cerebellar cortex, 360 General paralysis of the insane, 467 Gerlier's disease, 194 Giddiness, 190 Glioma of the brain, 455 of the spinal cord, 331 Gliosis, 30 Globus hystericus, 489 Glosso-pharyngeal nerve, anatomy of the, 120 diseases of the, 121 sensory neuroses of the, 194 Glossoplegia, 129 Goal idea, 609 Goitre, exophthalmic, 538 Golgi's cells, 8, 361 Goll, column of, 214, 217, 219 Gombault, triangle of, 216 Graves' disease, 538 Gray matter, central, 16 cortical, 17 Groups, symptom, 612 Gudden, commissure of, 163 Gumma of the brain, 454 of the spinal cord, 331 Habit as a factor in the etiology ol nervous diseases, 25 Ha^matomyelia, 239 Hrematorrhachis, 238 Ha^midrosis, definition of, 38 Hallucination, 612 Hand, cord centres for muscles of the, 227 Head, cord centres for muscles of the, 222 Headache, 176 hydrotherapy in, 593 location of pain in, according tc the cause, 179 morning, 179 sick, 181 treatment, 612 Hearing, centres for, 375 hysterical disturbances of, 485 Heat, effects of, in the treatment oJ nervous diseases, 65 Hebephrenic type, 637 Hemianopsia, 169 Hemiatrophy, lingual, 130 progressive facial, 562 Hemicrania, 181 Hemihypertrophy, progressive facial 563 Hemiopic pupillarj' reaction, 170, 45! Hemiplegia, 386, 425 definition of, 35 hephwstic, 551 hereditary, 326 hysterical, 487 infantile, 437 organic, 487 Hemorrhage, cerebral, 423 meningeal, 422, 423 spinal, 238 Henle, sheath of, 9 Hephtestic hemiplegia, 551 Hereditary nervous diseases, 326 Heredity in the etiology of nervou diseases, 23 INDEX. 677 Herpes, 176 zoster, 199 Ileterophoria, definition of, 109 spinal, 237 Hiccough, 133 Hind-brain, 344 Hutchinson face, 108 pupil, 428 Hydrocephalus, acute, 397 chronic, 399 Hydromyelia, 333 Hydrorrhachis interna, 236 Hydrotherapy in nervous diseases, 65, 591 sedative, 64 tonic, 62 Hygiene of the nervous system, 60 Hyperacusis, 194 Hypenvmia, cerebral, 405 meningeal, 392 spinal, 242 Hyperastlusia, auditory, 194 definition of, 36 hysterical, 4s7 Hyperalgesia, definition of, 36 Hyperidrosis, definition of, 37 Hyperkinesis, 32 Hyperosmia, 162 Hypertrophy, iiseudo-muscular, 321 Hypnotism, 579 lethargic, 580 major, .580 minor, 579 Hypochondriasis, 628, 633 Hypoglossus nerve, anatomy of the, 128 motor neuroses of the, 129 IIypf)piiysi8, cerebral, tumors of ihc, 453 Hysteria, 481, 633 anuiesia, 493 amyosthiMiia, 488 ana'sthesia, 485 aiihonia, 4HH blue a'dema, 493 catalepsy, 493 cerebral automatism, 493 contractures, 489 convulsions, 483, 484, 495 Hysteria, diagnosis, 494. 634 etiology, 481 fever in, 493 globus, 483 hearing in, 485 hydrotherapy in, 593 hypera'sthesia, 487 major, 483 mental state in, 490 minor, 483 motor symptoms, 487 neuralgia, 487 paralyses, 487 pathology, 494 prognosis, 495, 634 sensory symptoms, 484 stigmata, 409 suggestibility in. 491 symptoms, 483 of the crises, 483 of the iuterparo.xysmal state, 484 taste disturbance in, 486 trance, 493 treatment, 495, 608, 634 tremor in, 489 trophic disorders, 491 vasomotor sj-mptoms, 493 viscera, symptoms. 491 visual disturbances in, 485 Hysterical insanity, 633 Hystero-epilcpsy. 492 Hystcro- neurasthenia, 523 Idua, 608 Ideation, disorders of. 613 Idiocy, 601 hereditary amaurntic, 326 Ignipedites, 90 Illusion. 612 aural, i'A'i visual, 612 Inibeeiliiy, 601 Impiiteuce, hydrotheraiiy in. 594 treatment, 608 Impulse, morbid. 616, 632 Iinjtulsive act. 616 insimity. (528. 629 muuias. 632 678 INDEX. Incoutincncc of iiriuc, liydrotherapv iu, 594 Inebriety, G54 Infantile spinal paralysis, 261 Infection as a factor in the etiology of nervous diseases, 26 Infection psychoses, 652 Inflammation, classification of, 28 exudative, 28 of nervous tissue, 27 productive, 28 Insanit\', accessor}- causes, 605 age, 603 alcoholic, 652 alcohol in, 604 choreic, 654 circular, 646, 647 civilization, 6U3 classification, 601 climacteric, 646 climate, 604 compulsive, 628, 629 congenital conditions, 603 definition, 601 degenerative, 628 delusional, 649 direct causes, 605 education, 604 etiology, 603 general pathology, 605 hereditj- in, 604 hysterical, 633 imposed, 651 impulsive, 628, 629 in urban life, 605 legally speaking, 601 manic-depressive, 641, 646 medically speaking, 601 mj-xfrdematous, 652 neurasthenic, 628 occupation, 605 phj-sical symptoms of, 019 puerperal, 654 race, 604 sex, 603 syphilis, 604 thyroid, 652 Insanities, drug, 655 functional, 602 Insanities, neurasthenic, 602 organic, 602 Insomnia, 572 treatment, 60S Instinctive feelings, how divided, 610 Instincts, 609 Insulliciencies, muscular, of the cj'e, 108 Intention tremor, 33 Intercostal nerves, sensory neuroses of the, 198 Iridoplegia, 106 Irritabilitj' of a nerve, 21 Irritation, spinal, 525 Isthmus, 344 Judgment, disorders of, 612 Jumpers, 497 Kakke, 90 Karyochromes, 7 Katatonia, 583, 638 Kleptomania, 632 Knee jerk, 48 Korsakoff's psychosis, 652, 655 Lacrymation, 176 Laryngeal epilepsy, syncope, or ver- tigo, 194 Larynx, chorea of the, 497 Latah, 497 Latent regions of the brain, 377, 379 Lateral sclerosis, 295 amyotrophic, 318 Lead pais}', 141 Leg, cord centres for muscles of the, 229 Leptomeningitis, cerebral, 393 lumbar puncture in, 394 spinal, acute, 245 chronic, 247 Lethargic hypnotism, 580 Lethargy, 583 Levator palpebrne, spasm of the, 110 Lewis, scavenger cells of, 14 Light reflex, 51 Lisping, 129 Lissauer's column, 211 Little's disease, 295, 442 INDEX. 679 Localization, cerebral, 372 spiual, 222 Lockjaw, 111 Locomotor ataxia, 274 arthropathies of, 281 ataxic stage, 275 brain symptoms in, 284 complications, 284 course of, 284 crises in, 283 definition, 274 diagnosis, 291 etiolog}', 274 exercise treatment of, 610 kye symptoms of, 279 forms, 274 fractures in, 282 gait in, 277 gastric crises of, 283 hearing in, 279 liydrotherapy in, 593 Initial stage, 275 joint affections in, 281 laryngeal crises in, 283 muscular atrophies in, 283 neuralgia in, 277 optic atrophy in, 279 pains in, 277 paralytic stage, 276 patellar tendon rellcx in, 277 pathological anatomy, 285 pathology, 288 prognosis, 291 sexual power in, 284 skin disorders in. 283 spot pains in, 277 symptoms, 275 syphilis in the etiology of, 274, 291 treatment, 292, 009 trophic disturl)aii(rs in, 283 Luinbnr nerves, anatomy of the, 148 motor ne\iroses of the, 149 sensory neuroses of the, 200 Lays' body, 358 Ma.iou psychoses, 001 Mania, 041 |)eracute form, 647 Maniacal excitement, 613 Mauical excitement, acute, 617 Manic-depressive insanity, 646 diagnosis, 647 etiology. 646 manic phase of, 646 prognosis, 647 symptoms, 646 treatment. 647 Marie's disease, 563 Massage in the rest treatment, 595 in the treatment of nervous dis- eases, 65 Mastodynia, 199 Masturbation, 534 treatment, 611 Mechanisms of the nervous system, 20 Median nerve, paral^'sis of the, 144 Medulla oblongata, functions of the, 379 po.sition of the cranial nuclei iu the, 112 tumors of the, 452 Medullary sheath, 11 Melancholia, 614, 641, 647 acute, 641, 642 etiology, 642 functional, 642 prognosis, 045 recurrent. 642 simple, 042 .symptoms. 642 agitata. 044 chronic, 641, 644 etiology, 644 symptoms, 644 treatment, 645 hypochondriacal, 644 manic, 041 of involution, 644 the disease, 641 the symptom, 641 .Memories. f tlie, 392 680 INDEX. Meninges, cerebral, functions of the, 367 liemorrbage in the, 423, 423 hyperaemia of the, 392 spinal, 208 hemorrhage in the, 238 infianimatiou of the, 243 Meningitis, alcoholic, 401 cerebral, 392 epidemic cerebro-spinal, 395 external cerebral, 392 spinal, 243 internal spinal, 244 lepto-, 245, 393 lumbar puncture in, 600 pachy-, 243, 392 serous, 401 spinal, 243 tuberculous, 397 Meningocele, cerebral, 392 spinal, 236 Meningo-myelitis, 247 Meningo-myelocele, 236 Meralgia, 154, 200 Mesencephalon, 3, 344 Mesocephalic, definition of, 42 Metence^ihalon, 3, 344 ]\Iicrencephaly, 390 Microcephaly, 390 Micromyelia, 238 Mid-brain, 344 Migraine, 181 fulgurating, 182 Milkers' spasm, 551 Milliampere, definition of, 68 Milliamperemeter, 69 Mind, diseases of the, 601 Miners' nystagmus, 110 Minor psychoses, the, 601, 628 etiology, 629 symptoms, 629 Mixed forms, 646 Monomania, 649 Monoplegia, definition of, 35 Monro, fissure of, morphological im- portance of, 345 Morbid compulsion, 632 fear, 630 impulses, 616, 632 Morphinism, 653 Morton's neuralgia, 204 Mor van's disease, 146 Motility, disordered, examination for, 44 Motor tracts in the brain, 362 Movements, Fraenkel's, in the treat- ment of nervous diseases, 66 Mucous enteritis, 522 Multiple neuritic psychosis, 652, 655 Multiple neuritis, 85, see Polyneuritis sclerosis, 416 aborted types of, 418 Muscles, table showing innervation, functions, etc., of the, 222 Muscular asthenopia and insufficien- cies, 108 Muscular atrophy, arthritic, 327 hereditary progressive, 327 of leg type, 314 infantile progressive, 325 occupation, 328 progressive, 309 spastic form of, 318 Muscular dystrophies, progressive, 330 Muscuio-spiral nerve, paralysis of the, 141 Musicians' cramp, 550 Myelencephalou, 3, 344 Myelin sheath, 11 Myelitis, 249 acute, 249 definition, 249 diagnosis, 253 disseminated, 250, 256 etiology, 250 forms, 249 pathological anatomy, 253 prognosis, 255 symptoms, 250 transverse, 249, 256 treatment, 255 annular, definition, 349 central, symptoms, 358 chronic, 256 diagnosis, 259 etiology, 256 forms, 256 INDEX. 681 Myelitis, chronic, pathology, 259 prognosis, 259 symptoms, 257 syphilis in etiology of, 256 syphilitic spinal paralysis, 257 treatment, 260 classification of, 249 compression, definition, 249 s^'mptoms, 258 diffuse, definition, 249 dissemiuutetl, definition, 249 hemorrhagic definition, 249 marginal, definition, 240 peri-ependymal, definition, 249 symptoms, 258 purulent, definition, 249 septic, definition, 249 sj'philitic, definition, 249 transverse, definition, 249 tuberculous, definition, 249 Myoclonus multiplex, 507 Myoidema, definition and significance of, 46 Myospasia, 507 Myotonia congenita, 498 Myriachit, 497 .^lysophobia, 030 Myxiedema, 566 Myxoedematous insanity, 652 Narcolepsy, 583 Neck, cord centres for muscles of the, 223 Neck pains, 196 Necrosis, coagulation, 29 Negativism, 615 Nerve, abmia of, 79 auditory, anatomy of the, 186 neuroses of the, 186 brachial, jmralysis of the, 136 cerebrospinal, sensory neuroses of the. 152 Nerve, cervical, motor neuroses of the, 132, 136 sensory neuroses of the, 196, 197 circumflex, paralysis of the, 141 cranial, apparent origin of the, 99 sensory neuroses of the, 1.59 degeneration of, 80 diseases of special, 98 dorsal, anatomy of the, 147 motor neuroses of the, 147 efferent, 20 eighth, anatomy of the, 186 neuroses of the, 187 electrical currents in, travelling with impulses, 21 eleventh, anatomy of the, 122 diseases of the, 123 excito-reflex, 19 facial, anatomy of the. 111 diseases of the, 112 fifth, anatomy of the, 170 motor neuroses of the. 111 sensory neuroses of the, 170, 173 fourth, anatomy of the, 99 paralysis of the, 107 glossopharyngeal, anatomy of the. 120 diseases of the, 121 sensory neuroses of the, 194 hypera-mia of, 79 hyperplasia of, 95 hypertropliy of, 95 hypoglossus, anatomy of tiie, 128 motor neuroses of the, 129 inflammation of, 79, see ^^'euritis inhiliitnry, 20 intercostal, sensory neuroses of tiie, 19H lumbar, anatomy of the, 14>t motf)r neuroses of the, 149 sensory neuroses of the, 200 meilian, paralysis of the, 144 motor, 20 musculospinil, paralysis of the, 141 nintii, anatomy of tlie, 120 sensory neuroses of the. 194 682 INDEX. Nerve, nuclei of origin of, 78 oculo-motor, anatomy of tlie, 99 paralysis of the, 104 olfactorj-, anatomy of the, 159 neuroses of the, 161 optic, anatomy of the, 163 diseases of the, 164 origin of, 78 peripheral, blood-vessels of the, 15 diseases of the, 78 phrenic, neuroses of the, 133 pneumogastric, anatomy of the< 131 posterior thoracic, paralysis of the, 141 regeneration of, 83 sacral, anatomy of the, 149 motor neuroses of the, 150 sensory neuroses of the, 305 sciatic, neuralgia of the, 301 secretory, 30 sensory, 19 seventh, anatomy of the. 111 diseases of the, 113 sixth, anatomy of the, 99 special sense, neuroses of the, 159 spinal, anatomy of the, 131 motor neuroses of the, 133 spinal accessor}', anatomy of the, 133 diseases of the, 133 suprascapular, paralysis of the, 141 sympathetic of the eye, paralysis of tlie, 106 syphilis of, 458 tenth, anatomy of the, 131 third, anatomy of the, 99 paralysis of the, 104 thoracic, anatomy of the, 147 motor neuroses of the, 147 sensory neuroses of the, 198 trigeminus, anatomj' of the, 170 motor neuroses of the. 111 sensory neuroses of the, 173 • trochlear, anatomy of the, 99 paralysis of the, 107 trophic, 30 Nerve, tumors of, 95 twelfth, anatomy of the, 138 ulnar, paralysis of the, 144 vagus, anatomy of the, 131 Nerve cells, 3, 5, 16 body of the, 7 centi'al, 8 connection of, with nerve fibres, 13 in the cord, 313 nucleus of the, 7 peripheral, 8 physiology of the, 31 processes of the, 5 reproduction of, does not take place, 30 Nerve fasciculi, 9 Nerve fibres, 9 connection of, with nerve cells, 13 medullated, 11 non-medullated, 11 size of, 13 Nervous diseases, causes of, 33, 60 diagnosis of, 39 functional, 467 symptoms of, 31 treatment of, 60, 591 Nervous exhaustion, 513 Nervous sj'Stem, arrangement of, 3 blood-vessels of the, 15 chemistry of the, 83 histology of the, 5 hygiene of tlie, 60 mechanisms of the, 30 neuronic architecture of the, 16 patholog}' of the, 37 peripheral, anatomy of the, 78 divisions of the, 3 physiology of the, 19 sj'mpathetic, 17 ganglia of the, 4 Neuralgia, 156 cervico-brachial, 197 cervico-occipital, 195 congestive, of the feet, 304 epileptiform, 174 Fothergill's, 174 hysterical, 487 INDEX. 683 Neuralgia, in peripheral uerve dis- ease, 84 intercostal. 198 lumbo-abdominal, 200 mammary, 199 Morton's, 204 plantar, 203 red, of the feet, 204 sacral, 205 sciatic, 201 trigeminal, 173 Neurasthenia, 513 acquired, 506, 523 angiopathic, 526 climacteric, 515, 523 course, 530 diagnosis, 529 etiology, 513 forms of, 516, 523 gravis, 527 hydrotherapy in, 592 liystero-, 523 l^ithogeny, 527 j)atiiology, 527 primarj-, 516. 523 jirognosis, 530 , spinal irritation, 525 symptoms. 517 traumatic, 516, 523 treatment, 531 Neurasthenic insanity, 628 Neuraxon, 5. 11, 16 cellulipi'tal impulses in the, 16, 17 Neurilemma, 11 Neuritis, 79 ascending, 80 brachial, 140 comjilicating forms of, 94 degciicralivc. SO dermatitic. 199 descending, 80 dilTuse, 80 disseminated, ^0 interstitial, 79 migrating, HO, 145 nudtiple, 85, see Poh/iieuritiit peri-, 79 retrobulbar. 166 Neuritis, segmental, 80 trioual, cause of, 87 ulnar, 145 Neurofibromata. plexiform, 95 Neuroglia, 13 Neuromata, 95 Neurons, 2, 5, 16 collaterals of the, 6 commissural, 20 diagram showing the arrange- ment of the, 18 end brush. 6 independence of the individual, 716 iuterceutral, 20 terminal arborization, 6 Neuro-retiuitis, 164 Neuroses, acquired, 501 anxiety, 532 detinition of, 31 degenerative, 468 functional, 467 occupation, 545 professional. 545 secretory. 37 sexual, 534 traumatic, 523, 536 tropiiic, 562 vasomotor. 562 Nictitating spasm, 115 Nigiitmare, 576 Night terrors, 577 Nose, neuroses of the, 161 Nuclein, 22 Numbness, waking, 154 Nyctalopia. 169 Nystagmus, 110 OnsKssio.N, 616, 631 Obsessive phrenastiienia, 631 Occupation us a factor in tiie eti- ology of nervous diseases, 25 fears, 631 Occupation neuroses, .545 Ocidar hypenesthesia, 168 Oculomotor nerve, anatomy of the, 99 l)aralysis of the, 1<>4 Ui^dema, augio ueurotit , .509 684 INDEX. Oedema, blue, of hysteria, 493 circumscribetl, 569 Olim, definition of, 68 Ohm's hiw, 68 Olfactory nerve, anatomy of the, 159 neuroses of the, 161 Olivary bodies, functions of the, 379 Onanism, 534 Operculum, 350 Ophthalmoplegias, 104 partial, in myasthenic paralysis, 108 progressive, 107 Optic atrophy, 167 in locomotor ataxia, 279 Optic chiasm, 163 Optic nerve, anatomy of the, 163 diseases of the, 164 Optic thalami, 354 Optic tract, 163 Organic insanities, 603 defect of development, 603 Orientation, 609 disorders of, 613 Original psychopathic conditions, 638 Orthophoria, definition of, 109 Osteo-arthropathy, pneumogenic, 565 Osteoma of the brain, 456 Pachymeningitis externa, cerebral, 393 spinal, 343 hypertrophic, 244 interna, 344 Pack, the wet, 64 Pain palsy, 499 sense, testing the, 55 Pains, lancinating, of locomotor ataxia, 377 neck, 196 remedies for the relief of, 613 side, 198 spot, in locomotor ataxia, 377 transferred, diagram of location of, 157 Palate, cord centres for muscles of the, 223 Pallor, 176 Palsy, Bell's, 115 Palsy, bulbar, progressive upper, 107 facial, 115 night, 154 shaking, 555 Papillitis, 164 Paradoxical contraction, 51 Paresthesia, 153 aero-, 153 cephalic, 153, 517 definition of, 37 trigeminal, 176 Parageusia, 195 Paralysis, abducens, 107 acoustic, 187 acute ascending, 267 atropine, 361 agitans, 555 alcoholic, 85 analgesic, with whitlow, 146 arsenical, 85 asthenic bulbar, 316 bulbo-spinal, 316 birth, 441 brachial, 136 bulbar, asthenic, 316 progressive, 314 bulbo-spinal, asthenic, 316 cerebral, of children, 437 compression, 141 definition of, 35 diphtheritic, 85 distribution of, from injury or disease of the motor nerves, 98 divers', 340 Erb's, 139 facial, 115 glosso-labio-laryngeal, 314 hemiplegic, 431, 435 hypertonic, 396 hysterical, 487 in peripheral nerve disease, 84 infantile spinal, 361 Landry's, 367 lead, 141 lingual, 129 oculo-motor, 104 of the ciliary muscle, 106 of the circumfiex nerve, 141 of the diaphragm, 133 INDEX. 685 Paralysis of the iris, 106 of the lumbar nerves, 1-19 of the median nerve, 144 of the musculo-spirul nerve, 141 of the phrenic nerve, 133 of the posterior thoracic, 141 of the sacral nerves, 150 of the spinal accessorj*. 127 of the suprascapular nerve, 141 of the sympathetic nerves of the eye, 106 of the ulnar nerve, 144 pain, 499 progressive bulbar, 314 spastic spinal, 295 hereditary, 297. 327 subacute spinal, 266 testing for. 45 Paramnesia. 614 Paramyoclonus multiplex, 507 Paramyotonia, congenital, 499 Paranoia, 649 acute hallucinatory, 651 etiology, 649 forms, 650 original, 650 pathological anatomy, 651 persecutoria. 649 progno.sis, 651 secondary, 651 symptoms, 649 treatment, 651 Paranoid tyiH'. 639 Paraphasia, 388 Paraplasm, 7 Paraplegia, definition of, 35 hereditary ataxic, 305, 327 hysterical, 487 senile, 266 spastic cerebral, 442 tetanoid. 295 Paresis. deJiintion of, 85 Paridrosis, definition of. 37 Parkinson's disease, 555 Parosmia, 162 Patella-tendon refiex, 48 Pathology, general, of the nervous system, 27 Pavor nocturnus, 577 Percept, 608 Perception, 608 disorders of. 612 Perineurium, 10 Peripheral nerves, diseases of the, 78 Pernicious anaemia, combined spinal scleroses of, 299 Personality, feeling of. 609 Pharynx, cord centres for muscles of the. 222 Philias, 31 Phrenasthenia. 628, 633 diagnosis, 684 obsessive, 631 prognosis, 634 treatment, 634 Phrenic nerve, neuroses of the. 133 Physical symptoms of insanity. 619 Physiology, general, of the nervous system, 19 Pia mater, cerebral. 867 intlammation of the. 893 spinal. 208 intlannnation of the. 245 Pianists' cramp, 550 Pineal gland, tumors of the, 451 Plexus, brachial, anatomy of the, 135 Plexuses, vascular, of the spinal cord. 232 Pneumogastric nerve, anatomy of the. 121 Pneumogenic osteo-arthroj^athy. 565 Poisoning as a factor in the etiology of nervous diseases, 26 Policeman's disease, 805 Polioencephalitis, 262 acute. 413 Poliomyelitis, acute anterior. 261 ciironic anterior. 266 Polviestiiesia. definition of, 55 Polyneuritis, 85 acute pernicious, 90 complicating forms, 94 diugnosis, 93 diphtheritic neuritis. 88 endenuc type, 90 epidemic type. \M etiology, 86 forms of, 85 686 INDEX. Polyneuritis, malarial, 90 motor tj'pe of, 85 pathology, 91 prodromes, 87 prognosis, 93 pseudo-tabetic tj-pe, 89 sensorj- type, 89 symptoms, 88 treatment, 94, 611 Polypathic brain, story of the man with the, 620 Pons Varolii, functions of the, 379 hemorrhage in the, 429 nuclei of tlie, 358 tumors of the, 453 Porencephalus, 439 Posterior thoracic nerve, paralysis of the, 141 Post-syphilitic degenerative proc- esses, 462 Potential, difference in, defined, 67 Prsedorniitium, disorders of the, 585 Pressure sense, testing the, 54 Primary dementia, 652 Professional neuroses, 545 Prognosis, general, 626 Projection system of the brain, 363 Prosencephalon, 3 Prosopalgia, 174 Protogou, 23 Protoplasm of the nerve cell, 7 Pseudo-muscular hypertrophy, 321 Pseudo-tabes, 89 Psychical epileptic equivalent, 469, 477 Psychic tics, 617 Psychology, general, 607 Psycho-neuroses, 601, 628 Psychopathic conditions, original, 628 ■wards, annual census of patients, 603 Psychoses, alcoholic, 654 autotoxic, 652 exhaustion, 653, 655 infection, 653 the minor, 628 toxic, 652 Psychosis, definition of, 31 hypochondriacal, 644 Psychosis, Korsakoff's, 653, 655 manic-depressive, 641 multiple neuritic, 653, 655 presenile delusional, 644 sexual, 540 suicidal, 644 traumatic, 523, 536 Ptosis, 104 waking, 106 Puerperal insanity, 654 Pupil, Argyll-Robertson, 51, 170 hemiopic reaction of the, 170, 451 in locomotor ataxia, 280 Hutchinson, 428 reflex, shutter for testing the, 105 Purkinje's cells, 359 Rachisciiisis posterior, 235 Railway spine, 536 Ranvier, nodes of, 11 Raynaud's disease, 205 Reaction at a distance in nerve de- generation, 81 electrical, diagnostic table of, 76 of degeneration, 74 time, 22 Red nuclei of the brain, 358, 378 Reasoning, 609 Re-enforcement of the knee-jerk, 50 Reflex action, 31 Reflex causes of nervous diseases, 26 Reflexes, 35 deep, 48 examination of the, 47 skin, 47 superficial, 47 tendon, 48 Reil, island of, 349 Remak, fibres of, 11 Rest treatment, 594 partial, 597 Retardation of thought, 613 Retina, anatomy of the, 163 Retinal hypersesthesia, 168 Rheostat, definition of, 69 Rhinencephalon, 159 Rhombencephalon, 3 R L S people, 139 INDEX. 687 Rolando, gelatinous substance of, 212 Kumpf s symptom, 513 Sacral nerves, anatomy of tlie, 149 motor neuroses of the, 150 sensory neuroses of the, 205 St. Vitus' dance, 501 Salivation, 176 Saltatory spasm, 508 Sarcoma of the brain, 456 Scavenger cells of Lewis, 14 Schmidt, incisures of, 11 Schullze, comma of, 216 Schwann, sheath of, 11 Sciatica, 201 treatment, 612 Scleroses, combined, of the spinal cord, 298 lateral spinal, 295 amyotrophic, 318 multiple, 416 aborted types of, 418 of nervous tissue, 29 of the spinal cord, 270 Putnam's tyi)e of combined spinal, 299 Senile paraplegia, 266 Senility, nerve degeneration in, 05 Sensations, 608 cutaneous, methods of testing the, 53 delayed, 37 disorders of, examination for, 52 general, 608 referred, 37 reflex, 37 special, 608 time for perceiving, 55 transferred, 37 Senses, special, centres for, 374 neuroses of the nerves of, 159 Scnsori-motor area in the l)rain, 373 Sensory tracts in the brain, 364 Sentiments, 610 Sewing-spasm, 551 Sex as a factor in the etiology of ner- vous diseases, 25 Sexual neiiroses ann^. 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