i -/•': LIBRARY OF CONGRESS. ifCs^i — ®$ap iqpjraB !$*♦ UNITED STATES OF AMERICA. . •\ SEP 1885 A TREATISE NEKVOTTS DISEASES; SYMPTOMS AND TREATMENT. A TEXT-BOOK FOR STUDENTS AND PRACTITIONERS. BY SAMUEL G. ' WEBBER, M.D., CLINICAL INSTRUCTOR IN NERVOUS DISEASES, HARVARD MEDICAL SCHOOL ; VISITING PHYSICIAN FOR DISEASES OF THE NERVOUS SYSTEM AT THE BOSTON CITY HOS- PITAL ; MEMBER OF THE MASSACHUSETTS MEDICAL SOCIETY ; MEMBER OF THE AMERICAN NEUROLOGICAL ASSOCIATION, ETC., ETC. //*'/•&' NEW YORK: D. APPLETON AND COMPANY, 1, 3, and 5 BOND STREET. 1885. 1t( COPTEIGHT, 18S5, Bt D. APPLETON AND COMPANY. PREFACE. This book was commenced with the purpose of writing briefly, and including what is most essential for the study of nervous diseases, within as small a compass as possible. The limits originally marked out have been somewhat exceeded. The histories of discoveries, reports of cases, and discussions of disputed points have been omitted ; the opinions of different observers have been alluded to only rarely. An effort has been made to describe the symptoms with sufficient detail to render easy the recognition of a case in practice. My own views have been formed from observation and from reading the opinions of others ; to give proper credit in every instance might be impossible. The attempt has not been made. Of course, in the brief Bibliographies only a few authors could be mentioned, compared with the large number who have contributed to an increase of our knowl- edge during the last few years. The book is not written for specialists. Many will probably find that no department or division is so fully treated as they may sometimes wish. I iv PREFACE. trust that students and general practitioners who have little time to read will find what they most need for diagnosis and treatment of the cases occur- ring in practice. In some parts, especially the intro- ductory chapters, the condensation may seem to have been carried too far ; but more extensive descriptions would have required an increase in bulk. 133 Botlston Street, Boston, June 1, 1S85. CONTENTS CHAPTER I. PAGE General Introduction 1 Methods of Testing Sensation, 1 ; Methods of Testing Motion, 5 ; Reflexes, 8 ; Tdche Cerebrate, 9 ; Cheyne-Stokes Respiration, 10 ; Bed- Sores, 10; Constipation, 11; Cystitis, 12; Nutrition, 12. DISEASES OF THE BRAIN. CHAPTER II. Introductory 17 Anatomy, 18 ; Physiology, 33 ; General Symptomatology, 3*7 ; Disturbances of Speech, 46. CHAPTER III. Diseases of the Membranes 50 External Pachymeningitis, 50; Internal Pachymeningitis, 51; Simple Inflammation of the Pia Mater, 53 ; Tubercular, 61. CHAPTER IV. CnANGE in Blood-Supply 68 Cerebral Anaemia, 68 ; Cerebral Hypersemia, 74. CHAPTER V. LI^ilORRHAGE 84 Meningeal Haemorrhage, S4; Cerebral Haemorrhage, 86. CHAPTER VI. Occlusion of Cerebral Arteries " 107 Embolism, 107; Thrombosis, 112. vi CONTENTS. CHAPTER VII. PAGE TUMOES OF THE BbAIN 116 CHAPTER VIII. Abscess of the Bbain 124 DISEASES OF THE SPINAL CORD. CHAPTER IX. Anatomy of the Spinal Coed • . 131 Physiology of the Spinal Cord, 136 ; General Symptomatology, 138. CHAPTER X. Spinal Meningitis 149 Pachymeningitis Interna, 149 ; Inflammation of the Pia Hater (Leptomeningitis), 152. CHAPTER XI. Changes in Blood-Supply 156 Spinal Hyperemia, 156; Spinal Anaemia, 158. CHAPTER XII. Spinal H-emoeehage 159 Meningeal Haemorrhage, Haematorrhachis, 159; Haemorrhage into the Spinal Cord, Haematomyelitis, 162. CHAPTER XIII. Slow Compeession of the Spinal Coed 167 Spinal Tumors, 1*73. CHAPTER XIY. Syeingomyelia. — Foemation of Cayities. — Hydeomyelus . 176 CHAPTER XV. Myelitis, Acute 179 Chronic, 188; Acute Ascending Paralysis, 192. CONTENTS. v ii CHAPTER XVI. PAGE Poliomyelitis. Myelitis of the Anterior Coenua . . . 195 Acute Anterior Poliomyelitis, 195 ; Chronic Anterior Polio- myelitis, 202. CHAPTER XVII. Progressive Muscular Atrophy ...... 207 CHAPTER XVIII. Bulbar Paralysis (Labio-Glosso-Laryngeal Paealysis) . . 215 Acute Bulbar Paralysis, 222. CHAPTER XIX. Locomotor Ataxia. — Tabes Dorsalis. — Posterior Spinal Scle- rosis 224 CHAPTER XX. Sclerosis. — Multiple Sclerosis 242 Sclerosis of the Lateral Columns, 250; Amyotrophic Lateral Sclerosis, 252. CHAPTER XXI. Pseudo-Hypeetrophio Paralysis 255 DISEASES OF THE PERIPHERAL AND SYMPATHETIC NERVES. CHAPTER XXII. Simple Neuritis 261 Multiple Neuritis (Disseminated Neuritis), 266. CHAPTER XXIII. Neubalgia 270 Trifacial Neuralgia (Prosopalgia), 274; Cervico-Occipital Neu- ralgia, 2H; Cervico-Brachial Neuralgia, 275; Dorso-Intercostal Neuralgia, 275 ; Lumbo-Abdominal Neuralgia, 276 ; Sciatica, 276. viii CONTENTS. CHAPTER XXIV. PAGE Local and Post-Febrile Paralysis 285 Peripheral Paralysis, 285 ; Special Forms of Paralysis, 289 ; Paralysis of Ocular Nerves, 289 ; Paralysis of Seventh Nerve, 289 ; Paralysis of the Brachial Plexus, 293 ; Paralysis after Acute Dis- eases, 294 ; Diphtheritic Paralysis, 295. CHAPTER XXV. Spasm 298 Facial Spasm, 299 ; Torticollis, or Wry-Neck, 301 ; Spasm of the Diaphragm, 303 ; Professional Cramp, 304. CHAPTER XXVI. Diseases of the Sympathetic 307 Cephalalgia, Headache, 307 ; Megrim, Sick Headache, Migraine, 311; Graves's Disease (Exophthalmic Goitre), 316; Angina Pec- toris, 318 ; Symmetrical Gangrene, 322 ; Unilateral Facial Atrophy, 324. UNCLASSIFIED. CHAPTER XXVII. Vertigo 329 Meniere's Disease, 330. CHAPTER XXVIII. Chorea 332 CHAPTER XXIX. Paralysis Agitans. — Shaking Palsy.— Parkinson's Disease . 339 CHAPTER XXX. Epilepsy 342 CHAPTER XXXI. Hysteria Hystero-Epilepsy, 360. CONTENTS. lx CHAPTER XXXII. PAGE Netjeasthenia 371 CHAPTER XXXIII. Tetanus (Locked-Jaw) ........ 379 Tetany, 383. CHAPTER XXXIV. Mtxcedema 386 CHAPTER XXXV. Toxio Neueosis 389 Chronic Lead-Poisoning, 390 ; Arsenic, 394 ; Alcohol, 395 ; Hydrophobia, 399. CHAPTER XXXVI. Syphilis 403 Syphilis of the Brain, 403 ; Syphilis of the Spinal Cord, 408 ; Syphilis of the Nerves, 409 ; Treatment of Syphilis of the Nervous System, 409. A TREATISE ON NERVOUS DISEASES. CHAPTER I. GENERAL INTRODUCTION. Eulenburg, A., Lehrbuch der functionellen Nervenkrank- heiten. Berlin, 1871.— Ziemssen, Cyclopaedia of the Practice of Medicine. Vols. XI, XII, XIII, XIV.— Eosenthal, M., A Clin- ical Treatise on the Diseases of the Nervous System. Trans, by L. Putzel. New York, 1879.— Hammond, William A., A Treatise on the Diseases of the Nervous System. New York, 1881. — Ham- ilton, A. McL., Nervous Diseases : their Description and Treat- ment. Philadelphia, 1881. — Charcot, J. M., Lectures on the Dis- eases of the Nervous System, delivered at La Salpetriere. Trans, by George Sigerson. New Sydenham Society, 1877, 1881. — Gr as- set, J., Maladies du systeme nerveux. 1881. — Buzzard, T., Clini- cal Lectures on Diseases of the Nervous System. Philadelphia, 1882.— Axenfeld, A. (Huchard), Traite des nevroses. Paris, 1883. — Eoss, James, A Treatise on the Diseases of the Nervous System. 2 vols. New York, 1883.— Strumpell, A., Krankheiten des Ner- ven-systems. Leipzic, 1884. It will be an advantage to consider in a general way the methods of examining sensation and motion in pa- tients affected with nervous diseases. It will prevent the necessity of repetition if certain symptoms or com- plications are also considered in this introductory chapter. METHODS OF TESTING SENSATION. Changes of sensation of touch may be recognized by touching the patient as lightly as possible with the l 2 A TREATISE ON NERVOUS DISEASES. finger or a feather. The finger should be kept still, on the spot first touched ; if it is moved about, rubbing the skin, the patient will much more readily recognize that he has been touched. The temperature of the finger should be as nearly as possible equal to that of the body ; otherwise the difference in temperature is felt. Changes in the sensation of pressure may also be recognized with the finger by varying the amount of pressure and asking the patient whether it is greater or less. There are various apparatus for more deli- cately testing this sense by means of adding graduated weights, but these are unnecessary for ordinary pur- poses. In testing the sense of pain, a pin or a knife can be used, or the patient can be pinched with varying de- grees of severity. If one or two hairs on the patient's limbs are pulled, the sensation will be very nearly the same as if a pin were stuck into that place. Changes in the sensation of temperature may be ex- amined by means of spoons dipped in tumblers of water of different temperature. More delicate methods of ex- amining the variations in the sense of temperature may be found in having small bottles full of water of differ- ent temperatures. The patient is then asked whether the temperature of one is higher or lower than that of another. But these are rather refinements of examina- tion, which are rarely of any great practical value. The muscular sense may be tested by asking the patient, with his eyes shut, to move his limbs in differ- ent directions, or to find his feet in the bed, or, when the limbs are widely separated, to raise one foot and put it down by the side of the other. The (Bsthesiometer is used in testing the ability of the patient to recognize whether one or two points touch the surface of the body. A rough form of sesthesiom- eter may be contrived by holding two pins in the fin- gers and, varying the distance of their points, touching GENERAL INTRODUCTION. 3 the patient with, them ; or needles may be stuck in a piece of wood, and then the patient touched. There are, however, many simple instruments for this exami- nation, as compasses with a graduated scale, or points sliding on a graduated rod. In making this examina- tion, it is necessary that both points should touch the skin together with as nearly as possible equal force. In examining the opposite sides of the body, the points should be either transverse on both sides, or parallel with the axis of the limb on both sides. They should not be transverse on one side and longitudinal on the opposite. The various sensations may be more acute than nor- mal — hyperesthesia ; or less acute — anaesthesia ; or there may be a perceptible delay in their recognition. Occasionally, when only two points are applied to the skin, the patient will have a sensation as if three or more touched him. The vision may be affected in several ways. There may be partial blindness (amblyopia), or there may be entire blindness, or various other changes ; — diplopia, if the axes of the two eyes are not parallel. This defect may be present only when the patient looks in cer- tain directions, if one muscle is weaker than the corv responding muscle on the opposite side, so that the diplopia may not be noticed unless the patient looks to the right or left, or upward or downward. Vision may be limited in extent, so that the patient sees only ob- jects placed directly in front of him. Or, more rarely, central vision may be wanting, and only objects around the periphery of the field of vision may be recognized. The extent of vision for white light may be normal, or nearly normal, but the field of vision may be circum- scribed for colors. The extent at which colors can be seen is naturally not so great as the extent at which white can be seen ; thus, the field of vision for green is the most contracted, next in extent is the field for red, then blue, then yel- 4 A TREATISE OK NERVOUS DISEASES. low. In some cases, the field of vision, instead of be- ing limited concentrically, is lost on one side, so that the patient sees only that part of an object which is to the right or left of the median line. This is called he- miopia, as referred to the retina, or hemianopsia, as referred to the field of vision. If accuracy is required in an examination, it is ne- cessary to use a blackboard with a point of fixation, the patient being placed at a distance of a foot from that point, with one eye covered ; a bit of white paper or chalk is then moved from the outside inward until the patient can see it, and a mark is made on the board. This is repeated at short intervals around the central spot until we have mapped out roughly the field of vision of the eye. It is generally sufficient, however, with the patient sitting in front of the physician, with one eye covered, the other eye fixed upon the center of the physician's face, for the physician to move his fingers first one side and then the other, above and below, and inquire whether the patient sees the motion of the fingers. Sometimes the field of vision for white is natural, or nearly natural, but colors can be recognized only in one lateral half of the field of vision — hemianacropia ; for testing such a change, the blackboard, with bits of colored paper, would be necessary. The ophthalmoscope is absolutely necessary in order for a satisfactory examination of patients with diseases either of the brain or of the spinal cord, and it is better to use it in every case, no matter what the dis- ease may be supposed to be. To give any satisfactory description of the use of the ophthalmoscope would require altogether too much space, a short description being very unsatisfactory. It is better to refer to books on ophthalmology for such description. It is very necessary to examine the pupils, to note changes in their reaction to light and to accommoda- GENERAL INTRODUCTION. 5 tion, to notice whether both pupils act alike, or whether there are differences between the two. In examining the pnpils, it is necessary to cover the one not nnder observation, as otherwise the light, falling npon the sound eye, may cause contraction, when, if examined separately, the pupil would remain immovable. METHODS OF TESTING MOTION. The motor power may be examined by simply watching the movements of the patient. With chil- dren, it is a good plan to allow them to roam about the room, playing with whatever attracts their fancy. With adults, one can watch their gait as they enter the room, their manner of taking a seat or executing other motions ; if it is necessary for them to undress, the way in which they take off their clothing should be noted. Much can be learned by thus carefully watch- ing the ordinary motions of patients. If it is desired to recognize clearly slight losses of power in the limbs, the dynamometer may be used. There are several different forms of this instrument ; the simplest is the best. It is not necessary to estimate the exact power, in pounds, of pressure, but it should be possible, from the scale of the dynamometer, to esti- mate the relative power of the two sides of the body, A rough idea of the relative strength of the two hands can be gained by allowing the patient to squeeze one's hand. Slight fibrillary twitchings of the muscles may sometimes be excited, if they do not occur spontane- ously, by snapping the muscles with the finger. The natural tone of the muscle is also indicated by the energy with which a single contraction takes place under the snapping of the finger. The most delicate test of muscular power is elec- tricity. Under some circumstances the muscle loses its power of responding to the irritation of the faradic or 6 A TREATISE OF NERVOUS DISEASES. the galvanic current. Any muscle which is separated from its centers of nutrition in the spinal cord under- goes the above change of reaction, whether the disease is a destruction of those trophic centers or of the nerve- fibers passing from them to the muscle. The first change noticed in the muscle may be a slight and temporary increase of irritability for both forms of electricity. A day or two afterward the mus- cle begins to lose its power of reacting to the f aradic current. By the end of the second or third week it no longer responds to this stimulus. After a slight dimi- nution of reaction to the galvanic current, during the second week the irritability of the muscle for this cur- rent increases until it becomes much greater than nor- mal. This increased irritability for the galvanic cur- rent may continue for many weeks or months, but at length is gradually lost, until, if the paralysis is perma- nent, the muscle responds to neither current. With this change in the amount of irritability there occurs a difference in the manner in which the muscle reacts to the galvanic current. Instead of the natural, rapid, spasmodic contraction, the muscle contracts slowly, the contraction reaching its height only after a perceptible interval of time, and then slowly relax- ing — a change that is very evident, even to the un- skilled observer. There are also changes in the quality of the reaction to the galvanic current, according as the positive or negative pole is placed upon the muscle, and the cur- rent closed or opened. These changes are of less prac- tical value, and can be learned from works on electro- therapeutics. This " reaction of degeneration" is of great im- portance in diagnosis. Reflex actions play an important role in the internal economy of the body, and in its relation with the ex- ternal world. An impression made upon an afferent nerve is car- GENERAL INTRODUCTION. ? ried to a group of nerve-cells ; by means of these, alone or in connection with other groups, it is transformed into a motor impulse, which is carried by efferent nerves to muscles, and causes them to contract. This is the simplest form of a reflex action. The muscles excited are usually those nearest the point receiving the irritation. If, however, the irritation is severe, dis- tant muscles may be brought into action, even those on the opposite side. The muscles may not be voluntary ; they may belong to internal organs, as stomach, intes- tines, bladder ; the impression may be made upon these viscera, not on the surface of the body ; the groups of nerve-cells may not be in brain or cord, but in one of the sympathetic ganglia, or in the walls of the viscus. The impressions upon the special senses may give rise to reflex actions confined to the organ receiving the impression, as movements of the iris, contraction of the intrinsic muscles of the ear ; or the impression may be so strong as to call into action other muscles of the body, as when a loud noise or bright flash causes the head to turn, or sets the heart beating violently. Reflex actions control, in a very large degree, the secretions of the different glands and the supply of blood to various parts of the body. Thoughts and emotions have a great influence upon the circulation, the secretions, and the nutrition of the body ; this influence is generally reflex in its nature, and may often be utilized in the treatment of disease. It is not necessary that the brain should take cogni- zance of the impressions which excite reflex action ; in- deed, these actions are often more powerful when the subject is unconscious of the impression exciting them, as when the spinal cord is divided. The reflex centers for the different groups of mus- cles in the limbs are situated at about the level whence the nerves supplying those muscles arise. There are reflex actions which follow an irritation of the skin — cutaneous reflexes ; also actions which follow irritation 8 A TREATISE ON NERVOUS DISEASES. of deeper parts, of which the tendon reflexes are ex- amples. The various reflexes require a separate description, Gowers has given the clearest account of these. By gently irritating the skin, by tickling, scratching, or pricking, the superficial or cutaneous reflexes may be excited. Gowers mentions the plantar (from the sole of the foot), depending on the lower part of the lumbar enlargement ; the gluteal, by irritating the skin of the buttocks, depending on the cord at the level of the fourth or fifth lumbar nerve ; the cremaster, by which the testicle is drawn up when the skin on the inner aspect of the thigh is irritated, depending on the first and second lumbar pairs ; the abdominal, by irritating the skin at the side from the ribs downward, depending upon the eighth to the twelfth dorsal nerves ; the epi- gastric, produced by irritating the side of the chest in the fourth to the sixth intercostal spaces, depending upon the fourth to the seventh dorsal nerves. There are sometimes reflexes on the back, caused by irritating the skin along the edge of the erector-spin?e muscles ; and when the skin between the scapula3 is irritated, some of the scapular muscles contract, the scapular reflex. The deep reflexes, as they are sometimes called, in- clude the clonus and tendon reflexes. The more com- mon are the 'patella tendon reflex, and that developed just above the elbow. To obtain these, the limb should be semi-flexed, should hang free without voluntary muscular tension ; a sharp blow just below the patella, on its ligament, or on the tendon just above the olec- ranon process, produces a sudden contraction of the muscle and partial extension of the limb. To examine for the patellar tendon reflex, the patient should sit on a high chair or table, with the legs swinging free ; or, if the feet rest on the floor, one leg may be thrown over the opposite knee, or the physician can pass his arm under the knee, resting his hand on the other knee, the GENERAL INTRODUCTION. 9 leg hanging free over his arm. For the examination of the triceps humeri tendon reflex, the patient's arm, semi-flexed, should be supported so that the forearm can move with moderate freedom. Tendon reflexes are occasionally found with other tendons. Ankle-clonus is excited by holding the patient's leg extended, or very slightly flexed on the thigh ; then, by suddenly flexing the foot, and perhaps the toes too, the Achilles tendon and the flexors of the toes are put on the stretch ; then a rhythmic contraction and relaxa- tion of the calf muscles occur, which continue as long as the proper degree of flexion of the foot is maintained. Sometimes a strong pressure on the sole of the foot is needed to develop this, and sometimes only a very light pressure, the stronger checking the clonus. The clonus can sometimes be excited by a similar flexion of the wrist-joint. When the reflex excitability is much ex- aggerated, it may be possible to obtain a clonus in the toes or fingers. The front tap contraction, which Gowers says is a very delicate test of increased irritability, is obtained by keeping the leg nearly extended on the thigh, the foot moderately flexed so as to keep the tendo- Achilles slightly tense, then a gentle tap with the ends of the fingers is made over the edge of the tibia. The calf muscles contract, drawing the foot down ; the action is usually very slight, and is the stronger the nearer the ankle the tap. A tap over the head of the tibia will sometimes pro- duce a contraction of the rectus femoris ; or a tap over the radius at the wrist will cause contraction of the biceps ; over the ulnar at the wrist, of the triceps. TacTie cerebrate is developed by drawing the finger- nail or the finger across the skin, especially over the abdomen. A red line appears after a variable length of time, corresponding to the tract of irritation. This line can be produced in a large majority of patients. 10 A TREATISE ON NERVOUS DISEASES. It is of value as a symptom only when it appears very quickly and is of a deep color ; the line made with the nail is brighter than the broader line made with the finger. At the side of the red line the skin seems to acquire a paler tint, as if the smaller vessels were con- tracted. This sign is of less value than was formerly supposed. Cheyne-StoJces respiration, named from those who first described it, consists of a peculiar rhythmical change in the breathing. After a pause, in which two or three respirations are lost, the lungs are again filled, the breathing slowly increases in rapidity until a limit is reached ; the frequency then diminishes until there is another pause. This succession of respiratory acts is then repeated. This symptom is a very serious one, and almost always indicates a fatal termination. Bed-sores form with extreme rapidity in some cases of lesion of the spinal cord, as the result of irritation of the cord; at other times they are slow in appear- ance. They are among the most annoying complica- tions, and sometimes give great discomfort. Perfect cleanliness, bathing the skin after every passage, changing the bedding when wet or soiled, are absolutely necessary to prevent their occurrence. When the j>atient can be moved, his j>osition should be changed to relieve pressure. The whole back, especially the sacral region, should be bathed daily with strong al- cohol. When the skin becomes discolored and a bed-sore seems imminent, even greater care should be taken in bathing, that spot be relieved from pressure, and, if the skin is broken, zinc ointment may be used. Further mischief may sometimes be thus avoided. If a slough forms, the best treatment is the alternate use of ice and poultices — ice for two or three minutes, then poultice for two or three hours. Of course, the offensive dis- charges must be removed ; where the edges are under- mined, a gentle stream of water from a fountain syringe GENERAL INTRODUCTION. 11 must be used to wash out the pockets holding the dis- charge. Carbolic acid, thymol, phenol, or similar sub- stances, may be sprinkled on the poultices. A char- coal poultice is sometimes of benefit. Various water-beds, air-beds, and fracture-beds are in use for these cases, and may answer a good end. A mild galvanic current has been recommended, obtained by a silver plate on the sore, connected by wire with a zinc plate over the sound skin, and a piece of wet cloth placed between the zinc and the skin. Constipation accompanies many nervous affections, whether organic or functional. Violent means to reme- dy this are rarely desirable. Hyoscyamus, belladonna, nux vomica, can be added to prescriptions or given in- dependently, and may relieve the bowels sufficiently. If these are not sufficient, small doses of compound extract of colocynth may be added. Unless there is some contra-indicaf ion for strychnia, the following may prove serviceable : $ Ext. colocynth. comp., gr. \ to 2 ; Ext. belladonnse, gr. \ to \ ; Ext. nucis vomic, gr. \ to \. M. Fl. pil. A half -grain or grain of ipecac may be added to this with advantage if there is slight gastric disturbance. This should be given from once to three times daily, as may be necessary. Drinking copiously, especially a large supply of water, hot or cold, early in the morning, will many times be all that is necessary. In lesions of the spinal cord, more energetic cathar- tics may be needed ; aloin or podophyllin, with bella- donna or hyoscyamus, can be given in small pills. Ex- tract of colocynth may be combined with these. Ene- mata of soap-suds or castor-oil, or both, may be needed to assist the drugs. It is very desirable to avoid im- paction of the fffices. 12 A TREATISE ON NERVOUS DISEASES. If a stool has been long delayed, an enema of six to sixteen ounces of olive-oil, retained two or three hours, then followed by a pint or more of soap-suds, will often produce a motion with comparatively little discomfort to the patient. Of course, the physician should judge of the size of the enemata by the condition of the patient. A " fountain syringe " is much preferable to others. Cystitis is frequently a troublesome complication in cases of paralysis. It is most frequently associated with lesions of the spinal cord, and sometimes is rather early in its appearance. Whenever there is retention of urine, there is danger lest, being only partially evacu- ated, the residue should become alkaline, and phos- phatic sediments form ; the decomposed urine is a source of irritation, and inflammation of the bladder is set up ; this inflammation may extend to the ureters and kidneys, giving rise to much distress, and being itself a source of exhaustion and danger. The bladder should be emptied by catheter twice a day. A long rubber tube attached to the end of the catheter, hanging into a vessel on the floor by the side of the bed, helps to keep the bed dry, and acts as a siphon to more thoroughly empty the bladder. If the urine becomes alkaline, benzoic acid, five grains thrice daily, or boracic acid, or salicylic acid, may be given. The bladder should be washed out at least once a day with a double catheter, using a weak solution of carbolic acid or nitrate of silver ; the latter can be used of a strength of three or four grains to the ounce every third to sixth day. The diet should be easily digestible with mild drinks. The nutrition of patients is often below normal. It is a task to eat when there is no appetite, and the pa- tient, yielding to his aversion for food, eats little ; grad- ually the whole system suffers, yet there is no demand for more food ; the system becomes accustomed to the lowered standard of nourishment. GENERAL INTRODUCTION. 13 Many times the greatest patience and tact is needed to restore the lost strength. It is generally better to give food frequently in small quantities than to try to increase the amount taken at one time. The intervals may be as near as every half -hour or hour. Milk is the most convenient food. It can be made more palatable by adding salt, and more digestible by adding lime-water, half an ounce to six ounces of milk, or five grains of bicarbonate potassa or soda to the same amount. It should be slowly sipped, or taken with a teaspoon — not drank : one to three quarts a day, ac- cording to how much else is taken. Koumiss is a pleas- ant and easily digestible form of milk ; directions for making it are given in the Dispensatory. Eggs, if perfectly fresh, are usually acceptable pre- pared in various ways. It is very hard to obtain per- fectly fresh eggs in a city ; most city eggs are some- what stale, and sometimes, if eggs are laid in musty hay, they acquire a disagreeable flavor ; in either case patients may not be able to enjoy them. Eggs should not be fried. Fat is an important article of diet for nervous pa- tients. Often too little is taken. Cod-liver oil is ex- cellent if it can be taken; if not, cream and butter may be used as substitutes. Butter should not be heated above the boiling-point for water, and should not be used for cooking. A powder of beef, which is made by J. Fere, im- ported by E. Fougera & Co., New York, forms a valu- able article of diet in many cases. It can be mixed with water or milk ; it is already cooked. The ordinary beef-teas and essences are of very small value as food. Sometimes it may be necessary to feed with a stom- ach-tube. This may be passed twice or even three times a day, and it is much better to use it than to have a patient live half starved. In hysteria and in- sanity it is sometimes absolutely necessary to thus feed a patient. U A TREATISE ON NERVOUS DISEASES. When there is obstinate vomiting, it may be well to let the stomach rest a few days, giving only small pieces of ice ; then begin with small amounts of food, gradu- ally increasing. Patients may be fed by the rectum, using partially digested meat, milk, or, better than these, an egg beaten up with ten grains of pepsin. Generally an egg or two can be given in this way every five or six hours ; it is better to wash out the bowels once in twenty-four to forty-eight hours with a warm- water enema, Nutrient enemata should have a temperature of about 95° to 100°. If not too much exhausted at first, patients can be sustained for a fortnight or more in this way. DISEASES OF THE BRAIN. CHAPTER II. INTRODTTCTOKY. Anatomy.— Henle, J., Handbuch der Nervenlehre des Men- schen. — Weenicke, C, Lehrbuch der Gebirnkrankbeiten, Bd. I. — Schwalbe, G., Lebrbucb der Neurologie (Hoffmann's Lehrbucb der Anatomie des Menschen, 2. Bd., 2. Abt.).— Ranney, A. L., The Applied Anatomy of the Nervous System. — Ecker, A., The Cere- bral Convolutions of Man. Trans, by Robert T. Edes. 1873. — Duret, H., Recherches anatomiques sur la circulation de l'en- cephale. Arch, dephysiol., normal et pathol., 1874. — Duval, M., Recherches sur l'origine reelle des nerfs craniens. J. de Vanat. et de la physiol. , xii-xvi. , 1876-80. Physiology.— Fritsch und Hitzig, Ueber die electrische Erreg- barkeit des Grosshirns. Reichart und Du Bois-Reymond's Arch., 1870. — Ferrier, Experimental Researches in Cerebral Physiology and Pathology. West Riding Asylum Med. Rep., 1873.— Ibid., The Functions of the Brain. 1876.— Ibid., The Lo- calization of Cerebral Disease. New York, 1879. — Charcot, J. M., Lectures on Localization in Diseases of the Brain. Trans, by E. P. Fowler. New York, 1878.— Carville, C, and Duret, H., Sur les functions des hemispheres cerebraux. Arch, de physiol., 1875.— Dodds, W. J., On the Localization of the Functions of the Brain : being an Historical and Critical Analysis of the Question. Jour, of Anat. and Physiol., 1878. — Seguin, E. C, Lectures on the Localization of Spinal and Cerebral Disease. N. Y. Med. Record, 1878. — Pitres, J. A., Recherches sur les lesions du cen- tre ovale des hemispheres cerebraux, etudiees au point de vue des localisations cerebrales. Versailles, 1877. — Exner, Sigmund, Un- tersuchungen iiber die Localisation der Functionen in der Gross- hirnrinde des Menschen. Wien, 1881. — Munk, Hermann, Ueber die Functionen der Grosshirnrinde. Berlin, 1881. — Fere, Ch., Contribution a l'etude des troubles fonctionelles de la vision par lesions cerebrales. Paris, 1882. — Wadsworth, O. F., Three Cases of Homonymous Hemianopia. Boston Med. and Surg. Jour., May 22, 1884, p. 483.— Wilbrand, H., Ueber Hemianopsie und ihr Verhaltniss zur toplschen Diagnose der Gehirnkrankheiten. Ber- lin, 1881. — Ibid., Ophthalmiatrische Beitrage zur Diagnostik der Gehirnkrankheiten. Wiesbaden, 18S4. 18 DISEASES OF TEE BRAIN. ANATOMY. The accompanying diagrams from Ecker, with ex- planations, will illustrate better than any verbal de- scription the nomenclature of the convolutions. r cm. Fig. 1. — View of brain from the side. (Ecker.) F, frontal lobe ; P, parietal lobe ; 0, occipital lobe ; T, temporal lobe ; S, fis- sura Sylvii ; S', horizontal, 2 , second, 3 , third occipital convolution ; po, fissura parieto-occipital, internal perpendicular fissure ; o, sulcus occipitalis trans- versa; o 2 , sulcus occipitalis longitudinalis inferior ; T u first, T%, second, T 3 , third temporal convolution ; £,, first, t^, second temporal fissure. (t% is generally bridged, and so interrupted. ) ANATOMY. 19 In these diagrams only the important snlci are given ; these vary somewhat in different brains ; the convolu- tions between these snlci are subdivided by secondary sulci, whose arrangement is less constant. Occasion- ally one of the principal sulci may be bridged over by a convolution, causing an apparent irregularity. Fig. 2. — View of the brain from above. (Ecker.) Lettering same as in Fig. 1. From the cortex, medullary nerve-fibers pass through the white substance, the centrum ovale, converging to- ward the basal ganglia — corona radiata. They con- verge from all parts toward a tract of white substance 20 DISEASES OF TEE BRAIN. which separates these basal ganglia from each other — the internal capsule. This capsule is one of the regions whose physiology is best known, whose lesion gives the most definite and permanent symptoms. ra fa-A-, ra t3 Fig. 8. — View of the brain from below. (Ecker.) F u gyrus rectus, the prolongation of the first frontal convolution ; F 9 , middle, F 3 , lower frontal convolution ; / 4 , sulcus olfactorius ; / 6 , sulcus orbitalis ; T t , second, or middle, T 3 , third, or lower temporal convolution ; T t , gyrus occipito- temporalis lateralis (lobulus fusiformis), T 6 , gyrus occipito-temporalis medialis (lobulus lingualis) ; t 2 , middle, t 3 , lower temporal fissure ; r 4 , sulcus occipito-tem- poralis inferior ; po, fissura parieto-occipitalis ; oc, fissura calcarina ; If, gyrus hippocampi; V, gyrus uncinatus; Ch, chiasma ; cc, corpora albicantia; EK, pedunculi cerebri ; C, corpus callosum. Fig. 4. — View of the medial surface of the right hemisphere. (Ecker.) CC, corpus callosum, cut through the middle ; Gf, gyrus fornicatus, IT, gyrus hippocampi, h, sulcus hippocampi, U, gyrus uncinatus ; cm, sulcus calloso-margi- nalis, Fi, first frontal convolution, its medial side ; c, end of sulcus centralis, A, anterior, B, posterior central convolution ; Oz, cuneus ; P', precuneus ; po, fissura parieto-occipitalis ; o, sulcus occipitalis transversus; oc, fissura calcarina; oo\ upper, oc", lower branch ; D, gyrus descendens ; T A , gyrus occipito-temporalis lateralis ; T 5 , gyrus occipito-temporalis medialis (lobulus lingualis) ; around the central fissure is a quadrilateral lobule, A, B, called the paracentral lobule. The accompanying representation, an outline from a photograph by Bitot, will give a sufficiently clear idea of the more important divisions. The caudate nucleus and the outer or third member of the lenticular nucleus receive few fibers from the co- rona radiata, nearly all of whose fibers pass into the in- ternal capsule. Fine bundles of white fibers pass from the lenticular nucleus into the internal capsule, and seem to pass on to the pyramidal tract. From the caudate nucleus many bundles of fibers pass into the anterior limb of the internal capsule ; others cross this and enter the lenticular nucleus. 22 DISEASES OF THE BRAIK The fibers which have been described as entering the internal capsnle are destined in part for the basis of the cms ; the remainder are lost in the different parts of the optic thalamus, and in the tegmentum cruris, some reaching the cerebellum. Fig. 5. — Horizontal section of the brain. ccl, corpus callosum ; en, caudate nucleus ; fv, fifth ventricle ; cl, claustrum ; i, island' of Eeil ; cf, crura of the fornix, which, turning upon themselves, form the corpora albicantia ; ee, external capsule ; tv, third ventricle ; th, optic thalamus ; cge, external corpus geniculatum ; era', the lower part of caudate nucleus ; pv, pul- vinar ; cq. corpora quadrigemina ; egi, internal corpus geniculatum ; i, n, in, the three divisions of lenticular nucleus (on the left only two divisions are seen) ; aic, hie, pic, the anterior limb, knee, and posterior limb of the internal capsule. The following diagrams, in some respects slightly modified from Wernicke, will help to an understand- ing of the course of the most important bundles of fibers, and the relations of the ganglia. ANATOMY. Charcot has shown that only a part of the fibers of the internal capsnle passes beyond the pons. The cap- sule is divided into an anterior and a posterior limb, the angle formed by the two being called the knee of Fig. 6. — Diagram of a perpendicular section of the brain, showing the internal capsule and its relations. gf, gyrus fornicatus ; cc, corpus callosum ; v, ventricle ; f, fornix ; nc, caudate nucleus ; tk, optic thalamus ; ci, internal capsule, upper (anterior) limb ; p, pedun- cle ; ci', internal capsule, lower (posterior) limb ; nc'-, lower part of caudate nucleus ; o, optic tract ; gh, gyrus hippocampus ; i, island of Eeil ; el, claustrum ; nl, len- ticular nucleus. the capsule. The fibers from the anterior limb pass through the inner portion of the basis cruris. When a lesion implicates only these, the descending degener- 24 DISEASES OF THE BRAIN. ation can be traced as far as the pons, but not beyond. That portion of the fibers of the basis which arises from Fig. 7. — Diagram of a horizontal section of the brain, showing the course of the peduncular fibers. ca, anterior commissure ; i, it, in, the three divisions of lenticular nucleus ; pi, pm, pe, the internal, middle, and external portions of the peduncular fibers passing below the optic thalamus. Other letters as in Fig. 5. ANATOMY. 25 the inner two thirds of the posterior limb passes throngh the middle third of the basis, and secondary- degeneration of these fibers can be followed throngh the pons and medulla into the pyramidal tracts of the cord. In Fig. 7 this portion of the internal capsule is shaded. Lesion of the outer third of the posterior limb of the capsule is followed by no descending de- generation; hence it is supposed that its fibers are centripetal, and they pass into the corona radiata of the occipital lobe. Fir. 8. — Diagram illustrating decussation of optic nerves in the chiasms, and the effect of lesions of portions of the optic tract, o, optic nerves ; ot, optic tracts ; eg, corpora geniculnta ; a, b, c, lesions in front, at side of chiasma, and on optic tract. 26 DISEASES OF TEE BRAIN. The decussation of the optic nerves at the chiasma is only partial. The diagram on page 25 may give an idea of the arrangement of the fibers. The fibers from the right optic tract pass to the right side of both reti- nas, the larger portion decussating with those of the opposite side ; and vice versa for those of the left optic tract. Fig. 9.— This is modified from Huguenin, to agree with Wernicke's description of the origin of the fibers of the optic tract. ag, anterior corpus quadrigeininum ; pu, pulvinar ; cpq, eras of posterior corpus quadrigeminum ; cgi, internal corpus geniculatum ; eye, external corpus genicu- latum ; cr, posterior fibers of the corona radiata, passing to the occipital lobe ; oe, external division of the optic tract, passing to the external corpus geniculatum, the pulvinar, and the anterior corpus quadrigeminum ; oi, the inner division of the optic tract, passing to the internal corpus geniculatum, and the posterior corpus quadrigeminum ; p, peduncular fibers ; p', the hemispherical bundle seen in trans- verse section of the crus cerebri; sn, substantia nigra; in, third nerve; m', its nucleus ; scp, superior cerebellar peduncle (red nucleus) ; plb, posterior longitu- dinal bundle ; as, aqueduct of Sylvius. ANATOMY. 27 When an attempt is made to study the optic tract, tracing its fibers to their central origin, we meet some opposing statements made by different authors. Wer- nicke describes the optic tract, passing from the chiasma backward, as dividing into two portions — an external, which is much the larger, and a smaller internal ; the former can be traced to the external corpus genicula- tum, the posterior portion of the optic thalamus called the pulvinar, and the anterior corpus quadrigeminum ; the internal portion, he says, arises from the internal corpus geniculatum, and the posterior corpus quadri- geminum ; this division, he says (following v. Grudden), has no connection with the optic nerve. A bundle of fibers seems to pass directly from the corona radiata of the occipital lobe to the optic tract. The preceding diagram, Fig. 9, which follows Wer- nicke, is modified from Huguenin, and will aid in un- derstanding these divisions of the optic tract. The advantage of following the different bundles of fibers through the crura cerebri, pons, and medulla would be, to say the least, very doubtful. Huguenin, Wernicke, and Duval have given us studies of this re- gion. A few outline drawings or diagrams, with brief explanation, will serve to localize the important nerve- centers at different levels. The third nerve enters the crus near the anterior border of the pons, not far from the median line, form- ing the internal boundary of the pyramidal fibers; The nerve splits up into bundles of fibers which diverge, the inner bundles following a slightly waving course back- ward to the nucleus ; the outer bundles, forming a curve, pass through the outer edge of the cerebellar peduncu- lar fibers (the red nucleus), then converge to the nucle- us, which is situated on either side of the median line just anterior to the aqueduct of Sylvius. Anterior to the nucleus the nerve passes through the posterior lon- gitudinal fasciculus. The nucleus of the third is irregu- larly pear-shaped, the smaller end pointing forward, 28 DISEASES OF THE BRAIN. lying near the median raphe. Curving around from the posterior longitudinal fasciculus can be seen the de- scending (motor) root of the fifth nerve. Posterior to these is the anterior corpus quadrigeminum, and ex- ternal to this the internal corpus geniculatum. Fig. 10. — Origin of third nerve. (After Wernicke.) as, aqueduct of Sylvius ; plb, posterior longitudinal bundle ; in, third nerve ; m', its nucleus ; p, basis of crus cerebri (foot of the peduncle) ; sn, substantia nigra ; cp, superior cerebellar peduncle (red nucleus) ; cgi, internal corpus genicu- latum ; acq, anterior corpus quadrigeminum ; v, descending (motor) root of tri- geminus. The fourth nerve enters the valve of Vieussens just behind the posterior corpus quadrigeminum, decus- sates in the valve, curves around the aqueduct of Syl- vius, and enters its nucleus, which is situated just be- hind (below) the nucleus of the third nerve in relatively the same position. Both the third and fourth nerves receive a few fibers, ascending from the sixth nerve, from the posterior lon- gitudinal fasciculi, which do not enter their nuclei. The nucleus of the third nerve receives fibers from the anterior corpus quadrigeminum, and probably simi- lar fibers pass to the nuclei of the fourth and sixth nerves. ANATOMY. 29 The sixth, and seventh nerves are closely connected at one point in their course. The sixth enters the an- terior aspect of the pons just at its junction with the medulla oblongata not far from the median line. It crosses the pons, changing its direction several times so that no one section can follow its whole course, and enters its nucleus just external to the eminentia teres near the median raphe on the floor of the fourth ven- FiG. 11 represents sections through the pons, so as to show on the left the seventh and sixth nerves, with their nuclei; on the right, the sixth and eighth nerves, half schematic. vn, seventh nerve ; vn', eminentia teres, where the seventh nerve turns down- ward ; vn", the proper nucleus of the seventh nerve ; vi, sixth nerve ; vi', the common nucleus of sixth and seventh ; vin, eighth nerve ; vm', its nucleus ; v, ascending root of the fifth nerve ; r, restiform hody ; so, the superior olive ; p, the peduncular fibers. tricle. This nucleus is also the origin of some of the fibers going to the seventh nerve, which enters the pons just anterior (forward) to the eighth, crosses diagonally in a gentle curve to this nucleus, from which it receives some fibers ; then it can be followed to the eminentia teres, where it turns downward ; it soon turns again to pass forward and outward, slightly downward, to its in- ferior nucleus. The fibers, in passing from the eminen- tia teres to this nucleus, divide and separate more or 30 DISEASES OF THE BRAIN. less widely from each other, and form a wide network rather than a compact bundle. The nucleus is com- posed of three or four groups of cells, in each section, which are each surrounded by separate bundles of fibers. Just outside the facial nerve, and anterior to its inferior nucleus, is the ascending root of the fifth nerve. From the nucleus of the sixth nerve thin bundles of fibers pass forward (upward) in the posterior longi- tudinal fasciculus to the third and fourth nerves. These communicating fibers decussate in their course quite near the point where they unite with the other fibers of the third and fourth nerves. The course of the eighth nerve is not as yet of so Fkj. 12. — Transverse section of the medulla on the right at a higher level than on the left. (After Wernicke.) P, the anterior pyramidal fibers ; 6>, the inferior olivary body ; Ic, the lateral column ; cr, the restiform body ; pc, the posterior columns ; /, longitudinal fibers ; c, central canal ; Va, ascending root of the fifth ; x, xi, xn, the corresponding :', xi', xii', their nuclei ; x", anterior vagus nucleus. ANATOMY. 31 much practical interest. It enters the pons just behind (below) the seventh, and divides into three bundles, which are distributed to separate nuclei. It is scarcely necessary to give the particulars of its deep origin. Fig. 13. — Schematic view of the relative situations of the nuclei in the medulla. (After Erb.) v-xn, the nerves or their nuclei ; 1, middle, 2, superior, 3, inferior cerebellar peduncle; 4, restiform body ; 5, eminentia teres ; 6, acoustic fibers ; V, ala cinerea. The relations and origins of the nerves of the me- dulla oblongata can be easily learned by a study of the accompanying figures (12 and 13), and it is scarcely necessary to give more detailed descriptions. The distribution of the blood-vessels in the brain has been studied especially by Duret. The results ob- tained are of much practical value. The circle of Wil- 32 DISEASES OF TEE BRAIK lis at the base of the brain furnishes rather free com- munication between the carotids and the vertebrals of the same side, and between the arteries at the posterior part of the brain on opposite sides, unless there are anomalies in the size of the arteries. Anteriorly, the only communication between the two carotids is the anterior communicating artery. The nutrient arteries for the corpus striatum and optic thalamus arise from the first few centimetres of the anterior, middle, and posterior cerebral arteries ; those from the posterior cerebral are distributed to the optic thalamus, the others to the caudate and lenticular nuclei. These nutrient arteries arise, then, from a posi- tion where they are the more likely to feel any increase of blood-pressure ; anastomoses between the secondary arteries supplying these regions are very unusual. The convolutions are supplied with blood-vessels from the pia mater covering them. The anastomoses between the different arterial systems in the pia mater are very few and unimportant. The arterioles, after entering the gray substance, quickly subdivide into the minutest branches ; these anastomose freely with each other. The vessels for the subjacent white substance pass through the cortical layers, giving off only a few branches, and finally subdivide in the medullary sub- stance into elongated meshes. There are no important anastomoses between the arteries of the convolutions and those of the large ganglia at the base, even where the two come very near together, as in the corpus stri- atum opposite the insula. The veins anastomose more freely, and are so dis- posed with reference to the arteries of the convolutions that the blood is delayed, especially in the arterioles in the gray substance, and the nerve-cells are continuous- ly bathed in arterial blood. As the arteries branch at nearly right angles, and subdivide rapidly into very small vessels, the blood- pressure is diminished ; but the absence of communi- PHYSIOLOGY. 33 cations between the larger branches does not allow of the removal of pressure from weakened arteries. Most of the first and second frontal convolutions, and the convolutions in the median fissure as far back as the termination of the sulcus calloso-marginalis, are supplied by the anterior cerebral arteries. The third frontal convolution, the anterior central and posterior central, and very nearly all the parietal and the upper part of the temporal lobes and the insula, are supplied by the middle cerebral. The lower portion of the tem- poral and the occipital lobes are supplied by the pos- terior cerebral artery. One of these arteries, or any of their branches, may be obstructed mechanically, or may be subject to tem- porary reflex spasms, so as to interfere with the proper flow of blood. Hyperemia may also affect any one dis- trict, leaving the others nearly unaffected. PHYSIOLOGY. Fritsch and Hitzig (1870) first called attention to the irritability of certain districts of the cerebral cortex as suggesting the localization of motor functions in sepa- rate and distinct regions of the brain. Ferrier soon after (1873) published observations made in the same direction, and has since greatly extended our knowl- edge. During the last ten years the literature of the subject has increased wonderfully. The region of the cortex immediately anterior and posterior to the fissure of Rolando has been found to be excitable ; an irritation applied to this region causes motion in the voluntary muscles, according to the lo- cality of the irritation. Other regions may be excitable, and probably are, but the above central region is the one which seems to act most directly upon the limbs. When motion is produced by irritation of other regions, it is probably indirect. Other regions than these may, when irritated, cause various sensations or give rise to mental actions ; but these are not revealed to us by 34 DISEASES OF THE BRAIK motor phenomena. A careful study of Ferrier's plate, with the motor centers marked on Ecker's diagram of the convolutions, will be all that is needed to fix these centers in the mind. F IG . 14. — Location of motor and other centers in the cerebral cortex. (Fierier.) 1, on the upper or superior parietal lobule center for the opposite leg ; 2, 3, 4, around the upper end of central fissure, centers for opposite leg, arm, and trunk ; 5, centers for motion of opposite arm and hand forward ; a, J, c, d, on the posterior central convolution, centers for motions of fingers and wrist of opposite hand ; 6, supination and flexion of the opposite forearm ; 7, 8, 9, 10, 11, on the anterior central convolution and around the base of central fissure, motions of mouth, lips, and tongue (9, 10 are called oro-lingual centers by Ferrier) ; 12, eleva- tion of eyelids, dilatation of pupils, conjugate deviation of eyes, and turning of head to opposite side ; 13, 13', centers which seem to have relation to vision and cause motions of the eyes ; 14, centers which seem to be concerned with hearing, and give rise to motions expressive of attention. The views as to the sensory centers are still unset- tled. It is much more difficult to locate these ; and, indeed, the facts as yet known rather tend to show that PHYSIOLOGY. 35 the centers for different sensations are much less clearly denned than those for motion. Ferrier locates the centers for sensation in the pari- etotemporal region ; sight in the snpra-marginal and angnlar convolutions (13, 13') ; hearing in the superior Fig. 15. — Location of motor and other centers in the cerebral cortex. (Ferrier.) Lettering same as Fig. 14. or first temporal convolution (14) ; taste and smell in the lower extremity of the temporo- sphenoidal lobe — region of the subiculum cornu Ammonis ; tactile sensa- tion in the region of the hippocampus. The centers for sight and hearing are probably correctly located, but there are also centers for sight in the occipital lobe 36 DISEASES OF THE BRAIN. quite as important as those in the angular and supra- marginal convolutions. There is some uncertainty as to the other sensory centers. Petrina is of opinion that the faculty of sensation is more generally diffused, and that at least the fibers for tactile sensation follow the motor fibers to the motor centers, and terminate there in sensory cells. Thus he regards each motor center as also in some degree sen- sory. The location of the centers for tactile sensation must be considered as undetermined. It is, however, settled that the sensory fibers pass through the posterior third of the posterior limb of the internal capsule, through the outer part of the cerebral peduncle, the lateral part of the pons Varolii near the floor of the fourth ventricle, to the sensory region of the cord. The fibers of the corona radiata may be classed as motor or sensory, according to the portion of the cortex with which they are connected. Lesion of the white fibers passing from the motor centers of the cortex to the internal capsule causes serious disturbance of mo- tion ; if extensive, a permanent hemiplegia of the oppo- site side will be produced ; if limited, they may give rise to monoplegias, just as limited lesions of the cortical motor zone. Following these fibers into the internal capsule, Franck and Pitres found : 1. Quite in front the fibers which, on irritation, cause motion in the face and eye- lids on the opposite side. 2. Next behind, the fibers for the anterior limbs on the opposite side. 3. A bundle of fibers which move both limbs on the opposite side. 4. A very small bundle for the opposite hind limb. 5. In the posterior part of the caudate nucleus those which cause elevation of the opposite ear. These experiments were made upon animals ; clini- cal observations and post-mortem examinations must finally show how nearly the same order is followed in man. GENERAL SYMPTOMATOLOGY. Zl The functions of the ganglia at the base are not yet well determined. We know nothing in regard to the functions of the caudate and lenticular nucleus ; they do not seem to have any direct control over either mo- tion or sensation, which has as yet been discovered. The functions of the optic thalamus are still a subject for investigation and discussion. Nothnagel, from ex- periments on animals, concludes that motor impulses, which are excited, or depend upon peripheral sensory impressions, take their origin in the optic thalami. Wernicke's conclusions agree very nearly with this view. "They serve, 1, for acquiring consciousness of motions through 'muscular sense' or innervation's sense ; 2, for the involuntary adaptation of our motions to external relations by means of the reflex mechan- ism which they contain ; 3, as a way for certain sensory tracts, which, according to Meynert, serve for trans- mission of muscular or innervation's sense." The posterior portion of the optic thalamus, the pulvinar, forms a part of the visual centers ; it stands in intimate relations with the corresponding halves of both retinas, as is shown by the symptoms in cases where it is destroyed. Exactly how these relations are maintained is not yet definitely known. The physiology of the pons, medulla, and neighbor- ing parts can be inferred from the anatomical descrip- tions given above, or will be mentioned more conven- iently in connection with the symptoms due to their lesion in the following sections. GENERAL SYMPTOMATOLOGY. Lesions affecting the brain may be divided into two classes, destructive and irritative. These may act only upon the nerve-fibers which they immediately affect ; or they may exert an influence at a distance, which may be different in its nature from their immediate in- fluence. A haemorrhage will destroy nerve-fibers, which 38 DISEASES OF TEE BRAIN. are torn across ; it will also, if of sufficient size, inter- fere with the function of others by compressing them, and it may give rise to symptoms of irritation. A tumor may irritate certain fibers, and, by compression, prevent the action of others, or it may destroy those among which it grows, and irritate others at a dis- tance. As a rule, a lesion which occurs suddenly, as a haemorrhage, will give rise to more symptoms depend- ing upon interference with distant regions than those lesions which slowly increase in size. It may be neces- sary, then, in forming an opinion as to the seat of a lesion, to wait until the commotion produced by the first shock of the disturbance has subsided and the remote symptoms have disappeared. Destruction of the motor centers, or of the white fibers of the corona radiata underlying these centers, is revealed by paralysis of the limbs or muscles over which they preside. Irritation of these parts gives rise to spasm of those muscles. It may happen that there is first an irritation due to the destruction of fibers, shown by a spasm : then follows the paralysis depend- ent upon the permanent lesion. If the irritation is very strong, it not only excites to activity the center on which it first acts, but neighboring centers, and per- haps the whole motor area of both hemispheres, may be thrown into commotion ; then general convulsions will result. By a careful study of the seat of the paralysis or convulsion, and a comparison of these with the motor centers, a reasonably accurate conclusion as to the seat of a cortical lesion may be formed. Spasms confined to one limb are much more clearly diagnostic of corti- cal lesion than paralysis. When convulsions are gen- eral, the diagnosis is less certain ; but, by watching the commencement of the attack, noting that invariably the same limb is first affected each time, and that the convulsions follow the same course, a correct diagnosis may often be made. GENERAL SYMPTOMATOLOGY. 39 The caudate nucleus and the lenticular ganglion may be nearly or quite destroyed without any disturb- ance of motion or sensation. Generally, however, es- pecially if the destruction is produced by a hsemor- rhage, there is more or less compression of neighboring parts, the internal capsule is thereby disturbed, and symptoms result therefrom. Often, also, a portion of the capsule is destroyed, and then the symptoms are permanent. If the destruction is limited to the gray ganglia, as the clot is absorbed the pressure upon the capsule is removed, and the symptoms may entirely disappear. The optic thalamus may be partially destroyed with- out special symptoms; those which occur seemingly depend upon pressure or implication of neighboring parts. At other times there are disturbances of sensa- tion which seem to arise directly from the lesion of the thalamus. Injuries to the optic thalamus may cause more or less disturbance of vision. When the anterior or middle portions are injured, this disturbance, if present, is temporary ; if the posterior part, the pul- vinar, is injured, the loss of vision is permanent, and generally affects only one half the visual field — hemi- anopsia. There is a small region, carrefour sensitif, lying external to the pulvinar, which serves as the course for sensory fibers. Lesion of this region will give rise to hemianesthesia ; and when there is disease of the optic thalamus or pulvinar, this region would very likely be disturbed. A peculiar motor disturbance is associated with injury of the posterior and outer part of the optic thalamus, and perhaps adjacent parts, though some observations seem to show that lesion of the thalamus alone is sufficient to produce the phenomena. The par- tially or entirely paralyzed limbs are in a state of un- rest ; they keep up a constant motion, which may be sim- ply a tremor, or a slow, irregular motion in all directions 40 DISEASES OF TEE BRAIK without co-ordination or rhythm, sometimes resembling chorea, sometimes peculiar and unlike any other motor phenomena. This has been called athetosis, or post- hemiplegic chorea. The internal capsule is the most important part of the base of the brain, so far as relates to the symptoms arising from its destruction. When the anterior limb of the internal capsule is destroyed, secondary degeneration affects only the in- ternal segment of the base of the eras, and this degen- eration can not be followed beyond the pons. When the anterior two thirds of the posterior limb are de- stroyed, there is descending degeneration, which can be followed through the middle segment of the eras, the pons, medulla, and anterior pyramids, where it crosses to the opposite side of the cord, excepting a small por- tion, the anterior pyramidal fibers, which pass down- ward on the same side. When the outer third of the posterior limb is destroyed, there is no descending de- generation. Hence we conclude that the most, if not all, of the motor fibers for the trunk and limbs from the motor area of the brain pass through the anterior two thirds of the posterior limb of the internal capsule, and follow the course taken by the descending degeneration. When the anterior limb of the internal capsule is destroyed, there is no paralysis of the limbs ; the facial nerve may be paralyzed. When the anterior two thirds of the posterior limb are destroyed (or pressed upon so as to interfere with function), there is always paralysis of motion in the op- posite side of the body. This paralysis is permanent, and is followed by late contraction, due to secondary degeneration of the pyramidal tract. When the posterior third of the posterior limb is destroyed, there is anaesthesia of the opposite side ; Charcot calls this cerebral hemianesthesia, and says it is a faithful reproduction of the characteristics of hys- terical hemianesthesia ; the insensibility extends to the GENERAL SYMPTOMATOLOGY. 41 profound parts, muscles, mucous membranes ; it in- volves also the sensory apparatus, the senses of taste and hearing, of smell and sight. The sight is lost by a concentric narrowing of the field of vision ; the percep- tion of colors is lost — first green, then red, orange, yel- low, and blue, until everything has a grayish hue. When disease of one hemisphere causes amblyopia or amaurosis, the disturbance of vision is observed in the opposite eye ; a slight defect may also be discov- ered in the corresponding eye if carefully sought, pro- vided the intelligence of the patient is not too much disturbed. The lesion is then situated in the posterior third of the posterior limb of the inner capsule, or in some portion of the cortex which is not yet exactly located, but which probably corresponds to Ferrier's centers (13, 13') in the angular gyrus, or it may be in some portion of the occipital lobe. Many times the loss of vision affects only one lateral half of the visual field. This is called hemiopia, in speaking of the loss of power in the retina, or more usually hemianopsia, as referring to the visual field. When there is double temporal hemianopsia — the loss of sight affecting the temporal half of both visual fields — the lesion must be in the chiasma, probably near its anterior border, at a, Fig. 8. When the nasal half of the visual field is lost — nasal hemianopsia — the lesion must be on the corresponding side of the chiasma, 5, Fig. 8 ; both sides are rarely thus affected. If there is amblyopia or amaurosis of one eye and nasal hemianopsia of the other eye, the lesion must be on the side of the chiasma correspond- ing with the amblyopic eye, and penetrate deep enough to affect the decussating fibers. When there is loss of vision for corresponding lat- eral halves of both visual fields, the defect is called lat- eral homonymous hemianopsia. This may be caused by lesion of the opposite optic tract (posing that there is local congestion ; but the active delirium is seen only when the affection has been developed rather rapidly, and is probably owing to the state of irritable weakness, to which reference has already been made. When the anaemia occurs during the course of an ex- hausting disease, either as a result of the disease or of insufficient feeding, the delirium is more likely to have a quiet character. Finally, the mental powers may be entirely lost. Diagnosis.— In forming a diagnosis of this affection it is necessary to take into consideration the previous circumstances of the patient. The diagnosis from hy- peremia may be very difficult, and, as the treatment would be quite different, it is important to be as nearly correct as possible. If there is a history of long-con- tinued, privation, with worry and anxiety, or of hard work, physical or mental, and loss of appetite, or ex- hausting discharges, it is probable that the condition is anaemic, although there may be much excitement. It is sometimes more difficult to decide, where there is active delirium, whether it is insanity or anaemia. Here also the previous history will be of assistance ; but, as anaemia may lead to change of structure in the nerve- cells, it may pass over into insanity, and without mania it may pass into melancholia. In insanity induced by cerebral anaemia there is not a long-continued period of CEREBRAL ANEMIA. 73 excitement ; the condition is rather one of depression, with occasional attacks of irritability. To recognize that delirium in febrile diseases is ow- ing to cerebral anaemia is all-important. Especially in children with gastro-intestinal affections the symptoms resemble those of serious organic brain disease ; the previous history must not be overlooked ; it would be disastrous to treat a child with anaemia for meningitis. During typhoid fever in adults there may be a similar mistake. It would seem that care in watching the patient — not only the fever, but also the feeding of the patient — might prevent such an error. Excessively high temperatures may give rise to symptoms similar to those of anaemia ; a careful use of the thermometer will guard against this mistake. Prognosis. — If there is no serious complication, as cardiac or Bright's disease, the prognosis is favorable, provided sources of exhaustion can be removed. The prognosis in the case of other diseases may be favor- able for the anaemia, though unfavorable for the pri- mary disease. Treatment. — If the case is one of acute anaemia, or of extreme weakness after protracted disease or ex- hausting discharges, it will be very important to keep the head low ; perhaps the foot of the bed should be raised ; the body should be kept warm, by artificial means if necessary ; stimulants may be necessary ; food in a form easily digested, in small amounts, frequently repeated. The chronic form needs methodical rest and feed- ing. As many of the symptoms are due to exhaustion of the nervous system, the effort should be made to withdraw the patient from all such influences as tend to exhaust him. In many cases the course of treat- ment recommended by Weir Mitchell in "Fat and Blood" will give excellent results. In every case the best tonic is food. The food must be easily assimilated, not in too great quantities, and should be taken at short 74 DISEASES OF THE BE A IX. intervals. Milk is one of the best to begin with ; not only is it easily digested and contains all the constitu- ents of the body, but is largely composed of water. Fothergill's remarks about water in anaemia are deserv- ing of attention.* Among drugs, arsenic, iron, and quinine are valuable. Where there is restlessness, sleeplessness, delirium, it may be necessary to give chloral and bromide of po- tassium, or paraldehyde. Small doses of these are worse than useless ; even if frequently repeated, they are not efficacious ; less than twenty grains of each is not sure of giving rest ; in many cases it may be necessary to give thirty or even forty grains at one dose. Yet chloral should be given with caution, and not administered every time a patient does not sleep ; it is often given injudiciously. Spirit will sometimes aid sleep. Opium is a valuable agent, and may often be given to advantage in small doses — a tenth or twelfth of a grain — the object being rather to obtain its stimu- lating effect. Sleep may sometimes be produced by a grain or two or quinine at bedtime, or by a dose of phosphoric acid, or by a light lunch just before retir- ing. A cup of beef-tea during the night may overcome the habit of lying awake. CEREBRAL HYPEREMIA. "When the arteries are distended, or there is an in- creased flow of blood through them, there is active hy- peremia ; when the veins are over-distended, it is pas- sive. The latter condition may, in reality, be one of anemia, so far as concerns the state of the circulation in the brain. Some authors deny the existence of cerebral conges- tion. Causes. — Probably a predisposition to cerebral hy- peremia is constitutional with some persons, just as * " Handbook of Treatment," pp. 51, 52. CEREBRAL HYPEREMIA. 75 some blush more easily than others ; the predisposition may be acquired. Whatever has a tendency to cause a fullness of the cerebral arteries, and keep the blood flowing rapidly through the brain, may give rise finally to a predisposition to cerebral hyperemia. Excessive and often-repeated emotional disturbances, excessive and protracted brain- work, are among these agents. But it must be kept in mind that these also produce exhaus- tion, and so irritability, which may lead the brain to respond unhealthily to the normal amount of blood, or to be excessively excited by less than the normal amount. Among other influences may be mentioned a low temperature ; thus, most cases are said to occur in win- ter. A very high temperature is also said to cause con- gestion, and especially if the sun shines directly upon the head ; but the symptoms following such exposure are rather due to elevation of temperature and change in the quality of the blood. Increased activity of the heart is also said to be a cause of cerebral congestion ; hence violent exertions may give rise to it. Certain drugs may cause cerebral hyperemia, as nitrite of amyl. Opium and belladonna have been thought to do so ; but this is not certain. Alcohol may act as a cause, but only acutely : chronic alcoholism acts rather by producing changes in the quality of the blood, and so changes in the nerve-structures. Malarial poison may excite congestion of the brain ; indeed, probably every attack of chills and fever is at- tended with cerebral hyperemia, and this may be one cause of danger in severe malarial diseases. Passive congestion may be caused by any interfer- ence with the return of the blood from the brain. Pathology. — In acute cases very little change may be expected ; much or most of the blood drains off post- mortem. Yet even then, and with rather more fre- quency in cases of longer standing, the smaller vessels 76 DISEASES OF THE BRAIK in the cerebral substance show with unusual distinct- ness upon section. The surface of the section is thickly- sprinkled with bloody points, the gray substance is darker, and the white substance may have a decided pinkish color, from the fullness of the minutest vessels. In chronic cases the constant dilatation of the ves- sels may lead to changes around them ; the perivascu- lar sheaths may contain granules of blood pigment. There are seen, also, cavities in the brain containing the transverse section of a vessel. These are thought by some to be caused by dilated perivascular sheaths, by others to be dependent upon dilatation of the vessels. The latter may act as one agent in their production, another may be shrinking of the cerebral substance, a slight atrophy which causes a dilatation of the peri- vascular sheaths. Constant and repeated hyperemia must interfere with the nutrition of the nervous structures ; the high blood-pressure is unfavorable for the interchange of elements. The changes thus resulting occur slowly, but finally may be very serious and may lead to insanity. These changes will also explain why it often requires so long a time for recovery from symptoms which seem insignificant. In this connection it must be remem- bered that not only do the proper structures of the brain suffer, but also the walls of the blood-vessels and their vaso- motor nerves undergo changes — at least functional changes, and probably slight organic changes. Symptoms. — Many of the symptoms of cerebral hy- peremia are the same as are found in cerebral anamiia, and many which are usually ascribed to hyperaemia are quite as dependent upon exhaustion from overwork, anxiety, etc. It is impossible to entirely separate the two classes of symptoms in giving an account of the affection. If not severe, there may be a sense of heaviness, or pain in the head, with tinnitus (though this is more common in anaemia), dizziness, sleeplessness, more or CEREBRAL HYPEREMIA. 7? less agitation, perhaps at times a tingling sensation in the fingers or feet, as if they were "asleep." These symptoms at first recur only occasionally, but may be- come more permanent. There may be more serious symptoms : the tempera- ment may be changed and the patient be fretful and irritable, the mental power diminished, and there may be absolute inability to apply the mind in certain direc- tions. When an intense application of the mind to one class of questions has brought on the affection, there is inability to apply the mind in that direction. A teacher can not teach ; the effort to do so may cause such con- fusion that he will have no command over his speech ; or a lawyer may be unable to try a case before a jury, the attempt to do so being preceded by sleepless nights, and accompanied by such distress, or even semi-delirium, as to make it impossible. It would seem as though in these cases there is a local irritability of the nerve- cen- ters relating to such pursuits, which, when an attempt is made to use these centers, gives rise to an increased flow of blood, not only to them, but to other parts of the brain also. It is interesting to note that the use of other centers has not this effect : thus, the lawyer who can not try a case in court may be able to attend to other busi- ness (though it is not by any means safe to allow it) ; the merchant may not be able to keep the run of his goods, but he can attend to his garden and care for his country residence without distress. Memory is affected: there is confusion, dullness, wrong words are used in talking ; there may be deliri- um, or the excitement may run into mania. At times there may be weakness of the limbs, twitching of mus- cles, especially of the face ; paralyses almost never oc- cur ; convulsions belong rather to anaemia or epilepsy ; and also disturbances of sight and hearing are more fre- quent in anaemia ; vomiting is rare. Respiration is little affected ; the pulse is usually full and resistant, perhaps rapid, possibly moderate. The face is usually flushed 7S DISEASES OF THE BRAIN. or ruddy, is rarely pale, and the conjunctivae may be injected. Many authors describe a form of this affection at- tended with convulsions, which, however, Trousseau refers to epilepsy, and this explanation is now gener- ally accepted. There is a condition which I have met a few times which seems to be dependent on congestion rather than anaemia. I have only seen it in women run down ner- vously ; so nervous exhaustion is one element in causing it. The patient, after some emotion or shock, only slightly more severe than usual, or after some exertion, as ascending stairs, feels weak, is unable to stand or sit, has distress in the head, then loses all power of motion, and speech ; lies as if in a faint, but the face is flushed ; the heart beats vigorously, perhaps not more so than normal ; respiration is little if at all affected. If the attack is not severe, the patient may lie utterly help- less, unable even to move an eyelid, yet know all that is said and done. In severer cases, consciousness is lost. I have known such an attack to last two or three hours. There is no spasmodic action. Recovery is gradual, then respiration may be sighing ; subsequently there is great distress in the head and confusion of thought for several hours. These attacks may occur during the night, either in consequence of a dream or from the previous day's ex- haustion and the recumbent position. One gentleman told me that, after learning that his wife had these, the peculiar respiration, in her case noisy, aroused him. These attacks differ from epilepsy in that a definite cause can be so frequently traced that it is reasonable to think such a cause always exists ; they recur as ir- regularly as the causes which give rise to them. Diagnosis. — It is not always easy to distinguish congestion from ansemia or from simple nervous ex- haustion. Sometimes it is necessary to suspend judg- ment for a while to watch the course of the symptoms. CEREBRAL HYPEREMIA. 79 A superficial examination of the patient will be as likely to lead to an error in diagnosis as to give correct re- sults. Some physicians recognize hyperemia in almost every obscure morbid functional state of the brain ; others disbelieve in it entirely. The previous history of the patient will assist mate- rially in diagnosis. Has the patient been well fed, or poorly \ been happily situated, or miserably % had pros- perity or poverty % have there been exhausting drains upon the system, frequent small haemorrhages, or se- verer haemorrhages % Is the patient full-blooded or gen- erally anaemic ? Is the face ruddy, flushed, or pale ? Did the attack come on as the result of excitement, or during the strain of some intense mental effort, or dur- ing a violent physical exertion? All these inquiries will assist in forming a correct diagnosis when the symptoms are uncertain. A diagnosis depending upon the symptoms may be made in many cases with some degree of probability. In anaemia the symptoms are those of excitement only in rare cases, and then the excitement is not of long duration ; as a rule, in the more chronic cases there is depression. In hypersemia, excitement and exaltation predominate, and there is apparent depression only when the brain is overpowered by the severity of the attack, or the congestion is passive. The headache is more acute in anaemia ; more of a feeling of painful full- ness in hypersemia. The pulse is fuller and more bounding in hypersemia. These peculiarities, with at- tention to the whole group of symptoms as described above under both these affections, will in most cases lead to a correct diagnosis. It would be easy to pick out typical cases of both these conditions from actual practice and describe them, but such cases are not easily mistaken, and, unfortunately, form only a small proportion of the cases we see. As in many other diseases, a careful examination and consideration of 80 DISEASES OF THE BRAIX. all the circumstances are necessary to a correct diag- nosis. Other affections which must be separated from cere- bral congestion are cerebral haemorrhage, cerebral em- bolism, and thrombosis. These will be better consid- ered under those affections. Vertigo from disease of the ear and from derangement of the digestive organs also needs to be distinguished. The most important affection, next to ansemia, to correctly recognize is epilepsy. Some forms of epi- lepsy are so obscure, especially in the commencement of that affection, that it is no uncommon circumstance to have it overlooked, and the patient, his friends, and perhaps the physician, consider the attack is a mere passing rush of blood to the head. This will be more intelligently considered under epilepsy. A reasonable care in the examination of the urine will suffice to distinguish Bright's disease, which may give rise to symptoms closely resembling those caused by disturbance of the cerebral circulation. The urine should be examined more than once if the diagnosis is doubtful. Prognosis. — The danger from an attack of cerebral congestion depends upon the severity of the attack and its suddenness. The brain may be completely over- powered by the sudden influx of blood, consciousness may be lost, and, if the medulla is also affected, life may be extinguished at once or very soon. Walter Moxon, however, finds no satisfactory post-mortem evi- dence that acute congestion is ever a cause of death. But generally the patients do not die at once, and in chronic cases there seems to be no immediate danger to life. Recovery, however, is tedious. Almost al- ways there have been various circumstances in the pa- tient's history acting as predisposing causes, and this is one reason for the slow recovery. Where there is no complication, a recovery may be expected in time, pro- vided the patient will submit to proper treatment. CEREBRAL HYPEREMIA. 81 Among other complications, the most unfavorable is organic change in the nervous elements of the brain. This may give rise to insanity. Teeatment. — Congestion of the brain may be ac- companied with so severe symptoms, with snch imme- diate danger to life, with unnatural fullness of the arteries, with such strong action of the heart, that gen- eral bleeding is indicated. These cases are, however, rare, and such bleeding would not be advisable in any except a robust and plethoric patient. Local bleeding by cups or leeches would be beneficial in a larger num- ber of cases. In the severer forms, when it is not de- sirable to withdraw blood, means may be taken to in- crease the flow of blood to distant parts of the body, as by hot foot-baths or mustard foot-baths ; or to diminish the amount of blood by acting on the bowels, saline cathartics, croton - oil, etc. ; or by promoting copious sweating by hot-air baths, steam baths, hot -water baths, keeping ice on the head. Jaborandi acts espe- cially on the skin ; but, as it frequently gives rise to vio- lent vomiting, it would be hardly safe, lest the straining in vomiting should increase the congestion. Cold applications to the head — ice, a rubber tube coiled up, with cold water running through it, evapo- rating lotions — may give relief ; but to be of much bene- fit, the application must be continuous. When there is violent delirium, mania, as one of the most marked symptoms, it will be frequently found that there have been circumstances tending to render the brain excitable. The measures already mentioned may be employed : sometimes a wet cup to the back of the neck taking a few ounces of blood aids in giving relief ; sometimes a dry cup gives equal relief. Bro- mide of potassium and chloral, in doses sufficient to produce sleep, are especially indicated ; from thirty to sixty grains of each. Small doses of chloral repeated hourly have no effect, but rather aggravate the symp- toms, and the combination of the two drugs is more 82 DISEASES 01 THE BRAIN. efficacious than either alone. Hyoscyamus will often procure sleep and quiet if given in large doses. In cases of mania from cerebral hyperemia, opium should not be given, but during delirium from anaemia it may be beneficial. Where the hyperemia is chronic and has been pro- duced by excessive mental application, or by constant emotional excitement, the first indication is to remove the cause. The patient should drop his studies, his business, whatever has intensely occupied him, and withdraw from all associations which give rise to emo- tional disturbance. A quiet, regular, systematic life, with easily digested, mild food, is the most favorable. Bromide of potassium, without chloral, fifteen or twenty grains three times a day. Bromide of sodium, lithium, calcium, or ammonium, have been used instead, and are more agreeable to some patients. Ergot, either as fluid extract, half a drachm to a drachm, or ergotin, three to five grains, three times a day. Ice to the back of the neck will sometimes relieve the discomfort in the head better than when apyxLied to the head directly. Most cases of chronic cerebral hyperemia are also complicated with nervous exhaustion, and it may be desirable to give tonics to counteract the exhaustion. The vaso-motor nervous system is at fault, and requires not only a temporary stimulant to cause the arteries to contract, but it needs also to be permanently strength- ened. A systematic course of hydrotherapy may be of value in this direction ; also the ordinary tonics. The chief object of these remedies is to restore the normal action of the arteries and the vaso-motor nerves. To do this, iron, strychnia, arsenic, quinine, zinc, nu- tritious but unstimulating food, are the most valuable agents. Spirituous liquors are to be avoided ; tea and coffee taken only in moderation, if at all ; tobacco should be forbidden. It is scarcely necessary to men- tion that the digestive and other functions should be kept in a normal condition. CEREBRAL HYPEREMIA. 83 Those who have had attacks, or who seem liable to attacks of cerebral congestion, should avoid public gatherings where the air is likely to become impure and heated, and where there is more or less excitement, as theatres, concerts, balls, etc. They should be quiet in all their movements, avoiding exertions which would cause an increase of blood - pressure in the brain, as running, lifting weights, straining at stool, and venereal indulgence. They should sleep in cool, well-ventilated rooms ; better on a hair mattress, with head elevated. They should take exercise in the open air, but avoid being chilled in cold weather. All intellectual efforts which produce the least discomfort in the head should be avoided. As one can not stay at home surrounded by familiar objects without the mind running more or less in its old ruts, and being recalled by old associa- tions into old trains of thought, it is especially impor- tant to break up all such associations in cases of chronic hyperemia, and, where the patient's health permits, traveling or a sojourn away from home is very desira- ble. Often it is the method whereby quickest relief can be obtained. CHAPTEE V. HEMOREHAGE. Charcot et Bouchard, Nouvelles recherches sur la patho- genie de l'hemorrhagie cerebrale. Arch, de physiol., 1868. — Du- rand, C, Des anevrysmes du cerveau consideres principalement dans leurs rapports avec rhemorrhage cerebrale. Paris, 1868. — Bourneville, Etudes cliniques et thermometriques sur les mala- dies du systeme nerveux. Paris, 1872. — Broadbent, William H., On Ingravescent Apoplexy, a Contribution to the Localization of Cerebral Lesions. Med. Chir. Trans., 59, 1876.— Gowers, William R, On "Athetosis" and Post-hemiplegic Disorders of Movement. Med. Chir. Trans., 59, 1876. — Lidell, J. A., A Treatise on Apo- plexy, Cerebral Haemorrhage, Cerebral Embolism, etc. New York, 1873.— Thomson, W. H., Prophylaxis of Hemiplegia. New York Med. Record, 1878.— Sanders, Edward, A Study of Primary, Im- mediate, or Direct Haemorrhage into the Ventricles of the Brain. Am. Jour. Med. Sci., July and October, 1881. — Drozda, Jos. V., Statistische Studien iiber die Hemorrhagia cerebri. Wien. med. Presse, March 7, 1880. MENINGEAL HEMORRHAGE. When a vessel of the dura mater ruptures, the blood may escape either between the dura and the skull, or into the dura itself, between the layers of its fibers, or between it and layers of false membrane. The former is more frequently the result of an injury ; the latter is found in pachymeningitis hemorrhagica. The blood may also escape into the arachnoid space. This is not common, and, when it occurs, it can not be distinguished from haemorrhage following the rupture of one of the vessels of the pia mater. MENINGEAL EMMOREEAQE. 85 ^Etiology. — The causes of haemorrhage are blows and falls, bursting of aneurisms, other disease of blood- vessels, or thrombosis of sinuses. Kupture of aneurisms is the more common cause ; these may be either mili- ary or of considerable size. The effused blood may be but little in amount, or may cover a large extent, even dipping down into the sulci and fissures, and extending to both sides or penetrating into the ventricles. Pathological Anatomy. — The blood is usually poured out in such quantity that death follows before any change can take place in the clot ; occasionally death is delayed long enough to show that absorption has commenced, and in a very few instances the blood has been in such small quantity that it has been ab- sorbed, and, subsequently, the remains found in pig- mented spots on the membranes. In these cases there is a reasonable doubt whether the disease is not pachy- meningitis rather than meningeal haemorrhage. Symptoms. — The symptoms will vary according to the locality and extent of the haemorrhage. If there has been previous disease of blood-vessels, especially an aneurism of considerable size, there will have been corresponding symptoms preceding the attack. Many times these will be merely headache, lassitude, heavi- ness, vertigo. If the blood escapes suddenly in one gush, there will be a sudden and immediate loss of consciousness, and paralysis with slow pulse and stertorous respira- tion, and the patient may soon die. If the blood es- capes less rapidly, the loss of power will come on gradu- ally, and the patient may be able to walk across the room, or even farther, and call for assistance before sinking to the floor and losing consciousness. According to the locality of the haemorrhage, to the irritation excited by it, and perhaps other illy defined circumstances, there may be convulsions attending the attack. These may affect one or more limbs, may be universal, or may only affect certain cranial nerves. 86 DISEASES OF THE BRAIN. Occasionally the patient recovers from the first at- tack of unconsciousness, and seems to be gaining until another, and, perhaps, several successive attacks ter- minate fatal] y. The symptoms are the result of a combination of local irritation, pressure, and anaemia of the brain. If the vessel is in the pia mater, the blood may be poured out with such violence and in such a direction as to tear up a portion of the cortex immediately adjacent. Diagnosis. — The peculiarities wherein meningeal haemorrhage differs from intra-cerebral haemorrhage are, the more frequent occurrence of convulsions and contraction in about a quarter of the cases ; the paraly- sis is less likely to be local, all the limbs suffer alike, and there is gradually diminishing power until total paralysis is reached, though sometimes there is hemi- plegia. The temperature follows very much the same course as in intra-cerebral haemorrhage. Prognosis. — Excepting in very rare instances, death is the invariable result. Treatment. — The treatment is the same as for in- tra-cerebral haemorrhage. CEREBRAL HEMORRHAGE. Cerebral haemorrhage and apoplexy are not syn- onymous terms. The latter is applied to all attacks wherein there is sudden loss of consciousness without convulsions, coma continuing for a longer or shorter time, ending in death, or partial or entire recovery. This may be the result of other causes than haemor- rhage, as congestion, or plugging of an artery by an embolus. ^Etiology. — The amount of blood poured out de- pends upon the size of the blood-vessel ; also upon its situation. The white substance is much more easily torn up than the gray substance, and, when the blood bursts into one of the ventricles, there is much less CEREBRAL HEMORRHAGE. 87 resistance to the bleeding than when it is confined by the cerebral substance. The form of the clot and of the cavity containing it depends upon the direction of the nerve-fibers among which the blood is poured out. The size of the clot may vary from that of a pin's head or of a pea to a clot occupying nearly the whole of a hemisphere. The largest clots are those where the haemorrhage begins in the corpus striatum or the optic thalamus, and extends into the white substance of the centrum ovale. The relations which the size of the clots and the frequency of haemorrhage bear to the cerebral circulation are considered by Duret. The anterior part of the caudate nucleus is supplied by nutrient branches arising from the anterior cerebral and anterior commu- nicating arteries. These are all small ; haemorrhages here are rare, and are usually small. The lenticular nucleus, and the anterior portion of the optic thala- mus, are supplied by arteries from the middle cere- bral, which is a large artery and nearly in line with the carotid ; the nutrient branches are comparatively large, and haemorrhages more frequently occur from these and are more likely to be copious. There are no large arteries running through the centrum ovale ; hence haemorrhages here are rare and of small extent. The posterior lobe is supplied with larger vessels from the posterior cerebral artery ; hence haemorrhages of consid- erable size may be found there. These are some of the more important and interesting conclusions at which Duret arrives. To Charcot and Bouchard belongs the credit of re- ferring cerebral haemorrhage to a periarteritis of the smaller arterioles, the external coats being first affected. There is an increase of nuclei of the lymphatic sheath ; the adventitia is also affected. The nuclei may be so crowded together that nothing else can be seen. Some- times, with less increase of nuclei, the adventitia may be thickened and may have longitudinal striae. Next, the muscular elements disappear without fatty degen- 88 DISEASES OF TEE BRAIX. eration, the muscular markings on the artery becoming less distinct and fewer, until finally they disappear in limited regions ; then the artery may dilate, bulge out locally, and a minute aneurism is formed ; some- times only a fusiform swelling of the artery is seen. These miliary aneurisms may be very numerous through- out the brain, or a few in a limited region. They some- times seem to be quite large from the staining of the tissue immediately around them. They are found with most frequency in the corpus striatum and the optic thalamus, then in the pons Va- rolii, and the gray substance of the convolutions. These minute aneurisms bear an important relation to cerebral haemorhage, as in much the larger number of cases their rupture is the cause of the haemorrhage. Atheromatous degeneration of the larger arteries may favor a rupture by impairing the elasticity of the vessels. Increased strength in the action of the heart will also act as a cause of haemorrhage by sending the blood with increased force into the diseased vessels ; hence many cases occur while the patient is making violent effort ; but also many occur during sleep. While it is true that disease of the kidneys is found in many instances with cerebral haemorrhage, it is not as yet determined how frequent this association is. Some writers lay stress upon a vitiated state of the blood as a cause. This might affect the nutrition of the arteries, and so favor the disease. The condition of the brain is mentioned as another element in the production of haemorrhage. It is scarcely possible for periarteritis with many miliary aneurisms to exist without interfering with the nutrition of the brain, and doubtless many of the so-called premonitory symp- toms are thus produced ; but how much such change favors the occurrence of haemorrhage we have no means of estimating. Whether such changes are of the nature of softening, or of an increase of the interstitial tissue, is not yet known. Minute haemorrhages are sometimes CEREBRAL HMMORRHA GE. 89 found around tumors in the brain ; generally they are very small, and cause no special symptoms. It is well to mention that cerebral haemorrhage oc- curs the more frequently after the age of forty years ; but it is also found in infancy ; it is perhaps more com- mon in winter than in summer, and in men than in women. Pathological Anatomy. — The changes in the brain and the blood-vessels predisposing to haemorrhage have been already described when speaking of the aetiology. The blood which escapes from the ruptured artery forces its way among the nerve-elements, separating some, tearing apart others, sometimes, if the clot is large, entirely isolating masses of cerebral tissue torn from their connections. At first the clot is dark red, uniform in consistency, resembling any other clot of blood. In a few hours the clot is somewhat less con- sistent, the watery constituents are absorbed, the color becomes lighter ; finally only a pale, yellowish-colored remnant with a few blood-crystals can be found. The nervous structures which have been torn and bruised undergo fatty degeneration, there is more or less soft- ening around the clot, the surrounding structures im- bibe the coloring-matter and are yellow, and granular corpuscles and fatty degeneration increase the extent of this colored zone. Inflammation may set in which will destroy extensive tracts of brain-substance and aid in bringing about the fatal termination. If the inflammation is slight and the patient sur- vives, the cerebral tissue immediately around the clot undergoes a fibrous change, the interstitial elements increase, and a cyst is formed, a firm wall separating the diseased from the healthy brain-substance. If the clot is small, there may be no cyst ; there is simply a small cicatrix of tough connective tissue. Sometimes there is no well-defined cyst- wall, the wall being soft and formed of a mixture of fibrous tissue and granular corpuscles in such proportions as not to have the firm- 90 DISEASES OF THE BRAIN. ness above mentioned ; then this character of tissue passes imperceptibly into the normal cerebral structure. When the haemorrhage is situated so as to implicate the deeper layers of the cortex and the white substance beneath, and especially the anterior two thirds of the posterior limb of the internal capsule, a secondary de- generation appears after some weeks or months, follow- ing the nerve-fibers, through the crus cerebri, pons, and medulla, into the cord. According to Jaccoud, the clot remains soft and homogeneous during three to five days ; then absorp- tion continues to the tenth or twelfth day. After fifteen or twenty days the clot has contracted into a dense, solid mass of a yellowish color, quite different in ap- pearance from coagulated blood. The new formation around the clot begins generally on the seventh or ninth day ; toward the twentieth the cyst is formed, and by the thirtieth or fortieth the limiting membrane has become organized. Symptoms. — Premonitory symptoms will be recog- nized less frequently with some classes of patients than with others ; the less observing may give no heed to sensations or conditions which others may notice. Many patients have for a short time, or even days and weeks, preceding the haemorrhage, symptoms which are worthy of notice. These premonitory symptoms are very important as indications for a course of treatment to ward off the threatening attack, and even if in the majority of such cases no attack occurs, yet they should never be neglected. Among the symptoms which precede haemorrhage for several days or even weeks, the most common are those which show disturbance of the circulation or nu- trition of the brain ; among these the most frequent are sensorial disturbances. Oftentimes there have been long-continued symptoms of cerebral hyperaemia, head- ache, or sense of pressure in the head, dizziness, dis- turbance of eyesight, noises in the head, pricking, and CEREBRAL EMMORRHAGE. 91 numbness, especially in the fingers, perhaps also in the feet, sometimes on one side, sometimes on both ; mental confusion, slight forgetfulness of words, loss of mem- ory, and change in disposition. Owing to impaired motor power or diminished sensation, there is a loss of delicacy in the touch, the character of the handwriting is changed, and there is awkwardness in using the hands. Sometimes, if severe and persistent, especially if uni- lateral, these symptoms are caused by slight haemor- rhages which may precede a more severe one. If there has been a haemorrhage with partial recovery, a recur- rence of these symptoms may be the warnings of re- newed danger. Ophthalmoscopic examination may occasionally show the presence of miliary aneurisms, dilatations of the retinal arteries, or slight retinal haemorrhages, and so be of value as indicating danger from the rupture of cerebral arteries. The symptoms attending the rupture of a blood- vessel in the brain will vary according to the locality of the lesion, the size of the vessel, and the rapidity and force with which the blood escapes. It is easily under- stood, therefore, that there may be great diversity in the initial symptoms as well as in the subsequent course of the case. The severest form of cerebral haemorrhage is that which may be called apoplectic. The patient suddenly loses control over himself, falls, if he is either sitting or standing, and soon entirely loses consciousness. At the same time reflex action of the limbs is abolished, and, unless there are convulsions, the patient lies limp and inert, simply breathing and swallowing if the substance is put far enough back in the fauces to excite the in- voluntary muscles of deglutition, though occasionally even these fail to act. The respiration may become noisy from the paralysis of the soft palate or from the accumulation of mucus in the bronchi ; at first the 92 DISEASES OF TEE BRAIN. countenance is generally pale, but, if respiration is in- terfered with, it becomes dusky red. The cheeks flap back and forth with every respiration, passively follow- ing the current of air. The shortest time on record be- fore death under these circumstances is five minutes ; more frequently from half an hour to several hours elapse before the fatal termination. The attack, as above described, is far from common ; much more frequently there is a gradual development of the symptoms ; the patient is conscious that some- thing is amiss, and may try to rise from his chair, may be able to reach the bed or sofa, or, finding himself unable to hold articles in his hands, turns to speak to a friend and can not make himself understood. Soon he sinks powerless, and passes gradually into coma, which is not so extreme but that he can be aroused by a loud voice, or a powerful irritation may give rise to expressions of pain. Reflex movements generally per- sist. The unconsciousness may continue only a few minutes, or may persist much longer — even until death. During the unconscious stage the physician can often recognize that one side is paralyzed. The mouth is drawn to one side, the limbs on one side are stiff er than on the other, or half voluntary movements are made only with one side ; a strong irritation causes movements only on one side. But little can be learned from the condition of the pupils, as they are very vari- able ; but many times the eyes are turned continuously, both toward the same side, and the head is rotated with the face toward that side. This phenomenon is not of long duration ; it is seen in only a small proportion of patients, but, when present, it is valuable as indicating serious organic lesion, and may aid in determining its location. (See above, p. 44.) After the return of consciousness it will be noticed that there is hemiplegia, generally affecting both the arm and the leg. This paralysis may be complete, total loss of power ; cutaneous reflex action is usually CEREBRAL HEMORRHAGE. 93 lost on the paralyzed side ; after a few hours or few- days power of motion returns, by degrees one act after another can be performed ; usually the legs gain the most rapidly, the more complicated action of the arms and hands being recovered later. Hughlings Jackson has formulated the proposition that the most instinct- ive, automatic actions are the first to return. The patient may continue to improve in his power of using his limbs for many months ; perhaps to a casual observer there is finally complete recovery ; but more frequently a stage is finally reached after which no fur- ther improvement can be expected ; the limbs on one side are weak ; certain motions can not be performed, or are executed only with difficulty and imperfectly ; there is hemi-paresis. The muscles of the face are often affected, and im- mediately after the attack the mouth is drawn to the opposite side, the naso -labial fold being more marked on that side. The nerve-fibers which supply the upper part of the face — the orbicularis palpebrarum, the front- al and corrugator supercilii muscles — usually are not affected. Nothnagel states that, when the tract of nerve-fibers passing along the base of the nucleus len- ticularis is involved, the above muscles are paralyzed. They may be paralyzed also if the lesion is in the lower part of the pons. Nothnagel also states that the muscles of the trunk are generally partially paralyzed. Speech may be interfered with ; the more frequent- ly from loss of power over the organs of speech, the muscles of the throat, and mouth and tongue. Only occasionally is there aphasia when the right side is af- fected. This is a much more frequent symptom in em- bolism. On the second to the fourth day after the attack symptoms may develop showing that there is an inflam- matory process around the clot. There is headache, confusion of thought, feverishness, contraction of the 94 DISEASES OF TEE BRAIN. paralyzed limbs, sometimes slight convulsions. The duration of this stage is variable, from a few to several days ; sometimes these symptoms recur two or three times or more. Bourneville, considering the temperature, divides cases of cerebral haemorrhage into three clases : 1. Ful- gurant or multiple hemorrhages, death occurring in a very few hours, with initial depression of temperature. 2. Cases ending in death in ten, fifteen, twenty hours, initial depression lasting only one to three hours or so, and subsequent rapid and considerable elevation of temperature. 3. Cases ending in death only after sev- eral days ; initial depression of short duration ; then a stationary period, continuing two to four days, with a primary slight elevation and subsequent oscillation about the normal ; finally an ascending period. Dur- ing the initial period of depression the pulse and res- piration are but little changed. If the patient is to recover, the ascending period is of brief duration, and the temperature does not rise very high, or it is entirely wanting. The above description refers to cases of severe cere- bral haemorrhage with loss of consciousness. In many cases there are no comatose symptoms. The patient more or less gradually loses power over one side, and falls with consciousness intact. The paralysis may be as complete, and the recovery of motion may occur in the same order, as in the other class of cases. After a first attack with the consciousness preserved, a second may occur soon in which that faculty is lost. Yet lighter attacks occur in which there is only a slight impairment of motion in only one or more limbs, or the attack may be confined to the face. There are all degrees of severity, from the very lightest to the most complete. Disturbance of sensation is not so common as that of motion. At first, indeed, sensation may be abolished, but it is more quickly recovered. Generally all varie- CEREBRAL HEMORRHAGE. 95 ties of sensation are equally affected. Occasionally other parts than those whose motion is lost show diminution of sensation. Sometimes there is a persist- ent change of sensation, which is perhaps not always sought for. An object is perceived on both sides, but the impression is less acute on the affected side, or con- tact with the object excites also a peculiar tingling sen- sation besides the usual sense of touch. Sometimes there is increased sensitiveness to painful impressions. Ollivier has found in many cases a change in the urinary secretion after cerebral haemorrhage. There is first an increased secretion of urine, and albumen is found in it ; later sugar may be found. These changes occur almost immediately after the attack and continue only twelve to twenty-four hours ; they are not depend- ent upon the locality of the lesion. Cutaneous reflexes may remain diminished or lost on the side affected. Tendon reflex is often exagger- ated, especially after contractures have appeared. Dr. Sanders has written upon haemorrhages into the ventricles, separating such cases from both cerebral and meningeal haemorrhages. He has collected ninety-four cases of such primary haemorrhages, and considers their aetiology and pathology, which differ little from those of other cerebral haemorrhages. The diagnostic symptoms he mentions are suddenness of the attack without premonitory symptoms ; convulsions in the be- ginning, or later ; partial or complete coma, paralysis, contracture, dilated or contracted pupils. Death usu- ally occurs early, generally within twelve hours ; a few patients recover. The above symptoms are almost ex- actly those found in any case of severe cerebral haemor- rhage. A positive diagnosis is in many or most cases impossible. An explanation of tJie phenomena attending cere- bral haemorrhage will aid to a clearer understanding of the subject, and will be of value in determining treat- ment. 96 DISEASES OF THE BRAIK Several explanations have been given of the initial loss of consciousness, the more important of which are, that by Niemeyer, who refers it to cerebral anaemia caused by compression of capillaries ; that by Trousseau and Jaccoud, and Jackson referring it to shock. The shock is direct on the side of the haemorrhage, is trans- mitted or reflex on the other. Nothnagel, after reviewing these and other theories, says: "We find ourselves, then, finally, obliged to ad- mit that the physiological relations of hemorrhagic apoplexy have not yet been made so clear as is com- monly believed." The most reasonable explanation seems to be that there is both shock with consequent exhaustion, and anaemia, not simply from compression of vessels, but also from reflex contraction. The paralysis, both of motion and sensation, is the result of the direct injury, of the shock, of the local or general anaemia from compression of the smaller ves- sels, the tearing across of others, of the oedema, the in- filtration of the surrounding cerebral substance with serum absorbed from the effused blood, this oedema also giving rise to anaemia. It is impossible to decide how large a share belongs to each of these elements in producing the patient's condition at the moment of re- covery of consciousness. The influence of shock and anaemia due to compression from the size of the clot pass off soonest. The anaemia due to the oedema will slowly disappear ; as the liquid parts of the clot are ab- sorbed, the uninjured nerve-fibers surrounding the clot gradually regain their function. Another probable source of improvement is found in the possibility that functions performed by the destroyed nerve-elements may be acquired by those of other parts of the brain, so that in time there seems to be very little paralysis re- maining. Also patients learn to use to the greatest ad- vantage the power which remains. One cause of delay in recovery may be found in the functional inertia of CEREBRAL HEMORRHAGE. 97 long disused nerve-fibers, so that even after organic restoration there may still be a period of diminished functional activity. Finally, it is not unlikely that many injured nerve-elements heal, and nerve-fibers which have been ruptured or bruised may recover their organic integrity. After these processes of repair have gone to their utmost limits, there must still be a very large number of nerve-elements destroyed beyond pos- sibility of recovery. If, then, the haemorrhage is so situ- ated that these elements are necessary for perfect mo- tion and sensation, there will be a residuum of paralysis from which it is utterly useless to expect recovery. As a result of the imperfect healing of the torn nerve-fibers, a certain amount of paralysis remains per- manently. After a few months — two to four — a stiff- ness of the paralyzed limbs is noticeable ; there is a certain amount of contraction. The degree of the con- traction varies from a scarcely perceptible stiffness of the fingers to a firm closure of the hand, with flexion at the elbow and adduction of the arm. The upper ex- tremity is more frequently affected than the lower ; the lower is rarely affected alone. The flexor muscles are almost invariably the ones affected. At first the resist- ance of the contracted muscles is easily overcome, and during sleep the muscles relax spontaneously. On first waking, the hand is as supple as the other ; involuntary motions of stretching and yawning may be made by it in unison with the unparalyzed hand. Soon, however, as voluntary actions are performed, the contraction re- appears, to persist until the patient again sleeps. Pa- tients and their friends are often encouraged by this relaxation. It is far from being a favorable indication, and should never deceive the physician. Eventually the contraction may become persistent even during sleep. These contractures must be distinguished from those which occur earlier, either at the time of the attack and soon disappear, or a few days after, at about the 1 98 DISEASES OF TEE BRAIHT. time when inflammatory action arises around the clot. These also disappear within a short time. These latter varieties have been explained by supposing a direct irritation from the clot or from the subsequent inflam- matory processes. The first variety of contraction has been explained, by Charcot and others, by the presence of secondary degeneration in the lateral columns of the spinal cord. Associated movements, interesting to observe, are often seen in hemiplegic patients. After the partial re- turn of voluntary motion, if the patient tries to move the paralyzed limb, the unaffected limb will involun- tarily perform the same motion. It would seem that the motor impulse required to act on the partially par- alyzed muscles needs to be so great to overcome the resistance offered by the injured nerve-fibers that the lower motor centers on the opposite side are also set in action, the impulse crossing by the commissures to the unaffected side. In many cases of cerebral haemorrhage, after a par- tial recovery of motion, the effort to perform an action gives rise to irregular contraction of the muscles of the paralyzed limb which may resemble chorea, or when the will is not exercised there may be slow, irregular, or more rapid movements of the partially paralyzed mus- cles. These post-hemiplegic movements are well de- scribed by Gowers. They vary from a very slight mo- tion of the fingers to an almost constant motion of the whole arm, and even of the toes and leg. Among these movements is that which has been named athetosis by Hammond, which is more frequently seen after hemi- plegia occurring in infancy, but may also occur in adult life. More rarely there is sometimes seen a reflex tremor on the healthy side, occurring whenever the affected limb is moved. The mental faculties are almost always impaired after cerebral haemorrhage. In severe cases, of course, CEREBRAL HEMORRHAGE. 99 these are at first entirely, or almost entirely, destroyed ; but even in light cases it is soon noticed that patients are very different in disposition and intellectual power. They are irritable and emotional, easily angry, or easily bursting into tears. One who has been very guarded in the use of language may, on slight provocation, or with no provocation, break out into oaths. The emo- tional excitement is almost exclusively associated with left hemiplegia. Memory may be more or less defect- ive. Even after almost perfect recovery some impair- ment of mental power may remain so as to render the patient unfit to carry on his business without assist- ance, and he may be so obstinate and suspicious as to render it advisable for him to give up all attempts to continue in business. The paralysis is usually confined to one side of the body, the face, arm, and leg being affected on the same side, but on the side opposite the seat of the haemorrhage. This is the common and regular form, a complete hemiplegia, and in these cases usually the upper branches of the facial nerve are not affected. There are, however, occasional irregular forms. What has been said in regard to localization of cerebral lesions will aid in diagnosticating the seat of the haemorrhage in these cases. Occasionally all four limbs are para- lyzed, either from multiple haemorrhages or from large effusions into the pons and medulla. Such cases are rapidly fatal. In a very few cases the paralysis has been found to be on the same side with the haemor- rhage. Sometimes the arms are affected on one side, the legs on the opposite side. Occasionally only the cranial nerves are affected, or only the arm is paralyzed. Acute bed-sores may form two to four days after the attack. They are situated on the paralyzed side, over the glutei muscles. Bed-sores may appear at a later period, being developed more gradually. They may occur on the knee or the heel, and are perhaps more frequent in elderly patients than in younger. 100 DISEASES OF TEE BRAIN. An eruption of herpes has been known in several cases to follow cerebral haemorrhage, the eruption fol- lowing the distribution of certain nerves. The skin may undergo a thickening, amounting to hypertrophy. There is frequently more or less oedema of the para- lyzed hand, sometimes of the foot. The nutrition of the nails and hair may also be interfered with on the affected side. An acute inflammation of the joints has been ob- served following cerebral haemorrhage. This is devel- oped first fifteen days or a month after the attack, about the time when the late contraction appears. The swelling, redness, and articular pains are sometimes as marked as in acute articular rheumatism. The affec- tion of the joints is limited to the paralyzed limbs. The general nutrition of the paralyzed muscles does not seriously suffer in adults, and there is no degenera- tion. When cerebral haemorrhage occurs in children there may be subsequent retarded development. Two cases have been reported in which there was muscular atrophy, with secondary degeneration of the cells of the anterior cornu.* As a rule, also, the electrical reaction of both nerves and muscles for both the faradic and galvanic currents is unchanged. Once in a while there may be a slight diminution, occasionally a slight in- crease in the irritability. Diagnosis. — Haemorrhage into the substance of the brain is to be distinguished from meningeal haemor- rhage, from thrombosis and embolism of a cerebral ar- tery. The diagnosis from these will be considered un- der those divisions. While the patient is unconscious there may arise a doubt whether the coma is due to haemorrhage or to poisoning by alcohol, opium, or whether it is a case of uraemic poisoning. The odor of alcohol may be recognized in the breath, * See Pitres in " Arch, de Physiol.," 1876, p. 657 ; and " Charcot's Lectures," t. i, p. 55. CEREBRAL HEMORRHAGE. 101 or, if there is vomiting, in the vomitus ; but this does not exclude cerebral haemorrhage. If, on examination, unilateral symptoms appear, and especially if there is conjugate deviation of the eyes and rotation of the head to the same side to which the eyes are turned, the diagnosis is made easier. The course of the tem- perature, at first lowered for an hour or so, then rising, will indicate haemorrhage. The diagnosis from opium poisoning may be made, in part by the above-mentioned symptoms, also by the more gradual advent and increase of the coma. The fact of there being convulsions would exclude opium poisoning. The state of the pupils could not be de- pended upon, as they may be contracted in haemor- rhage, and are occasionally dilated in opium poisoning, especially just before death. Uraemic poisoning is at times equally difficult to recognize. The unilateral character of the symptoms will generally aid here, though not always. The pres- ence of albumen in the urine will not necessarily ex- clude haemorrhage, for in many cases of Bright's dis- ease this accident occurs ; yet, from the history of the case and the condition of the patient, a probable opinion may be formed. Epileptic convulsions may be very slight and the succeeding coma deep, so as to give rise to doubt whether there has not been cerebral haemorrhage. Oc- casionally in epilepsy there is conjugate deviation of the eyes and rotation of the head ; also once in a while the attack is unilateral, and there remains a temporary paralysis afterward. The history of previous similar attacks, with rapid recovery from the paralysis, may clear up the doubt ; but if this is wanting, it may be impossible to come to a satisfactory conclusion. These cases of epilepsy are, however, very rare, and generally the diagnosis is not difficult. Hemiplegia may be assumed with a desire to de- ceive, as in a suit for damages after an injury. The ig- 102 DISEASES OF TEE BRAIN: norance of such persons usually gives rise to inconsist- encies in their account of the symptoms. The pre- tended contraction is not like the real. Associated movements on the healthy side do not occur when an effort is made to move the affected limb. Almost always the true hemiplegic will endeavor to aid the disabled hand with the well hand, or the body will be inclined to act as a fulcrum to help raise the arm. The pretender does not do this. Jastrowitz* states that pressing the greater saphe- nous nerve about a hand's breadth above the internal condyle of the femur causes the testicle to rise on the healthy side, but has no effect on the hemiplegic side. It has been said that other reflex acts also do not take place on the hemiplegic side. When the skin is ex- posed there is no goose-flesh ; tickling the nostril does not produce sneezing ; touching the eyelashes does not cause winking. If there should be a difference be- tween the two sides in these respects, a diagnosis as between narcotic poisoning or simulation and cere- bral lesion could be made ; but whether that lesion is a haemorrhage or some other must depend on other data. During the earlier hours or days the attempt to lo- calize the lesion will often be useless. It is not until the effects of the shock and pressure of the clot have passed away that the more permanent symptoms can be recognized, and these must chiefly be considered in localizing the lesion. Prognosis. — During the comatose stage, soon after the attack, it is impossible to form any opinion as to how severe the attack will prove ; but the longer this stage continues the less favorable the prognosis, and if it lasts beyond forty-eight hours there is very little probability of recovery. If the attack is accompanied with severe convulsions, which are not due to epilepsy, the prognosis is the more serious, as the convulsions attend large haemorrhages — those which burst into the * "Berlin, kl. WoeDenschrifV 1875, No. 31. CEREBRAL HAEMORRHAGE. 103 ventricles and those which are situated in the pons and medulla. The occurrence of Cheyne-Stokes respiration is of unfavorable augury. There is a form of attack which has been called in- gravescent, which is always fatal. With prodromic symptoms, coma gradually comes on, or there is a sud- den loss of consciousness of short duration, after which intelligence is partially or entirely recovered, to be gradually lost again ; the coma steadily deepens, and paralysis becomes more and more complete. The symp- toms steadily increase in severity until the patient lies helpless and senseless, simply breathing, not to be aroused by any form of irritation. These cases are hopeless ; the haemorrhage occurs from one of the larger vessels between the lenticular nucleus and the external capsule, the nerve-fibers are pressed apart, not many are torn asunder ; hence the earlier symptoms are slight. After the initial depression of temperature, if the patient survives and the temperature steadily rises, the prognosis is unfavorable. If there is a slight rise and then a stationary period varying but little from 100°, after which another rise of temperature, then the prog- nosis is unfavorable again. If the temperature does not rise a second time, or falls to normal, the prognosis is favorable. When polyuria, albuminuria, and glyco- suria exist in a very marked degree, the prognosis is grave. During the period of inflammatory reaction the prognosis depends upon the intensity of the fever and attendant symptoms. Acute bed-sores appearing shortly after the attack are extremely unfavorable, and are almost certain to be followed by death. If the patient survives, a complete recovery is rarely to be expected. Trousseau considers that if the motor power returns in the leg first, before the arm, the prog- nosis is more favorable, at least for retention of mental 104 DISEASES OF THE BEAIR. power. Recovery of motion may progress slowly for an indefinite period. If the late contraction appears, there is little or no chance of further improvement, and, in regard to disappearance of the contraction, the prog- nosis is absolutely unfavorable. A second attack may occur in any one who has suf- fered from a cerebral haemorrhage. If there is evident disease of the arteries, Bright's disease, or retinal haem- orrhages, this is more likely to occur. Also, if the pa- tient be past middle life, there is more probability of another attack. After an attack, a return of prodromic symptoms would indicate renewed danger. Treatment. — When the physician first sees a pa- tient attacked with cerebral haemorrhage, the injury has probably been done ; in most cases the blood has ceased to escape from the ruptured vessel. Trousseau advocates very strongly to let the patient alone ; others advise bleeding (Jaccoud, Huguenin) under certain con- ditions. If the patient is hearty, robust, with a strong- ly acting and healthy heart, and is evidently suffering from too great blood-pressure in the cranial cavity, they advocate general bleeding as the most effectual means of relieving this excessive blood - pressure. Bleeding is not indicated where the pulse is weak, if the patient is aged or feeble, or if there is heart dis- ease, or when the coma has been of short duration and consciousness has returned. Practically, very few cases are suitable for bleeding under these conditions. In by far the larger number of cases nothing can be done ex- cept to place the patient on a bed with the head rather elevated, loosen all the clothing, and wait. As perfect quiet as possible should be maintained, the patient not moved, and fed with the simplest diet : if previously in full health and well nourished, it will be no disadvan- tage to feed sparingly ; if in poor health and ill nour- ished, the feeding should be more abundant. If the heart's action is feeble and there is evident lack of vi- tality, stimulants, at first external, afterward, if neces- CEREBRAL HEMORRHAGE. 105 sary, internal, should be used. After return of con- sciousness no special medical treatment is needed until the period of inflammatory reaction, when cold to the head, a laxative to open the bowels, and, if there is much headache, chloral, or some preparation of opium or belladonna, to relieve the pain. Occasionally, dry caps to the back of the neck or local bleeding may be called for. Ergot, by mouth or subcutaneously, may be used to diminish the danger of renewed haemorrhage. After the danger from inflammatory reaction is passed, many times there will be necessity for medical treatment. The patient should be kept quiet, secluded, in a well ventilated apartment, with proper regard for all hygienic influences ; should have a plain, unstimu- lating diet, not half starved, but should receive suffi- cient food. After a few weeks the nutrition of the muscles would be benefited by systematic rubbing, massage ; later, after five or six weeks, electricity may be used. If proper care is exercised in not using too strong a current, and not continuing the application too long, this agent may be used without danger, and even with benefit, earlier than many authors advise it. The galvanic current, using from three or four to twelve cells, may be applied to the head — one electrode on the upper cervical vertebral, the other over the mastoid process, or just below — or one pole on each side of the head, the positive on the same side with the haemor- rhage. Great care is to be taken not to suddenly inter- rupt the current, to use it only one minute, or at most two ; to use a current which will not cause dizziness. Whether any benefit is ever obtained by this use of the galvanic current is extremely doubtful, and it is men- tioned entirely upon the authority of several European observers. The application of the induced or faradic current locally is attended with less risk, and is many times of positive benefit. One pole may be placed on some in- different point, and the other passed lightly over the 106 DISEASES OF THE BRAIN. different muscles, the current being graduated so as to cause the muscles to contract slightly without pain. The weakest current which wall do this is strong enough. It is not necessary to move the limbs. The application should not exceed half a minute to a minute for each muscle, and this not continuously, but one muscle after another may be exercised for a few seconds, and then the limb be gone over again. This application will have the advantage of sustaining the nutrition of the mus- cles ; also, the muscles would not fall into a state of sluggishness from simple inertia. Sometimes it will be found that electricity does harm ; then, of course, it should be immediately omitted. During the period of gradual recovery little can be done in the way of medication ; absorption and resti- tution of structure and function advance slowly. For- merly, and even now, strychnia has been given very freely. It is not of sufficient benefit to offset the danger arising from its use in these cases. The absorb- ent properties of iodide of potassium render that drug acceptable, but with care not to disturb the stomach. Occasionally, especially in syphilitic cases, mercury has seemed of value. After the occurrence of late contrac- tion, little or no improvement need be expected ; though some cases are reported of benefit from electricity in these cases, I have never seen any. As pneumonia and bronchitis are especially liable to attack the lung on the affected side, especial care should be taken after an attack to avoid exposing the patient. After an attack the patient is anxious to guard against its recurrence. All measures necessary to sus- tain perfect health are in place — the avoidance of what- ever will produce an increase of pressure in the cerebral blood-vessel, a quiet, composed life, with recreation and amusement sufficient for healthy action of the mind without excitement. If in active business, the activity should be moderated. CHAPTER VI. OCCLUSION OF CEREBRAL ARTERIES. Lancereattx, E., De la thrombose et de l'embolie cerebrales considerees principalement dans leurs rapports avec le ramollisse- ment du cerveau. Paris, 1862. — Gelpke, Ottomar, Vergleichende Zusammenstellung der Symptome von Hirnapoplexie und Embo- lie der Hirnarterien. Archiv der Heilkunde, 1875. — Meissner, Berichte liber Embolien und Thrombosen. Schmidt's Jahrb., 109, 117, 131. The cerebral arteries may be suddenly plugged by the lodgment of a portion of a clot or other foreign body brought from a distance, an embolus, or gradu- ally by the growth of a tumor, by the thickening of the walls of the artery, or by the coagulation of the blood at the point where the obstruction occurs. The sudden stopping of an artery by a clot brought from a distance is called embolism ; the plugging by a clot formed on the spot is called thrombosis. EMBOLISM. ^Etiology. — The emboli may arise in the pulmonary veins, or the left side of the heart, or in any of the ves- sels between the heart and the point where they lodge. Much the more frequently they arise in the heart as the products of acute or chronic endocarditis. Warty growths form on the valves, are torn off and carried into the circulation, or a blood-clot forms in the heart and portions are broken off. Aneurisms of the aorta are sometimes the source whence the fragments of clot 108 DISEASES OF THE BRAIN. arise. Disease of the lungs, as pneumonia or phthisis, cancer or embolism, or thrombosis of the pulmonary- vessels, may serve as the point of origin of an embolus which may be carried by the pulmonary vein to the heart, and thence to the brain. Any diseases, then, which may give rise to endocarditis or the above pul- monary affections are remote causes of embolism. Pathological Anatomy. — It is not necessary to describe the changes which the embolus undergoes, except to say that in rare cases it is broken down and absorbed. Immediately after the occlusion of an artery the blood from the veins flows back into the distal branches of the obstructed artery, and there is more or less sta- sis. In the brain it is very rare that the anastomoses are sufficient to maintain an active circulation, hence the region which depends upon these branches for its nutrition suffers from lack of healthy blood ; the walls of the vessels also suffer and allow the blood to escape. The cerebral tissue is infiltrated with serum, the blood undergoes change, and its coloring-matter is diffused through the part, and gives a red or yellowish tint to the broken-down nervous tissues. The nervous elements, being deprived of healthy blood, lose their vitality, soften, undergo fatty degen- eration, and are reduced to a semi-fluid pulp. If the region affected is small, this may be absorbed, a cica- trix is formed, and the spot of softening may finally disappear, but more frequently a cyst remains filled with serum and crossed by bands of connective tissue. The softening does not show itself immediately ; it is perceptible only thirty-six to forty-eight hours after the occlusion of an artery. Owing to the direction in which the different arteries are given off from their main trunks, emboli are much the more frequently carried into the left carotid, and are generally lodged in the middle cerebral artery or one of its branches. Duret has described the distribu- EMBOLISM. 109 tion of softening which belong to the various branches of the cerebral arteries. Symptoms. — Generally without warning, the patient is attacked with loss of consciousness and entire loss of power. There may be, for a few minutes, headache or vertigo, but the attack is usually sudden and complete. The loss of consciousness is of less duration than in haemorrhage, and may be only momentary. It is fre- quently accompanied with general epileptiform con- vulsions. Vomiting and delirium are sometimes pres- ent. Occasionally paralysis is the first symptom. Consciousness is not always lost ; there may be merely confusion of thought. After recovery of consciousness and voluntary power it will be found that the patient has paralysis of one side. Usually the face and limbs of the side opposite the lesion are affected, and as the left middle cerebral artery is much the more frequently the seat of embo- lism, the right side is usually the one affected. The temperature is slightly lowered immediately after an attack, but quickly rises, and, if the case proves fatal within three or four days, the rise of tem- perature is almost unbroken. If the patient lives from five to fifteen days, the temperature is irregular. If the attack is not fatal, the temperature falls to very nearly or quite to the normal after three or four days. After the earlier stage of the disease the symptoms are essentially the same as in haemorrhage. Contrac- tion of the limbs is seen less frequently than after haemorrhage, yet is essentially the same when it oc- curs. The intellectual disturbance is rather less marked. Disturbance of the faculty of speech is not uncom- mon in embolism, and when the right side is paralyzed there is almost always aphasia. Occasionally the aphasia is the only symptom pres- ent ; there is no loss of consciousness, nor paralysis. Some of these cases are due to embolism of small ar- HO DISEASES OF THE BRAIN. teries, some are due to disturbance of circulation de- pending upon other causes. The embolus may lodge in an artery, stop the blood- current for a few minutes, and then, by a change of its position, the blood may be able to pass it in sufficient quantity to restore the nutrition of the brain. If the embolus is then broken up and absorbed, there may be no further trouble ; or if it adheres firmly to the wall of the vessel, there may be no further trouble. If, however, its position is again changed, it may plug the vessel finally, and then the symptoms become perma- nent. When other than the middle cerebral artery is plugged by an embolus, the symptoms will vary ac- cording to the portion of the brain affected. Diagnosis. — The diagnosis is almost exclusively be- tween haemorrhage and embolism. The question as to the diagnosis of thrombosis is reserved till the latter affection has been considered. It is frequently impossible to be certain whether there has been embolism or haemorrhage ; but, by a careful consideration of all the symptoms and other circumstances, it will generally be possible to form a satisfactory diagnosis. Gelpke has given a valuable review of the diagnostic points between apoplexy and embolism. The first is age ; apoplexy is by far the more frequent after fifty— embolism before fifty. More than sixty per cent (near- ly or quite seventy per cent) of the cases of apoplexy occur after fifty ; more than sixty per cent of the cases of embolism occur before fifty. In haemorrhage there is disease of arteries ; so this is found most frequently in connection with Bright's disease or where there are atheromatous changes. Embolism occurs most where there is cardiac valv- ular disease. In haemorrhage there may be premoni- tory symptoms; in embolism the attack occurs gen- erally without warning. When there seem to be pre- EMBOLISM. Ill monitory symptoms, they are rather due to independent attacks. The symptoms which are found during and immedi- ately after the attack may be very much alike, yet there are slight differences which may aid in diagnosis. Both embolism and haemorrhage are frequently accom- panied with hemiplegia ; but in embolism it is almost always on the right side; in haemorrhage on either side : so left hemiplegia would rather point to haemor- rhage ; right hemiplegia not necessarily to embolism. Epileptic attacks at the time of seizure rather indi- cate embolism. The muscular paralysis is greater in embolism than in haemorrhage. Aphasia, agraphia, and amimia depend upon changes in or near the island of Keil, and are the more frequent in embo- lism. Ataxic loss of speech depends upon lesion of the corpus striatum, and is the more common in haem- orrhage. In embolism the symptoms of cerebral press- ure are wanting, as diminished frequency of pulse, stertorous respiration, vomiting, contracted pupil, and strabismus. After the attack the mental powers are more likely to be affected in haemorrhage, especially the emotional faculties. There is also more likely to be reaction ; and a return of function, if it occurs, is slower in haemor- rhage. The discovery of an embolism in other arteries, as radial, femoral, etc., would aid in establishing a diag- nosis. The temperature may also assist. In embolism, dur- ing the first few hours, the initial depression of tem- perature below normal is wanting or very slight ; in haemorrhage it is much more marked. In embolism, after a temporary rise, the temperature returns to the normal with irregular exacerbations or evening eleva- tions; in haemorrhage it returns less quickly to the normal unless a second haemorrhage occurs. After the stationary period the rise of temperature is slower in 112 DISEASES OF THE BRAIN. embolism, and generally does not attain so high a figure as in haemorrhage. Exceptional cases of embolism occur where the vari- ation of temperature more nearly resembles that found in haemorrhage. If there is complete recovery within a few days after an attack of complete hemiplegia, there probably was not haemorrhage. Prognosis. — "At the outset of and during the pri- mary attack, no prognosis can be given as to the prob- able course of the case, except that its severity is likely to be proportionate to the extension and severity of the primary symptoms. If the paralytic symptoms disap- pear after a brief period, there will be no reason to fear the presence of serious structural disease, but the chance of future attacks can not be excluded." ("Ziems. Cyclop.") Severe cases are more serious than severe cases of haemorrhage, and more likely to prove fatal. When the vertebral or basilar artery is plugged, the prognosis must necessarily be very unfavorable. Treatment. — Unless the patient is very feeble and requires slight stimulation, the less done during the first few days the better. Blood-letting and depressing measures are decidedly contra-indicated. If there arise indications of cerebral irritation from collateral hyper- emia, the bowels should be freely acted upon and the head kept cool. The subsequent treatment may be the same as in cerebral haemorrhage. THROMBOSIS OF CEREBRAL ARTERIES. JEtiology. — The causes of thrombosis of cerebral arteries are to be found either in the vessels themselves, in the composition of the blood, or in the diminished action of the heart. The walls of the vessels may be- come roughened from disease, as in arteritis obliterans, whether syphilitic or not, and also in case of atheroma, THROMBOSIS OF CEREBRAL ARTERIES. 113 especially if the inner epithelial layer is broken ; the vessel may be contracted through a small extent of its length, and thus the blood-current be retarded. The disease of the walls of the vessels as found in old age interferes with their normal elasticity, and so favors retardation and coagulation of the blood. Disease or weakness of the heart may also cause the blood to flow less rapidly, and so favor the formation of a thrombus ; or the blood may coagulate more readily than usual, as in certain febrile diseases. Disease of arteries and fee- bleness of heart's action are found combined in old age ; consequently thrombosis is most common in advanced life ; very few cases occur below forty years of age ; most patients are over sixty. Pathological Anatomy. — When the thrombus fills an artery whose branches are not connected by an- astomoses with other arterial supply, the brain, deprived of blood, must necessarily undergo the same degenera- tion as is found in embolism. Often the smaller end arteries are stopped up, and then small spots of soften- ing will be found throughout the brain ; this is most commonly seen in the white substance. The cavities thus formed may vary in size from a sixteenth of an inch in diameter to an inch or more ; if numerous, they average an eighth to a quarter of an inch ; they are crossed by bands of connective tissue containing blood- vessels ; there may be a new growth of vessels if inflam- mation has set in. The walls of these cavities usually contain granular corpuscles. If recent, the nerve-fibers around the border of the cavity may show enlargement of axis- cylinders and other inflammatory changes. Sometimes, instead of a cavity, cicatricial tissue forms and a hard nodule is left. Symptoms. — As the arteries are usually closed grad- ually, there is a less sudden onset of the symptoms than is found in embolism. For a variable length of time the patient has had more or less discomfort in the head — pain or dizziness — memory may be less strong, the 114 DISEASES OF THE BRAIX. patient may show signs of mental disturbance or tem- porary loss of consciousness, which are referred to old age, or there may be actual insanity ; sometimes tem- porary loss of power or abnormal sensations in the limbs, which soon pass away, but again appear, show that there is serious disturbance of the cerebral circula- tion. If the region of the pons and cerebral peduncles are affected, individual cranial nerves may be more or less paralyzed. There may be a numbness and tingling in the limbs on one or both sides, or a slowly increas- ing paralysis may be the result of gradual loss of power in the motor tracts. After these undefined, perhaps doubtful and confus- ing, symptoms have continued, it may be for months, there may occur an apoplectic attack ; the vessel which had been only partially obliterated is suddenly entirely plugged ; then the symptoms of embolism follow. Diagnosis. — Thrombosis and embolism differ in the above premonitory stage, which perhaps may be de- scribed more properly as the gradual development of the symptoms. It may be almost impossible to decide whether there is a thrombus or a haemorrhage when the artery is final- ly plugged suddenly. A number of independent attacks of paralysis, of unconsciousness, or of dizziness, from which the patient soon recovers, followed by the finally permanent attack ; the advance of the symptoms by stages, as it were, with intervals when there was no ad- vance — would point to a thrombus rather than a haemor- rhage. A preceding or accompanying acute disease, as pneumonia, or a great general feebleness, should cause a suspicion of thrombosis. Age, disease of arteries and of kidneys, would be as significant of one as the other. After the apoplectic attack the diagnosis of thrombus would be made from the same peculiarities as are found in embolism. When there are several attacks of unconsciousness, THROMBOSIS OF CEREBRAL ARTERIES. 115 or of paralysis, or of dizziness, there may be a question as to whether the patient is suffering from epilepsy. It should be kept in mind that epilepsy rarely originates in old age ; a careful study of the phenomena attending the attack will show a lack of resemblance with epilep- sy ; bromide of potassium is more likely to aggravate the symptoms in thrombosis, but relieves them in epi- lepsy. The diagnosis of locality must be made from com- parison of symptoms with facts which have already been given, only remembering that the symptoms due to pressure would be absent. Peognosis. — The physician must judge of the dan- ger to life by the course and severity of the symptoms. The more extended the signs of disturbance, the longer the unconsciousness continues, the more certain the le- sion can be located in the mesencephalon, the more serious must be the prognosis. Treatment.— When a diagnosis of thrombosis can be made, the treatment should be tonic and mildly stimulating ; when it is impossible to certainly exclude haemorrhage, it is not desirable to give stimulants free- ly ; and in very doubtful cases it may be better to do nothing more than to put the patient in as favorable hygienic conditions as possible, insure quiet, rest, and absence of excitement. If the patient is young, and has had syphilis, a course of iodide and mercury would certainly be appropriate. After an apoplectic attack the treatment would be the same as under similar circumstances arising from other causes. CHAPTER VII. TUMORS OF THE BRAIN. Ladame, Paul, Symptomatologie und Diagnostik der Hirnge- schwiilste. 1865. — Macabian, Jean Firmin, Quelques considera- tions sur les tumeurs du cervelet. Paris, 1869. — Bramwell, By- ron, Clinical Lectures on Intra-cranial Tumors. Edinburgh Med. Jour., 1881.— Nothnagel, H., Topische Diagnostik der Gehirn- krankheiten. Berlin, 1879.— Bernhardt, M., Beitrage zur Symp- tomatologie und Diagnostik der Hirngeschwiilste. Berlin, 1881. — Klebs, E., Beitrage zur Geschwulstlehre — Hirngeschwiilste. Prag. Vierteljschr., cxxxiii. — Jackson, J. H., Diagnosis of Tumor of Brain. Med. Times and Gaz., August 9, 1873. Pathological Anatomy. — Many of the tumors which are found within the skull are not properly tu- mors of the brain — that is, do not take their rise from the cerebral tissue, but arise from the meninges or the blood-vessels ; some arise from the bones of the skull. As all these are revealed to us by the symptoms pro- duced by their influence upon the brain, it is proper and most convenient to include all under the term "tu- mors of the brain." It is unnecessary to give details of the histology of the different kinds of tumors which may be found in the brain or connected with its envelopes. Tubercle, cancer, gummata, sarcoma, osseous growths, myxoma, and lipoma do not differ essentially from the same growths found elsewhere. Glioma, psammoma, and cholesteatomata are among the tumors which more peculiarly belong to the brain. The first, glioma, is simply a development of the normal neuroglia with sometimes the admixture of more or less fibrous tissue. TUMORS OF TEE BRAIN. H7 They vary in consistency according as cells or fibrous tissue predominate. Psammoma consist in the formation of grannies of calcareous substance infiltrated into the cellular tissue. There may be also hyperplasia of the pineal gland or of the pituitary gland. ^Etiology. — Certain tumors, as tubercle, cancer, or syphilitic gummata, must be referred to a constitutional diathesis. Blows and falls upon the head are often the direct cause of the development of abnormal growths. The cause of a large number of tumors can not be cer- tainly discovered. Symptoms. — There are certain symptoms which may be called general, or common, which are found in almost every case of intercranial tumor without reference to its locality ; other symptoms depend upon the situation of the tumor and aid in locating it. The latter symptoms are important as well in assisting to form a diagnosis of the presence of a tumor, the common or general symp- toms oftentimes not being definite enough for that pur- pose. Sometimes a tumor gives rise to so few symptoms, or they are so slight, that no notice is taken of them, or there may be no symptoms. This is more likely to occur where the tumor is quite small, where it is situ- ated in certain parts (anterior or posterior) of the white substance, and where it is very slow in growth. The symptoms depend upon the immediate effect of the tumor upon the nervous structures, destruction or irritation ; upon its effect at a distance, irritation and pressure ; and upon the inflammatory or other changes which it excites in the cerebral substance, more espe- cially in its vicinity. The general symptoms are, in most instances, due to the remoter effects or to the less direct changes excited by the new growth. The most common symptom is headache ; this is also usually one of the first, and is characterized by its persistency and the severity of the 118 DISEASES OF THE BRAIN. paroxysms. Remissions, sometimes even intermissions, may occur, in which the headache is replaced by a feel- ing of slight discomfort in the head. In some cases a slight noise or the least motion brings on an attack. When severe, remedial agents have no power to allevi- ate the pain. The more rapid the growth of the tumor, the more severe and persistent is the headache. Dizziness, or vertigo, is a frequent symptom in the early stages of the disease. Nausea and vomiting are very frequently present, and may be very obstinate. These are rather the more frequent when the posterior part of the hemispheres or the cerebellum is affected. Various mental disturbances belong among the ear- lier symptoms, such as change of disposition, a pleasant, good-natured patient becoming cross and irritable, or one who has been careless and unconcerned taking upon himself the opposite qualities ; one who has been open and frank becoming silent, morose, and suspicious. Memory fails, power of mental application is lost, and business cares and responsibilities become a burden. None of these changes are sufficient to rank as insanity ; there is simply slight mental disturbance, which may be perceived even before the headache shows itself. When all these symptoms are found together, per- sisting in spite of treatment or only partially relieved thereby, the presence of cerebral tumor is almost cer- tain. The diagnosis is yet more certain when any of the following symptoms are also present : There may be a general failure of muscular strength, no definite paralysis of any set of muscles, but a sim- ple and increasing enfeeblement. When the cerebral disease is secondary to disease elsewhere, as tubercular or cancerous, it may be impossible to decide how much this weakness is due to the constitutional state, or to the local disease in the brain. Spasms and convulsions are sometimes so general or indefinite that they are to be considered* as general symptoms. They are, however, probably dependent TUMORS OF TEE BRAIN. 119 upon an irritation of the cortical gray substance, either direct or remote, either primary or reflex. Spasms localized in one or a few groups of muscles belong to the localizing symptoms. There is rarely pain in the limbs, but various abnor- mal sensations, as numbness, formication, pricking, and tingling, are not uncommon ; sometimes there is great diminution of ordinary sensations. Disturbances of special senses, excepting eyesight, are not common ; deafness and anosmia are rare ; taste is lost only or chiefly when the mesencephalon is affected. Diplopia, amblyopia, amaurosis, and hemianopsia are not rare ; they belong more especially to localizing symptoms, and have been more or less fully considered already. Disturbance of speech, rotatory movements, com- pelled movements forward or backward, conjugate de- viation of the eyes and head, also belong to localizing symptoms, and have been considered in previous pages. Optic neuritis is very frequently one of the second- ary or remote symptoms of cerebral tumor, and, when present, may be of great value in forming a diagnosis. In every case of cerebral disturbance the ophthalmo- scope should be used, whether there is disturbance of vision or not. The neuritis may exist unsuspected by the patient. Other signs of ill health may be present, as emaci- ation, anorexia, pyrexia, constipation, retention or in- continence of urine, disturbance of circulation or of respiration. The symptoms which enable one to localize the tu- mor have been mentioned already ; they are also im- portant as showing the presence of organic change in the brain, but other symptoms indicate the nature of that change. The temperature of the body is not very often raised, but several observations of the temperature of the head show that there is an increase of surface-heat on the 120 DISEASES OF THE BRAW. side where the tumor is, especially immediately over it. This branch of inquiry has not been pursued far enough as yet to decide whether the degree of elevation has any relation to the nature of the tumor or its rapidity of growth. Great care is necessary in taking these ob- servations to guard against errors. The course of the disease varies greatly according to the rate of increase and the situation of the new growth. It is hardly necessary to say that a rapidly growing tumor will cause many more severe symptoms than one which increases in size more slowly. Inflam- mation or congestion around a tumor may give rise to a sudden outbreak of symptoms, and their rapid increase in severity. This may subside, and then a remission would succeed. As a rule, with occasional remissions, or even inter- missions, in the symptoms, there is a steady advance ; the headache may at length diminish in intensity, per- haps because of destruction of nerve-fibers, the con- vulsions may cease because the motor areas are de- stroyed, but with the apparent improvement the mental powers will be found to have diminished, the paralysis to have increased, the patient is more helpless ; while suffering less, he has evidently lost ground. At length there is complete hemiplegia, or possibly paralysis of the entire body, the bladder and rectum are affected as in other cases of hemiplegia, and bed- sores form ; it becomes constantly more difficult to give the proper nourishment, and the patient dies exhausted. Many times, however, the fatal termination is more speedily reached, the respiration or heart's action is interfered with, or pulmonary complications set in, and the patient soon dies. The duration is very variable ; cancer, tubercle, and syphilitic growths are rapid in their course ; glioma may slowly advance for years, with many intermis- sions. There are many questions which it would be inter- TUMORS OF THE BRAIN. 121 esting to consider, but the object is simply to lead to a correct diagnosis, and indicate the most rational treat- ment. Diagnosis. — The diagnosis of tumors of the brain from other cerebral affections is by no means always easy. Tubercular meningitis may sometimes closely resemble tumor. It is more common in children than adults, while tumors are more frequent in adults. Chronic thickening of the membranes, especially if occurring at the base, so as to involve the cranial nerves, may give rise to exactly the same symptoms as a tu- mor. Such thickening is more frequently seen as the effect of a syphilitic taint. Abscess of the brain is usually accompanied with less' headache, is less likely to have ocular symptoms, to cause vomiting and vertigo, and is more frequently the result of an affection of the ears. Apoplexy and embolism may generally be distin- guished from tumor by the suddenness with which the symptoms occur, and the peculiarities of the first at- tack. Nevertheless, in rare cases, tumors have re- mained comparatively latent for an indefinite period of time, and then manifested their presence by an at- tack closely resembling apoplexy. A careful study of the symptoms attending the onset, and the previous state of the patient's health, especially whether any of the general symptoms indicating tumor existed, also an examination of the heart and kidneys, would assist ma- terially to a correct diagnosis. An obstinate and persistent headache, such as some- times occurs at puberty, may give rise to anxious fore- bodings, lest it should be significant of serious brain trouble ; much more would such anxiety arise if the headache were attended with attacks of vomiting. A careful study of the whole history of the case, and a careful examination of the patient, will aid more than anything in forming a diagnosis ; but it may be neces- sary to wait for time to settle the question. 122 DISEASES OF TEE BRAIN. Prognosis. — The result is almost invariably fatal, the patient being finally worn out by bed-sores, or de- bilitated by insufficient nourishment from the difficulty of swallowing or the continuous vomiting. Sometimes the fatal termination occurs during an epileptic attack, or in an attack of apoplexy. It is almost impossible to judge with any degree of certainty in regard to the duration of life. Possibly, if the growth is syphilitic and has not at- tained too large a size, there may be recovery ; though recovery itself might throw some doubt upon the cor- rectness of the diagnosis. Treatment. — The treatment of cerebral tumors may be included under two heads — treatment designed to cure the patient, and that intended to relieve certain symptoms. Where there has been a previous syphi- litic infection, it is advisable to pursue an active course of antisyphilitic treatment — iodide of potassium with- out hesitation in sufficient doses to produce a marked effect within a comparatively short time, and mercury. Even where syphilis is not proved, a course of iodide of potassium may be of great benefit. Counter-irritation to the head and neck has been recommended. It is extremely doubtful if the growth of a tumor is influenced thereby, though some of the unpleasant symptoms may be mitigated. To fulfill the second indication — if convulsions of an epileptiform character are frequent — one of the bro- mides in large doses may give more or less relief. As headache is one of the most distressing symptoms, patients are imperious in their demands to be relieved therefrom ; if apparently not very severe, milder meas- ures may first be tried, as counter-irritation to the neck, bromide of potassium, cannabis Indica, caffein. If the pain is severe, probably nothing will relieve it except one of the preparations of opium. There should be no hesitation in using this drug in such doses as to give relief. Often a comparatively small dose will accom- TUMORS OF THE BRAIN. 123 plish the purpose ; it is well occasionally to intermit its use to learn whether the headache may not have ceased ; at such times a weak solution of quinine may very conveniently take the place of morphine by the mouth, or water may be used for subcutaneous injec- tion. The vomiting which accompanies cerebral tumor is often very obstinate and intractable. It should be treated according to the condition of the patient. Counter-irritation to the head and neck or over the stomach should not be omitted when other means fail. Ice to the head and neck may be useful. If other means do not succeed, morphia may control it. Of course, the conditions of the patient, which re- quire special treatment, as cystitis, bed-sores, etc., should receive the necessary care. CHAPTER VIII. CEREBRAL ABSCESS. Kohler, A., Ein Beitrag zur Lehre von Gehirnabscess. Schmidt's Jahrb., 183, 1879.— Meyer, E., Zur Pathologie des Hirnabscesses. Zurich, 1867. — N aether, R., Die metastatischen Hirnabscesse nach primaren Lungenherden. Deut. Arch. kl. Med., xxxiv, 1883.— Thompson, H., Case of Otitis, Cerebral Abscess, etc. Med. Times and Gaz., March 29, 1878.— Fenger, Christian, On Opening and Drainage of Abscess Cavities in the Brain. Am. Jour, of the Med. Sci., July, 1884. ABSCESS OF THE BRAIN. ^Etiology. — The causes of cerebral abscess are almost always evident. One of the most common, perhaps the most common cause, is inflammation of the ear. When the otitis affects the bone, there is always danger that the disease may extend to the brain ; either the bone is perforated, and so the dura and pia mater exposed to direct irritation, or, as is more frequent, the inflamma- tion is transmitted through the foramina or veins. In all cases of otorrhcea in children, the danger of this complication should be kept in mind. Injuries to the head, whether attended with fract- ure of the bone or not, are frequent causes of cerebral abscess. Disease of the bone, caries, from whatever cause, may give rise to abscess. An abscess may form about a haemorrhage, or the infarctus due to an embolism or thrombus. Pyaemia may be a cause ; erysipelas and acute dis- ABSCESS OF TEE BRAIN. 125 Pathological Anatomy. — The division has been made of red and yellow inflammation : the distinction depends npon the relative amount of blood or pus con- tained in the diseased tissue. Abscesses may be en- cysted, i. e., surrounded by a close, firm layer of new- formed tissue ; or they may have no containing wall, the pus, mixed with debris of the cerebral substance, being in direct contact with the softened, partly broken- down tissues. The abscess may vary in size from very small to in- clude nearly a whole hemisphere. The histological changes which the tissues pass through consist in a cloudy swelling of the elements, a gradual breaking up into granular debris and trans- formation into granular corpuscles, and increase of connective-tissue fibers and cells around the focus, when a capsule is formed. The nervous elements themselves are destroyed by fatty or granular degeneration, sometimes preceded by swelling, or hypertrophy of axis-cylinders and nerve- cells. Around the abscess there may be very great oedema of the cerebral tissue, and sometimes congestion, some- times an ansemic condition. Symptoms. — The symptoms are quite similar to those attending tumor of the brain. Headache is one of the most common. This is severe, and generally continuous. If not intense, there is at least a feeling of discomfort, of pressure, of lightness, or dizziness. Mental confusion, disturbed memory, sometimes delirium, show how seriously the higher intellectual faculties are implicated. Nausea and vomiting may be among the earlier symptoms, and, if very persistent soon after an injury to the head, or if they set in during an attack of otor- rhea, should give reason to suspect abscess. Paralysis and disturbance of sensation other than headache are not very common ; sometimes the motor 126 DISEASES OF TEE BRAIK centers, or motor tracts, are affected, and then local paralysis or hemiplegia may be noticed. Convulsions are rather common ; they may be local only ; or, as is more frequent, beginning as local, they become general ; they may, from their commencement, be clearly epileptic in character. The increased irrita- bility of the motor centers caused by the inflammation fully explains their occurrence. When pressure increases, there may be the corre- sponding symptoms — retarded pulse, stupor, stertorous respiration, etc. Sometimes meningitis is one of the results of the injury or disease causing the abscess ; then the symp- toms of cerebral meningitis may predominate. Either the abscess runs a rapid course, terminating fatally within a few days or weeks, or a period of re- mission may set in ; the abscess may remain latent for an indefinite time. When thus latent, it is probably always encysted. During this time of remission or latency, some of the symptoms may persist in a dimin- ished degree of intensity. In other cases there is no acute initial stage ; the abscess from the beginning runs a chronic or concealed course. At length an active in- flammation starts up around the abscess, and all the symptoms are aggravated, the patient becomes paralyzed and comatose, and soon dies ; or the cedema around the focus of disease increases suddenly and rapidly, and so the patient dies. The abscess may rupture into the lateral ventricles, giving rise to sudden aggravation of the symptoms ; general convulsions are usually excited ; there may be loss of consciousness. Yery rarely a local meningitis is excited, the mem- branes adhere, the bone is perforated, and the abscess is discharged externally. The evacuation may be fol- lowed by recovery. Occasionally recovery results with- out discharge of the contents. Diagnosis. — Cerebral abscesses have many symp- ABSCESS OF THE BRAIN. 127 toms common to cerebral tumors : headache, vomiting, dizziness, the symptoms of pressure, are common to both affections. The preceding otorrhcea, or the history of an in- jury not long before the cerebral symptoms are devel- oped, would indicate an abscess. If a tumor follows an injury, a much longer interval must elapse before it shows its presence. Local paralysis and hemiplegia are more common with tumors, excepting toward the later stages. A rapid increase in severity of symptoms after a period of remission, amounting perhaps almost to intermission, is indicative of abscess. Local convul- sions, followed sometimes by general convulsions, are met in tumors of the cortex ; general convulsions, with- out preceding local spasms, are more common in ab- scess. The diagnosis between abscess and tumor may, however, frequently be impossible. Meningitis is accompanied by higher fever, by more marked cutaneous hyperesthesia, less frequently by convulsions. Yet the diagnosis may be very difficult or impossible, especially as meningitis may be pro- duced by the same causes as abscess, and the two dis- eases may co-exist, one as the cause of the other, or both depending upon the same cause. The diagnosis of locality is less easy than in other forms of cerebral disease. The same general principles should guide in a decision, but, as a rule, the data upon which to found an opinion are fewer and less trust- worthy. After an injury the abscess may be on the opposite side, the brain having suffered there by contre coup. . Prognosis. — Recovery is the exception — so rare that little account need be taken of such cases. A remis- sion may excite strong hopes of cure, but there is the constant danger of a return of the symptoms in a more aggravated form. Treatment. — After an encephalitis has gone so far as to give rise to an abscess, medical skill is compara- 128 DISEASES OF THE BRAIK tively powerless. The treatment must then consist in quiet, rest, and avoidance of excitement. Counter-irri- tation might be used if there is doubt as to the abscess having been formed ; mercury, by mouth or inunction, is strongly advised. Cold may be applied continu- ously. More benefit can be hoped from the use of precau- tions to prevent the formation of an abscess. Otorrhcea should never be neglected, especially in children ; an effort should be made to cure the local disease. When there has been severe injury to the head, rest and quiet should be maintained for a while, and, if there is attendant headache, the enforced quiet should be kept up till that disappears ; during this time the diet should be sufficient, but light, easily digested, and unstimulating ; cold applied continuously, and leeches may be used. Free action of the bowels by cathartics. The question of trephining in injuries to the skull belongs to surgery. DISEASES OF THE SPINAL CORD. CHAPTER IX. ANATOMY, PHYSIOLOGY, AND GENERAL SYMPTOM- ATOLOGY. Bramwell, Byrom, The Diseases of the Spinal Cord. New York, Wm. Wood & Co., 1882.— Althaus, Julius, On Sclerosis of the Spinal Cord. New York, 1885.— Schuster, Diagnostik der Riickenmarks-Krankheiten. Berlin, 1884. — Charcot, J. M., Lect- ures on the Diseases of the Nervous System. 2d Series. New Syden- ham Soc, 1881. Lectures on the Localization of Cerebral and Spinal Disease. Ibid., 1883.— Leyden, E., Klinik der Riicken- marks-Krankheiten. Berlin, 1874. — Page, H. W., Injuries of the Spine and Spinal Cord. London, 1883. — Vulpian, A., Maladies de la moelle. Paris, 1879. — Buzzard, Thomas, Clinical Lecture on Diseases of the Nervous System. Philadelphia, 1882.— Drum- mond, David, Diseases of the Brain and Spinal Cord. London, 1883.— Gowers, W. R, The Diagnosis of Diseases of the Spinal Cord. Philadelphia, 1884.— Seguln, E. C, The Localization of Diseases in the Spinal Cord. Opera Minora. New York, 1884, p. 436 ; also p. 283.— Schiefferdecker, Beitrage zur Kenntniss des Faserverlaufs im Riickenmark. Arch. f. mikroskopische Anatomie, Bd. 10, H. 4, p. 471.— Hollis, W. A., Researches into the Histology of the Central Gray Substance of the Spinal Cord and Medulla Oblongata. Journal of Anatomy and Physiol., July, 1883.— Ranney, A. L., The Applied Anatomy of the Nerv- ous System. New York, 1881. — Ibid., The Architecture of the Spinal Cord and its Relations to Medicine. New York Med. Jour. , 1884. — Adamkiewiez, A., Die Blutgefasse des menschlichen Ruckenmarkes. Stzsbrct. der k. Akad. der Wiss., Wien, lxxxiv, 1881, lxxxv, 1882. See, also, Ross, Erb, in Ziemssen's Cyclopaedia, vol. xiii, Leyden, Drummond, etc. — Brown-Sequard, C. E., Lect- ures on the Physiology and Pathology of the Central Nervous System. Philadelphia, 1860. — Stirling, William, On the Reflex Functions of the Spinal Cord. Edinburgh Med. Jour., April, 1876, p. 914.— Purser, J. M., On the Anatomy and Physiology of the White Tracts of the Spinal Cord. Dublin Jour, of Med. 132 DISEASES OF TEE SPINAL CORD. Scl, 1878.— Ott, J., and Smith, R. M., The Paths of Conduc- tion of Sensory and Motor Impulses in the Cervical Segment of the Spinal Cord. Am. Jour. Med. Sci., Oct., 1879, p. 438.— Starr, M. Allen, Localization of the Functions of the Spinal Cord. Am. Jour, of Neurol, and Psych., Aug. and Nov., 1884, p. 443. — Ibid., The Sensory Tract in the Central Nervous System. Jour, of Nervous and Ment. Diseases, July, 1884, p. 327. — See, also, Ross, Erb, etc. ANATOMY. The membranes of the spinal cord are usually de- scribed as three — the dura mater, arachnoid, and pia mater. The dura mater is double, the outer portion forming a periosteum for the vertebrae ; the inner layer is connected with the outer by loose connective tissue, containing fat and blood-vessels. This inner layer is the portion usually referred to in speaking of the dura mater. Opinions differ as to the arachnoid : some authors consider it as forming part of the other two membranes, while others regard it as a distinct membrane. The pia mater is closely adherent to the cord, and through it run the nutrient vessels for the cord. It sends processes into the fissures of the cord ; it sur- rounds the nerve-roots in their course from the cord to the dura mater. From the pia mater, on each side, arises the ligamentum denticulatum, which keeps the spinal cord in the center of the spinal canal. It runs the whole length of the cord, and stays it, by means of twenty to twenty-three teeth-like processes, to the dura mater. The space between the pia mater and dura mater is filled with the cerebro-spinal fluid, which is contained in a very loose, wide-meshed connective tissue. The spinal cord is then suspended in the cerebro- spinal fluid by means of many processes of the pia mater, by the nerve-roots, and the posterior septa. This suspension is so contrived that the influence of jars and shocks may be reduced as much as possible. B ^ Fig. 16. — Diagram illustrating the relations of the nerve-fiber tracts in the spinal cord. The section is supposed to be taken transversely through the lower part of the cervical enlargement (slightly modified from Flechsig by Hammond) : A. Anterior Median Fissure. B. Posterior Median Fissure. C. Intermediate Fissure. D. Anterior Gray Cornu. E. Posterior Gray Cornu. F. Gray Commissure, with Central Canal. G. Uncrossed Pyramidal Tract (Flechsig), or Column of Turck. H. Fundamental Part of the Anterior Column (Anterior Koot-Zones of Charcot and his pupils). I. Anterior Part of Lateral Column. K. Crossed Pyramidal Tract of Lateral Column. L. Direct Tract from Lateral Column to Cerebellum. M. Column of Burdach, Posterior Root-Zones of Charcot and his pupils. N. Column of Goll. The posterior columns of descriptive anatomy include the fields M and N extending on the surface from B to R. The antero-lateral columns extend on the surface from R to A. Their anterior division includes the fields G and H ; their lateral division, the fields K, L, and I. ANATOMY. 133 The anastomoses between the arteries on the surface of the cord are very free, especially in the cervical and lumbar portions, least so in the dorsal region. The smaller arteries in the interior of the cord anastomose quite freely. The central gray substance and internal parts of the cornua are supplied chiefly by one set of vessels ; the white substance and outer part of the cor- nua by another. The gray substance has a larger blood- supply than the white. The cord extends lower in women than in men — in the former reaching the second lumbar vertebra, in the latter only the first. In men the proportion between the cord, the vertebral column, and the length of the body, is 1 : 1*62 : 3*76 ; in women the same proportion is 1:1-56: 3'58. The gray matter is arranged around a central cavity called the central canal, which extends throughout the length of the cord. Two processes project forward, one on either side, called the anterior coma; two similar processes project backward, one on either side, called the posterior cornu. The gray matter is relatively larger, and the cornua are thicker, in the cervical and lumbar enlargements, and smaller in the dorsal region. In the anterior cornua are large nerve-cells, with many processes arranged approximatively in groups — the in- ternal, the anterior, the antero-lateral, the postero-lat- eral, and central. Lockhart Clarke gave the name trac- tus intermedio lateralis to a group of cells correspond- ing to the postero-lateral group mentioned above. At the junction of the posterior cornua with the central gray matter there is found also, at certain levels, a group of cells of very nearly equal size ; these cells are nearly spherical, with only one process. Scattered among these are smaller cells, usually fusiform in shape ; this group is called the internal vesicular columns by Clarke ; many authors name it Clarke's column. The posterior cornua are formed of two varieties of structure, the spongy portion near the central gray sub- 134 DISEASES OF TEE SPINAL COED. stance, the gelatinous substance posterior to the former, and running forward on each side of it, having the form of an irregular crescent. A few large nerve-cells, with many processes, are found scattered through the gelatinous substance, especially along its outer border. The nerve-cells in the spongy portion are rarely of large size. In the posterior cornua are found also some of the smallest cells belonging to the spinal cord. The opposite sides are connected in front of the central canal by nerve-fibers forming the anterior or white commis- sure ; behind the central canal is a commissure formed of gray matter — the posterior or gray commissure. The white substance of the spinal cord is divided into two lateral halves by an anterior and posterior fissure. The anterior fissure is the better marked, and extends about one third through the cord to the white commissure. The posterior fissure is not quite so deep as the anterior, and is less well marked ; sometimes, in- deed, its position is only indicated by a small blood- vessel in a narrow band of connective tissue. Each half of the white substance is roughly divided by the anterior and posterior cornua into three col- umns — the anterior, lateral, and posterior. The ante- rior and lateral are frequently spoken of together as the antero-lateral column. The posterior column is divided into two portions by a septum of connective tissue, usually containing blood-vessels, situated at a variable distance exterior to the posterior fissure. The column between this septum and the posterior fissure is called the internal posterior column, or more frequently the column of Goll. The nerve-fibers in this column are on an average the smallest in the cord. This divis- ion of the posterior column is seen throughout the length of the cord, but the internal portion gradually diminishes in size downward, and in the lumbar region mere traces of it are found. The portion on each side between the lateral septum and the posterior cornu is called the external posterior column, or more frequently ANATOMY. 135 the external radical column or posterior root-zone, or column of Burdach. The anterior column is also di- vided into two portions, but with less definiteness than the posterior column. There is a narrow band along the edge of the anterior fissure, which, physiologically and pathologically, is distinct from the rest of the an- terior column. This is called the direct pyramidal col- umn, or column of Tiirck ; this column can be traced upward to the crus cerebri of the same side without decussating. In the lateral column there is also a dis- tinct group of fibers called the lateral pyramidal tract, which occupies about the center of the lateral column, in the cervical region, having the cerebellar fibers along its outside. In the lower dorsal and lumbar regions these cerebellar fibers gradually diminish in thickness until they disappear ; hence the pyramidal fibers come to the surface. The white substance around the extremi- ties of the anterior cornua may be called the anterior root-zones. The pyramidal fibers in both the anterior columns and the lateral columns can be traced from the brain. Arising from the motor centers in the brain, they pass through the anterior two thirds of the posterior seg- ment of the internal capsule, the middle of the crusta (basis) of the crus cerebri, through the pyramidal re- gion of the pons and medulla to the anterior pyramids. In the anterior pyramids the fibers intended for the lateral columns decussate and pass down the opposite half of the cord ; the direct fibers do not decussate, but pass down the anterior columns on the same side, next the anterior fissure. It may be mentioned here that the divisions above described are differentiated physiologically, pathologi- cally, and in some cases anatomically ; and also by the fact that the nerve-fibers in the different portions ac- quire a medullary sheath at different periods of devel- opment, as has been demonstrated by Flechsig, Ross, Charcot, Parrot, and others. 136 DISEASES OF THE SPIRAL CORD. The anterior nerve-roots enter the cord opposite the anterior cornna. Before entering the cord, the roots split np into small bundles of nerve-fibers, which are distributed laterally over a space corresponding in ex- tent with the width of the anterior cornua. These fibers pass directly through the white substance into the gray matter, or take a longitudinal direction for a short distance, and then pass into the anterior cornua. The posterior nerve-roots enter the cord near together on a vertical line; some of the fibers pass directly into the posterior cornua, but most of them pass into the external radical column, and enter the posterior cornua at different levels. Some fibers pass directly into the vesicular columns, and some of these pass forward to one of the groups of anterior cells. Some of the fibers of the white columns run long distances before entering the gray substance ; such are the fibers in the anterior and lateral pyramidal columns, the columns of Goll, and the cerebellar fibers. Other fibers run only a short distance, serving as commissural fibers for the gray substance at different levels. PHYSIOLOGY OF THE SPINAL CORD. The spinal cord is not a simple organ, as must be realized from the brief account of its anatomy ; the functions it is intended to fulfill are many, and its physiology, consequently, is complicated. We are jus- tified, then, in considering the cord, not as one simple organ, but as a series of organs having somewhat dif- ferent functions. The cord may be divided, theoreti- cally, into as many sections as there are pairs of nerves arising therefrom, and each section be regarded as a distinct unit connected with its fellows by commissural fibers ; or it may be viewed as several different nerve- entities arranged side by side longitudinally, each indi- vidual connected with the others by transverse commis- sures. Sometimes one view will be most convenient for understanding phenomena, and sometimes the other. • PHYSIOLOGY OF TEE SPINAL CORD. 137 The groups of nerve-cells in the gray substance act as centers of nervous influence, more or less independ- ent. Those in the anterior cornua are connected with the nerve-fibers of the anterior roots, and serve as media by which motor impulses are communicated through the nerves to the muscles, whether those impulses come from the brain or from the sensory nerves of the poste- rior roots — that is, whether they are volitional or reflex. Attempts have been made to assign different nerve- groups to certain muscles ; while this can be roughly approximated, as yet much that has been written in regard to such a division of function is theoretical. Among these cells are to be found also centers of nutrition, trophic centers for both nerves and muscles. It is not yet settled whether distinct nerve-cells have this function, or whether it is exercised by the motor cells ; as Ferrier expresses the thought, "We have as units of external function certain nerve- centers, cen- trifugal nerves, and peripheral organs, muscular, gland- ular, and their adjuncts. In union they exhibit certain vital properties and reactions which we call normal. . . . But dissolve the unity, and the tissues are left to their own powers of nutrition," and various forms of degeneration are seen. The posterior cornua are known to belong to the sensory portion of the cord. Their cells are in some way concerned in transmitting sensory impressions to the brain, or in transferring them into reflex phenome- na ; perhaps they intercept some impressions and utiliz- ing them for stimulating vital processes, do not permit such impressions to reach the brain unless they are un- usually strong. The sense of pain is conveyed specially by the posterior gray substance, and a very small sec- tion of this is sufficient to transmit pain ; when the pos- terior columns are diseased, probably some of the ordi- nary sensations pass through the gray substance by unusual paths ; hence, perhaps, the delay sometimes noticed in conduction of sensation. 138 DISEASES OF TEE SPIXAL COED. Sensations, whether of pain or the ordinary sensa- tions, after entering the cord by the posterior nerve- roots, soon pass to the opposite side and then ascend to the brain. The white columns are commissural ; some connect the brain with different groups of cells, others connect these groups of cells with one another. The pyramidal tracts connect the motor areas of the brain with the groups of cells in the anterior cornua — the lateral pyramidal tracts decussating in the anterior pyramids, the direct passing down without decussation. The fibers which govern the respiratory muscles seem to pass down in the lateral columns without decussation. The anterior root-zones are commissural, and are con- cerned specially in reflex actions, and, perhaps, in co- ordinating the action of nerve-cells at different levels. The posterior columns are sensory. The external radical columns, columns of Burdach, are probably chiefly commissural, and are employed for co-ordina- tion of the sensory impressions and translation of these into reflex or semi-reflex acts. Many of the fibers of the posterior nerve-roots pass upward or downward in these before they enter the posterior cornua. The fibers of the columns of Goll pass upward toward the brain ; their mode of termination and func- tion are not known. The posterior columns in one or both of its divisions transmit the ordinary sensations — touch, temperature, pressure, etc. — but not the sensation of pain. The direct cerebellar tract is composed of ascending fibers, and is said to be connected with Clarke's vesicu- lar column at the root of the posterior cornua. Its function is not known. GENERAL SYMPTOMATOLOGY. It will be convenient to mention the groups of symp- toms which indicate lesion of certain regions of the spinal cord. GENERAL SYMPTOMATOLOGY. 139 Total paralysis of motion, sensation not being af- fected, points to lesion of the antero-lateral columns and anterior cornua. If the paralysis is unilateral, it will be on the same side with the lesion. If, in disease of the cord, there is simply paralysis, without marked wasting or change of electrical reaction in the muscles, provided time enough has elapsed since its origin, neither the anterior cornua nor the nerve- roots at the level, whence arise the nerves supplying the paralyzed muscles, can be affected. If besides paralysis there is spasm, contracture, and increased reflex action in the affected limbs, without pain, the lateral columns are affected. The anterior columns may be diseased too, but the symptoms would not necessarily indicate it. The spasmodic phenomena and increase of reflex action follow, whether the lesion of the lateral columns is primary or secondary. If, in disease of the spinal cord, with the paralysis, there is also wasting of the paralyzed muscles and loss or great diminution of reaction to the faradic current, still more if there is increased reaction to the galvanic current, with reversal of qualitative reaction (degen- erative reaction), the lesion is either in the anterior nerve-roots or in the anterior cornu. It is rare to have the anterior nerve-roots affected as they pass through the anterior columns, unless the lesion is trau- matic in its origin. Unless the anterior cornu is dis- eased over a considerable length of the cord, the paraly- sis is local, and the muscles supplied by nerves arising below the seat of the lesion are healthy. When ouly a few muscles are affected, especially if they form a group which physiologically act together, the disease may be limited to a very small area. Ferrier ("The Localization of Atrophic Paralyses," "Brain," vol. iv, 1881-82, p. 226) gives the muscles sup- plied by the different nerves of the brachial and lumbar plexuses. Some of the muscles mentioned are supplied by fibers from more than one nerve ; only that nerve 140 DISEASES OF TEE SPINAL CORD. giving the largest proportion of fibers is mentioned. The enumeration can be considered as only approxi- mately correct ; yet it will serve as an aid in locating a lesion in the spinal cord, and perhaps will prove of most value where there is atrophy of muscles. As the skin over muscles is supplied by nerve-fibers from near- ly the same region as the muscles, the distribution of anaesthesia may serve roughly as a guide to diagnosis of the level of a lesion, though in such a case much less likely to be so nearly correct as when muscular symp- toms are the guide.* The first dorsal : The intrinsic muscles of the hand, viz., muscles of the thenar and hypothenar eminences and interossei. Eighth cervical : Long flexors, ulnar flexors of wrist, intrinsic muscles of the hand, extensors of wrist and phalanges, long head of triceps (pectoralis major ?). Seventh cervical : Teres major, latissimus dorsi, sub- scapularis, pectoralis major, flexors of wrist and fingers (median), triceps. Sixth cervical: Latissimus dorsi, pectoralis major, serratus magnus, pronators (flexor of wrist ?), triceps. Fifth cervical : Deltoid (clavicular portion), biceps, brachialis anticus, serratus magnus, supinator longus, extensors of wrist and fingers. Fourth cervical : Deltoid, rhomboid, supra- and in- fra-spinatus (teres minor), biceps, brachialis anticus, supinator longus, extensors of wrist and fingers, dia- phragm. In the lower extremity : Second sacral : Intrinsic muscles of the foot, strictly parallel to the first dorsal. First sacral: Muscles of the calf (plantar flexors), hamstrings, long flexor of big toe, intrinsic muscles of the foot. * See, also, M. Allen Starr, " Localization of the Functions of Spinal Cord," " Amer. Jour, of Neurolog. and Psychiat.," August and Novem- ber, 1884, p. 480. GENERAL SYMPTOMATOLOGY. 141 Fifth lumbar : Flexors and extensors of toes, tibial muscles, sural muscles, peroneal muscles, outward ro- tators of thigh, hamstrings. Fourth lumbar : Extensors of thigh, extensor cruris, peroneus longus, adductors. Third lumbar : Ilio-psoas, sartorius, adductors, ex- tensor cruris. By keeping this general scheme in mind, an idea may be formed, nearly correct, of the level of the lesion, and a record may be made by which to judge whether it is extending or receding. A study or examination of the various reflexes will also aid in the formation of a diagnosis of locality. (See page 8.) There may not be paralysis, yet the motor conduct- ors may be seriously affected, so that, while all motions are possible, yet there is clearly a loss of strength, and the movements are very slow ; there is a retardation of the motor conduction ; Burckhardt thinks this points to disease of the white columns. Burckhardt has also studied the acceleration of mo- tor conduction. This is not very rare, but is more dif- ficult to recognize. Some cases of exaggerated reflex action may be due to this condition. Burckhardt refers this phenomenon to an affection of the gray substance. There may be no paralysis, but the motions may be irregular ; there is a loss of co-ordinating power, a con- dition known as ataxia, which Erb defines as " the dis- turbance of movement, produced by defective co-ordi- nation of movement." He considers that it is of a motor nature. While all motions may be performed with power, the patient can not execute any movement with precision ; the hand or foot is carried beyond or falls short of the point it is desired to touch, or it is carried to one side. In attempting to grasp an object, the strength put forth is out of proportion to the end to be gained. When extreme, this ataxia may be shown in all the motions ; if the defect is but slight, it 142 DISEASES OF THE SPINAL CORD. may be necessary to ask the patient to close his eyes before the symptom can be clearly recognized. When the aid of sight is withdrawn, the patient may be un- able to touch a certain part of his face, as the chin or end of the nose, with his forefinger, or in walking may be unable to propel his feet properly. Yet not every defect in walking with closed eyes is due to ataxia ; weakness may cause a patient to totter and walk irregu- larly : vertigo may have a similar effect ; anesthesia of the soles of the feet or of the joints may cause a patient to stagger when the eyes are closed. Erb thus describes the ataxic gait: "It is charac- terized by irregular hurling movements ; the point of the foot is thrown forward and outward with force ; the heel is brought down with a stamp, the leg stiff at the knee. The patient's eyes are continually on the ground. The gait is tottering, staggering, or even reel- ing from side to side ; the movements are hasty, spas- modic, quite unequal ; in turning about, especially, there is great uncertainty, and danger of falling. In severe cases the patient falls after a few steps." This accurate description applies to rather advanced cases ; •there may be only a very slight degree of disturbance early in the disease. This ataxic condition, when dependent upon disease of the spinal cord, is the result of changes in the pos- terior columns, and more definitely the external radical columns. Involuntary muscular movements are among the prominent symptoms in certain affections of the spinal cord. These are of a reflex nature, or the result of direct irritation of the motor roots or motor regions of the cord. When the spinal cord is divided, or when destruc- tion by disease extends across the cord, so that commu- nication with the brain is cut off, reflex movements are exaggerated in all parts of the body below the seat of injury whose reflex nervous arc remains intact. The GENERAL SYMPTOMATOLOGY. 143 reflex phenomena, as mapped out by Gowers, may as- sist, then, in locating the seat of the disease. (See above, p. 8.) When there is increased irritability of the gray sub- stance, the reflex motions in the regions supplied by nerves arising therefrom will be exaggerated. The same exaggeration is found in disease of the lateral pyramidal columns, as in secondary degenerations and sclerosis. The pupillary reactions are reflex : if the cervical region of the cord is destroyed, the pupils may be con- tracted ; if there is irritation, they will be dilated. The normal reactions will not be present. Reflex action may be much diminished or abolished when any portion of the reflex arc is diseased ; whether the sensory nerves or posterior nerve-roots, the gray substance, or the anterior motor regions, or motor roots, are diseased. Reflex action may be delayed under similar conditions under which sensory impres- sions are delayed. In cerebral disease the reflex actions may be abol- ished on the paralyzed side. Westphal first called attention to the fact that the- tendon reflex is lost at an early period in locomotor ataxia; this has been confirmed by others, and it is now generally accepted as true of that disease. It has been found absent when the columns of Goll were not affected, the external radical columns alone being dis- eased (Westphal). It is also lost when the spinal cord is entirely disorganized ; when the sensory or motor roots (or peripheral nerves) are destroyed ; when the anterior cornua are diseased, so as to cause muscular atrophy ; and in some other less definite conditions. The tendon reflex may be greatly exaggerated, and may be then readily shown in connection with tendons with which it is not usually noticed, as those of the triceps humeri, of the fingers, of the sterno-mastoid. This increase of the phenomenon is one of the symp- 144 DISEASES OF TEE SPINAL CORD. toms attending sclerosis of the lateral columns ; it may be present also after injuries giving rise to spinal con- cussion (Edes), and in hysteria; it is sometimes seen during acute febrile diseases, as typhoid fever. As a symptom of disease of the spinal cord, it is most regu- larly associated with disease of the lateral columns, and we are not yet able to say that, when found in ap- parently exceptional relations, it is not dependent upon a change thus located. Ankle clonus is indicative of change in the lateral pyramidal columns. Growers says that a persistent an- kle clonus is always pathological ; in this he is proba- bly a little too emphatic, but its presence must be looked upon as strongly in favor of organic changes in the cord. The spinal cord, by a reflex mechanism, exerts a control over the bladder and rectum ; the will also regulates in some measure those viscera. When the contents of the bladder and rectum are sufficient to excite reflex action in their expulsory muscles, the sphincters relax, probably in consequence of an inhibi- tory action of the spinal centers, and an evacuation fol- lows. The will can restrain for a while this expulsive action, or can excite it before the reflex action would arise normally. If the spinal cord is destroyed above the lumbar enlargement, this voluntary control is lost, and then the contents of the viscera are expelled at intervals accord- ing as the reflex centers may be aroused to action by the irritation excited by the contents of the viscera. The patient then has his evacuations involuntarily, and without knowing that they occur. If the sensory tract alone is injured, the evacuations may occur without his knowledge, but he will have power to voluntarily evacuate the viscera. If the mo- tor tract is injured, the discharges will occur without the patient's control, but he will be conscious of the desire to evacuate the viscera, and will know when GENERAL SYMPTOMATOLOGY. 145 the evacuation is accomplished. When the voluntary control is weakened, or partially lost, while the sen- sory tract is unimpaired, the patient is obliged to re- spond quickly to the calls of nature, or, the restraining influence of the will being slight, involuntary evacu- ation follows. As the centers of reflex action for th,e sphincters and the detrusor muscles are not identical, one may be affected independently of the other ; then there will be incontinence when the sphincters are paralyzed, reten- tion when the detrusors are paralyzed. In the latter case, the sphincter acting, the urine accumulates until it may, by mere mechanical pressure, overflow, and so there may seem to be incontinence when there is really retention. Spasm may affect the sphincters or the detrusors, and corresponding disturbances will follow. Perversion of the sexual functions occur in many cases of spinal disease, much more marked in men than in women. There may be great increase of sexual desire, with power to gratify it ; or the desire may be present without the power, or with greatly diminished power ; or there may be frequent nocturnal or diurnal emissions, or spermatorrhoea. All sexual appetite may be lost, and there may be complete impotency. Pria- pism, complete or partial, may continue for a long pe- riod. Among women a similar disturbance of sexual desire may occur, but these symptoms have been less fully studied than among men. We can not at present draw any positive conclusions by means of the above variations from the normal condition. Vaso-motor and nutritive changes are not uncommon in different forms of spinal-cord lesions. The simplest change is disturbance of capillary circulation ; the af- fected parts are more or less cyanotic, or they may be unnaturally pale ; in either case the temperature is be- low normal ; sometimes there is great increase of heat, with less apparent disturbance of circulation. In one 146 DISEASES OF THE SPIRAL CORD. case there is irritation of the vaso-motor centers, in the other case paralysis. It is often noticeable that para- lyzed limbs are slightly cedematous, and sometimes the consequent swelling is very great. The skin may undergo changes similar to those found in neuritis ; there may be a scaly condition, due to ex- cessive multiplication of the epidermic cells ; the hair and nails may suffer in nutrition ; herpetic eruptions, pustules, and urticaria may be noticed. Bed-sores, chronic or acute, are the most troublesome trophic changes in some cases, and may gradually wear out the patient. The bones, especially their articular surfaces, undergo changes of structure and form, are worn away, or become brittle and easily break. The muscles undergo atrophy, their fibers becom- ing reduced to rows of fat drops or granules, and finally, these being absorbed, only the sheaths are left ; sometimes a deposit of fat between the muscular fibers obscures the wasting, and the affected limbs retain their usual proportions. The electrical reac- tion of degeneration will show whether this atrophy has occurred and enable one to form an opinion as to how far it has advanced. If only some fibers are degenerated, these reactions may be obscured and less readily obtained, the healthy fibers giving the normal reactions. This atrophy shows that there is lesion of the motor nerves or of the anterior cornu in the cord. The general nutrition of the body or limbs may be altered in disease of the spinal cord ; there may be great emaciation, or there may be an increased deposit of fat, subcutaneous, as well as in the deeper structures. When the nerve-cells of the anterior cornu are diseased in infancy, there is not only atrophy of the muscles, but, if the change is extensive, the paralyzed limb is retarded in its subsequent growth. The anterior part of the central gray substance is supposed to be the trophic center for the bones ; the posterior part for the skin, hair, and nails ; the ante- GENERAL SYMPTOMATOLOGY. 147 rior cornua are the trophic centers for motor nerves and muscles. Sensation is entirely lost only when the whole of the posterior portion of the cord, including the gray sub- stance, is destroyed. If even a small portion of the gray substance remains, sensation' is not entirely lost. It is probable also that certain parts of the lateral col- umns convey sensation, though the mode of distribution of sensory fibers in these columns is not known. When both sides are destroyed, a narrow band of hyperes- thesia may be found above the level of the anaesthesia. If only one side of the cord is destroyed, there will be hyperesthesia below the seat of injury on the same side with it, and anaesthesia on the opposite side ; a narrow zone of diminished sensibility on both sides of the body will be found at the level of the injury, and above this for a short distance there may be hyperes- thesia on the same side with the injury. When sensation is not entirely destroyed, the differ- ent kinds of sensation, as touch, temperature, pressure, pain, etc., may be affected in unequal measure. When there is not destruction of the cord, there may be great hyperesthesia, and the increase of sensitive- ness may be so great that even a slight touch causes great suffering. This is found when there is inflamma- tion of the meninges, or when the posterior nerve-roots are irritated, as by compression, and rarely in inflamma- tion of the cord itself, though local hyperesthesia is common in locomotor ataxia, especially after an attack of lancinating pain. A sensation of a band tied around the body — a girdle sensation or pain — is frequently found in myelitis, and where there is compression of the cord. It is difficult to define its nature ; it is sometimes painful, sometimes simply a slight sense of constriction. It is seated at the level of distribution of the nerves arising from the upper limit of the disease ; sometimes the girdle seems to surround one or both legs instead of the body. 148 DISEASES OF THE SPINAL CORD. When the posterior nerve-roots are exposed to irri- tation, as from pressure or inflammatory changes, pain of different kinds will be felt at the peripheral ends of those nerves ; if the nerves are suddenly compressed or bruised, a burning sensation, perhaps very painful, will be felt. The sensation referred to the periphery in disease of the spinal cord is much less likely to be pain ; it rather takes the form of tingling, numbness, formication, or that peculiar sensation known as being asleep. Backache is a very common complaint with patients ; it is more common in functional than in organic diseases. Tenderness on pressure over the vertebrae is rare in or- ganic affections ; it is common in connection with cer- tain functional disturbances. CHAPTEE X. SPINAL MENINGITIS. Joffroy, A., De la pachymeningite cervicale hypertrophique. Paris, 1873. — Spencer, W. H., Case of Idiopathic Inflammation of the Spinal Dura Mater. Lancet, June 14, 1879, p. 836. — Le- moine, G-., and Lannois, N., Perimeningite spinale aigue. Revue de Med., No. 6, 1882.— Tooth, Dorsal pachymeningitis. Brain, 1884. There are two subdivisions of spinal meningitis — one affecting the dura mater, pachymeningitis; the other the pia mater, leptomeningitis. External pachymeningitis, inflammation of the ex- ternal surface of the dura mater, is caused by changes in the adjoining parts — caries, abscess, cancer, tumor, aneurisms penetrating from without, etc. The symp- toms will be so united with those caused by the pri- mary disease that it is unnecessary to describe them. PACHYMENINGITIS INTERNA. Internal pachymeningitis may occur independently of other lesions. Generally, not only the internal sur- face of the dura mater is affected, but its whole thick- ness may be the seat of inflammatory hypertrophy ; the pia mater may also be somewhat thickened and in- flamed secondarily ; it can usually be distinguished from the dura mater. Owing to the thickening of the membranes, the cord is compressed, and undergoes inflammatory changes ; sometimes cavities are formed. The nerve-roots suffer from compression and second- ary inflammation as they pass through the dura mater. 150 DISEASES OF THE SPINAL CORD. The disease is confined almost exclusively to the cervical region. Symptoms. — During the first stage of the disease the prominent symptom is pain in the posterior part of the neck and the occipital region ; following the direc- tion of the peripheral nerves, it extends frequently in- to the arms ; it is aggravated by movements of the vertebra, sometimes is increased by firm pressure over the spine, and at times is extremely severe. Some- times before the pain ceases, more frequently after a period of comparative freedom from distress, para- lytic symptoms make their appearance, first weak- ness, which gradually increases to complete paralysis. With the paralysis there is atrophy of the muscles. The distribution of the atrophy is somewhat variable ; the muscles of the hand, the interossei, the lumbricales, and the muscles of the thenar and hypothenar eminen- ces are generally greatly atrophied ; in the forearm the flexors and extensors of the fingers, the flexors and pronators of the hand, are chiefly affected ; the muscles of the arm generally escape, while the deltoid and the supra- and infra-spinatus suffer. Owing to the atrophy of some muscles, and the fact that others are unaffected, the hand acquires an unnatural position : it is held in a position of extreme extension, with the fingers par- tially flexed, the thumb extended and adducted. In some cases this position may be overcome by passive motion ; in others it is noticed only when the forearm is in supination. If the disease affects the upper part of the cervical enlargement, the position of the hand is different. Ross thus describes the position : The arm is held close to the side, the forearm is extended on the arm and strongly pronated, the hand is flexed on the forearm, the fingers are in a line with or only slightly extended on the metacarpal bones, and the phalanges are ex- tended upon one another, while the thumb is flexed into the palm. The muscles supplied by the musculo- PACHYMENINGITIS INTERNA. 151 spiral nerve are more affected than those supplied by the ulnar and median. The disease has rarely been observed in the lower part of the spine. The paralyzed muscles undergo atrophy, and the electrical reaction is changed ; there is found the reac- tion of degeneration, or entire loss of electrical reac- tion. Trophic changes in the skin, vesicular, bullous erup- tions, dry and scaly condition of the skin, and a glossy skin, are occasional phenomena; sometimes bed-sores form. The temperature is frequently lower than nor- mal. Slight convulsive shocks, and the phenomena attending lesion of the lateral columns, are sometimes met. Diagnosis. — The first stage, where there is only pain without impairment of motion, is difficult of diag- nosis. The pains may be referred to a rheumatic affec- tion, to spinal irritation or hysteria, or they may give rise to the suspicion that caries of the vertebrae is pres- ent. The pain due to pachymeningitis is said to be characterized by an increase during movement of the vertebrae, always deeply seated in the back part of the neck, on the median line ; frequency of the attacks of pain, and their short duration. When muscular atrophy sets in, the diagnosis from progressive muscular atrophy may be made from the history of the preceding attacks of pain, from the fact that the muscles are affected less regularly ; in muscular atrophy the hand will assume a more or less flexed position when in the stage of contracture, but in pachymeningitis the hand is extended and supinated, or the hand and arm take the position described by Ross. Treatment. — During the first stage the most press- ing indication is to relieve pain, for which sedatives and anodynes may be used ; hot iron applied to the neck and upper part of the dorsal region may give re- 152 DISEASES OF THE SPINAL CORD. lief to the pain, and may also act favorably upon the progress of the disease. The galvanic current along the spine has been recommended, the positive pole above, the negative pole below, the cervical region. Paralysis and atrophy of the muscles can be treated locally by the faradic or galvanic current. Internally, iodide of potassium may be given. In judging of the value of treatment, it should be remem- bered that naturally the disease has periods of remis- sion. INFLAMMATION OF THE PIA MATER. Pathological Anatom y. — The term spinal menin- gitis is commonly used to designate inflammation of the pia mater, leptomeningitis. The pia mater is chief- ly affected; it is found congested, thickened, cedema- tous ; upon its surface and within its meshes there is more or less pus. The arachnoid is almost always im- plicated in the inflammatory process ; the dura mater is also sometimes involved. The amount of pus ex- uded varies greatly ; it may be so little as merely to give a yellowish tinge to the cedematous membrane, or the surface may be covered with a thick, creamy layer. The inflammation may extend over a very small sur- face, or may affect the whole cord. In about one third of the cases there is coincident cerebral meningitis. After the exudation has been absorbed, there may be left a thickening of the pia mater from the organi- zation of the inflammatory products ; the membranes may become adherent to each other, though this is rare. It can be easily understood that such serious dis- turbance of the pia mater, from which the spinal cord derives its blood-supply, must necessarily involve the spinal cord, and we almost always find some degree of myelitis associated with the meningitis. ^Etiology. — The principal causes are exposure to cold and dampness, over-exertion of any kind, insola- tion, jars, concussions, falls upon the back, and inflam- INFLAMMATION OF THE PIA MATER. 153 mation of neighboring parts. Occasionally, in tubercu- lar meningitis, tubercles are found in the spinal pia mater. Symptoms. — Sometimes a short prodromal period of general discomfort with fugitive pains precedes the at- tack of prominent symptoms, but generally the disease commences suddenly, with pain in the back and pain radiating into the limbs ; there is often a chill and the temperature rises; there may be headache and even vomiting, though this is rare, unless the disease is near the upper part of the spine or the cerebral membranes are also affected ; the surface of" the body becomes ex- tremely sensitive to the touch, the muscles of the ex- tremities are contracted, the body may be in position of opisthotonus, or there may be clonic spasms instead of tonic contraction of the limbs. The pain, which appears early in the back, is gener- ally very severe, is increased by the slightest motion, whether active or passive ; pressure upon the vertebrae may not increase it, but percussion almost always does ; extremes of temperature, either hot or cold, produce pain when applied over the region affected. The pain may radiate around the trunk in the form of a girdle, though this is perhaps less frequent than in myelitis ; it may also radiate with extreme severity into the limbs. The last phenomena are due to irritation of the nerve- roots. The cutaneous hyperesthesia is probably due to an irritation of the nerve-roots, and may be classified with other painful manifestations ; it is sometimes so extreme that even the weight of the bedclothes causes torture ; not only the limbs but the trunk may be thus affected, and the muscles and bones sometimes show an extreme degree of sensitiveness. The muscular stiffness and rigidity is probably at first due to an involuntary tension of the muscles in order to avoid motion because of the extreme pain pro- duced thereby ; later the contracture is probably due to direct irritation of the anterior nerve-roots. Some- 154 DISEASES OF THE SPINAL CORD. times, especially at the beginning of the disease, clonic spasms add to the patient's suffering. There is generally constipation and retention of urine, sometimes with a frequent desire to pass it. Respiration is frequently interfered with, especially when the disease is seated in the cervical region, and death sometimes arises from this disturbance preceded by Cheyne-Stokes's respiration. When the contraction diminishes sufficiently, it is found that there is partial or total paralysis, and that sensation is more or less affected ; sometimes with pa- ralysis there remains contracture of the limbs, either in extension or flexion. The electrical reaction of the muscles may be lost, or undergo the modification of de- generation. Death frequently occurs after only a few days, or the patient may die at a much later period, apparently from exhaustion. Sometimes recovery is complete and perfect, but more frequently there remain partial pa- ralyses and atrophies. A chronic leptomeningitis last- ing for months or years is said sometimes to result from the acute disease. Diagnosis. — Jaccoud says : "The only two diseases of the spinal cord which have a febrile beginning are acute meningitis and acute myelitis ; now, as a rule, these two inflammations exist together, and the differ- ence in diagnosis is only a matter of refinement or a question of relative preponderance." The principal diagnostic symptoms of spinal meningitis are the pain in the back and limbs, the hyperesthesia, the muscu- lar spasm, and contracture. The opisthotonus might give rise to the suspicion that the disease is tetanus ; but in that there is much less fever, less pain, except during the spasm, and little or no cutaneous hyperes- thesia ; at the beginning there is trismus, the other spasms are more violent, and the reflex irritability is excessive. If there is recovery, it is, as a rule, more complete in tetanus than in spinal meningitis. INFLAMMATION OF THE PI A MATER. 155 Prognosis. — The prognosis is said by Erb to be "in- fluenced for the worse by the following circumstances : A very youthful or very advanced age ; bad constitu- tion, ansemia, the previous occurrence of severe disease, etc. ; by the height to which the disease ascends in the spine toward the brain ; by early symptoms of paraly- sis, signs of general loss of strength, high fever, con- tinually rising temperature, and increasing frequency of pulse ; great difficulty in breathing, dysphagia, se- vere cerebral symptoms, etc." The disease is at best serious, and even after partial recovery relapses may occur. The paralysis and atro- phy that remain may disable the patient for the rest of his life. Treatment. — The sensitiveness of the skin may be such as to interfere with the use of cups, but, if possi- ble, dry or wet cups should be applied, or leeches may be used. ' Ice-bags should be kept constantly on the spine. After the first acute stage has passed, blisters or other counter-irritation may be applied over the spinal column. Most European authors recommend that mer- cury be used by inunction or internally. Ergot may be given in large doses frequently repeated. Iodide of potassium can be used after the earlier stages of the disease. The pain can be controlled by opiates, which should be given in large doses. It is scarcely necessary to mention that quietness, rest in bed, and the ordinary hygienic measures be ob- served. Decubitus on the side or prone is the best posi- tion in bed. The paralyses and contractures which remain after recovery may be treated by electricity, passive motion, friction, and baths. CHAPTER XL CHANGES IN BLOOD-SUPPLY. Mayer, Sigmund, Zur Lehre von der Anamie des Riieken- marks. Zeitschr. f. Heilk., iv, 1883, p. 26.— Gull, Paraplegia from Obstruction of the Abdominal Aorta. Guy's Hosp. Reports, 1858, p. 311. SPINAL HYPEREMIA. Congestion, and its opposite, ansemia, of the spinal cord and its membranes have been too frequently men- tioned as causes of symptoms which evidently arise from more serious lesions. Clinically, and even patho- logically, it is difficult to draw the line of separation between congestion and inflammation. It is almost im- possible, also, to separate these lesions of the meninges from similar lesions of the cord itself ; indeed, the spi- nal cord is always more or less implicated when the pia mater is diseased. While it is probably true that many slight disturbances of health are ascribed to congestion when there is really inflammation, yet it is convenient to speak of congestion, and describe it as an independ- ent disease. ^Etiology. — One of the most frequent causes is cold, acting upon the surface of the body when the patient is heated ; if dampness is combined with the cold, as when the patient's clothing is wet by a sudden shower, or when the patient, overheated, takes a cold bath, the influence of the cold is much increased. Suppression of the menses, or hemorrhoidal bleed- ing, or other habitual discharges, may act as causes of congestion. SPINAL HYPEREMIA. 157 Excessive bodily exertion, especially walking and standing, violent sexual excitement, or excess of coitus, may have the same effect. Much of the backache, and some of the pain in the limbs found at the commencement of febrile diseases, are probably caused by spinal hyperemia. Symptoms. — As already mentioned, it is impossible to separate the symptoms caused by congestion of spi- nal meninges from those produced by congestion of the spinal cord itself. The following description may serve for both conditions : There is a heavy, dull pain in the small of the back, or higher, sometimes radiating into the legs with sub- jective sensations of numbness and pricking; some- times a girdle sensation is felt ; a weakness or partial paralysis of the legs is generally present ; rarely slight spasms or twitches of muscles. These symptoms ap- pear rather suddenly, and may be aggravated by lying on the back. Unless inflammatory changes are set up, they are not accompanied with febrile action, and are usually of short duration, not lasting more than a few days or, in rare cases, weeks. Diagnosis. — The diagnosis is to be made from the slightness of the symptoms and their short duration, and the absence of fever, rather than from any pecul- iarity of the symptoms themselves. Treatment, — Active treatment, such as bleeding and purgatives, have been recommended; but, instead of general bleeding, wet cups or leeches, on both sides of the spine, are better : dry cups may be used with ad- vantage in the same place. The actual cautery may be tried with reasonable expectation of benefit. Purga- tives may be of use, but, if pushed far, would be of dis- advantage, from the necessity of disturbing the patient too often. Ice-bags to the spine may be used to advan- tage. Internally, belladonna and ergot have been rec- ommended. It is better for the patient to be kept quiet, confine^ 158 DISEASES OF THE SPINAL CORD. ment to the bed being preferred ; the causes liable to produce congestion should be avoided, and by some a position upon the back is forbidden. SPIXAL AN.EMIA. In animals, experiment has shown that the symp- toms of anaemia may vary according as it is suddenly produced, or is brought on gradually. If all the blood is shut off at once from the cord, convulsions occur ; if the cord is gradually deprived of blood, there is only loss of function, without convulsion. In man the sud- den stoppage never occurs, owing to the free anasto- moses. Sometimes, in aneurism of the aorta, anaemia of the cord is produced by occlusion of blood-vessels, and serious disturbance of function may result there- from. In general anaemia and chlorosis, in cardiac dis- ease, there may be a diminished supply of blood in the cord. The spinal symptoms are not sufficiently well de- fined to form a positive diagnosis from them alone. There is simply disturbed function, numbness, motor weakness, and tremor, without fever. There is a con- dition, usually called spinal irritation, which has been referred to anaemia of the spinal cord, but without suf- ficient reason. The diagnosis must be made chiefly from symptoms other than those due to the spinal dis- turbance. The treatment should be directed to the condition causing the anaemia ; the patient should be kept in bed on his back if the symptoms are at all serious ; hot- water bottles may be applied to the spine ; strychnia has been recommended. CHAPTER XII. SPINAL HAEMORRHAGE. Fox, E. L., Clinical Lecture on Spinal Haemorrhage. Med. Times and Gaz., Aug. 26, 1876, p. 219.— Goltdammer, E., Ein Beitrag zur Lelire von der Spinal- Apoplexie. Virch. Arch., lxvi, p. 1.— MacMunn, C. A., Notes on a Case of Spinal Apoplexy. Dublin Jour, of Med. Sci., March 1, 1880, p. 182. — Eichorst, H., Beitrag zur Lehre von der Apoplexie in der Buckenmarkssubstanz. Charite-Annalen, 1876, p. 192.— Hayem, C, Des hemorrhagies intrarachidiennes. Faris, 1872. MENINGEAL HEMORRHAGE. ^Etiology. —Spinal meningeal haemorrhage, haema- torrhachis, is rather a rare affection. It occurs as the result of injuries and falls, or in consequence of over- taxing the strength ; secondarily as following aneurism, or during tetanus, epilepsy, or some acute diseases, yellow, typhoid, or pernicious fever. Pathological Anatomy. — The blood may be poured outside the dura mater ; it may fill the whole of the vertebral canal, but is more frequently spread over the posterior surface of the membrane ; again, it may be limited to a comparatively small extent. The cervical region is rather more frequently the seat of the haemorrhage. The condition of the blood, as found at the autopsy, depends upon the length of time that has elapsed between the attack and death. . Intra-meningeal haemorrhage, where the blood is effused between the dura mater and arachnoid, is less frequent than the preceding. Hayem found thirty- eight cases of extra meningeal haemorrhage, and only eleven of this variety. 160 DISEASES OF THE SPIXAL COED. The haemorrhage under the arachnoid and into the pia mater is still more rare, Hayem finding only eight cases. Many times the blood found in these places is poured out only during the last hours of life, and has no effect upon the primary disease ; this is especially true where the haemorrhage is merely slight or punc- tiform. Where there is considerable blood, however, the spinal cord may be much compressed. Symptoms. — Many secondary haemorrhages give rise to no special symptoms, either because they are very slight, or because the primary disease masks the spe- cial symptoms which they would cause. The symptoms usually appear suddenly ; there is first severe pain, followed almost immediately by pa- ralysis. Occasionally the onset is more gradual. There are two classes of symptoms which must be recognized : those dne to pressure upon the cord, and changes in its structure ; those due to irritation of the membrane and nerve roots by the foreign body, the clot. The symptoms due to pressure upon the cord are primarily more or less complete paraplegia, affecting chiefly motion, but also giving rise to sensations of numbness ; after the commencement of the attack there may be pain in the back, or it may be absent. Reflex action may be exaggerated. The pressure may give rise to secondary changes in the cord, myelitis may fol- low ; the paralysis becomes more complete and perma- nent ; sensation may be more seriously implicated, con- tractions may appear, and, as the myelitis advances, may disappear ; the muscles may undergo atrophy. The symptoms due to irritation by blood-clot and pressure upon the nerve-roots are so united that it is scarcely worth while to separate them. These are pains radiating in the course of the nerves and others referred to the periphery, tingling and pricking sensations, more or less anaesthesia, with possibly tenderness to touch of the parts to which the nerves are distributed ; spas- MENINGEAL HEMORRHAGE. 161 modic contractions, generally clonic, sometimes tonic ; subsequently there may be atrophy and diminished electric excitability. Disturbed vaso-motor action may be found either below or at the level of the haemor- rhage. The patient may entirely recover, but more fre- quently some paralysis and atrophy remain perma- nently, accompanied, perhaps, with contracture. The electrical reaction undergoes the usual change in atro- phied muscles. The membranes are not very prone to secondary in- flammation ; fever is rarely present ; the pulse may be weak and slow. The symptoms vary somewhat according to the local- ity of the haemorrhage. When the upper part of the cord is affected, the pain and contraction and reflex phenomena will be most marked in the upper extremi- ties ; oculo-pupillary symptoms will be observed, and there may be disturbance of respiration. When the seat of the haemorrhage is lower, the above symptoms will be absent, and the sensory and motor phenomena will be most marked in the back and legs ; the bladder and rectum may be affected, priapism may give annoy- ance, or erection may be less frequent, and sexual power diminished. Diagnosis. — The chief diagnostic symptoms are the suddenness of the attack, the signs of meningeal irrita- tion, the absence of cerebral symptoms, and the course of the disease ; sometimes also the cause will aid to a diagnosis. It may not always be easy to determine at first whether the vertebrae have been fractured or the cord itself injured by the accident which has given rise to the symptoms. Extreme motor paralysis, especially if reflex action is diminished, at the commencement of the disease, and serious implication of the sphincters, would lead to an inference that the cord itself is in- jured. A careful study of the symptoms would probably 162 DISEASES OF TEE SPINAL CORD. be sufficient to prevent an error of diagnosis in regard to other affections of the cord and its membranes. Treatment. — The most important indication which should be strongly insisted upon is absolute rest. Erb says upon the side or face ; but the position is of less importance than the rest. Leeches or wet cups should be applied along the back. Strong purgation is recom- mended, but has the disadvantage that the patient must be disturbed too much. As in other cases of haemor- rhage, large doses of ergot may be given, if the case is one of those arising spontaneously. Pain may be re- lieved by opiates and anodynes. Later, iodide of potas- sium may be prescribed, and resulting paralyses can be treated by electricity, baths, passive motion, and mass- age. HAEMORRHAGE INTO THE SPINAL CORD.— HiEMATOMYELITIS. ^Etiology. — Haemorrhage into the spinal cord is about four times more frequent in men than in women ; it occurs chiefly in early adult life — from twenty to thirty-five. It may arise in the course of inflammatory changes in the spinal cord as a secondary complication, or be caused by influences which favor the active flow of blood to the cord ; a fall, a strain in lifting heavy weights, or other excessive bodily exertion, may be a cause. These are more likely to prove efficient if the blood-vessels of the cord are diseased. Pathological Anatomy. — Of course, the primary change in the cord is its destruction and the disasso- ciation of its fibers by the effused blood. The clot undergoes changes similar to those which follow cere- bral haemorrhage. The cord undergoes inflammatory changes and softening. It may sometimes be difficult to determine whether the softening is caused by the haemorrhage or preceded it. Haemorrhage is most fre- quent in the gray substance. The muscles and nerves undergo secondary changes, such as are found when the spinal nerve-centers are diseased. EMMORREAGE INTO TEE SPINAL CORD. 163 The meninges are almost always congested, but the inflammatory changes in them are not very marked. When the patient lives long enough, secondary de- generation, ascending and descending, will be found in the cord. Symptoms. — The symptoms due to haemorrhage into the spinal cord may be preceded by obscure symptoms of discomfort due to disturbances of circulation or nu- trition, which precede the rupture of the vessel, and perhaps depend upon the changes in the cord which give rise to the haemorrhage. These changes of nutri- tion may be such as are found in myelitis, yet the symp- toms caused thereby may not attract special attention, or may be the result of an acute disease,. as typhoid fever. When a blood-vessel ruptures, there may be intense pain in the back, continuing for a variable length of time, followed by paralysis of motion and sensation in the parts below. The occurrence of the haemorrhage is not always the cause of such tumultuous symptoms ; it may occur during sleep, or the symptoms may be de- veloped gradually during a period of several hours or, in rare instances, some days. In the latter case it is more probable that a myelitis has preceded the haemor- rhage. However it may arise, the chief symptoms are finally very similar. As the seat of the effusion is generally the central gray matter, sensation is more or less pro- foundly affected, and it may be entirely abolished ; mo- tion is restricted, and generally lost in the parts below the lesion. At the beginning there may be a certain amount of tetanic rigidity or spasmodic twitching, but this is of short duration, and the limbs are soon relaxed in paralysis. If the lesion is not so low as to implicate the lumbar nerves, the reflex irritability is increased, as in other cases where the lower part of the cord is sev- ered from communication with the brain, though im- mediately after the shock of the haemorrhage the reflex 16± DISEASES OF THE SPINAL CORD. functions may be temporarily suspended. Conscious- ness and intelligence are not affected. At the very onset, if there has been no previous ele- vation of temperature due to other disease, there is no fever; soon inflammatory changes commence around the clot, and then the temperature may rise ; as yet few observations of these changes have been made. The temperature of the paralyzed limbs was noticed by Levier to be 0*2° to l - 9° C. higher than the arms, the thermometer being in the fold formed by bending the knee and in the axilla. As the secondary changes extend, the symptoms be- come more decided ; if there was only a partial loss of sensation, the anaesthesia becomes complete ; there is entire loss of motion instead of partial paralysis. The muscles which arise from the portion of the cord de- stroyed undergo atrophy and show the reaction of de- generation. As secondary degeneration extends below the seat of the lesion, the symptoms due to affection of the lateral columns appear. The bladder and rectum are paralyzed, the urine may be very quickly changed in character, may contain blood, may be intensely acid, or may soon become alka- line. Some of these changes in the urine are dependent upon disturbed innervation of the kidneys and not upon cystitis, which may later cause much trouble. Bed-sores sometimes form with amazing rapidity, and become enormous in size. The symptoms will vary somewhat, in different cases, according to the height at which the haemorrhage oc- curs and the amount of blood poured out. In view of the physiology of the cord, it will not be difficult to locate approximately the upper limit of the lesion and, somewhat roughly, its lower limit. Diagnosis. — Haemorrhage into the substance of the cord can be distinguished from meningeal haemorrhage by the more complete and suddenly occurring paraly- sis of both motion and sensation, by the absence of HEMORRHAGE INTO THE SPINAL CORD. 165 signs of great irritation, and by the rapid appearance of bed-sores. The diagnosis may be easier in cases where there has been a preceding disease of the spinal cord. In rare cases the haemorrhage may be confined to one side of the spinal cord ; then the paralysis of mo- tion will be hemiplegic. The fact that there is no loss of consciousness, and that sensation is affected on the side opposite the motor disturbance, will prevent such a lesion from being mistaken for cerebral haemor- rhage. From myelitis arising spontaneously the diagnosis must be made by considering the causes, the mode of onset, and the progress of the symptoms ; a careful con- sideration of these points will probably prevent an error of diagnosis, unless the myelitis is developed with un- usual rapidity. MacMunn mentions intensely acid urine as peculiar to haematomyelia, distinguishing it from myelitis. From acute anterior poliomyelitis the diagnosis may be made by the fact that in this there is no disturbance of sensation, that the bladder and rectum are not para- lyzed, bed-sores do not form, and the fever, if any, is at the beginning, whereas in haematomyelia the fever appears later, unless the haemorrhage is secondary. In the former also there is a tendency for some muscles to regain their function ; in the latter the paralysis tends to increase. Peognosis. — If a large amount of blood is effused, the symptoms will be correspondingly severe, and the prognosis must be serious ; if only a small amount is effused, the symptoms will be proportionately light, and recovery, or partial recovery, may occur. If the haemorrhage is in the cervical region, death is more likely to follow. If the patient survives the first attack, he may die exhausted by cystitis or bed-sores. If he survives long enough, the paralyzed muscles may undergo atrophy, 166 DISEASES OF THE SPINAL CORD. which may persist during the rest of life, accompanied possibly with contracture. Treatment. — It is quite unlikely that any measures directed to stopping the bleeding can be applied in sea- son to be of any advantage. To prevent further dam- age by a renewal of the haemorrhage or by secondary myelitis, the patient should be kept quiet, and cold ap- plied to the back continuously. Local blood-letting may be resorted to, ergot may be given internally, pain should be relieved, the bowels and bladder should be sedulously cared for, the danger of bed-sores should be kept in mind, and subsequent paralyses and atrophies should be combated by the usual means. CHAPTER XIII. COMPRESSION OF THE SPINAL COED. Kadner, Zur Casuistik der Ruckenmarkscompression. Arch, der Heilkunde, 1876, p. 481. — Kahler, O., Ueher die Veranderun- gen welche sich im Riickenmarke in Folge einer geringgradi- gen Compression entwickeln. Zeitschr. f. Heilk., iii, 1882, p. 187.— Humphrey Laurence, Slow Compression of the Spinal Cord. Lancet, Jan. 5, 1884, p. 14.— Sayre, Lewis A., Spinal Disease and Curvature. London, 1877. — Marsh, H., On the Di- agnosis of Caries of the Spine in the Stage preceding Angular Curvature. Brit. Med. Jour., June 11, 1881, p. 913. — Russel, William, The Early Diagnosis of Spinal Caries. Brit. Med. Jour., Nov. 12, 1881, p. 771. SLOW COMPRESSION. Sudden compression, in so far as it is not surgical, has been mentioned in connection with spinal menin- geal haemorrhage. ^Etiology. — Slow compression is caused by caries of the vertebrae, by thickening of the membranes (pachymeningitis), by cancer of the vertebrae, or by tumors within the vertebral canal. Pathological Anatomy. — The changes found in the cord are the same as those found in myelitis ; sometimes the destruction is complete, the cord being softened ; sometimes it is pressed out of shape, and has undergone chronic interstitial changes, which give it a consistency firmer than natural. Secondary degen- erations are found above the point of compression in the posterior columns, sometimes in the cerebellar tracts, below in the anterior and lateral pyramidal columns. The membranes are more or less inflamed, thickened, 168 DISEASES OF TEE SPINAL CORD. and covered perhaps with pus ; especially in caries the dura mater may be pressed inward by collections of pus so as to press upon the cord. It is rare to find the vertebral canal so narrowed by displacement of the ver- tebrae that the bones press upon the cord. If there is no pus formed behind the dura mater, and if myelitis is not set up, the bones may soften and fall together, so as to form a very marked curvature, with almost no symptoms referable to the cord. If the membranes are inflamed and thickened, the nerves, as they pass out of the vertebral canal, sur- rounded by the diseased membrane, are also inflamed. Symptoms. — The symptoms will vary according to the level of the disease causing the compression ; but there are symptoms common to all localities. The earlier symptoms are dependent upon irritation of the nerves or the membranes ; subsequent symp- toms depend also upon disease of the cord. Pain generally first attracts attention. The pains due to irritation of the nerve-roots are of a shooting, darting character, referred to the peripheral distribu- tion of the affected nerves. If the upper cervical nerves are thus irritated, the pain may be felt over the back of the head, the side of the face near the angle of the jaw, or over the neck and shoulders. When the cervical or lumbar nerves are affected, the pain will be felt in the limbs. If the dorsal nerves, the pain will be felt in the chest or upper part of the abdomen, usually near the median line, sometimes a little on one side. It may simulate angina pectoris, or the stomach-ache, or colic, according to location. Instead of pain, there may be only a sense of discomfort or irritation, as itching. Motions which change the relation of the ver- tebrae to one another, as bending, or twisting the trunk, may increase the pain very much, this is especially so when the vertebrae are diseased. Jars, as in riding, or percussion on the shoulders, will increase the pain when the vertebrae are diseased. SLOW COMPRESSION. 169 Hyperesthesia may be noticed during or immedi- ately after the attacks of pain. This hyperesthesia may also be noticed between and independently of the attacks. Common sensation may be very much diminished. These disturbances of sensation depend upon le- sion of the nerves, and belong to the earlier symptoms. Later, the backache may be more marked ; there appear pains depending upon lesion of the cord, less lancinat- ing in character, which resemble those found in myeli- tis from other causes. These pains are found in the parts supplied with nerves arising from the cord below the seat of compression ; they consist in sensations of numbness, pricking or tingling, a sleepy sensation, as though the parts were asleep, or an aching. Ordinary sensation may be diminished or retarded. Finally, there may be complete anaesthesia below the lesion. In the beginning, even before there is any pain, there may be motor symptoms, which are frequently- overlooked. There is first a sense of fatigue ; the pa- tient dislikes to exert himself, and, if a child, will ex- change his active plays for more quiet sedentary ones. When carefully observed, he will be noticed to have a peculiar stiff gait, and, in stooping, the back will be kept rigid and the knees will be bent instead. This is most marked in caries and other diseases of the ver- tebrae. If the cervical vertebrae are affected, the pa- tient will steady his head with his hands when lying down or rising. Passive motion will be resisted, and, if the head or body is moved forcibly, pain will be ex- cited. The muscular weakness gradually increases until the patient is no longer able to support himself on his legs. Finally there is entire motor paralysis. When the disease is above the lumbar enlargement, the cutaneous reflexes are often exaggerated, so that severe contractions may follow even slight irritations. Tendon reflex may be increased, and ankle clonus may 170 DISEASES OF THE SPINAL CORD. be excited. When paralysis is complete, there is usu- ally contraction of the legs upon the thighs, and of the thighs upon the pelvis. This may be so strong that it can not be overcome by any reasonable amount of force. General epileptiform convulsions occasionally occur even when the disease is situated in the lower part of the cord. The muscles may undergo atrophy. There may be herpes zoster; bed-sores may form. Disease of the joints, spinal arthritis, has been seen in vertebral caries. In caries and cancer of the vertebrae, these symp- toms may be independent of any deformity ; neither is there tenderness on pressure over the spinous processes until after the earlier stages. When the cervical or upper dorsal part of the cord is affected, the pupil may be widely dilated or con- tracted ; generally the latter. The face and eyes may be more or less congested from paralysis of the vaso- motor nerves. The temperature of the whole body may be influ- enced by the disease in the cervical region. The heart's action may be slow ; respiration may be disturbed. Diagnosis. — It is important to form a correct diag- nosis early in vertebral caries, especially as the longer the delay the more likelihood there is of deformity. The earliest symptoms have already been mentioned, and whenever they are met a careful examination should be made of all the circumstances attending their origin, cause, and development. The physician must disabuse himself of the idea that in caries of the vertebrae there is necessarily deformity or tenderness to pressure over the spine ; there may not be tenderness even to direct percussion in the early stage, but percussion on the shoulders may give rise to pain in the diseased parts. Acute spinal meningitis is attended with pain in the back and limbs, but it commences suddenly with fever, and is evidently a severe affection. SLOW COMPRESSION. 171 The pain attending spinal irritation may lead to a suspicion of compression of the cord, and it may not always be easy at once to say there is no disease of the bones. The attending symptoms will generally clear up the diagnosis. There is less of the peculiar stiffness of gait and carriage, the pain is not felt so acutely at the peripheral end of the nerves, the pain is not in- creased by percussion on the head or shoulders to the same degree, and in spinal irritation there is much greater tenderness on pressure over the spinous pro- cesses than is ever found in compression at so early a date. The age of the patient, the history of the origin of the affection, and the past history of the patient, may aid in diagnosis, as will also the hysterical physi- ognomy which is often to be noticed in the less serious affection. The diagnosis between the different causes of com- pression of the spinal cord must often be made from symptoms other than those belonging to the spinal dis- ease itself. Aneurisms of the aorta may erode the ver- tebrae and press on the cord ; there is usually very lit- tle difficulty in recognizing the nature of this affection. Cancer of the vertebrae may give rise to very similar symptoms with caries. When the pain, shooting along the course of the nerves, is extremely severe, without intermission, apparently independent of movement, the probability is that it is caused by cancer ; yet, early in the disease, the pain may be much less severe, or may be scarcely noticeable. The spinal cord itself is less frequently implicated in cancer, and there is not the formation of pus which is seen when the bodies of the vertebrae are carious. The age of the patient may aid in diagnosis, caries being most frequent in early childhood, an age when cancer is very rare. The presence of cancer elsewhere, and the cancerous cachexia, would aid materially in diagnosis. A tumor within the vertebral canal may give rise to 172 DISEASES OF THE SPINAL CORD. symptoms closely resembling those of caries. The pain, central and peripheral, may be the same ; the paralysis may be similar. There is less marked stiff- ness in gait, less difficulty in bending the spine ; per- cussion of the shoulders is less painful. The age of the patient, and his previous history, will aid the diag- nosis. If a slight deformity is discovered, tumor would be excluded. Prognosis. —The prognosis of caries is not very un- favorable. If there is deformity, it can not be reme- died, but even extreme paralysis may disappear, and the patient recover. If muscles have undergone atro- phy, they may be partially restored. The nearer the disease is to the medulla, the more serious is the con- dition, and the greater danger of sudden death. The prognosis in cancer of the vertebrae and tumors, or aneurisms penetrating the spinal canal, is necessarily unfavorable. Treatment. — Of internal remedies, those which will restore the general health when the constitution is broken down are of most value. In caries the only hope of recovery is to be found in ankylosis of the diseased vertebrae. As the inflam- mation around the diseased bones is increased by their pressure one upon the other, and by the friction of dis- eased surfaces against one another, it is necessary, in order to diminish that influence as much as possible, to keep the diseased j)arts quiet and relieve the bodies of the vertebrae of pressure. The means of accomplish- ing this need not be mentioned here ; it belongs rather to surgery. The treatment of cold abscesses also be- longs to surgery. To relieve the paralysis in caries of the spine, the act- ual cautery, applied by the side of the spine, has been used with excellent results. This can not well be ap- plied while the patient is wearing a jacket, except as that is removed for a day or two, and this is rarely advisable. SPINAL TUMORS. 173 Electricity, faradic or galvanic, to stimulate para- lyzed muscles, should be used. The nutrition of the patient should be maintained as well as possible ; cod-liver oil and cream are espe- cially indicated in strumous subjects. The patient should be placed in the best hygienic conditions possi- ble. SPINAL TUMORS. The more common varieties of tumors found in the vertebral canal are cancer, generally arising from the vertebrae ; sarcoma and fibro-sarcoma, and osteoma ; parasites, echinococcus, or cysticercus, are more fre- quently connected with the membranes ; tubercular and syphilitic tumors may be either connected with the membranes or be seated in the substance of the cord itself ; gliomata are found in the substance of the cord. From pressure or from secondary inflammatory changes the spinal cord undergoes a degenerative pro- cess usually leading to softening ; sometimes, how- ever, there is simply atrophy of the nerve-elements, and the cord may acquire a somewhat firmer con- sistency than normal. When the tumor is in the sub- stance of the cord, its center may undergo degen- eration, and, by a process of softening, a cavity be formed. Many of the cavities found in the spinal cord originate in this way ; gliomata are most liable to this change. JEtiology. — Except in cases of tubercle, syphilis, and cancer, we know very little about the causes of spinal tumors, and even in regard to these varieties we can only say that the germs are conveyed by lymphat- ics or blood-vessels to their new seat of growth, or that a corresponding diathesis causes their growth. Some- times it would seem that an injury, as a fall or a blow upon the back, has served as a starting-point for the growth of tumors. X74 DISEASES OF TEE SPINAL COED. EXTRA-MEDULLARY (MENINGEAL) TUMORS. Symptoms. — The symptoms are almost the same as those found in connection with caries of the vertebrae. There are the symptoms due to irritation of nerve-roots and those depending upon compression of the cord. The symptoms may be unilateral or bilateral, according to the locality of the tumor. The growth of the tumor is usually very slow, and the development of the symp- toms is correspondingly slow, the slighter early symp- toms sometimes continuing for years before a definite diagnosis can be made. Pain at the seat of the tumor, of a dull, pressing nature, may be increased by motions of the body, but is felt at other times also. Percus- sion over the spinous processes may increase the pain or give it for a moment a more lancinating character. The nerves arising from the level of the tumor may be implicated ; then the pain will be felt at the periph- ery, as in caries. Atrophy of the muscles to which these nerves are distributed with the reaction of de- generation will indicate the serious change which the tumor may cause in the nerve-roots. Other trophic lesions, as herpes and bed-sores, may make their ap- pearance. Paralysis finally sets in with increased reflex irrita- bility, spasms, or contractures. A careful study of the nerves affected, as shown by the distribution of the paralysis or the anaesthesia, will indicate the level of the disease, and show also whether the cord is affected, or only the nerves of the chorda equina. Diagnosis. — No symptoms or combination of symp- toms are * sufficient for forming a positive diagnosis; it is only by a careful examination of all the circum- stances that other affections can be excluded and the probability of a tumor be recognized. Caries and can- cer of the vertebrae most closely resemble tumor in their symptoms. INTRA-MEDULLART SPINAL TUMORS. 175 INTRA-MEDULLARY SPINAL TUMORS. The tumors which have been found in the substance of the cord are gliomatous, tubercular, syphilitic, or sarcomatous. They are very rare. Their growth is often slow, but they give rise to symptoms sooner than the extra-medullary growth. There is no necessity for describing these growths, as they are like others found elsewhere. Symptoms. — The symptoms are very much like those belonging to acute or chronic myelitis, including dis- turbance of sensation and motion, atrophy of muscles, and local trophic changes. Sometimes the symptoms much more closely resemble those due to meningeal tumor, pain, both local and peripheral, and increased reflex irritability, being prominent. The symptoms must vary with the seat, rate of growth, and conse- quent size of the tumor. There are no symptoms diag- nostic of spinal tumors by which one can be guided to a certain conclusion. Prognosis. — The prognosis is necessarily unfavor- able. A syphilitic gummata may theoretically be ab- sorbed, but it would then be impossible to satisfy a skeptic that the diagnosis was correct. Treatment. — Except the use of iodide of potassium or some equivalent preparation, there is nothing to be done further than to care for the patient's comfort and look after any complications which may arise. CHAPTER XIV. SYRINGOMYELIA. — FORMATION OF CAVITIES. — HYDRO- MYELUS. Schuppel, 0., Ueber Hydromyelus. Archiv der Heilk., vi, 1865, p. 289. — Westphal, Ueber einen Fall von Hoblen- und Ge- schwulstbildung im Riickenmarke mit Erkrankung des verlanger- ten Marks und einzelner Hirnnerven. Arch. f. Psych, und Ner- venkr., v, 1875, p. 90.— Simon. Ibid., p. 108.— Schultze, F. Ibid., viii, 1878, p. 367.— Eickholt, August. Ibid., x, 1880, p. 695.— Westphal, C, A Contribution to tbe Study of Syringomyelia (Hydromyelia). Brain, July, 1883, p. 115. Occasionally cavities are found in the spinal cord, which are clearly the result of an abnormal develop- ment of the central canal ; this condition may be con- genital. The canal may be dilated through only a short tract, or through nearly its whole length. Sometimes the canal is double, or diverticula may be found which branch from the canal and can be followed for a few millimetres, running near the central canal. As an- other variety of malformation, cases are seen where the central canal has not been closed. The central canal may be secondarily dilated, when by pressure it is closed above or below the dilated portion, or it may be found dilated in connection with certain diseases, as cerebro-spinal meningitis, or occasionally in cases of chronic myelitis. In all these instances in which the central canal is enlarged, the walls of the cavity will be lined with epi- thelium, and it will be situated the same as the normal canal with reference to other parts of the cord. FORMATION OF CAVITIES. 177 In a large number of cases, however, the cavity is pathological and is independent of the central canal, which may be seen just in front or to one side of the abnormal cavity ; the central canal is usually distorted, and it may be so flattened as to be scarcely recogniz- able, only a narrow line of epithelial cells showing its location. An abnormal cavity, according to Simon, may be lined with cylindrical epithelium, as when one is formed in a glioma. He thinks position is most im- portant for diagnosis. The cavity is most frequently found in the posterior part of the cord, it may be formed at the expense of the gray commissure or the posterior cornua, may take part of the space occupied by the posterior columns, or it may be in the anterior cornua. The gray sub- stance is much the more frequently affected. The cav- ity may be single or double, may be a few millimetres in length or may extend the whole length of the cord, and may be very small or as large as the finger. ^Etiology. — The cause of the formation of a cavity is not the same in every case. A haemorrhage into the cord may leave a cavity after the clot has been absorbed ; the plugging of blood-vessels, much more rare, may be the cause. Several cases have been reported in which it has seemed that a glioma formed in the central gray substance, and that the center of this has softened and been absorbed. Hallopeau has suggested that an in- flammation about the central canal may give rise to an enlargement of that canal, or a central myelitis may lead to the formation of a canal outside the central canal. Eichorst and Naunyn found that, after crushing the cord in young animals, a cavity was formed above the point crushed. They referred this to the dilatation of a lymph-canal which they suppose runs at the bot- tom of the posterior fissure. Westphal accepts this as a possible explanation of the formation of some cavi- ties. There are no special symptoms caused by cavities, 12 178 DISEASES OF THE SPINAL COED. so far as is known. Those symptoms which have been found in cases of syringomyelia were such as were due to the disease which gave rise to the cavity. There is nothing to be said as to treatment other than what belongs to the primary disease, if any, which causes the formation of the cavity. CHAPTER XV. MYELITIS. Frommann, C, Untersuchungen iiber die normale und patholo- gische Anatomie des Kuckenmarks. Jena, 1864, 1867. — Dujar- din-Beaumetz, G., De la my elite aigue. Paris, 1872. — Anderson, M'C, On a Case of Myelitis. Edin. Med. Jour., Aug., 1881, p. 97. — Hallopeau, H., Etude sur les my elite chroniques diffuses. Arch. gen. de med., Sept., 1871. — Zunker, Beitrage zur Myelitis Chronica. Charite Annalen, v, 1880, p. 260. Myelitis is an inflammation of the spinal cord, and may be acnte or chronic ; the gray or the white sub- stance may be affected, the nervous tissues, cells, and fibers may be chiefly and primarily affected, or the principal change may be found in the interstitial tis- sue, the nervous structures suffering secondarily. ACUTE MYELITIS. ./Etiology. — Acute myelitis is most frequently caused by exposure to wet and cold ; these two influ- ences are most likely to give rise to inflammation of the spinal cord when the legs, more especially the thighs, and the back are thus exposed for a considerable length of time, as by sleeping upon the damp ground in cool weather, or riding in a carriage or on horse-back in a storm, with insufficient protection. The influence of the above causes is very much increased if there has been severe or prolonged bodily exertion at the time of the exposure or just preceding it. Excessive bodily exertions may alone be the cause of the disease. Many acute febrile diseases are occasionally accom- 180 DISEASES OF THE SPIRAL CORD. panied by a myelitis ; this will be referred to again (post-febrile paralysis). Lead-poisoning is not unfrequently the cause of symptoms closely resembling those of myelitis ; in- deed, it is probable that in such cases there is inflam- mation of the spinal cord, but generally of a chronic form. Excess in venery, and syphilis, may give rise to myelitis ; so may injuries to the back, from falls, blows, etc. Severe emotions, as fright and anger, may occasion- ally give rise to inflammation of the spinal cord. Pathological Anatomy. — The spinal cord affected with acute myelitis is generally softened, but occasion- ally its consistency is increased. The softening may be only slight, or the cord may be quite liquid. The color is either reddish, if there is an admixture of blood with the debris of the cord, or yellow, if fatty degen- eration has occurred to any extent, or white. The soft- ening may occupy a continuous stretch of the cord, or it may be scattered about in isolated spots ; the gray substance is rather more easily affected than the white. The dorsal region is more frequently the seat of softening than either the cervical or lumbar. When the cervical region is affected, it is said that the dis- seminated variety is the more common. Above the portion directly affected there is found secondary ascending degeneration of the posterior col- umns and cerebellar tracts ; below, secondary descend- ing degeneration of the pyramidal tracts. This second- ary degeneration can be best seen from the change of color after hardening in bichromate of potassa or chro- mic acid. With the microscope, the minute changes of struct- ure may be studied better upon hardened specimens. Either the nervous structures are chiefly affected, or the interstitial tissue is first altered. The nerve-fibers are first swollen, the myeline becomes granular, and the ACUTE MYELITIS. 181 axis cylinder is either broken up and disappears or is enlarged, even to ten times its normal diameter ; these enlarged axis-cylinders may be filled with cavities— vacuoles ; the enlargement is varicose or affects only a short length of the axis ; it may be spherical or fusi- form. These enlarged axes soon break up and disap- pear in the general debris of the softened tissue. When the cord acquires increased consistency, this hypertro- phy of the nerve-fibers is either entirely wanting or is very slight. The nerve-cells are also swollen, acquire a globular appearance, their outline may be less distinct than nor- mal, and the nucleus may be pushed to one side, even so as to project beyond the general outline of the cell ; they may be filled with vacuoles, or they may have a shining, glassy appearance — vitreous. There may be a large deposit of pigment in the cells. They finally become granular, break up, and disappear. Changes in the neuroglia may be the starting-point in myelitis ; then those in the nervous structures are secondary, and there is less likely to be hypertrophy of the nerve-fibers and cells. The nuclei of the neurog- lia multiply, the fibers swell up and are thicker, and they become brittle and undergo fatty degeneration. Granular corpuscles form at the expense of the nuclei and connective tissue. As the nutrition of the nervous elements is interfered with, they also degenerate, and the cord is soon reduced to a soft, semi-liquid consist- ency. When the cord acquires an increased consist- ency, the fibers and cells of the neuroglia are multiplied somewhat as in sclerosis, though to a less degree ; the nerve-fibers in these cases are destroyed, and their place is filled with granular debris or a liquid which becomes granular on hardening. The walls of the blood-vessels are rarely if ever thickened in acute myelitis ; they are more likely to lose consistency and rupture easily, giving rise to haem- orrhages which aid in the process of disintegration. 182 DISEASES OF TEE SPIJSTAL CORD. The walls of the vessels are often covered with granular corpuscles. Symptoms. — Acute myelitis may begin with a chill and fever before any distinctive spinal or nervous symp- toms appear. The temperature only rarely reaches 104° ; the pulse may be as high as 150 ; with the py- rexia are the usual constitutional symptoms — anorexia, headache, and general malaise. Very frequently the commencement of the disease is more gradual ; a sense of weariness, heaviness, with backache and undefined sensations in the limbs, precede the initial fever. Soon after the chill and fever, sometimes without any distinct pyrexia, a numbness or a pricking and tingling is noticed, usually in the toes and feet. These abnormal sensations increase in severity and gradually extend up the leg. "With these symptoms, or soon after their advent, rarely as the initial symptom, the patient is aware of a loss of strength in his legs ; he is soon wearied in walk- ing ; in a very short time this increases, so that he is unable to walk, and must keep his bed. In many in- stances there is tremor or cramps at the beginning of the attack, but no marked convulsions nor spasms. The disturbance of motion and sensation extends upward, affecting both limbs with increasing and nearly equal severity, until there may be entire paralysis of motion and complete loss of sensation in the legs. The different reflexes, cutaneous and deep-seated, are first diminished, then lost, unless the myelitis is limited to a comparatively short segment of the cord above the lumbar region. The reflex actions which control the bladder and rectum are lost ; there is, at first, usually retention of urine ; later the urine drib- bles away from over-distention of the bladder and pa- ralysis of the sphincter. There is constipation rather than involuntary action of the bowels. A sense of constriction, girdle sensation, is noticed ACUTE MYELITIS. 183 around the thighs — later around the waist. This may- be very annoying to the patient. As the inflammation extends upward in the cord, the trunk is affected, the costal respiratory muscles cease to act, the respiration becomes diaphragmatic, there is inability to expel the mucus which may accu- mulate in the bronchial tubes ; the breathing therefore becomes noisy, the upper extremities are also affected, the patient finally ceases to breathe, and dies of apncea. When the inflammation extends downward rather than upward, its progress can be recognized, though less certainly, by observing the loss of reflexes in a de- scending order, or the gradual extinction of electrical reactions. For this, careful comparative examinations are necessary, such as it is not always desirable to make. Pain is not a prominent symptom in acute myelitis ; it is not present unless the membranes are also impli- cated. The tingling numbness may be so severe as to give the patient much discomfort, and there may be aching and a sense of unrest in the limbs ; but it is not rare to have the disease run its course without even this amount of discomfort. Backache is said by some to be one of the symptoms of acute myelitis ; if this is promi- nent, there is probably an accompanying meningitis. There is no tenderness over the spinous processes, and spontaneous spasms or evidences of reflex irritability are wanting. Pain or tenderness may be shown by passing a sponge wet with hot water, or a lump of ice, over the back ; a severe burning sensation will be felt at the seat of the lesion. Electricity will sometimes act in the same way. Hyperesthesia of the skin is not found in myelitis, excepting occasionally a narrow zone at the upper limit of the region affected with anaesthe- sia. Symptoms of motor and sensory irritation, how- ever, are often seen in cases of myelitis, because very frequently the membranes are implicated. A tonic contraction of the legs, a rigidity in exten- 184 DISEASES OF THE SPINAL CORD. sion, is a symptom which belongs to the later stages, when the disease is above the lumbar enlargement; there is then difficulty in abducting the legs, and pass- ing a catheter may become difficult from the exaggera- tion of this contraction caused thereby. The urine may become alkaline early in the disease, as Erb thinks, not improbably from direct nervous dis- turbance of the secretory functions. There is always danger, also, of this change in the urine from retention, the bladder being only imperfectly emptied. Cystitis is one of the complications to be watched for. When the lumbar enlargement is not affected, the urine may be passed involuntarily, and, if sensation is much dis- turbed, without the patient's knowledge. Bed-sores sometimes form with great rapidity, enormous masses of tissue sloughing away and giving rise to possible purulent infection. Even if such acute disturbance of nutrition does not occur, it is very common to have a more slowly developed bed-sore. An eruption of herpes, bullae, or pemphigus may appear on the limbs. The nerves arising from the part of the cord affected and the muscles supplied by them undergo destructive degeneration, and there may be wasting of the limbs, appearing more or less rapidly. The electrical reaction is affected under these circumstances, there being the reaction of degeneration. Above and below the principal focus of disease there will be secondary degeneration if the patient lives long enough. Then there may be found the exaggerated tendon reflexes and other symptoms belonging to lesion of the lateral pyramidal tracts. This description has been rather that of a severe case, which runs its course to a fatal termination. Fre- quently the symptoms are less grave : sensation is not entirely abolished in the legs ; the reflexes are not ab- solutely lost ; perhaps one side is chiefly affected, the other slightly so ; after a variable length of time there is a recession of the symptoms, the disease has ceased ACUTE MYELITIS. 185 to advance, and the patient is recovering. The recov- ery is almost never complete. There generally remains some impairment of function. As an unusual complication may be mentioned op- tic neuritis, occurring at the same time or just preced- ing subacute myelitis, as observed by Erb. He thinks that the optic nerves and the spinal cord are both easily affected by the same injurious influences, and so may together be attacked with subacute inflammation. Diagnosis. — It is necessary to distinguish acute myelitis from meningitis, haemorrhage, and acute as- cending paralysis. It is also desirable to form an opinion as to the part of the cord affected. In meningitis there is much more severe pain, both in the limbs and back — such pain as to cause the pa- tient to complain of it bitterly ; this pain is increased upon motion. There is often great hyperaesthesia of the limbs ; fever runs higher in meningitis than in myelitis ; reflex actions are much more exaggerated and the con- tractions are more constant, and the limbs may be flexed, or there may be opisthotonus. Paralysis is a later symptom in meningitis ; trophic disturbances of the skin are rare. Haemorrhage is distinguished by the suddenness with which the initial symptoms arise, without fever, the injury preceding the disease, or, if spontaneous, the severe pain preceding or attending the commencement of the attack. The stationary character of the symp- toms after the first attack, or their gradual extension secondarily, also when the cervical and lumbar enlarge- ments are the seat of the haemorrhage, the rapid wast- ing and loss of electrical reaction, aid in forming a diag- nosis. If, however, the history of the case is imperfect, a diagnosis may be extremely difficult. Acute ascending paralysis may be diagnosticated by the fact that sensation is little if at all affected ; the bladder and rectum are not likely to be disturbed ; 186 DISEASES OF TEE SPINAL CORD. there is no bed-sore ; the muscles do not undergo atro- phy. The diagnosis of the seat of the lesion must be made from a study of the symptoms, keeping in mind the physiology of the cord. Unilateral acute myelitis is almost never seen, excepting as the result of injuries, and need not be specially considered. In most instances the central gray substance is first affected ; the dis- ease spreads then to the white substance. If the an- terolateral columns are first affected, there will be loss of motor power, and, if the disease begins in the pyramidal tracts, the symptoms of lesion of those tracts. A much less extent of disease of the motor tracts will cause paralysis of motion than is necessary to give rise to loss of sensation ; indeed, if but a small portion of the gray substance is left, sensation is not entirely de- stroyed. Myelitis is much more common in the dorsal region, possibly explained by its vascular supply being less sure, as pointed out by Adamkiewicz. An examination of the reflexes, as suggested by Gowers, will aid in fixing the upper limit, and some- times the lower limit, of the disease ; so will a careful study of the muscles paralyzed and of the region af- fected with anaesthesia, by which means we can recog- nize what nerves have lost their function. Peognosis. — When myelitis begins violently and the paralysis advances rapidly, the prognosis is un- favorable; the same is true when the disease has reached or has commenced in the cervical region, and especially if respiration is disturbed. If there is much cystitis, or if bed-sores form, the prognosis is unfavor- able, even if other symptoms seem mild, and the more so if the general health suffers severely and if the pa- tient's constitution seems undermined. It is, however, often impossible to convince either the patient or his friends that he must die, so little discomfort does he experience. ACUTE MYELITIS. 18? The more gradual the advance of the disease, and the more incomplete the loss of function, the more favorable is the prognosis. A slight remission of symp- toms and sustained general strength are also favorable. Even when the patient has apparently nearly re- gained his health, a relapse is possible, and, after one attack, a slight imprudence may cause another, so that the patient must take extra care of himself. Teeatmejstt. — As soon as the disease is recognized, the patient should be put to bed and kept there. As perfect rest of mind and body as possible is absolutely necessary, even against the protest of the patient, who may be conscious of only slight numbness or weakness. Ice-bags to the spine, applied continuously, are of benefit in meningitis, and may be used in myelitis, though their value is less certain. A mild form of counter-irritation, dry-cupping, is of value, and should be employed ; two to six or eight cups can be applied daily ; usually two are sufficient, changing their place each time. The cups should remain on about half an hour, and should leave the skin much congested when removed. If the attack is very severe, the danger of bed-sores may contra-indicate cupping. Ergot, drachm doses of fluid extract, or six or eight grains of ergotin, should be given three times a day. This may be combined with one of the preparations of belladonna. Iodide of potassium may be used even in the earlier stages with advantage, and later even more efficacious- ly, especially where syphilis is suspected, and in those cases mercury may be combined with it. The greatest care should be taken to sustain the pa- tient's nutrition, to relieve the bowels, to prevent cysti- tis and bed-sores. When the patient is recovering, electricity can be used to maintain the nutrition of the muscles ; this may be combined with massage, or the latter can be used alone. 188 DISEASES OF THE SPINAL CORD. Counter-irritation to the back, actual cautery, and dry-cupping may be employed during recovery, but are of doubtful efficacy then. CHRONIC MYELITIS. Chronic myelitis sometimes succeeds acute myelitis, or may result from injuries. It may also follow expos- ure to cold, fatigue, and long-continued emotional dis- turbances ; the eruptive fevers and other acute diseases may be complicated with chronic changes in the spinal cord ; syphilis is a very common cause. In many cases it will be found that lead has been received into the sys- tem. So frequently is lead one element in the aetiology, that it should be sought for in every case. Arsenic may give rise to the same symptoms. Pathological Anatomy. — After death the spinal cord is sometimes found softened; more frequently, however, it is found firmer in consistency than normal. The seat of the inflammatory changes may vary in dif- ferent cases ; sometimes the gray substance is chiefly affected, sometimes the white substance, and more fre- quently both gray and white are affected ; sometimes the disease extends through the whole thickness of the cord, and sometimes only one half is affected ; again, only the periphery of the cord is diseased — chronic cor- tical myelitis, as it has been called. The microscopic changes vary according as the con- nective tissue (neuroglia) or the nerve-fibers and cells are chiefly affected. If the neuroglia is primarily dis- eased, we have thickening of the connective tissue with increase of its elements ; secondary to these changes the nervous elements gradually disappear. When the latter are chiefly affected, they rjass through changes similar to those found in acute mye- litis ; the neuroglia may be somewhat thickened, or it may apparently suffer no change. The walls of the blood-vessels are usually somewhat thickened. The tissue around the vessels may undergo CHRONIC MYELITIS. 189 granular degeneration, and thus spots of softening may form. Symptoms. — The symptoms of chronic myelitis will vary somewhat according to the seat of the lesion. The first symptoms may appear either in the sensory or motor function ; the motor phenomena consist in a gradually increasing weakness, affecting one or more limbs, the first sign of failure being a sense of heavi- ness in the legs or arms, and an unusual liability to become fatigued. These symptoms slowly increase in severity, the weakness becomes more marked, and the patient may be confined to his bed many months be- fore there is entire paralysis. There are rarely spasms ; but chronic contractures are not so infrequent, the legs being held in extension and adducted, rarely flexed. Reflex actions are sometimes moderately exaggerated ; this is often shown simply by an increase of the pre- existing contraction : thus, if it is desired to draw off the water, the introduction of a catheter may increase the adduction of the thighs so as to render the opera- tion very difficult, especially in a female. The tendon reflexes are sometimes exaggerated and sometimes di- minished, according to the location of the disease. When the anterior gray substance is affected, there is, of course, wasting of the muscles, in which case the electrical phenomena undergo the usual changes ; other- wise the electrical reactions may even be exaggerated. Disturbances of sensation appear very early, and are often the first symptom to attract the patient's atten- tion. These disturbances are often simply a sense of numbness and tingling, as if the limbs had been asleep, without any disturbance of tactile sensibility ; but sometimes the sense of touch is affected, and there is more or less marked anesthesia. Pain is not very common, but is occasionally very severe. In some cases there is hyperesthesia to touch, or the sense of touch is perverted so as to give rise to a peculiar vibrating pain. This sensory disturbance may remain limited to 190 DISEASES OF THE SPIFAL COED. one limb, to a toe or finger, during several weeks be- fore extending, or before other symptoms appear. The condition of the bladder and rectum varies ac- cording to the seat of the lesion. There is danger of cystitis when urine is retained, as in the acute form. The sexual function is gradually abolished, though occasionally the sexual appetite may be increased. After the patient is confined to bed, bed-sores are liable to form, especially if cleanliness is neglected. The disease is slowly progressive toward a fatal ter- mination, but there are occasionally periods of remis- sion and improvement which may be so great as to encourage the hope of final recovery ; but some imj^ru- dence or exposure starts up the inflammation again, and causes an aggravation of the symptoms. Death may not occur for several years after the commence- ment of the disease. Diagnosis. — In well-marked cases this form of myelitis is not likely to be mistaken for other diseases of the spinal cord ; but in some instances it may be doubtful whether there is locomotor ataxia, multiple sclerosis, lateral sclerosis, or disease of the anterior cornua. When multiple sclerosis affects chiefly the spinal cord, it may be impossible to make a correct diagnosis. Vulpian says: "Every time there is found in a chronic affection of the cord an irregular course of the disease — causing weakness and paralyses of different parts of the body, giving rise to combinations of symp- toms belonging some to one systematic lesion, some to another, and presenting, as a whole, symptoms which, except for the rapidity of their appearance and their succession, would be more or less similar to those no- ticed in acute diffuse myelitis — it may be asserted that it is a case of chronic diffuse myelitis. "Whenever, in any. chronic affection of the cord, the assemblage of symptoms allows the elimination of systematic lesions, of sclerosis in patches, of chronic CHRONIC MYELITIS. 191 myelitis of the anterior cornua, the case is one of chronic diffuse myelitis." Prognosis. — The disease is one of long duration and, as has been said, with periods of remission and improvement. Complete recovery is extremely rare, except in cases caused by lead or those occurring after fevers ; it probably never occurs, there always being some impaired function remaining to show that mis- chief has been done to the cord. In judging whether there is immediate danger to life, the circumstances of each case must be taken into account, and no general directions can be given. Treatment. — Active measures, such as are used in acute myelitis, would be entirely out of place in chronic myelitis. Dry- cupping, the actual cautery, the iron being heated to a white heat and drawn rapidly and lightly over the back, so as to simply char the cuticle without producing suppuration, small blisters applied in suc- cession along the spine, and iodine, may be employed as counter-irritants ; of these, the best are dry-cupping and the actual cautery. Brown- Sequard recommends a douche of hot water to the back, the application be- ing made for two or three minutes every day. The galvanic current may be used, one pole being placed above, the other below the probable seat of the disease ; the direction of the current may be varied at different sittings, both electrodes being held stationary, or one moved slowly up and down the back ; rather a weak current should be used, only for a few minutes at a time, the application being made daily, and the treat- ment persevered in for months. Sometimes this treat- ment will give rise to unpleasant symptoms ; it should then be discontinued. Erb says that he has obtained benefit in fifty-two out of one hundred cases treated by galvanism. Erb says : " The water-cure is, all things considered, one of the most important and most promising means 192 DISEASES OF THE SPINAL CORD. of treating chronic myelitis. The mistrust with which it is regarded by some authors is, as far as my own ex- perience goes, entirely unjustifiable. It is suitable for most all cases, though, of course, the method of appli- cation must vary according to the peculiarities of the individual cases. " Simple rubbing with wet cloths, foot-baths, spong- ing the back, hip-baths, half-baths, with affusions to the back, local compresses to the back, left on till they become warm, etc., seem to be the measures which are chiefly applicable. The treatment should always be begun with moderate temperatures (20° to 25° C., or 68° to 77° F.), and we should never go below 16° to 12° C. (60-£° to 53|° F.). I believe, also, that excessive pro- longation of the treatment is injurious." Of internal remedies, nitrate of silver, a quarter to half a grain three times a day for four or five weeks, then omitted for a short time ; ergot, half a drachm to a drachm of the fluid extract three times a day ; double chloride of gold and sodium, gr. -^ three times a day ; ext. of belladonna, gr. £ to £ twice or three times a day ; iodide of potassium should be used if there is lead, and anti-syphilitic treatment when it is indicated. In chronic myelitis there is less reason to keep the patient quiet and at rest than in acute myelitis ; yet over-exertion should be carefully avoided. It is much more prudent to restrain the patient's activity more than is necessary than to allow even a slight over-ex- ertion. The same may be said of all imprudent expo- sures to influences which are likely to cause the disease. ACUTE ASCENDING PARALYSIS. This is sometimes called Landry's paralysis, because Landry first described the combination of symptoms. It is defined by Erb as "a motor paralysis which generally begins in the lower extremities, spreads pretty rapidly over the trunk to the upper extremities, and usually also involves the medulla oblongata, which ACUTE ASCENDING PARALYSIS. 193 sometimes runs its course without fever, sometimes with more or less active fever, which but slightly in- volves the general sensibility and the functions of the bladder and rectum, and which runs its course without notable atrophy of the muscles, and without any dimi- nution or change in their electrical excitability." This definition gives nearly the whole symptoma- tology of the disease. It is only necessary to add that prodroma, disturbed sensations, numbness, and aching in back and limbs, may precede the motor paralysis ; that the disease may commence in the upper extremity ; that reflex actions may be much diminished or entirely lost ; the tendon reflex has not been carefully studied ; and the functions of the brain do not seem disturbed until just before death. The disease usually ends fatally when the nerves arising from the medulla are affected. The symptoms may cease to advance at almost any stage, may recede, and the patient may recover. The symptoms recall those which are found in acute or subacute anterior poliomyelitis ; the reten- tion of electrical reaction in the muscles is the chief difference. Many cases have been examined after death, and no lesions discovered in the cord. When Landry described this form of paralysis in 1859, the electrical reaction of muscles was not taken into account in forming a diagnosis, and there seems no special reason why that should be added in order to form a distinct disease. Several autopsies (Eisenlohr, Fox, v. d. Velden, Peabody) have lately shown that there are changes in the cord ; though these changes have seemed to be very slight, yet they have been quite diffused, and are such as may indicate an early stage of myelitis, sometimes affecting the white substance, sometimes the gray ; sometimes attended with no change in electrical reaction, sometimes accompanied with such change. No case has yet been reported in 13 194 DISEASES OF THE SPINAL COED. which a proper examination of the peripheral nerves has been made. The causes of this form of paralysis are said to be the same as those of myelitis ; the treatment should be the same as in acute myelitis. It is not my purpose to enter upon a long discussion of any doubtful points. In view of the cases which have been published, I can see no satisfactory reason for retaining acute ascending paralysis as the name of a distinct disease ; the cases coming under that desig- nation can be included under one of the forms of acute or subacute myelitis. CHAPTER XVI. POLIOMYELITIS.— MYELITIS OF ANTEEIOE COENUA. Petitfils, A., Considerations sur l'atrophie aigue des cellules matrices. Paris, 1873. — Gombault, Note sur un cas de paralysie spinale de l'adulte, suivi d'autopsie. Arch, de physiol., 1873. — Bernhardt, Ueber eine der spinale Kinderlahmung ahnliche Af- fection Erwachsener. Arch. f. Psych, u. NervenJcr., 1874, p. 370. — Bennett, A. H., On Chronic Atrophic Spinal Paralysis in Chil- dren. Brain, Oct., 1883, p. 289.— Seguin, E. C, Myelitis of the Anterior Horns. New York, 1877.— Proust, A., and Ballet, G., Contribution a l'anatomie pathologique de la paralysie generale spinale diffuse subaigue de Duchenne. Arch, de physiol., Oct., 1883, p. 330. ACUTE ANTERIOR POLIOMYELITIS. This is the name that has lately been given to a class of diseases characterized by changes in the anterior cor- nua. These changes are generally considered to be of an inflammatory nature. The so-called infantile paralysis was for a long time the only recognized manifestation of this disease, but during the last ten years or so cases have been reported as occurring among adults having very nearly the same symptoms, and after death presenting similar lesions of the anterior cornua. It ought to be mentioned that some authors consider this affection primarily a disease of the muscles. This view is not generally accepted. Leyden refers the symptoms in some cases to a diffused or general neuri- tis. ^Etiology. — By far the larger number of patients 196 DISEASES OF THE SPIXAL CORD. are infants from one to three years of age ; among adults, the larger number are attacked between the years of twenty and forty; between the years from four to fourteen there seems to be comparative exemp- tion from this form of myelitis. During infancy both sexes are about equally liable to the disease ; among adults, males are rather more frequently attacked than females. During dentition the nervous system of a child is in a more irritable state, and perhaps more likely to suf- fer from injurious influences ; this may explain the fre- quency with which infantile paralysis occurs during the first and second years. Cold acting upon the surface of the body may be a cause of this form of myelitis as of other forms. In a very few cases I have been able to learn that during the night preceding the occurrence of the paralysis the child has been found to have kicked off the clothing, and thus become chilled. Falls and other injuries have sometimes seemed to be a cause. In adults, excessive exertion. The summer months show a larger proportion of attacks than the other seasons. Pathological Anatomy.— There are reasonable grounds for the opinion that the first change is a con- gestion of the anterior cornua, and perhaps of other parts of the cord also. In the foetus and in early in- fantile life the capillaries more closely surround the nerve-cells, each cell being inclosed in a net-work of small vessels. Adamkiewicz has shown that in the adult a system of canals, smaller than the capillaries, can be injected from the vessels so as to form a net- work, by which each nerve-cell is surrounded. After the first shock of the disturbed circulation, which causes the paralysis, the congestion diminishes, and with this the paralysis disappears, except where the in- jury to the nutrition of the cells has been sufficient to destroy or seriously impair their vitality. ACUTE ANTERIOR POLIOMYELITIS. 197 Tbe essential change seems to be destruction of the nerve-cells ; other changes are either accidental compli- cations or secondary. When the patient has survived many years, the affected cornua are found deformed and diminished in size ; the neighboring white columns may also be misshapen. The anterior nerve-roots arising from the affected tract are atrophied and contain degenerated nerve- fibers, or the libers may have so entirely disappeared that simply connective tissue remains. The muscles undergo change at a comparatively early period. The muscular fibers lose their transverse striation, are broken up into granular and fatty debris ; sometimes the muscular nuclei are increased in num- ber ; the granular and fatty materials are absorbed, and there remains only the sarcolemma with a larger or smaller number of muscular nuclei. Sometimes, instead of undergoing atrophy, the muscles suffer from a waxy or colloid change, in which the fibers may be greatly enlarged. The interstitial tissue is usually increased in amount, and often fat is deposited between the mus- cular fibers. The bones of the affected limbs grow less rapidly than the corresponding healthy limbs, when the patient is a child. In adults there is no atrophy of the bones. Observations are not yet sufficiently numerous to deter- mine whether the bones become brittle. Symptoms. — In children the disease begins sudden- ly, sometimes, though rarely, with convulsions. Most frequently the child, having been put to bed apparently in good health, is somewhat restless during the night, perhaps awakes and cries, then sleeps quietly until morning ; in the morning it is discovered that one or more limbs are paralyzed ; generally one or both legs are affected ; sometimes the paralysis is confined to one or both arms, or an arm and a leg ; very rarely are the four limbs affected. The loss of power may not be complete at first, but it reaches its height in a very few 198 DISEASES OF THE SPINAL COED. hours. The right leg is said to be the most frequently- affected. Sensation does not appear to be much dis- turbed ; except at the very beginning, there seems to be no pain, and it is doubtful if there is pain even at the beginning. Occasionally a slight febrile attack pre- cedes the development of paralysis ; but often this is so slight, especially in very young children, and of such short duration, as to attract little or no attention, and the severity of the succeeding paralysis is not propor- tionate to the amount of fever. When convulsions usher in the attack, they are usually of short duration and differ materially from the severe convulsions of cerebral origin preceding many cases of hemiplegia in infants. Within a few days, from two or three days to one or two weeks, an improvement in the paralysis is no- ticed, which may, in light cases, advance to complete recovery, though more frequently the improvement ceases after a few weeks, leaving some muscles still paralyzed. Where more than one limb is affected, the muscles of one limb may entirely recover, while those of the other limb or limbs only partially recover. Within a short time after the paralysis appears, the muscles begin to undergo the atrophic changes already mentioned, and after a few weeks the affected limb shows decided evidence of wasting. Its growth is also retarded, and after some years there may be a differ- ence of from one to six or seven inches in the length of the legs. Erb says that, while the atrophy is progress- ing, the muscles are quite sensitive on pressure. The affected muscles show a change of electrical action — reaction of degeneration — within a few days (four or five) after the attack. The skin may be dry and scaly, and the circulation sluggish, on account of which the limb is cold and more or less cyanotic. Bed-sores do not form, nor is it likely that herpetic and allied forms of skin eruption are caused by this disease. ACUTE ANTERIOR POLIOMYELITIS. 199 The reflexes, cutaneous and tendinous, are more or less disturbed according to the amount of muscular paralysis. After months or years, sooner or later, according to the amount of wasting, deformities result. Where there is inequality of the limbs, the bones of the pelvis are tilted and the spine is curved. The affected limb suf- fers also from contracture ; club-foot and deformity of the knee and hip joint are seen. The upper limbs are much less frequently subject to contracture and de- formity than the lower limbs. Erb divides the causes for these contractures into three classes : 1. "The most frequent cause is the continued approximation of the points of attachment of the muscles, induced partly by the weight of the parts, partly by external pressure in walking, standing, etc." 2. "The antagonists of the paralyzed muscles remain effective." 3. "The prolif- eration of interstitial connective tissue and its subse- quent retraction, which takes place with the degenera- tive atrophy of the muscles." After the first febrile attack, the bladder and the rectum are not affected, and all the functions of the body, except those of the paralyzed limbs, are normally performed. Life is not shortened by this disease, and the mental powers of the child are, as a rule, not af- fected. In adults the course of the disease is somewhat dif- ferent from that noticed in children ; as with other febrile affections, convulsions are absent ; pain is a rather more prominent feature ; febrile reaction is rather more marked, though it may be absent ; the pa- ralysis is developed rather more slowly ; sensibility is more frequently disturbed at the beginning, though this usually soon disappears ; occasionally vomiting and gastric disturbances are noticed. After some days or weeks, longer than with children, the paralysis amends, and, as in children, there may be complete recovery, though partial recovery and wasting are the 200 DISEASES OF THE SPINAL COED. more frequent result. Of course, there is in adults no retarded development, and subsequent deformity is much less than in children. The electrical reaction and other symptoms are almost identical. Diagnosis. — The disease which has been most fre- quently confounded with acute anterior poliomyelitis in children is hemiplegia from cerebral cause. In this, convulsions are much more frequent and severe, the paralysis is hemiplegic rather than paraplegic, the elec- trical reactions remain unchanged, contractions resem- ble the hemiplegic contractions found in adults, and there may be post-hemiplegic chorea; the growth of the paralyzed limbs is much more retarded. Hemorrhage into the spinal cord, though occurring suddenly without febrile reaction and followed by change in the electrical phenomena, may be recognized by the initial pain which usually attends it, by the dis- turbance of sensation, and the subsequent progress of the case, even partial recovery being much slower and more tedious. The history of the case ought to lead to a correct diagnosis from other diseases. Prognosis. — The prognosis, so far as life is con- cerned, is favorable. Complete recovery of motion in the paralyzed limbs can be expected only in very mild cases, and even in such, more frequently than not, when the child is tired there will be a slight awkward- ness in using the affected limb. Generally the recov- ery is imperfect. After five or six months all is gained that can be expected. If proper treatment is pursued, a much larger amount of motion can be recovered than when the child is left without treatment. Nothing can be done to prevent retardation of growth, but deformities resulting therefrom may be at least partially prevented by mechanical appliances. Treatment. — In the first stage the fever may be combated with the ordinary measures, and, if a diagno- sis can be made out early, ergot, belladonna, and iodide of potassium may be given in rather large doses ; coun- ACUTE ANTERIOR POLIOMYELITIS. 201 ter-irritation is also indicated, dry cups and the actual cautery being the most desirable forms ; as Seguin sug- gests, tincture of iodine and blisters cause too much pain and make the skin sore. After the fever has ceased, and in cases where there is no fever, when time enough has elapsed to guard against unfavorable reaction, electricity should be used. The galvanic current should be used from the begin- ning, even if the muscles respond to the faradic cur- rent ; the positive pole or anode should be placed on the spine near the origin of the nerves leading to the affected muscles ; the negative pole, cathode, should be passed slowly over the muscles, or, the motor point for each muscle having been found, the cathode may be placed there, and the current may be slowly interrupt- ed. Only such strength of current need be used as will cause perceptible contraction in the muscles. The ap- plication should be made every day or every other day for about one minute to each muscle. The reaction of degeneration may appear while the electricity is being used, if its use is commenced early. In order to obtain benefit from the use of electricity, it must be continued for months ; a short treatment of a few weeks, except in very mild cases, would proba- bly be of little value. To obtain the best results, it should be used as soon as possible after all symptoms of irritation have ceased. With children, a little caution may be necessary in order not to frighten them at the beginning by the nov- elty of the application ; also a very mild current should be used until they are accustomed to the peculiar sen- sations. Bathing the affected limbs in hot water is of advan- tage, allowing them to remain immersed for several minutes ; then the limbs should be rubbed and knead- ed for several minutes. The warmth of the limbs must be maintained by proper clothing or other means. Over-exercisino: of the limbs should be avoided : bath- 202 DISEASES OF THE SPIXAL CORD. ing and rubbing should not follow too closely after the use of electricity. After all hopes of further improvement have to be laid aside, much assistance can sometimes be given by orthopaedic surgery and mechanical appliances. Except in the first stage, no advantage can be gained from the use of medicines internally. Hypodermic in- jections of strychnia into the affected muscles have been recommended ; but it is very doubtful whether more can be gained in this way than by the persevering use of electricity. CHRONIC ANTERIOR POLIOMYELITIS. Attention has been called within only a few years to a form of atrophic paralysis which closely resembles acute poliomyelitis, yet is, in some respects, different, the attack being less abrupt, the symptoms not exactly the same. Duchenne, in 1872, and Erb, in his volume on the spinal cord, in Ziemssen's " Cyclopaedia, " in 1877, gave detailed descriptions of the disease, under the name of poliomyelitis anterior subacuta or chron- ica. Since then many cases have been reported, some authors preferring to call it subacuta rather than chron- ica. As in regard to several other forms of nervous diseases, it seems that it was only necessary to have at- tention called to its peculiar symptoms in order that many cases might be recognized. E. C. Seguin has given a very careful study to both the acute and subacute or chronic form of lesion of the anterior cornua. When the cases included by different authors are compared, it will be seen that they are simply cases of chronic myelitis in which the anterior cornua, especial- ly its nerve-cells, are affected early in the course of the disease so as to give a special physiognomy to the symptoms. Except for some peculiarities in the course of the symptoms, it would not be desirable to give these cases a separate designation. CHRONIC ANTERIOR POLIOMYELITIS. 203 .ZEtiology. — We must confess our ignorance of the cause of the disease in many cases ; in other instances chronic lead-poisoning seems to be the chief if not only cause ; certainly in several patients whom I have seen with this assemblage of symptoms there was lead in the system. Injuries and chills may be the starting- point in this as in other forms of myelitis. Most of the patients are adults. I have, however, seen one child twelve years old with the disease, and an infant seemed to have at first acute poliomyelitis, but later the disease followed a chronic course. It may occur in aged per- sons also, though rarely. Pathological Anatomy. — Very few autopsies have been made — only five or six. In nearly all of these, other parts of the cord than the gray anterior cornua were diseased. In a case reported by Baumler, the only change found was in the gray substance. There is atrophy and destruction of the cells of the anterior cornua ; the nerves and muscles undergo cor- responding degeneration. Other portions of the cord than the cornua may also be affected, and thus would be explained variations in symptoms, the chief lesion, and that which gives its name to the disease, being, however, constant ; the other lesions are variable. Symptoms. — The more marked features of the dis- ease are found among the motor functions. The patient finds a difficulty in following his usual occupation on account of weakness, which may be noticed first in the lower or upper extremities, usually the former. After a longer or shorter time this weakness increases until there is paralysis ; sometimes one limb alone is at- tacked, or both arms or legs may be ; at length the paralysis extends to those limbs not previously affected. The reflexes are diminished and lost in proportion to the severity of the paralysis. Inco-ordination is rare. When time enough has elapsed, the affected muscles will be noticed to have wasted, unless, as occasionally happens, the increase of fat conceals the atrophy, or a 20± DISEASES OF TEE SPIXAL CORD. sclerotic degeneration of the muscular fibers enables them to keep their size while losing their distinctive muscular character ; they will then be felt as hard re- sisting masses. The electrical reactions show the changes due to de- generation of nerves and muscles. These changes will depend somewhat upon the progress of the disease and the amount of structural changes. Yet very careful observations made by Kahler and Pick show that there is no absolute relation between the electrical reactions and the loss of voluntary power. The muscles may show reaction of degeneration, yet may contract under the influence of the will. In the case recorded by Kah- ler and Pick there was a steady diminution of the fara- dic contractility, until nearly all the muscles of the limbs, body, and face were thus affected, even while the voluntary control was improving. This anomaly is the more frequently seen during restoration of the mo- tor functions. The progress of the disease may be arrested at any period ; then, after an interval, either the symptoms may be aggravated or, more frequently, the power may slowly return ; occasionally the recovery is complete, more frequently it is only partial. The above are the constant and essential symptoms. Other phenomena depend upon what other parts of the cord are diseased. When the pain is severe, there is probably a limited meningitis. It is more common to have soreness of the muscles, especially before any aggravation of motor symptoms. Numbness, tingling, and a sense of weari- ness may precede and accompany the earlier motor dis- turbances. Cutaneous sensibility is, as a rule, only slightly diminished, and is often not affected. Patients are rarely seen at the very commencement of the disease, so that the symptoms at that period are only occasionally studied ; fever is sometimes present, but is • not very marked. The limbs which are para- CHRONIC ANTERIOR POLIOMYELITIS. 205 lyzed, and yet more if atrophy has set in, are generally cold and may be cyanotic. The bladder and rectnm are rarely affected. There are no bed-sores. The ordinary functions of digestion are not disturbed. Cerebral symptoms are absent, ex- cept, in a few instances, nystagmus. Diagnosis. — It is scarcely necessary to recapitulate the symptoms in acute anterior poliomyelitis for the sake of diagnosis. It is quite probable that formerly chronic anterior poliomyelitis was confounded with progressive muscu- lar atrophy. The latter is more slowly progressive ; the paralysis or weakness appears after the atrophy or about the same time ; the reaction of degeneration is wanting or is much less clearly marked ; the reaction to both the faradic and the galvanic currents decreases, though the latter may persist longer than the former. In the progressive atrophy certain muscles are attacked by preference, and there is rather an irregularity in the progress of the affection ; it seems to jump from one region to another, leaving intermediate muscles unaf- fected. There is less likely to be remissions or cures ; the reflexes persist. Prognosis. — A large proportion of the patients either regain a certain amount of motor power, or, more rarely, recover. The tendency is toward remission. The course of the disease is long and slow, and years may elapse before it can be said that all the gain pos- sible has been made. A few cases of death have been recorded, showing that life is not always spared. Of course, if the disease affects the medulla oblongata or the respiratory centers, the prognosis must be unfavorable. Treatment.— When lead seems to be a cause, iodide of potassium should be given at once. If, after a week's use of that drug, lead can be found in the urine, it should be continued for months. Some advise large doses in order to eliminate the lead quickly. The advantage is 206 DISEASES OF THE SPINAL COED. doubtful ; it is frequently necessary to be cautious lest symptoms of acute lead - poisoning should appear. Sometimes one or two grains are as much as can be given. Early in the disease, or when there are exacerba- tions, ergot and belladonna may be given as in acute myelitis. If the pain is severe, morphia or atropia may be ne- cessary, or the galvanic current may be found sufficient to relieve the pain. The galvanic current should be applied to the spine even early if there is no fever ; positive pole above, negative below. A current from six or eight cells, such as will not cause discomfort, can be used daily, or every other day, for five minutes at a time. Later the para- lyzed muscles should be stimulated to contraction by the direct application of the electrode to them, the cur- rent being interrupted. The faradic current is less effi- cacious. Counter -irritation to the back, blisters, dry cups, or, better than either, the actual cautery, may be of great benefit. Kest in bed while the disease is advancing is desir- able. If its progress is slow, it may not be necessary, however, to stay in bed all the time. As the muscles are regaining power, care should be taken not to over- tax them by too prolonged or too severe use. Massage and warm bathing, not too warm, are use- ful adjuncts as a means of maintaining the nutrition of the limbs. CHAPTER XVII. PROGRESSIVE MUSCULAR ATROPHY. Friedreich, N., Ueber progressive Muskelatrophie. Berlin, 1873. — Charcot et Gombault, Note sur un cas d'atrophie mus- culaire progressive spinale protopathique. Arch, de physiol., 1875, p. 736.— Sturge, Allen. Lancet, May 21, 1881, p. 828.— Fox, A. W. , Case of Progressive Muscular Atrophy with. Bulbar Paralysis. Brit. Med. Jour., Jan. 15, 1881, p. 82. — Clarke, J. L. Arch, of Med., London, 1863, p. l.—Med. Chir. Trans., 1873, p. 103. Zimmerlin, Franz, Ueber hereditare (familiare) progressive Muskelatrophie. Zeitschr. f. M. Med., vii, 1883, p. 15.— Erb, W., Ueber die juvenile Form der progressive Muskelatrophie. Dent. Arch.f. M. Med., xxxiv, 1884, p. 467. Three theories have been advocated in regard to the nature of this disease : That it is primarily a muscular affection, the changes in the nervous system being sec- ondary ; that it is a disease of the sympathetic system ; that the seat of the disease is in the spinal cord. The question as to which of these is the correct theory has not yet been settled, and I have not the data upon which to form a final opinion. I give it a place among lesions of the spinal cord because constant changes have been found in the cord, and because it seems useful to place it alongside of other affections which somewhat resemble it. Etiology. — As the first symptoms appear gener- ally in those muscles which are most used, it is proba- ble that excessive use acts as one cause, at least as the cause for localizing the disease at the beginning. Men are more frequently attacked, and middle adult 208 DISEASES OF THE SPINAL CORD. age is the most favorable for the development of the disease. At least sometimes heredity seems to be an impor- tant ^etiological factor. There is a close resemblance between progressive muscular atrophy and pseudohypertrophic paralysis, in that brothers are frequently attacked, and the dis- ease seems to be transmitted through the females of a family. Pathological Anatomy. — Unfortunately, it is im- possible to give a satisfactory account of the post- mortem changes connected with the nervous system, because in many cases the examination has been im- perfect. The spinal cord has been frequently found either normal or with very slight changes, not always affect- ing the cells. In some of the cases where there was no change, the question has been raised whether they were cases of progressive muscular atrophy. In a large number of cases the cells of the anterior cornua have been found diseased, atrophied. In a very few cases, comparatively, the sympathetic has been found diseased. In many more it has been examined and no disease found. In a large number of cases, even where the cord has been healthy, the sym- pathetic has not been examined. The weight of evidence to the present time is in favor of the seat of the disease being in the cord ; but it is necessary that more examinations should be made of thoroughly typical cases before the question can be decided. The changes in the muscles are only occasionally of an active nature ; they are rather regressive in charac- ter. In many fibers there is a tendency to split up lon- gitudinally ; much less frequently they separate trans- versely. Frequently there is a simple atrophy ; some- times a waxy degeneration or a fatty degeneration can be recognized. PROGRESSIVE MUSCULAR ATROPHY. 209 The nuclei of the muscles may be increased quite early, and sometimes the sarcolemma sheath is filled with these nuclei after the contractile substance of the muscular fiber has disappeared. Finally the proper muscular structure disappears, and there remains only a fibrous-like substitute in place of the muscle. An increase of the interstitial tissue with, or less commonly without, deposit of fat may proceed uni- formly with the degeneration of the muscles, or may even advance so rapidly as to give the muscles an ap- pearance of having undergone hypertrophy. Symptoms. — The atrophy from which the disease takes its name, with the attending weakness and pa- ralysis, is the principal symptom. The wasting is almost or quite imperceptible in its beginning, pro- gresses very slowly, and may have advanced so as to seriously interfere with the use of the limb before it is noticed. The patient is aware, perhaps, for a short time of a slight loss of skill or readiness in his motions, or that he is more quickly tired than usual ; then he finds that he is unable to use his hands or arms with natural ease and strength ; then notices the change in configuration, and may think the whole has occurred within a few hours ; yet, on closely questioning him, it will be discovered that several weeks at least have elapsed since the first slight symptom appeared. A large majority of patients are first attacked in the hands or arms ; usually the muscles of the thenar or hypothenar eminence, the interossei and lumbricales, are the first to undergo atrophy, and the right hand or arm is much the more frequently affected first. Authors disagree as to whether the atrophy attacks the interos- sei or the muscles of the thenar eminence first. The position of the fingers is peculiar when the disease has made considerable progress. There is the claw-shaped hand. The thenar eminence is thinned, leaving a flat- tened, slightly concave surface in place of the normal convex swelling of the ball of the thumb. 14 210 DISEASES OF THE SPIXAL COED. Next to the small muscles of the hand, the flexors and supinators of the forearm, or the deltoid, are at- tacked ; then other muscles connected with the scapula and those of the trunk, and finally the muscles of the lower limbs, may be affected. The progress of the dis- ease from muscle to muscle observes no regular order, but muscles widely separated may be attacked before the intermediate muscles suffer. Generally both sides are affected nearly at the same time, though often several days or weeks elapse before the second side is attacked. The rate of progress dif- fers very widely ; there may be long intervals when the symptoms remain stationary. Very rarely the disease may begin with the lower limbs— either in the thighs or the legs — though Eulen- burg thinks this form occurs only among children in a form allied to pseudo-hypertrophic paralysis. As the power of motion is not lost until the muscles have almost entirely disappeared, the patient may be able to move his limbs even when there is great emacia- tion. When the atrophy has advanced far, so that a large number of muscles, both those of the limbs and of the trunk, are greatly wasted, he presents a pitiable appearance ; especially if the facial muscles have also been attacked ; he becomes a "walking skeleton," the bones apparently only covered by the integument. Even before a muscle is seen to waste, and while that process is going on, very slight and rapid contrac- tions of individual muscular fibers can be seen, which, occurring repeatedly in the same or adjoining bundles of fibers, produce what is called fibrillary contractions. These may be compared to the fitful flashing sometimes seen as the light of the aurora spreads over the sky. If these contractions do not appear spontaneously, they may be excited by giving the muscles a fillip with the finger or a pencil. By observing this phenomenon in muscles not yet wasted, it is often possible to foretell which will be next attacked. PROGRESSIVE MUSCULAR ATROPHY. 211 The electrical reaction of both nerves and muscles is diminished in proportion to the amount of atrophy. The galvanic current will cause contractions longer than the faradic current. Rosenthal says that the nerve- filaments nearest the centers may react normally, while the peripheral ramifications may show diminished reac- tion. Remak discovered that when the negative pole is placed over the fifth or sixth cervical vertebra, and the positive pole is placed on the side of the neck in the carotid fossa, or in the triangle between the lower jaw and the ear, there follow contractions in the atrophied muscles on the side opposite that where the positive pole is when the current is interrupted. This reaction is most easily shown with the galvanic current, but it is not constant. If both poles are placed on the side of the neck, with a weak current, the contraction may be excited on both sides. Remak called this "diplegic contraction." He referred it to a reflex contraction ex- cited through the medium of the superior cervical gan- glion. Others do not agree with this view. Sensibility is usually not affected ; even when dis- turbed, the change is very slight. Pain, however, in the affected muscles is not uncommon ; this pain may be excited by motion or by pressure, and it is some- times spontaneous. Cutaneous reflexes are sometimes heightened, especially in the early stages. The patel- lar tendon reflex has been found present in a case where the muscles of the legs and thighs were not atro- phied ; in another case slightly diminished. It is some- times exaggerated, its strength depending upon the state of the muscles which contract in response to the stimulus. The temperature of the affected limbs is sometimes at first moderately elevated, but later it is lowered. The joints may be swollen and painful, more particu- larly the smaller joints. There may be bed-sores to- ward the close, unless some intercurrent disease short- 212 DISEASES OF TEE SPINAL COED. ens life. Occasionally herpes and changes in the hair and nails are to be noticed. The pupils may not be symmetrical, and there may be a variation in their relative size, but in very many patients there is no deviation from the normal con- dition. The disease slowly advances, with occasional pauses, more muscles being invaded, until the patient is help- less. The duration may extend over two to twenty years. Finally respiratory muscles, or those of deglu- tition, are affected, and the patient dies. Erb describes a special form of muscular lesion, which he calls the "juvenile form of progressive mus- cular atrophy," consisting in part of hypertrophy with subsequent atrophy, with greater or less formation of fat tissue and increase of interstitial connective tissue. The same sets of muscles are attacked in different cases, especially the pectorales, cucullares, latissimi, flexor group on the arm, triceps ; forearm and hand are not affected ; in the lower limbs, those of the thigh, the peroneal region, and the calf are attacked ; also the lumbar extensors. There is no fibrillary tremor nor degenerative reaction. The disease begins in childhood or youth, and may be mistaken for progressive muscu- lar atrophy or pseudo-hypertrophy. Peognosis. — There is no immediate danger to life unless bulbar symptoms or disturbed respiration set in, but the prospect of cure is very slight. When seen early, it may be that the disease can be checked and even muscles restored ; but this is very rarely the result. As a rule, there is before the patient only a life of gradually increasing weakness, ending in total disabil- ity, which may be prolonged through years. Diagnosis. — The disease which has been most fre- quently confounded with progressive muscular atrophy is poliomyelitis — anterior, subacute, or chronic. The commencement and progress of the disease are much PROGRESSIVE MUSCULAR ATROPHY. 213 more gradual in the former, the sensation is less fre- quently disturbed early in the disease, the electrical reactions are different, the paralysis is more propor- tionate to the atrophy, except when there is increase of fat, and the irregular order in which the muscles are attacked is quite characteristic. In many cases of the chronic anterior poliomyelitis, lead is found to be a fac- tor in causing the disease ; this has not yet been recog- nized in progressive muscular atrophy, though it was found in one of my patients. Local injuries to both muscles and nerves may simu- late progressive muscular atrophy, and wasting of mus- cles in consequence of joint disease may lead at first to doubt as to diagnosis, but careful study of the history and of all the circumstances will probably guard one from mistake. The local paralysis of the hands from lead, the wrist- drop seen in that aifection, can be recognized by the fact that the extensors are chiefly affected, and the in- terossei and the muscles of the thenar eminence escape ; the fact of exposure to lead, previous lead colic, the lead cachexia, and the condition of the blood, would aid in diagnosis. Yet once in a great while a case may occur which will require great care to decide correctly. Teeatment. — Internal remedies are not likely to be of much value. If, however, lead can be detected in the system, an effort should be made to eliminate it by using iodide of potassium. Electricity is of value — either the faradic or galvanic current — applied locally, so as to cause muscular con- tractions ; that current is to be chosen which will most readily cause the muscles to contract ; sometimes a very strong current will be needed. The galvanic current, of moderate strength, may be applied to the spine at the same time. Exercise should be restricted within the limits of fatigue. Patients are mistaken in supposing that by taking much exercise they can restore the strength of 214 DISEASES OF TEE SPINAL COED. diseased muscles. It is necessary to caution them on this point. When the muscular power is much re- duced, and even before, Swedish movement is of value. Massage should be used from the beginning where it is practicable. These means for help should be used perseveringly through many months before discontinuing treatment. No benefit can be expected from a short treatment. CHAPTER XVIII. BULBAE PAEALYSIS (LABIO-GLOSSO-LARYNGEAL PARALY- SIS). Kussmaul, A., Ueber die fortschreitende Bulbai-paralyse und ihr Verhaltniss zur progressiven Muskelatrophie. Volkmann's Tel. Vortrdge, No. 54, 1873. — Strumpell, Adolf, Zur Casuistik der apoplektische Bulbarlahmungen. Dent. Arch. f. kl. Med., xxviii, 1880, p. 43. — Beevor, C. E., Case of Glosso-labial Paralysis witb Progressive Muscular Atrophy and Lateral Sclerosis. Brain, Oct., 1882, p. 403. — Leyden, E., Zur progressiven Bulbarparalyse. Arch. f. Psych, u. Nervenkr., ii, iii. — Finny, J. M., Clinical Re- marks on Cases illustrating the Essential Identity of Progressive Muscular Atrophy and Progressive Bulbar Paralysis. Brit. Med. Jour., June 14, 1884, p. 1132.— Bennett, A. H., Bulbo-spinal Atrophic Paralysis. Brit. Med. Jour., March 8, 1884, p. 647. — Eisenlohr, C, Ueber acute Bulbar- und Ponsaffectionen. Arch. ' f. Psych, u. Nervenkr., ix, p. 1, x, p. 31. — Ross, James, Labio- glosso-pharyngeal Paralysis of Cerebral Origin. Brain, 1882, p. 145. — Kirchhoff, Cerebrale Glosso - Pharyngo - Labial - Paralyse mit einseitigem Herd. Arch. f. Psych, u. Nervenkr., xi, 1880, p. 132. BULBAR PARALYSIS. Duchenne first called attention to the combination of symptoms which are known as bulbar paralysis un- der the name of glosso-labio-laryngeal paralysis. There is paralysis of the muscles with atrophy of the tongue, of the soft palate, of the lips, of the pharynx and lar- ynx ; muscular atrophy may also extend to other re- gions, until with the symptoms of bulbar paralysis there are united those of progressive muscular atrophy. Pathological Anatomy. — Muscles undergo the changes which are found in other cases of atrophy. The nerves, especially the hypoglossal, facial, and ac- 216 DISEASES OF THE SPIXAL COED. cessory, exhibit the usual appearances of fatty degen- eration, such as are found in other cases of muscular atrophy of central origin. The medulla oblongata seems to be the primary seat of the disease. Often nothing abnormal can be recog- nized with the naked eye ; but under the microscope changes will be discovered in the motor nuclei of the medulla, The ganglion nerve-cells undergo degenera- tion and atrophy either with or without disease of the surrounding tissues. The nuclei of the hypoglossal, accessory, vagus, and that part of the facial nucleus connected with its inferior branch, are most frequently affected ; the nucleus of the glossopharyngeal nerve is less frequently affected. When the disease spreads so as to implicate the muscles of the extremities, the cor- responding parts of the spinal cord will also be found affected. JEtiology. — Of the causes of bulbar paralysis we know almost nothing. It is confined almost entirely to advanced life, and is more frequent among males ; but it has been seen as early as twelve years ; Erb saw it in a girl of twenty years. Syphilis, exposure to cold, and injuries have been mentioned as causes. Symptoms. — As with most chronic diseases of the spinal cord, the earliest symptoms are so insignificant as to be often overlooked or neglected. They vary in different cases according as the nucleus of one or another of the nerves of the medulla oblon- gata is chiefly or primarily affected. The hypoglossal nucleus generally suffers first, and in the majority of cases the first motor disturbance is noticed in the tongue. The patient is not able to move his tongue quite as freely as normal, and his articulation becomes imperfect. Some letters can not be readily pronounced ; e is first lost, then there is trouble in expressing the sounds r, sh, s, Z, £, g, t, and later d and n ; the mo- tions of the tongue, apart from speech, are interfered with, and it can not be protruded beyond the teeth ; BULBAR PABALY8IS. 21T the affection being bilateral, it is not protruded to one side, it is not moved forward, it can not be turned in the mouth to loosen food from between the gums and cheek, and it can not be formed with a trough-like de- pression in the center ; the tip can not be raised against the upper teeth, and the center or root of the tongue can not be arched to touch the hard and soft palate ; it can not be used to press food backward in the first act of deglutition. When the nucleus for the lower branch of the facial nerve is affected, the lips act less readily, and, if the disease begins thus, the letters in which the lips chiefly act are first pronounced indistinctly ; if the lips are affected later, then the power to pronounce those letters is lost later ; these letters are o and u first, later e and a ; of the consonants, p and f ; later b, m, and v are lost. When the lips can not be readily moved, there is much difficulty in keeping food in the mouth while eating ; the saliva runs out of the mouth. When the soft palate is paralyzed, which is only after the tongue or lips have been affected, the voice acquires a nasal tone, and the explosives can not be clearly pronounced, especially b and p. If the loss of power in the soft palate is considerable, drinks will re- turn through the nose, and, if it is extreme, even solid food will thus return. The glottis is not properly closed, and therefore food, or more especially drink, enters and excites paroxysms of coughing. The pa- tient gradually gives up drinking and tries to swallow only soft solids. The patient's countenance acquires a characteristic expression ; from the paralysis of the lower branches of the facial nerve the mouth and lower part of the face are motionless ; the lower lip is dragged down and rolls outward from its own weight ; the saliva acquires a more tenacious character, and, not being swallowed, collects and flows out at the corners of the half-open mouth. The tongue can not be protruded nor moved, 218 DISEASES OF TEE SPINAL CORD. but lies on the floor of the mouth, atrophied and shrunken, constantly agitated by fine fibrillary tre- mors. The superior branch of the facial nerve is not paralyzed, and hence the forehead and eyelids move naturally. The ocular muscles are unaffected. Sensation is not disturbed, nor are the special senses, taste remaining intact. The disease advances slowly, sometimes with remis- sions, but as a rule steadily, until the patient at last is a pitiable spectacle, talking with extreme difficulty, perhaps unable to make himself understood ; intelli- gent, conscious of his condition, with bright and speak- ing eyes, he eagerly desires the food which he can not swallow, or, if he tries laboriously to swallow, is nearly strangled by choking. He necessarily becomes weak and emaciated from lack of nutrition ; but, apart from this cause of debility, it is not infrequent that the mus- cles of the extremities and even of the trunk suffer atrophy, as the disease of the motor cells extends to those in the anterior cornua of the cord ; thus general muscular atrophy is added to the local. The arms and neck are usually first the seat of this change. The pulse is sometimes irregular or rapid, and there may be dyspnoea, especially toward the close of life ; coughing and sneezing become impossible. Life may be cut short by disease of the lungs, ex- cited by the entrance of food into the bronchi, or by suffocation during an attack of dyspnoea, or more slow- ly by starvation. The atrophy and paralysis are attended with changes of electrical reaction in the affected muscles, such as are found in progressive muscular atrophy. The faradic reaction may seem to have suffered little, as many mus- cular fibers remain without atrophy, though at a late stage it will be diminished ; but the galvanic current will show the reaction of degeneration when the disease has advanced somewhat. Not only the tongue, but the other affected muscles, BULBAR PARALYSIS. 219 may be the seat of fine fibrillary tremors, such as are seen in progressive muscular atrophy. Nattjke or the Disease. — The nature of the atro- phy and paralysis in bulbar paralysis, and its relation or connection with progressive muscular atrophy, has been the subject of controversy. In both diseases there is the same combination of symptoms, making allow- ance, of course, for the difference of function in the different muscles. There is diminished skill or facility in the execution of movements, a slight paralysis, which gradually increases in degree ; at length atrophy is no- ticed, but not until so much of the muscular structure has degenerated as to cause the loss of function to be prominent ; fibrillary tremor ; change of electrical re- action when so much of the muscle is affected that the change can be recognized; the disease progresses to finally almost entire and absolute paralysis ; in both, sensation is very rarely disturbed ; the destruction of the large motor cells in the nuclei of the cranial nerves and the anterior cornua in the cord is the same in na- ture, so far as our means of examination enable us to judge. Besides these points of correspondence, the two dis- eases run into each other. Before bulbar paralysis ends in death, it is usual to see the limbs affected with muscular atrophy ; and often, in progressive muscular atrophy, bulbar symptoms apj)ear near the close of life. The two affections may, then, be justly looked upon as pathologically one disease, as clinically distinct only because of the wide difference in the function of the parts innervated by the regions affected in the cord and medulla. In very many cases, at the autopsy it has been found that the pyramidal tracts in the lateral and even in the anterior columns were altered. In some of these cases the exaggerated reflexes of lateral sclerosis were recog- nized during life. It is as yet doubtful whether this is 220 DISEASES OF THE SPINAL CORD. to be considered as a secondary degeneration and com- plication, or whether the few cases of this character are to be classed as amyotrophic lateral sclerosis. Diagnosis. — Especially in the early stage it will re- quire a careful examination of all the symptoms to recognize the disease ; similar symptoms may be seen in the early stages of general paralysis ; then the vari- ation in pupils, the general weakness of the limbs, the tremor, and the mental condition of the patient, may aid in diagnosis, but sometimes it will be necessary to wait for further developments. When the disease is well advanced it can hardly be mistaken, yet, if a patient is seen in an advanced stage, without having a knowledge of the history of the origin and progress of the symp- toms, it may be very difficult to decide whether it is the chronic or acute bulbar paralysis. Prognosis. — There is no case on record of recovery in uncomplicated, primary bulbar paralysis. All the instances of recovery, if carefully examined, will be seen to have presented bulbar symptoms as secondary only. The prognosis is, therefore, unfavorable. When the significance of the peculiar early symp- toms is generally recognized in the profession, so that treatment can be commenced early, a more favorable result may be obtained. Eemissions of longer or shorter duration are not un- common, as in all chronic and slowly progressive dis- eases. The duration of the disease is only a few years ; Erb says from one to five. Treatment. — It is certainly rather discouraging to consider that no treatment has as yet been successful. Electricity is the most promising, and may, for a short time at least, contribute to the comfort of the patient ; it may render swallowing less difficult. The galvanic current should be used. It may be passed from one mastoid to the other, keeping the electrodes in one place ; Erb also recommends galvanization of the cervi- cal sympathetic (anode on the back of the neck, cathode BULBAR PARALYSIS. 221 at the angle of the lower jaw). The electrodes may be applied to the sides of the neck so as to excite the mus- cles of deglutition, and to stimulate the recurrent laryn- geal nerve, using the faradic and galvanic current alter- nately. As the muscles are weak, having undergone partial atrophy, they are easily tired, therefore the ap- plication should be short — three to five minutes ; this may be repeated daily, or every other day. The treat- ment by electricity should be persevered with for sev- eral months. Counter-irritation, by means of dry cups, blisters, or cautery, has been recommended ; also hydrotherapy is advised. All these means may be employed, at least with the advantage of making the patient more con- tented. Erb says that medicines taken internally have never produced the very faintest effect. Still, he recommends the trial of nitrate of silver, iodide of potassium, iodide of iron, chloride of gold and sodium, ergotin, bella- donna, etc. The most important part of treatment is the general care of the patient. The general health is to be cared for by regulating the habits ; too prolonged exercise fatigues and exhausts, therefore injures the patient, especially after the muscles of the limbs are affected. If efforts to converse are continued too long, they ex- haust the muscles of the throat. The food should be soft, so as to require very little mastication, and be- cause soft solids are most readily swallowed. The pa- tient should be fed slowly, time enough being allowed for the partially atrophied muscles to rest. It may be well to increase the number of meals during the day. Finally, it may be necessary to feed the patient through a tube introduced into the stomach. When dyspnoea, or, as patients sometimes describe it, "attacks of asthma," occur, sedatives, narcotics, and stimulants, internally or by inhalation, or subcutane- ously, must be used. 222 DISEASES OF THE SPINAL CORD. ACUTE BULBAR PARALYSIS. Many cases have been reported in which the symp- toms of bulbar paralysis have appeared suddenly, without the progressive character. Such cases may be considered as acute, and may be so called if we keep in mind that they are due to pathological changes quite different from those found in the progressive disease. iEiTOLOGY. — The causes of the combination of symptoms in these acute cases are: softening due to plugging of vessels by a thrombus or an embolus ; haemorrhage ; acute inflammation ; tumors ; and, in a few cases, cerebral lesions. The causes of the acute form would then be those that would give rise to the above pathological conditions. Symptoms. — The symptoms vary considerably from those found in the chronic cases. The onset of the dis- ease is sudden, the paralysis reaching its height in a few hours, or at most a few days. Convulsions of an epileptiform character may be among the earlier symp- toms. After the first attack there may be a slight im- provement or a remission, and afterward a steady pro- gression in the disease. Besides the bulbar symptoms due to lesion of the nerves of the medulla or their nuclei, there will proba- bly be also a rapidly occurring paralysis of the limbs, and sensation may be affected, as it is not in the chron- ic form. The paralytic symptoms may extend so as to show that parts anterior to the bulb are affected ; also the paralysis of the limbs may be unilateral and alter- nate — i. e., on the side opposite to that on which the cranial nerves are affected. In cases of acute inflam- mation of the medulla, such as has been reported by Leyden, the symptoms appear less suddenly than in hemorrhage or in occlusion of vessels, but they are developed in a comparatively short time, and other than bulbar symptoms appearing with them will aid in forming a correct diagnosis. ACUTE BULBAR PARALYSIS. 223 Several times clearly marked bulbar phenomena have been seen where the lesion was entirely cerebral ; this has been noticed where the lesion has been multi- ple, affecting both sides of the brain : but bulbar symp- toms have also been found where the cerebral lesion has been unilateral. The diagnosis of the nature of the process giving rise to acute bulbar paralysis must be made from a consideration of the circumstances attending the at- tack : on the same principles as will aid in forming a diagnosis in other cases of cerebral lesion. These need not be reviewed here. The prognosis of acute bulbar paralysis is not so se- rious as of the progressive. Eisenlohr has reported re- coveries in several cases. Strimipell reports a case of recovery. Erb reports favorable results in a case of seven months' duration. The insidious, unpretending, progressive disease, which seems so much milder, and at first insignificant, is much the more dangerous and fatal. The treatment must depend upon the nature of the pathological process. Iodide of potassium is indicated if there is reason to suspect an occlusion of arteries, especially if there has been syphilis ; also if there is possibly a syphilitic thickening of the membranes. Erb passed a current from eight cells through the head from one mastoid process to the other ; and also galvan- ized the cervical sympathetic. CHAPTER XIX. LOCOMOTOR ATAXIA. TABES DORSALIS.— POSTERIOR SPINAL SCLEROSIS. Trousseau, A., Clinique medicale de THotel-Dieu de Paris, t. ii. — Eisenmann, Die Bewegungs-Ataxie. Wien, 1863. — Buzzard, T., On Articular and Osseous Lesions in Locomotor Ataxia. Med. Times and Gaz., Feb. 14, 1880 ; Brit. Med. Jour., March 5, 1881. — Williams, J. A., Remarks upon the Osseous Lesions of Loco- motor Ataxia. Lancet, Dec. 9, 1882, p. 977. — Fere, Ch., Descrip- tion de quelques pieces relatives aux lesions osseuses et articulaires des ataxiques. Arch, de neurol., iv, 1882, p. 202. — Lecoq, Etudes sur les accidents apoplectiformes qui peuvent compliques le debut, le cours, la fin de Tataxie. Rev. de med., No. 6, 1882. — Gee, Lo- comotor Ataxia associated with Perforating Ulcer of the Foot. St. Barthol. Hosp. Rep., xviii, 1882. — Friedreich, N., Ueber Ataxie mit besonderer Beriicksichtigung der hereditaren Formen. Virch. Arch., Bd. 26, 27, 68, 70.— Johnston, Nerve-Stretching. Brit. Med. Jour., July 2, 1881.— Bastian. lb *'<2.— Spencer. Ibid., Jan. 28, 1882.— Lamont. Lancet, Jan. 6, 1883.— Seguin, E. C, On the Early Diagnosis of some Organic Diseases of the Nervous Sys- tem. Med. Record, Feb. 26, 1881, p. 225.— Voigt, Syphilis with Ataxia. Berl. kl. Wochenschr., 1881. — Erb. CM, f. Nervenhk., Psych., etc., Aug. 15, 18S1.— Reumont. Ibid., Sept. 1, 1881.— Gowers. Lancet, Jan. 15, 1881.— Abadie. Gaz. Hebd., Dec. 1, 1882. — Buzzard. Lancet, June 10, 1882.— Weber, Leonard. Med. News, March 29, 1884.— Seguin, E. C. Arch, of Med,, Aug., 1884. Pathological Ax atomy.— In the fresh state, to the naked eye, the posterior columns will be seen to have a semi-translucent appearance. This change may- affect the whole of the posterior columns, where the disease has been long present, generally in the lumbar region ; where the lesion is recent, only the external LOCOMOTOR ATAXIA. 225 radical columns, the posterior root-zones, are affected ; and in its earliest periods the change of structure is found near the posterior cornua, not quite touching them and not quite reaching the periphery of the cord. This change of color in rare cases extends to the direct cerebellar tracts. The disease is commonly most extensive in the lum- bar enlargement, where it usually begins ; sometimes the cervical enlargement is first attacked. At whatever level the disease is found, it is situated in the posterior root-zones, or in corresponding parts in the medulla. Above the medulla the locality of the lesion has not been made out. The central parts of the posterior col- umns — columns of G-oll— are affected secondarily. The pia mater covering the part of the cord affected may be thickened and somewhat adherent. After hardening in some chromic solution, the dis- eased parts acquire a yellowish color, distinct from the darker color of the healthy parts. Under the microscope it will be found that the nerve- fibers have undergone change ; they have lost their med- ullary sheaths, and are reduced to their axis cylinders. Sometimes the axis cylinders are slightly hypertro- phied. The neuroglia has increased. This gives the cord its translucent appearaAce. When a section is stained by carmine, the diseased part is more intensely colored. The nerve-fibers are not all destroyed in any area, except in a very advanced stage of the disease, and groups of nearly healthy fibers, or single ones, are found scattered irregularly through the altered por- tions. Corpora amylacea are seen thickly scattered through the affected regions. Granular corpuscles may be rather numerous in early stages of the disease, but are less in number in the more advanced stages. The walls of the vessels are thickened. 15 226 DISEASES OF THE SPIRAL CORD. The nerve-cells of the anterior cornua are degener- ated in those cases where muscular atrophy occurs ; they have also been found affected in several cases of articular and osseous lesions. iETiOLOGY. — By far the larger number of patients are men, comparatively few being women ; children are only rarely affected. The age at which the first symp- toms are generally noticed is between twenty-five and forty-five years. Heredity is thought by some to act as a predisposing cause ; excess in the use of alcoholic liquors, and acute diseases, are also predisposing causes. Exposure to cold, especially to cold combined with wet, is one of the most frequent exciting causes. Over- exertion, excessive labor, especially on the feet, are other frequent causes of the disease ; hence, the larger number of patients are to be found among those whose occupation requires them to stand or walk nearly all the time, whose feet are much exposed to cold and wet. Lately the connection of syphilis with locomotor ataxia has attracted much attention. A very large pro- portion of ataxics are found to have had syphilis in early life, more than half of these to have had second- ary symptoms ; very many have never had these. Erb assigns much importance to this relation between the two diseases. Gowers seems to count syphilis as a pre- disposing cause. " It seems," he says, " that one effect of constitutional syphilis may be to induce a neuro- pathic state in which certain degenerative diseases of the nervous system readily occur." The proportion of ataxics who have had syphilis seems to be less in America than in Europe. Whatever connection there may be, or if there is none, it is an interesting fact that from forty-five per cent to eighty-eight per cent of ataxics are found to have had syphilis. Venereal excesses are generally considered as one of the causes of locomotor ataxia. Many times such ex- LOCOMOTOR ATAXIA. 22V cesses must be reckoned among the early symptoms of the disease. Injuries, as jar or concussion of the spine, have sometimes seemed to be the cause of ataxia. Cases in which such a relation can be traced are, however, rare. Symptoms. — The earliest and most extensive changes in the cord are found in those regions which are act- ive in transmitting sensation ; the earliest symptoms of the disease are perverted sensations ; and, as the changes are found throughout the whole length of the cerebro-spinal axis, commencing at any level, it may be expected that the symptoms would show a great va- riety both in the beginning and during the course of the disease. This is the case. The earliest symptom is pain, which is thought to be rheumatic or neuralgic, and no inquiry made as to its nature or cause. In most cases the pain is in the legs or feet. If the upper part of the cord is first affected, it may be first felt in the arms, or may follow the course of the occipital nerve over the back of the head ; once in a while the fifth nerve is affected, and the pain is felt in the face. The pain is peculiar in character ; it is of a stabbing, cutting nature, deep-seated rather than superficial, as if in the muscles or bones ; each stab is of only momentary duration, and is no sooner felt than it is gone ; these darts of pain succeed one another in rapid succession, or may be separated by a short interval. The attacks may continue several minutes or hours, commencing without warning, and as suddenly ceasing. At first they are not of frequent occurrence, but as time goes on they recur at shorter intervals. Some- times an aching or tired sensation is noticed between the throbs of pain, which gives the attack a resem- blance to rheumatism ; but the severe pain is quite dif- ferent from a rheumatic pain : it occurs entirely inde- pendent of any movement of the limbs; the aching between the attacks is less than is usually found in 228 DISEASES OF THE SPINAL COED. rheumatism with equally severe pain ; the part affected is neither red nor swollen; the joints do not so fre- quently suffer as other parts of the limbs. The unex- pected occurrence of the pain, and its severity, may cause the sufferer to cry out and grasp the part affected. The terms used by patients are expressive ; they speak of the pain as resembling a "stroke of lightning," "a knife-thrust into the bone," " a red-hot iron suddenly buried in the flesh," though the pain does not always have this severity. The seat of the suffering varies ; the pain may be in the foot, again in the calf or thigh, sometimes in the right leg, again in the left, but gener- ally it does not give a preference for one side more than the other ; also in the arms and head the different at- tacks affect different localities, yet, as a rule, localities supplied by the same plexus of nerves. So little importance is given to the above symptom when first present, that medical advice is rarely sought until the attacks become more severe. Let the physi- cian be on the watch to inquire into the particulars, and ataxia will be oftener recognized in its earliest stage ; other symptoms will be found confirming the diagnosis. During the continuance of the pain, and for a short time after the attack has ceased, there will be a tender- ness of the part affected ; a very light touch will be painful, yet a severer irritation, as a prick with a nee- dle, may be scarcely felt. The hyperesthesia is of short duration ; anaesthesia is found to be more persistent, and between the attacks there is diminution of sensation of touch as well as of pain. The anaesthesia often affects the soles of the feet ; it may be found in circumscribed spots on the limbs or body, on the face or head ; its distribution is independent of the seat of the pain ; it is generally symmetrical. Localized anaesthesia is as constant a symptom as the pain, but is less strikingly evident to the patient, and may need to be searched for carefully LOCOMOTOR ATAXIA. 229 by the physician. The different forms of sensation, as touch, pain, temperature, may be affected separately, and so each should be tested. Delay in the transmission of sensation, so that a touch or prick is not felt for several (three to ten or fifteen) seconds after contact, is less frequently an early symptom, but is often to be noticed later. Sometimes the touch is first recognized, the pain is felt later, show- ing a difference in the rate of transmission of the two varieties of sensation. A sense of a girdle around the body is often no- ticed. The muscular sense is not impaired till late in the disease. The patient can tell where his limbs are, even when there is much disturbance of motion ; but finally he loses this power. The special senses may be disturbed early in the dis- ease, even before any disturbance of general sensibility. Vision is affected much more frequently than hearing ; taste and smell are very rarely lost. The sight may be diminished by reason of disturb- ance of accommodation, by paralysis of motor muscles, or by limitation of the field of vision. The field of vision is limited because of atrophy of the optic nerve. The limitation, often unilateral at first, soon affects both eyes ; it begins on the temporal side, and advances so that the center of the field of vision remains longest unaffected. The ophthalmoscope will show the disk with the characteristic appearance of atrophy. If the change is recent, it may be possible to exclude a preceding neuritis ; if old, the neuritis can not be excluded with so much certainty. The atrophy and consequent limitation of vision are permanent. The field of vision for colors may be limited when perception of form is still nearly or quite perfect. This is a condition which has not been very carefully studied as yet. The atrophy of the optic nerve, and consequent 230 DISEASES OF TEE SPIXAL CORD. limitation or loss of vision, may be the only symptom present for several years. If with this there is absence of patella tendon reflex, the diagnosis of ataxia may be made with a fair degree of certainty. It may be as well to mention here the motor dis- turbances of the eyes, as they also interfere with vision. The pupils may be extremely contracted ; they may be less contracted or even dilated, and not respond to vari- ations in the amount of light, while they will respond to accommodation. This has been called the "Argyll- Robertson symptom," from its first observer. Buzzard suggests that slight changes in the iris can be best seen by casting a strong light upon the eye with the ophthal- moscopic mirror, and watching the motions through, a convex lens of about -f 8 or + 10 placed behind it. Presbyopia is one of the earlier ocular symptoms. The change is not gradual, as when the consequence of advancing years, but, when symptomatic of tabes, occurs suddenly, perhaps in one eye only ; after a short time this symptom may disappear. Diplopia from partial paralysis of some of the ex- ternal ocular muscles is another form of defective vision ; there may also be partial ptosis of one or both eyelids. Rarely nearly all the ocular muscles may be affected. The paralysis of these muscles may pass away and the patient may almost forget its occurrence when he applies for relief from the later symptoms of ataxia. The hearing may suffer early— one ear may be af- fected or both ears may be dull of hearing. In one pa- tient, where the hearing was practically entirely lost, partial deafness occurred suddenly, then gradually in- creased in degree rather rapidly. Tinnitus aurium is mentioned as a symptom, but is so common under varying circumstances that it would be difficult to prove more than a coincidence. Visceral disturbances, gastric, nephritic, laryngeal, and bronchial crises are phenomena of disturbed sensa- tion occasionally met in ataxia. LOCOMOTOR ATAXIA. 231 The disturbance called "gastric crises" is the most important of these visceral symptoms. This may be the dominant symptom for years, and so absorb the attention of both patient and physician that other phe- nomena are overlooked ; the patient is thought to have gastric ulcer, nervous dyspepsia, chronic catarrh of the stomach, etc. A close questioning will bring to light "rheumatic pains" in the limbs, an examination may show pupillary phenomena, and tendon reflex will be found absent. The diagnosis can not then be doubtful. These gastric crises are irregularly periodical, recur without certain cause, and without warning. The pa- tient is seized with severe pain in the epigastrium, as if his bowels were being tied up or twisted around ; this continues for a variable time, and then vomiting sets in, at first of ingesta, then of a glairy mucus similar to that ejected in catarrh or ulcer of the stomach. The amount of vomitus may be very great, enormous, and the pa- tient is surprised at the quantity. With the vomiting there is usually a short period of relief, only a slight soreness remaining. Soon the same scene is repeated. These attacks recur at short, sometimes long, intervals, for a few days or some weeks, and then cease for weeks or months. During the attack the pulse is commonly greatly in- creased in frequency ; but the temperature is not ele- vated. Sometimes during the vomiting the severe shoot- ing pains in the limbs are felt in their greatest intensity, adding materially to the patient's misery. Between the attacks the appetite and digestion are good ; the former may be ravenous. Nephritic crises have been described by Raynaud, characterized by attacks resembling renal colic with re- traction of testicles, anuria or ischuria, vesical tenes- mus, the attacks continuing six or eight days, recur- ring frequently, separated by intervals of health. There is no blood, nor pus, nor gravel found in the urine. These are much less common than gastric crises. 232 DISEASES OF THE SPINAL COED. Laryngeal crises, where there are obstinate and causeless paroxysms of coughing, ending, perhaps, in spasm of the glottis, are even less common. Charcot and Vulpian have recorded cases of laryngeal crises in which epileptiform convulsions occurred immediately after the spasm of the glottis. The bronchial crises, where there is great dyspnoea, sense of constriction across the chest, as if suffocation were impending, are also very rare. The absence of patella tendon reflex (Westphal's symptom, as it has sometimes been called) is very con- stant in locomotor ataxia. In order that this phenome- non may be of value, it is necessary that during the ex- amination the knee should be bare, the leg should hang free, and there should be no semi- voluntary contraction of muscles. In doubtful cases it is well to have the pa- tient shut his eyes and to strike one knee or the other without giving him warning as to where the blow is to fall. The absence of patella tendon reflex may be found in other diseases, but in locomotor ataxia it is associ- ated with considerable voluntary muscular power, and when the vastus internus is smartly filliped, it is seen to contract. Buzzard and Erb both insist upon the need of these conditions as aids in judging of the sig- nificance of the phenomenon. Occasionally patella tendon reflex is present in an undoubted case of locomotor ataxia, and I have seen cases where it reappeared after having been absent. It is absent in about 1 - 5 per cent of healthy persons. This is usually an early symptom, and by some au- thors it is claimed that it may be noticed before any other symptom. It is one of the most constant, as will be mentioned later. Sometimes, however, the tendon reflex does not disappear till after other symptoms have been long present. Cutaneous reflexes are, as a rule, retained in normal intensity, though when there is hyperesthesia the re- flex excited by irritating such a spot may be exagger- LOCOMOTOR ATAXIA. 233 ated, and, when sensation is markedly delayed, cutane- ous reflexes may also be delayed. Motor disturbances do not belong to the earliest symptoms in locomotor ataxia. The first discomfort in this respect noticed by the patient is a sense of weari- ness ; he is more quickly tired than usual. This may be laid to various causes, and frequently is thought to be one result of the rheumatism which causes the pain. At a later period there is a loss of co-ordination in the use of the muscles. The patient is aware that he needs to use his eyes in order to walk reasonably straight ; or, before he is conscious of this, if examined, he will be found to have lost the control of his limbs, and he can not walk straight with his eyes shut. If in bed, with feet wide apart, he is told to shut his eyes, raise one foot, and slowly carry it across the bed and bring it down by the side of its fellow, the foot is moved irregularly with a jerking motion and is not placed correctly in the place mentioned. The inco-ordination may affect the arms before the legs, or after. Then the patient has difficulty in feed- ing himself or in writing or performing other acts re- quiring delicate manipulation. If, with eyes shut, he is told to touch the end of his nose with his forefinger, the finger will go wide of the mark. The gait of an ataxic is peculiar ; he walks with his feet wide apart, straddling ; they come down heavily upon the floor, the heels striking first ; the body sways somewhat from side to side ; if the inco-ordination is great, support is needed, and then the legs move irregu- larly. Inco-ordination is not as constant a symptom as many others, and is much less important than was for- merly supposed. With the loss of complete control over the limbs, and perhaps an inability to walk, there is comparatively little loss of muscular strength ; while lying in bed, the patient can move freely, and resist passive flexion or 234 DISEASES OF THE SPWAL CORD. extension of the limbs with great power. Not until the closing period of the disease is there decided pa- ralysis, except that occasionally a paralysis, which soon disappears, may follow a severe attack of pain. Sexual desire is sometimes exaggerated, and hence venereal excess may be one of the symptoms rather than one of the causes ; but it is probably rather an early symptom of the disease. Frequent emissions are also met. Sometimes sexual desire is greatly increased, but there is entire loss of power to gratify the desire, and, while suffering from it, there is not the slightest trace of erection. This impotence is not one of the earliest symptoms, though it may be noticed by the patient before he has given much thought to the other earlier symptoms. The bladder may be affected ; rarely there is pain with dysuria, and frequent calls to empty the viscus. It is more common to have difficulty in voiding the urine from partial paralysis or anaesthesia, and finally the retention may lead to cystitis. The bowels are usually unaffected, except a slight constipation ; but this may give some trouble. Rarely there are attacks of looseness. When there is great anaesthesia, the faeces may pass without the patient's knowledge. Trophic changes are not uncommon ; among these the affection of the joints is most striking and charac- teristic. The limb swells from effusion into the joint, which may be very great, and a large part of the limb may be enlarged ; there is oftentimes some redness and slight pain, but these are only moderate. Within a very short time it will be found that the articular sur- faces forming the joint have suffered loss of substance, and, when the limb is moved in certain directions, crepi- tus will be felt. After a while the serous effusion is absorbed, and the erosion of the articular surfaces con- tinues if the joint is still used. The surface of the bones is roughened, and their chemical composition LOCOMOTOR ATAXIA. 235 altered ; the earthy salts are absorbed, and a great ex- cess of fat is deposited. The larger joints are most commonly affected — the knee and hip, the elbow and shoulder ; but the jaws and smaller joints may be attacked. The chief characteris- tics of this change are the sndden and rapid effusion into the joint, without fever, and with but little pain, if any ; the early erosion of the articular surfaces, also without pain. The changes in the joints give rise to dislocations, and the bones assume abnormal positions ; the destruc- tion of ligaments or their elongation allows the limbs to be hyperextended. Occasionally osseous growths form in the vicinity of joints in the soft parts, as if an effort were made to compensate for the injury by the formation of osseous splints or supports. Sometimes the ends of the bones are not eroded, but undergo hypertrophy. The change in the composition of bones, which fa- cilitates erosion of articular surfaces, renders them also liable to fracture ; and this accident easily happens, not only to the long bones, but to those of the pelvis as well, sometimes from simple muscular action. The callus thrown out in such cases is usually very large, and lacks in solidity. These osseous lesions are not among the earliest symptoms, but they sometimes are the first to attract notice. Charcot places them between the pains and the inco-ordination, though sometimes they appear later. In a few instances muscular atrophy has been seen in cases of locomotor ataxia ; when an autopsy has been obtained in such cases, it has been found that the cells of the anterior cornua were secondarily affected. Less frequent than the osseous lesions we find tro- phic changes in the skin, erythema, herpes, bullae, pus- tular eruptions, ulcerations, as mal perforant. These changes may appear and disappear frequently, and are 236 DISEASES OF THE SPIRAL CORD. found over the region supplied from the plexus, whence arises the nerve in which pain is felt, though the erup- tion may not occur in the tract of that nerve. They are most frequently met during the continuance of pain. Serious mental disturbance is rare except in those cases associated with general paralysis. The symp- toms of ataxia may arise before those of general pa- ralysis appear, or the latter may be primary, and the spinal affection set in later. Sometimes the patient becomes irritable or melan- cholic, but generally is in good spirits, and very pa- tient. A very few instances of suicide have occurred in patients who dreaded a long and helpless illness. Among rarer symptoms or complications may be mentioned apoplectic attacks with hemiplegia (Lecoq) and aphasia, usually not permanent. A form of spinal or cerebro-spinal disease, which is probably a sclerosis, has been described by Friedreich, Carre, Eiitimeyer, and others, under the title of heredi- tary ataxia. It attacks several members of a family, sometimes appearing at the age of four years, some- times as late as the eighteenth year. There is not the lancinating pain, the ataxic gait appears early, and soon there is inco-ordination of the upper extremities; the speech shows disturbance of co-ordination, and there is ataxic nystagmus ; tendon reflex is absent ; there is often a slight diminution of sensibility ; muscular sense is not disturbed ; at length there is paraplegia with contracture ; bed-sores rarely form ; there is no disturbance of the bladder ; the mind is not affected. Rutimeyer thinks the lesion affects the spinal cord primarily ; the medulla oblongata and corpora quadri- gemina secondarily. It is certainly not simple locomo- tor ataxia. Bernhardt, Erb, and Yoigt have given the percent- age of cases in which the different symptoms occur in locomotor ataxia. LOCOMOTOR ATAXIA. 237 The following table gives the percentages according to these three observers. The nnmber of cases of each was under sixty ; the agreement between the three is noteworthy : Tendon reflex absent Ataxia Staggering, with eyes shut Staggering, non-ataxic Sense of tiredness Loss of power in walking Loss of strength Upper extremities affected Sensory disturbance Diminished sense of touch Diminished sense of place Diminished sense of temperature Diminished sense of pressure. . . . Diminished sense of pain Delayed sensation Painful after impressions Paresthesia Girdle sensation Lancinating pains Diminished muscular sense Bladder symptoms Constipation Impotence Gastric crises Immobile pupil Myosis Paralysis of ocular muscles Diplopia.. Optic atrophy Voigt. Per cent. 96-5 93 95 ' 59-5 19 98 ' 94-5 35 45-5 68 72 41 89-5 78-5 94-5 51 82 8-5 63 45-5 28 17-5 Per cent. 95-6 94-1 92 85- 31-6 34-37 79-5 76-07 43-7 48-4 27-2 39-6 10-3 'er cent. 98 100 93-5 92-5 81 54 38-7 12-3 A resume of the clinical history may group these symptoms together more connectedly. The earliest symptoms are apt to be mistaken or neglected ; they are a temporary diplopia or blurring of vision from presbyopia, which soon passes ; occa- sional attacks of pain in different parts of the body, these sometimes very severe, but of momentary dura- tion; these attacks, thought to be rheumatic, recur with increasing frequency ; hyperesthesia during the 238 DISEASES OF THE SPINAL CORD. attacks and just after ; circumscribed anaesthesia, often symmetrical ; more serious loss of vision from atrophy of optic nerve ; pupillary phenomena, Argyll- Robertson symptom ; occasionally deafness or tinnitus, unilat- eral or bilateral ; weariness and rapidly occurring tired sensation on exercising ; absence of patella tendon re- flex ; various trophic changes ; ataxic gait and inco-or- dination with at most only fugitive paralysis, and rarely even that. Such are the earlier symptoms, and those of the fully developed disease. As time elapses, the sensory and motor disturbances increase in gravity ; the ataxic phenomena become more and more marked, until walking and even standing is impossible ; sensation is finally entirely lost ; the arms as well as the legs are affected ; the patient is helpless. If to this blindness and deafness are added, his condi- tion is jritiable ; fortunately, this is rare. Death may result from some intercurrent disease, or from exhaus- tion. The disease is of long duration. The earlier stage, during which the patient can keep about, suffering only during the attacks of pain, may continue for ten to twenty years. There are frequent periods of remission, or even apparent cure. The average duration of typi- cal cases is eight or ten years. Diagnosis. — When the history of a case is fully known, the early occurrence of lancinating j>ain in the legs or elsewhere, with a sense of tiredness, occurring soon after exertion ; the pupillary and ocular phenome- na ; the absence of tendon reflex ; the anaesthesia ; and the ataxic disturbance of motion, occurring at a some- what later period — are sufficient for diagnosis. At a late period of the disease, if the history is not known, the diagnosis might be less clear. There may be anaesthesia and a resemblance to in- co-ordination arising from weakness in myelitis ; but in this case there will probably be little or no pain, and the weakness would show itself when the patient is LOCOMOTOR ATAXIA. 239 lying down. If the myelitis were at all acute, the du- ration would probably have been short, with some febrile action. Spinal meningitis is not likely to be mis- taken for ataxia. In disease of the cerebellum there may be lack of co-ordination, with retention of muscular strength ; but the disturbance of co-ordination is rather different from that seen in ataxia. In walking, the patient has not the same gait, and there are head symptoms which are not found in ataxia. Cerebro-spinal sclerosis generally differs from ataxia in that there is more muscular weakness, tremor on performing voluntary acts, disturbance of speech, little or no disturbance of sensation, and ataxic inco-ordina- tion is rare. There are cases, however, where the dis- ease has extended to the posterior columns, which it is almost or quite impossible to diagnosticate from loco- motor ataxia, especially if tremor is absent, as occa- sionally happens. Pkogjstosis. — In advanced cases recovery can not be expected ; there may be pauses in the progress of the disease, or the patient may grow worse so very slowly that both he and his friends are encouraged in the hope of his recovery, but such hopes are almost invariably delusive. Seasons of apparent improvement, in which the pains cease and the ataxia diminishes, are not rare in the earlier stages of the disease. It is not unlikely that reported cures are cases where such improvement has occurred. If the disease is not too far advanced, its progress may be checked by treatment ; individual symptoms can almost always be ameliorated. The du- ration is always long, extending over many years, and the knowledge of this fact is often a source of comfort to the patient and his friends. When the disease seems to be of short duration, yet to have advanced rapidly — cases which seem to run an acute course— the prognosis is less unfavorable, though in such cases the diagnosis is not sure. Lesion of pe- 240 DISEASES OF THE SPINAL CORD. riplieral nerves may give rise to the symptoms observed under these circumstances. Teeatment. — If possible, patients should be re- stricted in regard to exercise, especially walking, and forbidden to over-exert themselves so as to cause a sense of exhaustion. They should also avoid getting their feet wet, and exposure to draughts of cold air about the feet and legs. The extremities should be warmly clothed. Mental over-exertion, excessive care and worry, are only a little less injurious than physical exertion. Much indulgence in coitus should be abso- lutely forbidden. Benefit is found sometimes from confining the patient to bed during several weeks, every exertion and motion being forbidden, the patient not being allowed to rise for any purpose whatever. This can be endured by the patient only when accom- panied with daily frictions and massage. Of drugs, nitrate of silver, in doses of one quarter to one half a grain three times daily, is of great benefit in many cases ; many times this relieves the pain and increases the feeling of strength. Double chloride of gold and sodium is also recommended. Ergot has been much used and commended. Iodide of potassium, is sometimes followed by benefit. The galvanic current is well deserving of trial, and frequently seems to be of benefit ; it should be applied to the back, one pole being placed in the cervical region, either in the center of the back or on the side of the neck, the other pole being passed slowly over the dorsal and lumbar region. The duration of the application should not exceed from five to eight minutes ; a compara- tively weak current should be used, not so strong as to produce any discomfort. The actual cautery, passed very rapidly over the spine, may be of great service. In Europe, hydrotherapy is much commended. Cold baths are not to be recommended ; cool baths, with a temperature of from 70° to 80°, especially sponge-baths, LOCOMOTOR ATAXIA. 241 may often be used with advantage. Hot baths are to be avoided. The pains in the legs frequently require special treatment. Sometimes external applications, as lini- ments, especially irritating liniments, will give relief. A lotion composed of chloroform and alcohol, in vary- ing proportion, with a small amount of tincture of aconite-root, will often give relief ; this should be put on a piece of flannel wrapped around the limb, and cov- ered with a towel wet in water, to prevent evaporation. Sulphide of carbon may be used in the same way. Iodide of potassium internally is said to sometimes give relief. The actual cautery to the back may be used to relieve the pain in the legs. The galvanic cur- rent may be applied to the limb. If it is possible to relieve the pain without having resort to morphia, it is desirable to do so, especially in view of the long dura- tion of the disease ; sometimes, however, it is neces- sary to use that drug, and its effect is prompt. The frequent use of morphia endangers the development of the opium habit. Lately nerve-stretching has been tried ; many cases have seemed to be temporarily benefited, but it is rarely that any permanent benefit has been obtained. The lancinating pains have been more relieved than other symptoms by this operation, which deserves further trial. 16 CHAPTER XX. SCLEEOSIS. Bourneville et L. GrUERARD, De la sclerose en plaques disse- minees. Paris, 1869. — Moxon, W., Eight Cases of Insular Sclero- sis. Guy's Hosp. Reports, 1875. — Buzzard, T., On Some Points in the Diagnosis of Spinal Sclerosis. Lancet, July 27, 1878, p. 111. — Wood, H. C, Multiple Spinal Sclerosis. Med. Record, Sept. 21, 1878, p. 224.— Althaus, Julius. Brit. Med. Jour., May 10, 17, 24, 31, 1884.— Dickinson. Med. Times and Gaz., Feb. 2, 1878, p. 112.— Bastian, H. C. Med. Times and Gaz., Oct. 20, 1883, p. 451. Charcot, Sclerose des cordons laterales. Gaz. hebd., 1865, No. 7 ; Arch, de physiol, 1872, p. 509. — Erb, Ueher die spastische Spinalparalyse. Virch. Arch., lxx, 1877, p. 241.— Dreschfeld, J., A Contribution to the Morbid Anatomy of the Primary Lateral Sclerosis. Journal of Anat. and Physiol., July, 1881, p. 510. — Weiss, N., Ueber spastische Spinalparalyse. Wien. med. Wochen- schr., Feb., 1883. — Charcot, Sclerose laterale amyotrophique. Gaz. des Hop., Nov. 20, 1879.— Cox well, Amyotrophic Lateral Sclerosis. Lancet, Feb. 23, 1884, p. 343.— Debove et Gombault. Arch, de physiol., Sept., 1879. MULTIPLE SCLEROSIS. Multiple sclerosis is the name given to a chronic in- flammation of the interstitial tissue of the spinal cord and brain, occurring in patches of greater or less size scattered irregularly throughout the white substance, only rarely invading the gray substance. The proper nervous structures are affected secondarily, undergoing atrophy, and finally disappear. Pathological Anatomy. — The pathological pro- cess is similar to that found in interstitial inflammation in other organs. The cellular elements are increased in number and in size ; the fibrous tissue is increased ; the MULTIPLE SCLEROSIS. 243 nerve-fibers suffer in their nutrition, are secondarily- affected with inflammatory changes, suffer atrophy, lose their medullary sheaths ; the axis cylinders persist for an indefinite time, and finally disappear. There is left then a close net-work of fibers surrounding and inclosing nuclei and cells of the neuroglia. Granular corpuscles are found in the earlier stages. The cord acquires sometimes a firm consistency, though it may be softer than normal; it has a grayish, translucent appearance, the white substance somewhat resembling thus the gray substance. The walls of the blood-vessels are thickened, and it is impossible to tell how soon this change sets in. It is only exceptionally that the nerve-cells of the gray substance are altered. The spots of disease, varying greatly in size, may be situated in any portion of the central nervous sys- tem ; sometimes there are few in the cord and more in the brain, or the brain may be the less affected. They are found in all parts of the brain, in the crura, pons, and medulla, and are perhaps less frequent in the cere- bellum. The nerves, especially the optic and auditory nerves, may also be affected. .ZEtiology. — The cause of sclerosis can be definitely determined in only a few cases. It is a disease of early adult life, yet it is found in childhood, and even in in- fancy, Seeligmuller reporting a case aged one year and nine months ; several cases have been reported between four and ten years of age. It is, however, most fre- quent between twenty and thirty years. Charcot sets forty as the extreme limit when it appears. Heredity seems to have little or no setiological influ- ence, though Seeligmuller reports four cases, all under ten years, in one family. Charcot and some others following him have stated that the disease is more common among women than men. This may be so to some extent, but statistics are too meager to settle this point. 2U DISEASES OF TEE SPIXAL COED. Accidents involving the spine, causing concussion or jar of the cord, may be exciting causes of the dis- ease. Acute diseases, typhoid fever especially, may be followed by cerebro-spinal sclerosis. Protracted and excessive toil seems sometimes to be the cause; also mental disturbances, as worry, anxiety, or fright. Symptoms. — After injuries, mental shocks, or when following acute diseases, cerebro-spinal sclerosis may develop rapidly, so that an early diagnosis is possible. Generally, however, the first symptoms are so insignifi- cant that they are not considered by the patient to be of importance, and so are neglected ; indeed, it is not possible to foretell whether the slight motor and sen- sory disturbances which first give warning of more seri- ous trouble will continue, or may not prove mere tran- sitory phenomena. The earlier symptoms are generally not continuous ; they are also varied in character, sometimes referable to cerebral disturbance, sometimes to spinal; the pa- tient may be thought to be hysterical, or suffering sim- ply from neurasthenia. Very frequently the first complaint is in regard to motor disturbance — there is weakness, and it is difficult for the patient to ascend or descend stairs ; he wearies sooner than usual in walking ; he can no longer follow his usual occupation with comfort ; after a while a tre- mor of the hand is noticed, the handwriting becomes less legible, and then it is impossible to write on account of the tremor. The disturbances of sensation during the earlier stages are not constant ; there may be distress in the head, and sometimes headache or dizziness ; severe pain anywhere is rare, though it sometimes occurs ; there may be backache or weariness following exertion ; numbness and abnormal tingling sensations in the limbs are not uncommon. Diplopia and ambliopia are occa- sionally noticed. Nystagmus is a much more frequent symptom. MULTIPLE SCLEROSIS. 245 These earlier symptoms may be present for many weeks or months in such slight degree, or with such varying conditions of apparent good health, that no notice is taken of them. Finally they become so severe as to oblige the patient to acknowledge that he is ill ; it is more frequently the tremor and weakness which cause the most annoyance. Often there is so little sen- sory disturbance, that the patient does not consider himself seriously sick. The tremor is characteristic. When at rest, the limbs are quiet and motionless ; when a voluntary motion is performed, the limb trembles, at first only slightly ; later, the tremor is so severe as to interfere seriously with the use of the hands. It is seen most clearly when the patient tries to perform some act re- quiring a careful balancing of the muscular forces, as the carrying a cup or spoon to the mouth, or the use of a pen. As the disease advances, the trembling may in- crease until all use of the limbs is impossible, or the whole body may be tossed about, or the tremor may disappear ; then there is left great weakness, partial paralysis. The legs are affected similarly to the arms, but the tremor is less easily recognized in them ; yet, by asking the patient to execute movements with the legs while lying or seated, the tremor can be recognized. There may be stiffness and weakness which interfere with walking, but differing from the inco-ordination found in ataxia. As the disease advances, the instability and weakness of the legs become so great as to oblige the patient to give up walking. The nystagmus, which has been mentioned in con- nection with ocular affections, is clue to the tremor of the muscles of the eyeball. The motion is a lateral one ; it can sometimes be made more prominent by asking the patient to look to one side or at an object held near the eyes, so as to require an exertion of the will to adjust the axes of the eyes to distinct vision — 246 DISEASES OF THE SPIRAL COED. that is, when the eyes are at rest there is no tremor, but a voluntary effort causes it. Allied to the other motor disturbances is a peculiar manner of speaking : at first there is merely a slight hesitation, a drawling utterance ; then there is more delay in pronouncing the individual syllables, and the sentences are, as it were, scanned. Some disturbance of speech is very common. Reflex motions are not lost, may be somewhat ex- aggerated, especially the patella-tendon reflex, except toward the close of the disease, or in the rare cases where the posterior columns are much affected. Ankle clonus may be present when the lateral columns are considerably diseased ; it may appear, and after a while disappear, according to changes in the cord during the progress of the disease. The electrical reaction of the muscles is not altered unless, in rare instances, the disease invades the ante- rior cornua, and then there is muscular atrophy. In the later stages, sensation may be more affected, and spots of anaesthesia may be found scattered over the limbs or body. Pain is rare even in the later stages. Disagreeable sensations of tingling, formication, a sen- sation as if the limbs were asleep, are not uncommon. A sinking or faint feeling may give much distress. Sometimes the cerebral symptoms are very promi- nent; headache, dizziness or vertigo, change of dispo- sition, mental heaviness, are among the more frequent cerebral symptoms. Pseudo-apoplectic attacks may occur; the patient suddenly becomes unconscious, is hemiplegic, and may have convulsions ; the symptoms closely resemble those of an ordinary attack of cerebral haemorrhage. The attack may end fatally, or gradually consciousness is regained, the motor power returns, and the patient re- covers, yet is usually not quite so well as before the attack. The course of the temperature is a valuable aid in diagnosis in these attacks. According to Charcot, MULTIPLE SCLEROSIS. 247 the temperature rises with the commencement of the attack, and may reach 104° within twenty-four hours ; unless death occurs, the temperature falls to normal by the second or third day. The pulse is also rapid at the beginning of the attack. Several of these apoplecti- form attacks may occur at intervals during the course of the disease. When the interstitial changes affect the posterior col- umns, we may have symptoms of locomotor ataxia com- plicating and masking those of the original disease. When the lateral columns are chiefly affected, symp- toms corresponding with the location of the disease will be noticed. Besides cerebro-spinal multiple sclerosis, some au- thors recognize a cerebral form and a spinal form of the disease. While it is true that the brain or spinal cord may be chiefly affected, it is very rare that either is exclusively the seat of the disease. Occasionally the spinal symptoms predominate, all mental phenomena, even trembling, being absent. Such a case may resem- ble simple chronic myelitis, except that the symptoms are more general and advance more irregularly than in that disease. It is very doubtful whether cerebral sclerosis has ever been seen without lesion of the spinal cord. Diagnosis. — Multiple sclerosis was formerly con- founded with paralysis agitans on account of the tremor. If the nature of this tremor is observed, it is scarcely possible to make such a mistake ; in sclerosis the tremor ceases when the limbs are at rest, or is very much less marked in the few cases where it is so severe as to be nearly constant. In paralysis agitans the tremor is at least as well marked during repose, and usually it is much diminished during voluntary exer- tion. Ordinary cases of chorea and multiple sclerosis are not likely to be mistaken, except where the tremor of sclerosis is extremely severe and almost continuous. 2±S DISEASES OF TEE SPINAL CORD. There is much similarity between the motions in such a case and those found in severe cases of chorea. A care- ful study of the history and course of the disease would probably prevent a mistake. Cerebral pachymeningitis may also resemble multi- ple sclerosis, but a careful study of the history of the case and examination of the symptoms will guard against error. When the sclerosis affects the posterior columns of the spinal cord, the symptoms may correspond in many respects with those found in locomotor ataxia. If the tremor is slight, or has not shown itself, and the tendon reflex is lost, it may not be possible to make a correct diagnosis. When the characteristic tremor is present, and the tendon reflex is retained, there should not be any mistake made. It may not always be easy to decide the diagnosis between sclerosis and general paralysis, especially if the mental symptoms are slight or entirely absent in the latter. In general paralysis there is tremor of the facial muscles and tongue during voluntary motion rather than of the muscles of the extremity ; the pupils may be unequal ; the disturbance of speech is different, the person talks with an indistinctness of utterance and a hesitation, repeating his words or sentences, sometimes pausing for a few seconds or a minute, then finishing his sentence. In sclerosis the patient is aware that his health is defective ; in general paralysis he seems to consider himself well, and does not recognize symptoms which are evident to others. If delusions of grandeur or other mental disturbances characteristic of general paralysis show themselves, the diagnosis, of course, is easy. Peog^osis. — When once multiple sclerosis has been certainly recognized, we must consider that the patient's fate is sealed, that he will not recover health, that the disease will probably steadily progress to a fatal ter- mination unless life is shortened by some intercurrent MULTIPLE SCLEROSIS. 249 affection. The progress of the disease may, however, be interrupted by remissions of longer or shorter dura- tion ; during these the severity of the symptoms may diminish, and there may seem to be a flattering pros- pect of recovery, but the symptoms are sure to return. It is not possible to fix the duration of the disease with any degree of certainty ; from the time the nature of the affection is recognized to the fatal termination may be only twenty or thirty months, but is usually much longer, and, if the disease is confined chiefly to the spinal cord, its duration may extend to fifteen or twenty years. Treatment. — The general testimony of observers is that treatment is frequently of no avail. The remedies which have proved of temporary value are, nitrate of silver in doses of from £ to £ grain three times a day ; double chloride of gold and sodium, ■£$ grain ; ergot, iodide of potassium, and arsenic either by mouth or subcutaneously. Bathing has been recommended ; the baths should be neither too cold nor too hot, but cool rather than warm. Greater advantage may be expected from a persistent use of electricity ; the applications should be made daily or every other day with the gal- vanic current, not too strong, to the back, one pole above, the other below, over the spine ; the direction of the current is a matter of indifference — it may be varied at different sittings. A much weaker current may be passed transversely through the head, the poles being placed behind the ears ; great care must be taken not to use too strong a current. To obtain good results from electricity, it must be continued through many months. Patients should not be allowed to fatigue themselves, either by attending to the ordinary occupations of life, or by taking exercise under the impression that it will strengthen them ; over-fatigue of mind should also be avoided ; alcoholic drinks had better be forbidden, and tea or coffee used only in moderation. 250 DISEASES 01 THE SPINAL CORD. SCLEROSIS OF THE LATERAL COLUMNS. This affection lias also been called spastic spinal paralysis and spasmodic tabes dorsalis, and, though pre- viously described by Tiirck, was first recognized as a distinct form of sclerosis by Charcot, and later by Erb. Though for some years there was doubt whether scle- rosis of the lateral columns can properly be considered a distinct disease, the opinion seems to be gaining ground that it is distinct from other lesions of the cord. Pathological Anatomy. — The pathological changes are such as are found in locomotor ataxia, and are generally confined to the lateral pyramidal tract — that portion of the lateral columns affected by secondary descending degeneration. The pathological change may extend somewhat beyond this region. A variety of lateral sclerosis, called by Charcot amyotrophic, is characterized by destruction of the nerve-cells in the anterior cornua, in addition to the changes in the lat- eral columns. The causes are obscure, and no satisfactory obser- vations have been made on that point. Symptoms. — The motor symptoms are most promi- nent, and may commence in the upper or lower ex- tremities ; rather more frequently, perhaps, in the latter. First is noticed a slight weakness and tendency to be- come easily fatigued. The weakness gradually in- creases until the patient has great difficulty in getting about, or is confined to the bed. This symptom may first appear in one limb only ; but after a while the other limb is also affected, and before death all four extremities are usually implicated. Ataxic symptoms are very seldom seen. Besides the above paralytic phenomena, a class of symptoms are developed which are peculiar to lesions of the pyramidal tracts. These may appear even in the early stages of the disease, when the weakness is SCLEROSIS OF THE LATERAL COLUMN'S. 251 as yet very slight ; they consist in spasmodic jerkings and tremors, with other signs of irritation. The tendon reflex is greatly exaggerated ; a very slight tap just below the knee causes the leg to jerk forward with considerable force ; other tendons also show an increase of reflex irritability, as in the arms just above the olecranon at the elbow, over the tendon of the triceps, or at the wrist, and sometimes over the tendons of the muscles of the shoulder and neck. An- kle clonus is generally very strong. Owing to this increase of tendon reflex, the patient' s gait is peculiar, called by Erb the spastic gait, and thus described by him: "The legs are somewhat dragged, the feet seem to cleave to the ground, the tips of the feet find an obstacle in every inequality of the ground ; every step is accompanied by a peculiar hopping eleva- tion of the whole body, dependent on a reflex contrac- tion of the calf ; the patient immediately gets upon his toes and slips forward on them, showing a tendency to fall forward. The legs are close together, held stiffly, the knees somewhat depressed forward. There is no throwing about of the feet. This gait depends on muscular tension and reflex contractions in the various groups of muscles, which are set in activity during the process of walking." The increase of reflex irritability is shown by spon- taneous jerking and twitching of the limbs occurring when the patient is lying down, but in extreme cases occurring also when he is sitting. The extensor mus- cles are most frequently affected ; sometimes, however, the flexors draw the knees and legs spasmodically ; the spasm consists simply of a strong tremor of the limbs, which is often excited by the act of stretching. A spasmodic stiffness of the limbs, at first intermittent, interferes with motion ; when this stiffness becomes continuous, there is permanent contracture of the limbs, the legs and feet being extended, the toes are sometimes flexed ; the adductor muscles keep the legs 252 DISEASES OF THE SPINAL CORD. closely approximated to each other. The arms are much less frequently affected with contracture. Erb found the skin reflexes generally normal in about two thirds of his cases, increased in hardly one third. He found the faradic and galvanic excit- ability of the motor nerves slightly lowered, never increased. The functions of the bladder and rectum, and the sexual function, are not interfered with. There are no brain nor bulbar symptoms. Sensa- tion is not disturbed when only the lateral columns are diseased. AMYOTROPHIC LATERAL SCLEROSIS. Gharcot first described a form of disease in which sclerosis of the lateral columns is associated with atro- phy and destruction of the cells of the anterior cornua. The pathological changes are the same as those in lat- eral sclerosis, with the addition of destruction of nerve- cells of the anterior cornua, those in the upper part of the cervical region being most affected ; one group of cells is not more likely to be diseased than another ; both sides are usually affected. The hypoglossal nu- cleus, and sometimes the other nerve-centers of the me- dulla oblongata, may be affected as well as the cells in the cervical region of the cord. The nerve-roots and trunks, which take their origin from the diseased cornua, suffer secondary atrophy, and the muscles supplied by them undergo the usual atrophic changes. The first symptom is a weakness of the hands, fol- lowed soon by wasting and spasmodic rigidity ; fibril- lary contractions are generally to be seen in the affected muscles. Finally, the symptoms of bulbar paralysis (labio-glosso-laryngeal paralysis) show themselves ; the tongue and lips are paralyzed, swallowing is difficult or impossible, and speech is very much interfered with. The legs rarely show marked signs of wasting ; the AMYOTROPHIC LATERAL SCLEROSIS. 253 symptoms, as already described as due to lateral scle- rosis, are developed in the legs. The electrical contractility of the muscles suffers in so far as there is atrophy. Sensation is but little disturbed, though there is sometimes a painful hyper- sesthesia of the muscles affected. Sometimes the con- tractures disappear before death. The prognosis is decidedly unfavorable, and the course of the disease much more rapid than that of simple lateral sclerosis, the usual duration being only two or three years. Pkognosis and Diagnosis.— The progress of the disease is very slow, and, interrupted by periods of re- mission, it may extend through many years. Recovery is more frequent in cases of lateral sclero- sis than in many other forms of chronic disease of the spinal cord. The disease itself rarely causes death, the fatal termination usually occurring in consequence of some complication. There is no other disease in which such a complex of symptoms is found as described above ; the reflex and spasmodic phenomena are peculiar, and, so far as known, occur only when the lateral pyramidal tracts are affected. When these tracts are subject to second- ary degeneration, the result of cerebral disease or dis- ease of the mesencephalon, similar reflex phenomena are observed ; but then the history of the origin and progress of the disease will render a diagnosis easy, and even without these the hemiplegic character of the symptoms would indicate their cerebral origin. In multiple sclerosis the lateral columns may be chiefly affected, in which case the symptoms peculiar to such lesion will predominate, and, if the disease ex- tends but little beyond those columns, an error of diag- nosis is inevitable. Generally, however, there will be other symptoms pointing in the right direction. The physician's skill will be tested in unraveling the com- plication of symptoms so as to recognize those depend- 254 DISEASES OF TEE SPINAL CORD. ing upon lateral sclerosis and those depending upon sclerosis of other parts. Treatment. — Comparatively little may be said in regard to treatment ; nitrate of silver is recommended by some. Erb mentions the galvanic current as afford- ing the best results ; he also favors a " reasonably con- ducted water treatment " ; indeed, the treatment is very similar to that in other cases of chronic myelitis. CHAPTER XXI. PSETTDO-HYPERTROPHIC PARALYSIS. Duchenne, G. B., De l'electrisation localisee, 3 me edit., 1872. — Ord, W. M., Notes of a Case of Duchenne's Pseudo-hypertrophic Muscular Paralysis. Med. Chir. Trans., 2d Series, vols, xxxix, xlii.— Poore, C. T. New York Med. Jour., 1876.— Moore, M. Lancet, June 19, 1880.— Gerhard, G. S. Pliila. Med. Times, Oct. 16, 1875. — Gowers, Pseudo-hypertrophic Paralysis. Lon- don, 1879. tEttology. — This disease is almost confined to males, very few cases having been seen among females. It is not nncommon to find several cases in the same family, the boys being affected, and the girls as a rnle escaping. When several branches of a family are affected, the dis- ease is almost invariably fonnd among the mother's relatives, not the father's. The subjects of pseudo-muscular hypertrophy are children ; very few adults are attacked ; it usually be- gins before six years, and sometimes before the child learns to walk. Gowers finds that it begins later in girls than in boys. The conditions or circumstances which cause the disease to appear are unknown. Symptoms. — The earliest noticeable symptom is diminution of motor power : the child either leams to walk late, or loses its steadiness and acquires peculiari- ties of gait and posture. Notwithstanding this weak- ness, the muscles seem to be of good size, especially those of the calves, and the parents think it is strange that, with such large, plump legs, their children find so 256 DISEASES OF TEE SPIRAL CORD. much trouble in getting about. This apparent hyper- trophy may be noticed in other muscles, as those of the thigh, the glutsei, more rarely those of the upper extremity. Duchenne gives a representation of a pa- tient who had enlargement, apparently, of all the mus- cles except the pectorals, which were atrophied. Slowly the weakness extends and increases ; the en- largement of muscles does not extend, but the loss of power is usually attended with atrophy, so that the pa- tient finally appears reduced almost to a skeleton with enormously large legs. The loss of power in various muscles leads to pecul- iarities of posture and gait which are characteristic. The patient, in standing, throws his abdomen forward, his shoulders backward, and bends his head slightly forward so as to keep his balance. Duchenne thinks this posture is caused by weakness of the muscles of the back. Gowers ascribes it to weakness of the exten- sors of the hip, which causes the pelvis to incline for- ward more than normal. When this lordosis is marked, if the patient stands, a plumb-line falling from the shoulders passes more or less in rear of the sacrum. In standing, the patient keeps his feet widely separated, and walks with a waddling or rolling gait, which de- pends upon the weakness of the glutsei. When the weakness has advanced only a little, the patients need to help themselves with their arms in ris- ing from a chair, and, if the loss of power is consider- able, the patient must help himself more, and, so to speak, climbs up his own legs. Gowers describes the different ways in which patients assist themselves : Some put their hands on their knees, then on the thighs, grasping them, and the hands are moved alter- nately higher and higher until they are upright ; oth- ers, to rise from the floor, take a position on hands and knees, then on hands and feet, or rather toes, with the feet wide apart, then, moving the hands backward on the ground till the legs are nearly perpendicular, they PSEUDO-EYPERTROPHIG PARALYSIS. 257 put one hand on one knee, and with a slight spring rise upright. Fibrillary twitchings are often seen in muscles un- dergoing atrophy, as in progressive muscular atrophy. Reflex functions, cutaneous and tendinous, suffer, apparently, according to the amount of disease in the muscles. Electrical reactions are diminished in proportion to the muscular atrophy and the amount of fat deposited, a large increase of fat making it necessary to use a stronger current to obtain equal reaction. Sensibility is not disturbed, and it is very rare that there is pain. Mental powers are only exceptionally blunted. In a few cases epileptic fits have been recorded ; but, as Gowers says, they are probably the result of an associ- ated, not of a related, cerebral disease. The progress of the disease is slow ; gradually one muscle after another is affected, sometimes one side be- ing attacked a little before the other, but usually both nearly together. There are periods of quiescence, but the tendency is steadily onward. When the disease commences early, life is not prolonged many years ; when later, the patients may live to adult years. Usu- ally death occurs between ten and twenty-five. Death is usually caused by some intercurrent disease, often of the respiratory organs. Pathological Anatomy. — The hypertrophied mus- cles are found at the autopsy to be largely composed of fat ; the muscular fibers are diminished in size and widely separated by masses ■ of connective tissue filled with fat. Statements of observers do not agree as to fatty degeneration of the muscular fibers ; probably it sometimes occurs ; they more frequently suffer simple atrophy. Finally, the muscular tissue disappears and gives place to fibrous tissue. Changes in the spinal cord are not constant. Many times none have been found, sometimes the cells of the 17 258 DISEASES OF THE SPINAL CORD. anterior cornua are more or less diseased, and some- times the white substance near the gray is diseased. Gowers concludes that pseudo-hypertrophic paralysis of early life is not a disease of the spinal cord. The only constant change found, in all cases, so far, has been the muscular degeneration. I am not pre- pared to accept Friedreich's views as to the nature of the affection. I can not form any satisfactory theory, and must leave that for the developments which may be learned in the future. Diagnosis. — There is no danger of mistaking the fully developed disease if care is taken in examination. If the legs or thighs are not much hypertrophied, there may be some doubt about the nature of the disease, and progressive muscular atrophy may be thought to be present. In the earliest stage a portion of muscle may be removed by a "harpoon," and examined under the microscope in order to settle the diagnosis. Peognosis. — The most that can be hoped is that the disease will cease advancing for a while. What has been said in regard to its course and progress will aid to an intelligent prognosis. If in any case, however, friends desire to know how long a child thus afflicted will live, we need to be cautious about giving a definite answer. We do not know. Teeatment. — The plan recommended for progres- sive muscular atrophy is that which is most rational. Gowers has obtained slight benefit from arsenic and from phosphorus. DISEASES OF THE PERIPHERAL AND SYMPATHETIC NEEVES. CHAPTER XXII. NEURITIS. Mitchell, S. Weir, Injuries of Nerves and their Consequen- ces. Philadelphia, 1872.— Niedick, W., Ueber Neuritis Migrans und ihre Folgezustande. Arch. f. exper. Pathol., vii, 1876, p. 205. — Mills, C. K., Traumatic Neuritis involving the Brachial Plexus. Philadelphia Med. Times, 1877, p. 564.— Treub, Hec- tor, Ueber Reflexparalyse und Neuritis Migrans. Arch. f. exper. Pathol., x, 1879, p. 398. — Gombault, Contribution a l'etude anato- mique de la nevrite parenchymateuse subaigue et chronique. Arch, de nevrolog., i, 1880, pp. 11, 127. Multiple Neuritis.— Eichhorst, H. Virch. Arch., 69, 1877, p. 265. — Leyden. Charite Ann., v, 1880, p. 206.— Stewart. Edin- burgh Med. Jour., 1881, vol. xxvi, p. 865.— Caspari. Zeitschr.f. hi. Med., 1882, p. 537.— Pierson. Volkmann's Sammlung, No. 224, 1883.— Strumpell. Arch. f. Psych., xiv, 1883, p. 339.— Muller. Ibid., p. 669. — Vierordt. Ibid., p. 678. — Webber, S. G. Archives of Med., xii, Aug., 1884.— Scheube, B., Die Japanische Kak-ke (Beri-beri). Deut. Arch. f. M. Med., 31, 1882, p. 141 et seq. SIMPLE NEURITIS. Pathological Anatomy. — The nerve-fibers, or the sheath of the nerve, may be the seat of inflammation, which may be acute or chronic. When the nerve-fibers are affected, the nuclei in the neurilemma are multi- plied, the medullary substance divides and undergoes a granular or fatty degeneration, the axis cylinder may be hypertrophied, but finally is destroyed, and there remains only a fibrous band in place of the nerve. When the sheath of the nerve, the perineurium, is chiefly af- fected, it becomes thickened by formation of new tis- sue and the infiltration of serum ; the nerve-fibers are compressed, and undergo degeneration secondarily. 262 DISEASES OF THE PERIPHERAL NERVES. In acute neuritis the nerve is rather more congested, the nerve-fibers are the more frequently most affected, and pus is more likely to form ; sometimes haemor- rhages occur into the sheaths of the nerve, leaving pigmentation after the blood has been absorbed. Chronic neuritis may follow as the result of acute, or may occur spontaneously ; the sheath is more likely to be the chief seat of the disease, and the nerve-trunk is thereby much thickened. The nerve-fibers degener- ate and undergo atrophy. The nerve beyond the seat of inflammation under- goes the secondary Wallerian changes when the fibers are entirely severed. Trophic changes in the limbs may follow as results of the neuritis. ^Etiology. — Injuries are the most common cause of neuritis. All kinds of wounds, bruises, and contusions may give rise to the disease ; tumors, abscesses and inflammatory changes in the vicinity of the nerve, com- pression of the nerve, whether from external or inter- nal causes, may give rise to the disturbance. Rheumatic thickening of the sheath, from exposure to cold, is a very common cause. Neuritis sometimes occurs after eruptive fevers or diphtheria, or is the result of syphilis. Symptoms. — Pain is the most prominent symptom of neuritis, at least in the patient's opinion. There may be fever with chills before the pain is felt ; but this is not very common. The pain is often severe, of a burning character, sometimes more aching in nature ; it is felt in the course of the peripheral distribution of the nerve ; the limb is hyperresthetic, sometimes a very slight touch causing distress ; there is always tender- ness over the course of the nerve, especially where it is superficial. The pain is continuous, but with sea- sons of exacerbation ; often is most severe at night. When the nerve is seriously affected, the sense of touch is much diminished or lost ; even in rather mild cases there is a dullness of that sense, yet the anses- SIMPLE NEURITIS. 263 thetic part may be very tender, and a slight pressure may cause pain. The pain may prevent motion, but subsequently the muscles to which the nerve is distributed lose their power, are paralyzed, and undergo more or less wast- ing according to the amount of change in the nerve. When the nerve is entirely destroyed, the motor pa- ralysis is complete, the atrophy extreme, with the reac- tion of degeneration. When the muscles are only partially paralyzed there may be tremor, very closely resembling the tremor of sclerosis ; or more extensive spasm and twitching may occur. After the acute symptoms have subsided, or from the beginning in other cases, a chronic neuritis may be recognized. The symptoms are the same, though per- haps less severe than in the acute, except that there is no fever, and at length other symptoms are added. The pain may have less of the burning character, but be quite as wearing ; often, however, it is only moder- ate in degree, and in very mild cases is not present con- tinuously ; it is excited or increased by use of the limb. The numbness and pricking are the same as when the disease is acute. There is always tenderness over the affected nerve, which is often swollen. The motor disturbance is the same as in acute neu- ritis, but may be more slowly develoj)ed ; the reaction of degeneration is proportionate to the amount of atro- phy ; when the disease is very slight, the electrical irri- tability may be increased. Tremor, as in sclerosis, is more common than in the acute form. Trophic changes in other than the muscular tissue are almost always noticed. These have been studied especially by Mitchell, and consist in herpetic, vesic- ular, and other eruptions, atrophy of the skin, "glos- sy skin," with a peculiar hypersesthetic condition, "causalgia." The nails may become clubbed, brittle; their growth is less rapid. The hair is brittle, may fall 264 DISEASES OF THE PERIPHERAL NERVES. off, or may grow abnormally long, or it may become white. Acute neuritis may be of short duration, the nerve soon recovering its normal condition. Chronic neuri- tis persists for many weeks or months, and, when it has apparently disappeared, the symptoms are easily excited again. Neuritis shows a tendency to extend toward the nerve-centers, or to pass to adjoining nerves. Not in- frequently the inflammation extends until it seems as if all the nerves of the limb were affected. I have seen this in the arm rather than the leg, perhaps be- cause the patients could not or would not give the limb the needed rest. This extension is not always by con- tinuity ; the inflammation may jump over a stretch of healthy tissue. The disease may extend to the cord, and thereby death may result. Prognosis. — The patient's life is only rarely threat- ened when the disease extends to the nerve-centers. Perfect recovery is possible when the disease has con- tinued comparatively long, if the changes have not become too extensive, and even serious and severe cases may do well. Many times, however, the tro- phic changes in muscles and other structures are so considerable that a complete recovery of function is not possible ; the symptoms of neuritis disappear, but the parts remain partially helpless. In less favorable cases more or less pain may be felt at intervals, show- ing that the nerve-fibers are still subject to irritating influences. A relapse, or a second attack, is not uncom- monly the result of comparatively slight imprudence in over-exertion or exposure. Treatment. — Rest is of great importance in both acute and chronic neuritis. The limb affected should be kept quiet ; if necessary, the patient should be con- fined to bed. If the arm is affected, it may be well to secure a splint lightly to the limb. In acute cases, cold may be applied constantly over SIMPLE NEURITIS. 265 the seat of the inflamed nerve. A rubber bag, so ar- ranged that a stream of cold water will flow continu- ously through it, is convenient. Galvanism has been advised, and is of benefit in some cases. It is not likely to do much good in acute cases, and in chronic is often less useful than blister- ing ; it may even increase the pain and aggravate the symptoms. After recovery is fairly established, and the pain has ceased, electricity will be of value in re- storing the use of the partially paralyzed muscles. In subacute and chronic cases the most efficient means is blistering. A blister the size of a ten-cent piece or a quarter should be put over the tender points in the course of the nerves. If several nerve-trunks are affected, one after the other may be thus treated. It is not well to apply many at one time. Sometimes the pain is worse until a day or two after the blister is drawn, when a marked relief will be experienced ; the blister seems to be of most benefit while the raw sur- face is healing ; for this reason the healing should be favored as much as possible by not removing the cuti- cle, and by avoidance of irritating ointments and fric- tion. It may be necessary to control pain by giving mor- phia or other narcotics. A four-per-cent solution of carbolic acid, applied to the limb on compresses, may be useful in relieving the pain. Salicylic acid in rheumatic cases, iodide of potas- sium, quinine in rather large doses, and, later, cod-liver oil and other tonics, would be of value. During convalescence, when pain has nearly or quite ceased, electricity, massage, passive exercise, or the Swedish movement, may be used to restore function and increase the nutrition of the limb. In syphilitic neuritis, of course the specific treat- ment should be used. 266 DISEASES OF TEE PERIPHERAL NERVES. MULTIPLE NEURITIS (Disseminated Neuritis). Pathological Anatomy. — The affected nerves show no special gross change ; they do not seem to be enlarged or congested. Under the microscope the nerve-fibers are found to have undergone extensive changes. There is inflammation, and below this the medullary sheaths, with the axis cylinders, are seg- mented, then divided into smaller granular masses, and finally these are absorbed. The nuclei increase in numbers. There is only a moderate increase of the interstitial tissue. The muscles show changes due to degeneration — a granular appearance ; fat is deposited between their fibers, which may undergo simple atrophy; their nu- clei are multiplied. ^Etiology. — Exposure to cold and over-exertion are considered important as causes. Certainly many patients refer their disease to ' ' catching cold. " Cas- pari suggests that multiple neuritis may be an infec- tious disease. It has been thought by several, who have had op- portunity to observe it, that beri-beri, or 7cak-7ce, is a multiple neuritis. Scheube has carefully examined twenty cases, post-mortem, and reaches this conclu- sion. Symptoms. — The disease may begin with fever, pre- ceded or not by a chill, or the fever may be absent. The pulse is habitually rapid throughout the disease. Pain and stiffness in the limbs are usually first to at- tract the patient's attention — usually the legs, some- times the arms, being first affected. Any effort to move the limbs increases the pain, which may then be most acutely felt about the joints. A hyperesthesia of the muscles increases the resemblance to rheumatic fever. The pain is almost constant, may be extremely se- . vere, is attended with a sensation of tingling or prick- ing, or may be of a burning character, as if very hot MULTIPLE NEURITIS. 26? water were applied to the limb. Sometimes the pain seems to be confined to the course of the diseased nerve or nerves, or it is generally diffused over the region to which the nerve is distributed. Not only is there gen- eral hyperesthesia to pressure, but the course of the nerve is tender, and, upon pressure over the nerve- trunks, the pain is increased in the limb also. The sense of touch is diminished in the affected parts ; especially is this noticed by the patient after the pain has partially or entirely disappeared. The muscles supplied by the affected nerves are par- tially paralyzed early in the course of the disease, yet motion is restricted more by the pain excited than by the weakness ; later there may be total paralysis of single muscles or groups of muscles. The cutaneous reflexes are absent in about half, and the patellar tendon reflex is absent in more than nine tenths of the cases ; the latter is very late in returning. The limbs are more or less flexed, and this position may be maintained by contracture of the muscles ; then passive extension is very painful. The muscles waste and show the reaction of degen- eration. This change may occur very rapidly in acute cases. Abnormal positions of the fingers and limbs may be caused by the wasting, as in other cases of mus- cular atrophy. Trophic changes may be seen in the skin, occasion- ally there is oedema of the limbs, and sometimes ex- cessive sweating. The inflammation extends more or less rapidly from nerve to nerve, not following any regular order, though the disease is usually roughly symmetrical, both legs or both arms being affected at about the same time. The different muscles are not equally paralyzed on the two sides. Mental and cerebral symptoms are usually wanting ; when present, they have seemed to be due to some complication ; the suffering has seemed to give rise to a 268 DISEASES OF THE PERIPHERAL NERVES. hysterical condition ; occasionally a mild nocturnal de- lirium is noticed. The paralysis may extend until so extensive that life is threatened, and death may result from paralysis of the respiratory nerves. In most cases, however, after a time the pain and tenderness diminish and final- ly disappear, leaving the anaesthesia and weakness. Recovery is slow, delayed by contractions of the limbs, and, if the nerve-structures have been seriously dam- aged, it may never be complete. Diagnosis. — Multiple neuritis is most likely to be confounded with anterior poliomyelitis, progressive muscular atrophy, lead paralysis, and rheumatic fever. The sensory disturbances distinguish it from disease of the cells of the anterior cornua of the cord ; these and the marked changes in electrical reactions will dis- tinguish it from progressive muscular atrophy, where there are only very slight electrical changes, simple diminution of reaction, and rarely if ever the reaction of degeneration. Lead paralysis has many of the symp- toms of multiple neuritis ; but, as a rule, the sensory disturbance is less severe ; the other signs of lead-poi- soning and the elimination of lead by the kidneys un- der the use of iodide of potassium are of value in mak- ing a diagnosis. It is only at the very beginning that neuritis and rheumatic fever resemble each other ; the latter is ac- companied with a higher temperature, and soon the joint affection and the course of the disease will make the diagnosis clear. Treatment. — During the earlier stages of the dis- ease, salicylic acid or the salicylate of soda, in large doses, is apparently of most value. Bags of hot water to the spine have seemed to relieve the pain ; hot baths are said to be helpful. Small and frequently repeated doses of aconite are sometimes of value. The chief indication at first is to relieve pain. Mor- phia should be given as freely as needed. For external MULTIPLE NEURITIS. 269 use, chloroform, or a four- to five-per-cent solution of carbolic acid, may be found serviceable. A subcutane- ous injection of a two-per-cent solution of carbolic acid is recommended by Caspari. If the disease is not widespread, blisters might be of advantage. Best in bed is, of course, necessary ; massage and passive motion should not be attempted till after the disease has come to a standstill. The same is true of electricity. These agents are, however, of great value in restoring their function to the paralyzed muscles; the galvanic current is preferable in most cases. Mass- age and passive motion should be used systematically to overcome the contractures which remain after the acute symptoms have disappeared. CHAPTER XXIII. NEURALGIA. Valleix, F. L. I., Guide clu medecin practicien, 1866, t, i, p. 693. — Anstie, F. E., Neuralgia and the Diseases that resemble it. London, 1871.— Trousseau, Clinique medicale. Paris, 1865. (Al- so New Sydenham Soc/s translation, 1868.) — Mitchell, S. Weir, The Relations of Pain to Weather, etc. Am. Jour, of the Med. Sci. , April, 1877, p. 305.— Wood, H. C, The Trigeminal Neuralgias. Med. Record, Oct. 27, 1877, p. 673.— Seguin, E. C, Report on Aconitia in the Treatment of Trigeminal Neuralgia. N. Y. Med. Jour., Dec, 1878. — Ibid., A Contribution to the Medicinal Treat- ment of Chronic Trigeminal Neuralgia. N. Y. Med. Record, Jan. 4, 1879. — Chapman, John, Neuralgia and Kindred Diseases. Lon- don, 1873. — v. Pith A, Prof., On the Diagnosis and Treatment of Neuralgia. Med. Times and Gaz., 1875, ii, pp. 356, 591.— Eulen- burg, Die Osmiumssaurebehandlung der periph. Neuralgien. Berl. M. Wochenschr., No. 7, 1884.— Alexander, R. G., Practi- cal Notes on Neuralgia and its Treatment. Lancet, June 3, 1882, p. 908.— Dujardin - Beaumetz, On the Treatment of Neuralgia. Med. News, April 14, 1883, p. 405. — Seeligmuller, A., Lehrbuch der Krankheiten der peripheren Nerven, und des Sympathicus. Braunschweig, 1882. Neuralgia is the name given to an affection of which the chief symptom is pain. This pain is of variable intensity and character, it follows the course of the affected nerve and its branches, occurs in paroxysms with periods of more or less perfect remission or even intermission, and is not dependent upon any discover- able organic lesion. Symptoms. — The essential symptom of neuralgia is pain, which may be confined to a limited region, or may follow the course of the nerve and its branches, even radiating into other nerve-districts. The char- NEURALGIA. 271 acter of the pain varies ; the superficial cutaneous branches are the most frequently affected, though the pain is sometimes deep-seated, and the visceral nerves may suffer. The pain may be very light, and cause very little discomfort ; or may be severe, lancinating, cutting, tearing, burning, boring, twisting. Patients use different words in describing the attacks, and there is probably a difference in the character of the pain, though in a severe paroxysm one is scarcely able to make a very nice distinction, and so the patient uses that term which occurs to him at the time as most ex- pressive. Before an attack of neuralgia the patient may be conscious of impaired general health ; or there may be more direct warning in a period of discomfort, a sense of weariness, of weight, or tingling, or some abnor- mal sensation in the parts about to be affected. Slight twinges of pain, which are really less severe attacks, precede the more severe ; twitching, tremors, and slight loss of power, may be among the prodromes. Similar phenomena may precede each attack of neuralgia, so that the patient learns to anticipate it. In other cases the pain suddenly bursts out and overwhelms the patient's fortitude by its severity and its unexpected onset. These sudden attacks are proba- bly rare in the early stage of the disease, but are less rare after several attacks have followed one another with intervals of entire intermission. Between the paroxysms there may be less severe pain, which is then more frequently of an aching, burn- ing, or pricking character. The duration of an attack may vary within very wide limits ; paroxysm after paroxysm succeed each other with almost lightning-like rapidity, and even in the intervals the pain is very intense, so that the whole series of paroxysms may be looked upon as one attack. At another time there is only one sharp sting of pain. The attacks may recur several times an hour or day, or 272 DISEASES OF TEE PERIPHERAL NERVES. may be absent for days or months. An extended pe- riod of freedom from all pain is rare in a patient veiy much affected. In severe cases remissions are more common than intermissions. The first attacks are often comparatively light, and the severity of the pain gradu- ally increases as the attacks multiply. The pain is always felt either at one point of a nerve or along the course of a nerve. Not infrequently a patient unacquainted with anatomy will map out the affected nerve and its branches. The locality of the pain may be different in the different attacks, shifting perhaps to the opposite side of the body. When the pain always affects the same nerve, there is a strong probability that it is due to an organic lesion of that nerve. In the beginning of the disease, and in uncompli- cated cases throughout, there is no elevation of tem- perature. When one nerve has been long the seat of pain, there is usually a loss of acuteness in common sensibility of the skin, and an increase in acuteness to sensation of pain. Certain points become tender, so that a very light touch is painful. These points, points doulou- reux, were specially studied by Valleix, and are some- times named from him. They are found where the nerve passes through bony canals, or through fasciae, becoming thus superficial. These points may not be painful when the disease has but recently commenced ; sometimes they are entirely wanting. If the pain is clearly intermittent, they may not be tender to pressure during the intermission. It is not uncommon to find the spinous processes of the vertebrae, between which the affected nerves pass, painful upon pressure, points apophysaires. The pain of neuralgia is increased by all motions of the affected parts ; thus, motions of the jaw in chewing, or of the face in talking and laughing, will increase the severity of facial neuralgia ; so walking will render the NEURALGIA. 273 suffering more severe in sciatica. Necessarily, there- fore, under such conditions, neuralgia will interfere with motion. Besides the above causes of immobility, there may be actual weakness of the muscles, a partial paralysis. Twitchings, tremor, and even more severe spasms of the muscles, may attend the paroxysm as well as pre- cede it. There may be changes in the circulation or the nu- trition of the affected parts. The arteries are at first contracted, and the skin is pale ; later, relaxation of the vessels gives rise to a more congested appearance, and there may even be a tendency to cyanosis. (Ede- ma is sometimes noticed in the limbs or face. The se- cretions may also be altered, the tears flow freely, and the saliva and urinary secretions are abundant. Decided trophic changes are usual in old, obstinate cases, especially in neuralgia of the limbs ; the muscles are wasted more than can be explained by their lack of exercise. This wasting has been explained by the changes in the nerve which give rise to the pain, peri- neuritis, or by supposing a change in the circulation of the cord, and hence disturbance of nutrition in the motor cells of the anterior cornua. Cutaneous eruptions, herpes, erythema, pemphigus, urticaria, and psoriasis may be found among the com- plications of neuralgia. The skin may become thick- ened, and the hair may change color. Except in severe and long-continued cases, the gen- eral health and disposition rarely suffer. Persistent and extreme pain, however, impairs the digestion, dis- turbs sleep, prevents exercise, taxes the endurance, and at length there is evident a disturbance of the general health ; the temper becomes more irritable and peevish, mental power may be weakened, and finally there may be insanity. This is rare, as the i^atients usually quick- ly regain health when there is even temporary relief from pain. 274 DISEASES OF THE PERIPHERAL NERVES. TRIFACIAL NEURALGIA (Prosopalgia) Is one of the most common forms of neuralgia. As the branches of the fifth nerve pass through bony canals they are much more readily compressed by a very slight swelling of their sheaths, and the pain thus produced is proportionately severe. Exposure to cold, decayed teeth, and exostosis are likely to be among the causes ; but disturbance of the stomach, intestines, generative organs, and other dis- tant parts, may give rise to the disease. The symptoms are such as have been already de- scribed. The pain is often excessive; spasm of all the muscles of the affected side of the face is excited by the agony. The painful points are the palpebral, at the external part of the upper eyelid ; the supra- orbital, where the frontal nerve turns up over the edge of the brow ; the nasal, at the upper part of the nose ; the malar ; the infra- orbital, at the point of emer- gence of the infra-orbital nerve ; the mental, where the inferior maxillary nerve ends in the mental and passes out from the foramen. There are less important points mentioned: the ocular; the labial ; the lingual; the parietal, which is common with the cervico-occipital neuralgia. The points apopliysaires are found over the spinous processes of the first and second cervical vertebrse and the occipital protuberance. The conjunctiva of the eye on the affected side, and sometimes of the opposite eye, may be deeply con- gested, tears may flow freely, and the nasal mucous membrane may secrete profusely. The pupil is often dilated. CERVICO-OCCIPITAL NEURALGIA Is seated in the region to which the first four cervical nerves (cervical plexus) are distributed. This includes the back and side of the head as far forward as the ear, the neck and apex of the shoulder, and posterior part DORSO-INTERCOSTAL NEURALGIA. 275 of the lower jaw. The painful points are the occipital, between the mastoid process and the first vertebra ; the mastoid, over that process close to the ear near the exit of the seventh nerve ; the parietal, in common with trifacial neuralgia, and sometimes the rim of the ear is tender. The points apophysaires are over the four upper cervical vertebrae. It is important not to mistake the pain caused by caries of the upper cervical vertebrae for this form of neuralgia. When the nerves of the brachial plexus are involved we have cermco-brachial neuralgia. This is more fre- quently traumatic in origin. The painful points are. found in the axilla, over the median nerve at the elbow, the ulnar just above the elbow, the radial where it fol- lows round the humerus, at the lower angle of the scapula, and at the lower end of the ulna. The points apophysaires are over the lower cervical and upper dorsal vertebrae. Many times there is really chronic neuritis as cause of the pain. DORSO-INTERCOSTAL NEURALGIA Is a very frequent form. The thoracic nerves are in- volved ; it is rather more frequent on the left side ; it is one of the accompaniments of various pulmonary dis- eases ; is common in phthisis. Herpes zoster is very common around the chest ; it may be excited by dis- turbances of the abdominal viscera, especially of the stomach. The painful points are found just to the side of the vertebrae ; then near the center of the course of the in- tercostal nerves ; and, anteriorly, the region of terminal expansion, as Trousseau calls it. In tracing the nerve, the curvilinear course of the ribs should not be forgot- ten. The points apophysaires are found over the ver- tebrae corresponding with the affected nerve. Infra-mammary neuralgia is one variety of inter- 276 DISEASES OF THE PERIPHERAL NERVES. costal, which gives much annoyance and causes much suffering, exciting, also, fears in the patient of inflam- mation of the breast. When intercostal neuralgia is severe, the respiration is disturbed, rapid, and painful ; the pain radiates to the arm ; there is palpitation, and angina pectoris may be closely simulated. LUMBO-ABDOMINAL NEURALGIA Is the name given to the disease when the crural plexus is the seat of pain. The painful points are near the spinal column ; just above the crest of the ilium, near its center : above the pubis ; near the lower part of the rectus muscle ; there may be points in the vagina or about the scrotum ; over the anterior-superior spinous process ; over the crural nerve as it passes out from un- der Poupart' s ligament ; on the inside of the knee-pan ; and over the saphenous nerve in front of the ankle. Sometimes congestion and haemorrhages from the uterus and vagina seem to depend upon this neuralgia. The pain may lead to a suspicion of uterine disease. Lumbago may be distinguished by the fact that mo- tion causes pain, which is absent during complete quiet. The pain caused by renal calculi may be mistaken for neuralgia. SCIATICA Is one of the most common, most rebellious of neural- gias ; it is rather more frequent in men. In the ma- jority of cases there is a neuritis. Between the par- oxysms of pain there is usually an aching or burning sensation ; a heavy, bruised feeling. Exertion will of- ten cause a relapse. The painful points are : near the sacrum ; where the nerve emerges from the pelvis ; near the great trochan- ter of the femur (Erb considers this the most constant) ; at the lower border of the gluteus muscle ; in the pop- liteal space ; frequently the whole course of the nerve in the thigh is tender, and it can be felt to be enlarged ; SCIATICA. 277 just below the head of the fibula ; behind the outer ankle. Wasting of muscular tissue of the leg is not uncom- mon in cases of long standing. JEtiology. — Anstie considered every case of neu- ralgia to be one of debility. This is somewhat too sweeping a statement, yet it is true of most patients suffering from this affection that they are below par in physical or nervous strength. Heredity is an important factor in the aetiology of neuralgia. A large proportion of the patients are born with less than the normal nervous stamina ; the parents may not have neuralgia, but the children have less than normal strength and vigor. Much might be written on this division, but it is scarcely necessary. Women are more subject to some forms than men ; some authors consider that the majority of patients are women, and this is probably true, though Axenfeld says the difference is less than is usually supposed. Children rarely have neuralgia. The most suscepti- ble age is middle life. The more marked the heredi- tary tendency, the earlier the disease will be likely to appear. It is necessary only to mention that a predisposition to neuralgia may be fostered, or even developed, by hy- gienic surroundings, by overwork, by anxiety, grief, etc. These influences are much the more powerful in youth, yet do not lose their power in adult years. Acute and chronic disease may bring the system into such a state of anaemia or debility as to greatly favor an outbreak of neuralgia. Among exciting causes, " catching cold " maybe the most frequent. Exposure to wet and cold is often mentioned by patients as the cause, and probably with truth. In such cases there is many times a rheumatic thickening of the nerve-sheath, and the disease is really a neuritis. It is not always possible to recognize this by the symptoms. The nerves most exposed to this 278 DISEASES OF TEE PERIPHERAL NERVES. injurious influence are those of the face, the sciatic, and less frequently those of the arms. Many patients suffer from sciatica after sitting on a stone or a metallic seat. Injuries of nerves or in their vicinity may be a cause of the disease. A slight injury may give rise to neu- ralgia only after months or years. Sometimes in such cases a change in the sheath, a thickening, has been slowly taking place, until at last, either spontaneously or as the result of a forgotten exposure, the attack of pain follows. Tumors, exostoses, caries of teeth, disease in tho- rax or pelvis— these and other changes near nerves, by pressure or extension of inflammation, may cause pain, and the exciting cause may not be discovered, owing to its hidden location. Such cases are not, properly speak- ing, cases of neuralgia, yet the diagnosis of the true cause of the pain may be impossible. Neuralgia may be excited in a reflex way by dis- eases of the viscera ; this is especially so in regard to the genito-urinary and digestive organs, and in regard to caries of the teeth. Several poisons, as mercury, copper, lead, alcohol, and tobacco, are both predisposing and exciting causes ; the same may be said of malarial influences. Syphilis is an active agent in many instances, but not so often a cause of neuralgia as of headache. Pathogenesis. — From the definition of neuralgia, it is evident that there can be no special pathological change in the nerves. Many times, doubtless, neuritis is called neuralgia, and that name is given to other con- ditions where organic changes are found. It is proba- ble that very many cases of neuralgia ought to have another name ; but this is the result of ignorance or carelessness on the part of the observer. Anstie advocated that every case of neuralgia is in reality a case of anaemia of the spinal centers, with atrophy of the posterior nerve-roots. Chapman claims NEURALGIA. 279 that congestion of the spinal cord is the cause of the pain. The truth is that we do not know definitively the nature of this affection. It would be easy to quote au- thors to show the varying views held in regard to this subject, but it would be of doubtful advantage. Diagnosis. — Erb gives six characteristic symptoms of neuralgia : 1. The pain is limited to a definite nerve- path, or area of distribution, and is usually unilateral. 2. Without any clear reason, the pain is either inter- mittent or distinctly remittent. 3. The pain is very peculiar and acute. 4. Certain spots in the course of the nerve, or in the area of its distribution, are very sensitive to pressure. 5. The pain is associated with certain sensory, motor, vaso-motor, and secretory phe- nomena. 6. The pain is not accompanied by any in- flammatory or local symptoms, or any general disturb- ance of health at all corresponding with the amount of subjective disorder. These six diagnostic marks are only presumptive of neuralgia. A very large proportion of cases are proba- bly neuritis, and it may be as well to recognize the fact in practice. The pains of locomotor ataxia are very much the same as those of neuralgia, and it is necessary to bear this in mind. Caries of the vertebrae may give rise to pain which can be easily mistaken for neuralgia ; the same is true of other diseases of the spine or spinal membranes, of cerebral lesions, and of malignant growths in the tho- racic and abdominal cavities. In all these cases a care- ful study of symptoms may lead to a correct diagnosis ; but without this, serious mistakes must be made. Prognosis. — Unless there is a neuritis or a morbid growth, pressing upon the nerve, recent cases are usu- ally readily relieved ; but there is a great probability of return. The greater the number of attacks, and the more localized the x>ain, the less probable is relief, be- 280 DISEASES OF THE PERIPHERAL NERVES. cause under such circumstances there is almost always a neuritis or a perineuritis. The most rebellious cases are those affecting the fifth and sciatic nerves. Treatment. — In neurotic subjects the treatment of neuralgia should begin before the pain appears — that is, much can be done to prevent its development. The young child should be fed and educated, its habits formed with special regard to the possible occurrence of nervous disorders. This regimen should be all the more carefully followed after the affection has appeared. Light, air, exercise, and food are necessary in large meas- ure. Over-feeding is sometimes of great value ; fre- quent feeding, hourly, is one means of inducing the system to receive more than it would from the usual number of meals. So far as possible, all causes should be avoided ; warm clothing will aid much ; keep the feet dry. Any disease which may give rise to neuralgia should, of course, be treated ; this is self-evident, yet easily forgotten in the presence of the pain of an attack. Teeth should be looked after. Dyspeptic or other vis- ceral disturbance, and uterine disorders, attended to. Alcohol and tobacco should be stopped. It is scarcely necessary to mention that metallic poi- sons should be eliminated if possible. In syphilitic patients a corresponding treatment must be followed. Internally, quinine is often of benefit, not only in cases due to malarial poisoning, but where there is no such taint. In recent cases, given in moderately large doses, five grains every hour until the head aches or the ears are affected, it will frequently cut the attack short. It is also useful as a tonic to prevent recur- rence. Anstie found it useful in affection of the oph- thalmic division of the fifth nerve. Cod-liver oil, or other form of fat, cream, or butter, is very valuable. Many patients find the oil disagree- able. Begin with half or quarter of a teaspoonful, to which a little salt may be added ; continue this dose, NEURALGIA. 281 after meals, until there is no regurgitation of the fumes of the oil ; then the dose can be rapidly increased to a tablespoonful. Phillips's emulsion is very palatable. Iron in its various preparations is indicated, espe- cially in angemic and chlorotic subjects. The tincture of the chloride is one of the most valuable forms. An- stie recommends very highly a mixture of this with strychnia, ten minims of the iron tincture with ^ grain of the strychnia. The soluble saccharated oxide of iron, in doses of half a teaspoonf ul, is a very pleasant prepa- ration. Arsenic is valuable in the same cases as the iron ; it is also useful in malarial cases. Iodide of potassium, or the syrup of hydriodic acid, is useful not only in syphilitic neuralgia, but also in rheumatic ; colchicum may help in such cases, though the bowels should not be too strongly acted upon. Phosphorus has been very highly praised, especial- ly by many English physicians. Mr. Thompson ad- vised it in large doses, not less than -^ grain ; he ad- vised -jJg- grain every four hours ; after six doses, -^ grain at the same interval. After forty-eight hours, if no re- sult, he thinks some good may be effected by increas- ing the dose still further. This dose rarely causes trou- ble, yet occasionally a patient is unusually susceptible, and acute poisoning has been observed ; caution is, therefore, necessary. Gelsemium, fluid extract, in ten- to twenty-minim doses, or tincture, in half-drachm doses, is very service- able in facial neuralgia, and perhaps in intercostal and ovarian. The preparations of this drug are sometimes inert. The dose may be repeated every half-hour, but it is prudent not to give more than three doses so near one another. Croton chloral has been used in facial neuralgia with very good results by many ; but I have never seen any special benefit from it. Aconitia is a very valuable drug ; it is especially 2S2 DISEASES OF THE PERIPHERAL NERVES. useful in angina pectoris, in intercostal and facial neu- ralgia, but is of benefit in any form of reflex or consti- tutional neuralgia. The pure alkaloid, made by Pu- quesnil, crystallized, should be used, or the effect will be uncertain. The dose varies from -^ to -j^- grain. Dr. E. C. Seguin recommends the following formula : # Aconitire (Duquesnil's) g r - tjt ~i j Glycerine ) _ . fl _ . Alcohol f aafl3j; Aq. menth. pip q. s. ut ft. fl 5 ij. M. S. A teaspoonf ul two or three times a day, on an empty stomach. This may be given even more frequently, as often as every two hours, if the effects are carefully watched ; so soon as the pulse is affected, or there is tingling of the lips, tongue, or fingers, the drug must be discon- tinued. Fereol found sulphate of copper, - 05 to "10, of value in epileptiform neuralgia. Other drugs that have been used are chloride of gold and sodium, nitrite of amyl, chloride of ammo- nium, strychnia, which is praised by Anstie, and phos- phide or oxide of zinc. During the attack of pain, to relieve the distress it may be necessary to use morphia or other preparation of opium, Morphia subcutaneously is the most effica- cious ; but care is needed lest the morphia habit should be formed. In old and obstinate cases the smallest dose which will relieve the pain, ^ or ^ grain, should be used only when it is necessary to give such relief. In recent cases one large dose will sometimes work a cure. Atropia subcutaneously will frequently give as much relief as morphia ; -^ grain is usually the largest dose necessary. Anstie recommends atropia, especially for ophthalmic neuralgia. Chloroform, in doses of five to ten minims, injected NEURALGIA. 283 under the skin in the vicinity of the affected nerve, often gives relief. Schultz used carbolic acid, two to one hundred of distilled water, subcutaneously, injecting from a quar- ter of a drachm to a drachm of the solution. Eulenburg injected a one-per-cent solution of osmic acid with benefit in recent cases, which were probably neuritic or perineuritic. The subcutaneous injection of a drachm of hot wa- ter near the nerve — of course not so hot as to scald the tissues — will frequently give as much relief as small doses of morphia. Acupuncture, passing a needle into the skin until the point is near the nerve, will give relief in many cases. The needle should be worked in slowly and gradually, as near the nerve-trunk as pos- sible ; if its point can just touch the nerve, which may be known by the peculiar sensation, and then be slightly withdrawn, the result is the better. This prob- ably is most efficacious in recent cases. Various external applications will soothe the pain during an attack, and render the use of morphia less necessary. Hot water is useful ; so, too, is spirit of turpentine. Chloroform, diluted more or less with al- cohol, applied on a piece of flannel and covered with a towel wet with water, eases the pain. Generally one part of chloroform to seven of water is a good mixture, though one stronger is often better. Veratria oint- ment can be used, but aconite is better. The tincture of aconite may be used freely, or the ointment may be applied over the affected surface. The ointment of aconitia, if made with Duquesnil's aconitia gr. j to 3 j lard, will be stronger than the regular officinal oint- ment. Care must be taken not to get any of this into the eyes, nose, or mouth, and not to rub it where the skin is abraded. The person who applies it should not use his uncovered hands. A portion half as large as a small pea is sufficient for one application. I know of no simple external application of equal value. 234 DISEASES OF THE PERIPHERAL NERVES. Blisters over the tract of the nerve, especially over the points douloureux and over the points apophy- saire, not only give relief, but often effect a cure. The blisters need not be large ; an inch by an inch, or inch and a half, is sufficient. They may need to be repeated over different points, or near the same spot. The actual cautery over the same spots may be even more valuable than blisters — may give immedi- ate relief without so much discomfort. Electricity is a most satisfactory agent in many cases. Sometimes the faradic, applied through a wire brush to the seat of pain, gives immediate relief. The galvanic current passed through the affected nerve or limb is usually the better. It should be used daily, with as little shock or variation of strength as possi- ble. Vibration communicated to the nerve at the seat of pain, by rapid percussion over the tender points, some- times gives permanent relief. The percussion may be made by means of rubber balls attached to handles, or by mechanical contrivances. The application of ice by means of the rubber ice- bag to the spine, either a portion or the whole, as ad- vised by John Chapman, is soothing and grateful. If properly applied, it has a tendency to restore warmth to the feet, and will relieve pain. It should be applied from thirty to sixty minutes several times a day. Oc- casionally Chapman uses hot water over the upper part of the spine in facial neuralgia with hypereemia or swelling of the face. Surgical operations are sometimes needed to cure neuralgia ; these are excision of portions of nerves, which has been frequently done for facial neuralgia, and stretching of nerves. The latter is of compara- tively recent date, and has given very good results. Patruban has tied the carotid for facial neuralgia with success in many cases. CHAPTER XXIV. LOCAL AND POST-FEBEILE PAEALTSES. Leyden, Ueber Keflexlahmung. Volkmanri's Sammlung, No. 2, 1870.— Feinberg, Ueber Eeflexlahmung. Berl. hi. Wochen. , 1871. — Panas, De la paralysie reputee rheumat. du nerf radial. Arch, gen., 1872. — Webber, S. G., Cases of Peripheral Paralysis : their Causes and Nature. Boston Med. and Surg. Jour., Dec. 18, 1873. — Bernhardt, M., Zur Pathologie der Kadialisparalysen. Arch, f. Psych., iv, 1874, p. 601. — Comegys, Facial Paralysis and Laby- rinthine Vertigo. Med. Record, April 24, 1880, p. 445.— Joffroy, A., Paralysie radiale. Theorie de la compression. Arch, de physiol., Mai, 1884, p. 478. — Westphal, C, Ueber eine Affec- tion des Nervensystems nach Pocken und Typhus. Arch, fur Psych., iii, 1872, p. 376. — Landouzy, L., Des paralysies dans les maladies aigues. Paris, 1880. — Dejerine, J., Eecherches sur les lesions du systeme nerveux dans la paralysie diphtheritique. Arch, de phys., x, 1878, p. 107.— Wood, H. C, Diphtheritic Pa- ralysis. N. Y. Med. Jour., Dec. 29, 1883, p. 705.— Kidd, P., A Contribution to the Pathology of Diphtheritic Paralysis. Med.- Chir. Trans., vol. lxxxiv, 1883, p. 133. PERIPHERAL PARALYSIS. By peripheral paralysis may be understood paraly- ses which, depend upon lesions of the muscles them- selves, or the nerves after they leave the spinal cord. vEtiology. — Among the causes may be mentioned injuries from falls or blows, or wounds ; pressure upon nerves, either by the position of the limbs or by bur- dens carried so as to press upon the nerves ; or by tu- mors, or other products of disease. Cold is a common cause of certain forms of paraly- sis, so-called rheumatic paralysis. Disease of neigh- boring parts, even when the nerves are not directly 286 DISEASES OF THE PERIPHERAL NERVES. implicated, may give rise to loss of motion, as in hip- disease, there is loss of power in the mnscles of the leg, which may be attended with atrophy. Acnte diseases are many times followed by paraly- sis. Certain poisons, as lead, arsenic, and some vege- table poisons, canse paralysis, apparently due to dis- turbance of the nerves. The same, also, may be said of syphilis, though with this there is generally a for- mation of new tissue around the nerves. Over-exertion of limbs, exhaustion, may lead to temporary paralysis, or even to a more serious and more permanent loss of motion. In some cases the paralysis is spoken of as reflex, as if it arose from disease of certain organs by reflex action through the spinal cord. It is rather doubtful whether such paralyses are really reflex, as is claimed, and do not, rather, depend upon disease either of the nerves themselves or of the spinal cord. Symptoms. — As most of the nerves are mixed nerves, there is usually loss of motion and disturb- ance of sensation. Sometimes pains or peculiar numb feelings and unpleasant sensations precede any loss of power ; but very soon, if not at the same time with the disturbance of sensation, the patient recognizes that there is loss of power. He finds that he can not per- form certain acts as readily as formerly. The nature of the disturbance of motion will de- pend, of course, upon which nerve is affected. If the paralysis is not complete, the ordinary reflexes may not be seriously impaired ; but if there is entire loss of either motion or sensation, both the superficial and deep reflexes will disappear. In every case of paralysis depending upon a lesion of the nerve itself, the electrical reactions will be such as have been described under the name of the reaction of degeneration. Frequently the paralysis is attended with a moder- ate decree of swelling of the affected limb, due to a PERIPHERAL PARALYSIS. 287 loss of tone in the blood-vessels on account of paralysis of the vaso-motor nerves, which accompany the nerves of motion and sensation. For the same reason there may be at first a rise of temperature in the limb, though subsequently the temperature is lowered, and the limb may have a cyanotic appearance. Certain trophic changes are found after injuries and serious lesions of the nerves. These affect the nerves themselves, the muscles, and the skin. The nerves un- dergo a degeneration ; the medullary sheath breaks up into granular material, which is absorbed, the axis cylinder also undergoing a change. The muscles lose their striated character, and after a while are changed into fatty debris, which is finally absorbed. Accom- panying these changes, there is usually more or less multiplication of nuclei. The skin may be covered with an erythematous eruption, or the eruption may be vesicular. Herpes and eczema are not uncommon. Sometimes the skin is thickly covered with minute scales of epithelium, which can be readily brushed off. Mitchell has described the glossy skin which is found frequently after nerve-lesion. This is most com- monly seen in the fingers, perhaps in the foot. The skin has a peculiar shiny appearance, without wrinkles, without hairs. When the fingers are affected, they ta- per off to their ends, and it is very common to have a severe pain as an accompaniment of this condition, cau- salgia. Occasionally ulcers form, mal perf orant, though this is comparatively rare. The nails become brittle, rough, and deformed. The hair may fall out, or grow to an inordinate length, and sometimes loses its color, becoming gray or white. Diagnosis. — The diagnosis between paralysis of peripheral origin and of central origin must be made in large part from the other symptoms. Electricity is the most valuable agent in forming the diagnosis. If there is the reaction of degeneration, it is certain that either 288 DISEASES OF THE PERIPHERAL NERVES. the nerves are diseased or the large cells of the anterior cornua of the spinal cord have undergone degeneration. If, then, a disease of the spinal cord can be excluded, the diagnosis is clear. Multiple neuritis has been already considered. Prognosis. — A very large number of cases of pe- ripheral paralysis recover completely. The more se- vere, however, the original injury, or the more com- plete the degeneration of the nerve caused by disease, the slower will be recovery, and the more likely per- manent impairment of motion will result. Among the most favorable cases are those which arise from simple pressure, from rheumatic disturb- ance, or from poisons and from syphilis. Even where the reaction of degeneration is found, recovery is not to be despaired of, and treatment should be persevered in for many months. The less perfectly the reaction of degeneration is established, the more favorable is the indication. When secondary contrac- tion has set in, or when the reaction of degeneration has evidently continued for many months, the progno- sis is very unfavorable. Treatment. — The treatment of these paralyses must be directed first, of course, to a removal of the cause if possible. Injuries and other diseases should receive their appropriate treatment. If tumors can be removed without destruction of a nerve, in course of time the paralysis will disappear. In cases of exhaustion, rest is sometimes sufficient for recovery ; if not, then the same means should be used as in other cases of protracted paralysis. In cases of syphilis, the anti-syphilitic treatment should be vig- orously pursued. Warmth to the limb is quite impor- tant. Electricity is of more value than any other agent. The galvanic current should be used, the current being slowly interrupted, the negative pole being placed over the motor points of the affected muscle. In cases of paralysis due to pressure or exhaustion, or after acute PERIPHERAL PARALYSIS. 289 diseases, this is usually sufficient. In cases of rheu- matic paralysis it may be well, also, to paint over the affected nerve with tincture of iodine. Where, how- ever, there is reason to suspect that a neuritis has oc- curred, small blisters placed over the nerve, as described under neuritis, will hasten the cure. Internal remedies are of little or no value so far as the paralysis is concerned ; they may be required, how- ever, for the genera] health and condition of the pa- tient. SPECIAL FORMS OF PARALYSIS. The nerves which move the eye are frequently sub- jected to pressure and injury from syphilitic disease of surrounding parts, especially of the membranes of the brain ; and, as these nerves pass through the bony ca- nals at the base of the skull, they are easily com- pressed, not only by such growths, but also by the in- fluence of cold, producing a congestion and swelling and inflammation of the surrounding tissues. When these nerves are paralyzed, vision will be more or less interfered with. If the third nerve is affected, the drooping of the eyelid and loss of power of ac- commodation may disturb vision, even when the mo- tions of the eyeball seem to be perfect. When the muscles of the eyeball are paralyzed, in consequence of injury to their nerves, there is more or less immobility of the eye, and hence strabismus results. A very care- ful description of the various forms of strabismus may be found in Ziemssen's "Cyclopaedia," vol. xi, or in Ross's work on the " Diseases of the Nervous System," or in books on diseases of the eye. The seventh nerve; the facial nerve, is perhaps more frequently affected by the so-called rheumatic pa- ralysis than any other nerve of the body. Passing through a bony canal near the ear, being very super- ficial where it leaves that canal, it is specially exposed to such a disturbance. Draughts of air while riding, or sitting at an open window, or other exposure of one 19 290 DISEASES OF THE PERIPHERAL NERVES. side of the face, may be sufficient to give rise to this paralysis. As the seventh nerve passes through the temporal bone, separated by a very thin lamina of bone from the tympanic cavity of the ear, it is very liable to disturb- ance in cases of inflammation of the middle ear. New growths in the ear may also, by pressure, cause absorp- tion of the thin layer of bone, and press upon the nerve. Blows upon the side of the head, and other in- juries, may likewise result in facial paralysis. As the facial nerve is at its origin exclusively a nerve of motion, when it is paralyzed the symptoms are chiefly those of loss of motion ; in its course, how- ever, through the Fallopian canal it receives a few branches — one of special sense, of taste, and another, near its exit from that canal, of common sensation. The auricular branch, from the vagus, passes through the temporal bone, quite near the facial nerve, and gives a small branch to it. Probably in consequence of the proximity of this nerve, many times the first symptom of facial paralysis is pain in the region of the ear, and generally there is more or less discomfort, if not actual pain, during the early part of the disease. The most common symptom in paralysis of the seventh nerve is loss of power in all the muscles on that side of the face. Not only those of the lower part of the face, which are affected in cases of cerebral dis- ease, but also the muscles of the forehead, and the or- bicular muscles of the eyelids, are paralyzed ; hence the eye remains partly open, and even in sleep is not en- tirely closed, although the eyeball may turn upward, so that the pupil is covered. The lids are not closely applied to the eyeball ; hence, the tears do not find a ready entrance to the nasal duct, and the eye waters continually. There may also be a loss of taste in the anterior part of the tongue, and it has been claimed that the secretion of saliva is less on that side. PERIPHERAL PARALYSIS. 291 Sometimes the velum palati is affected and hangs down loosely on the paralyzed side, and, when the mus- cles are brought into action in speaking, the action be- ing much greater on the sound side, the palate is drawn over toward that side. Sometimes the uvula has an ob- lique direction. Sense of hearing may be somewhat more acute on the paralyzed than on the opposite side. The tongue is protruded straight ; but sometimes, owing to the uneven position of the lips, the tongue appears to deviate. Careful observation of its position relative to the teeth will prevent any error. The reaction of degeneration is found in the mus- cles. The electrical reaction is of value as aiding in a formation of prognosis. In very mild cases the reac- tion of degeneration may not set in ; in cases of me- dium severity, the extreme form of the reaction of de- generation will not appear. It is possible, from certain peculiarities of the pa- ralysis, to diagnosticate very closely the seat of the le- sion. Erb has briefly stated the points of diagnosis, which may be summarized as follows : 1. If there is complete paralysis of all the branches, if there is no disturbance of taste or hearing, and no paralysis of the palate, and if the electrical reaction is normal, the trunk of the facial is affected external to the Fallopian canal. 2. Paralysis of all the external branches, with reac- tion of degeneration and absence of disturbance of taste, shows that the cause of the paralysis is within the canal and below the origin of the chorda tympani. 3. With the same symptoms and disturbance of taste, the cause is between the origin of the chorda tympani and the ganglion geniculatum. If the hear- ing is abnormally acute, the lesion must be above the origin of the stapedius nerve ; otherwise below it. 4. If, with the above symptoms, there is paralysis of the velum palati, the lesion is in the vicinity of the ganglion geniculatum. 292 DISEASES OF THE PERIPHERAL NERVES. 5. If all the above symptoms, except disturbance of taste, are present, and especially if there is also dull- ness of hearing and tinnitus, the lesion is at the base of the skull ; and this is rendered still more certain if other cranial nerves are affected. 6. Erb states that if the same symptoms as in No. 5 are present, except simple diminution of the electri- cal instability instead of reaction of degeneration, and especially if unusual or crossed reflex action be pres- ent, lesion of the facial nucleus may be diagnosticated ; and this is yet more certain if other cerebral nerves having their origin in this part are also paralyzed. After facial paralysis has continued for two or three months, it is not uncommon to have secondary contrac- tion set in, which delays recovery. The face, when at rest, may then have a more natural appearance ; but, when the mouth is moved, the difference in the two sides becomes apparent. Erb explains this condition as due to the changes that occur in muscles where there is the reaction of degeneration. Diagnosis. — The diagnosis of peripheral facial paralysis, from that caused by central lesion, is of much importance, especially for the comfort of the patient. The reaction of degeneration is one of the most im- portant aids ; in cases due to lesions of the brain, as a rule, only the lower branches of the nerve are affected, those that go to the eye and forehead acting normally. In cases of tumor or other disease within the skull, pressing upon the nerve just before it leaves the skull, there are general symptoms of tumor as well as those relating to other nerves, especially the auditory, which will aid materially in a diagnosis. Paralysis due to diseases of the ear must be diag- nosticated by the symptoms which are more particu- larly referable to the ear. The large majority of cases are due to the action of cold, so-called rheumatic pa- ralysis, and the history will not always aid in forming a PERIPHERAL PARALYSIS. 293 diagnosis, as patients very often are not aware that they have been exposed. Prognosis. — In the lighter forms of rheumatic pa- ralysis the majority of cases get well. Some of the se- verer cases recover without special treatment ; yet, gen- erally, if there is no treatment, a certain amount of deformity remains which no subsequent treatment bene- fits. The best results can be obtained by the early use of appropriate measures. The prognosis in cases arising from disease of the ear depends entirely upon the nature of that disease and the amount of mischief which has been caused to the facial nerve. The prognosis in cases of disease within the cranium must be guided by the nature of that disease. Treatment. — It is necessary to say but very little in regard to the special treatment of facial paralysis. In the rheumatic form, painting over the neck just be- low the ear and behind the ear with tincture of iodine may be of some benefit. Electricity, the galvanic cur- rent by preference, interrupted at short intervals, is of most value. The internal use of remedies is of no value except in syphilitic cases. PARALYSIS OF THE BRACHIAL PLEXUS. There is nothing peculiar in the symptoms found in paralysis of the brachial plexus. A knowledge of the distribution of the nerves to the muscles will show what nerves are specially affected, and the resulting paralysis or deformity depends upon which muscles are affected. Among the most common causes are dislocation of the humerus, the head of the bone pressing upon the nerves in the axilla ; pressure of a crutch upon these same nerves ; pressure upon the radial nerve as it passes around the lower part of the humerus. This is most frequently found in patients who have fallen asleep upon their arm, especially if the arm rests upon 294 DISEASES OF THE PERIPHERAL NERVES. any hard substance, and is more likely to occur when the sleep is very heavy, or from intoxication. Carry- ing burdens upon the arm, the hand resting upon the hip, may also be a cause. Among infants, paralysis of these nerves is some- times found as the result of delayed labor ; the press- ure upon the nerves in the neck, especially by forceps, may be a cause ; or, if the arm is drawn down in breech presentations, the nerves may be injured in the opera- tion. This is the so-called obstetric paralysis of in- fants. Other forms of peripheral paralysis require no spe- cial mention. PARALYSIS AFTER ACUTE DISEASES. Many acute diseases are sometimes accompanied with or followed by paralysis. Apparently the nature of the lesion which caused the paralysis is different in different cases. Among the diseases which are most frequently thus accompanied with local or more general paralysis may be mentioned small-pox, measles, scarlatina, typhoid fever, dysentery, sometimes diarrhoea, cholera, pneu- monia, and diphtheria. Generally, except in diphtheria, the paralysis oc- curs during the course of the disease, and may be found accompanying apparently light cases as weU as the more severe. Many times it seems as though an unusually high fever, perhaps of very short duration, were the exciting cause of the paralysis. Several times changes have been found in the spinal cord. This is especially true of small-pox. In other cases the paralysis seems to be of peripheral origin. The leo-s are more frequently attacked than the arms. The prognosis in almost all these cases is compara- tively favorable unless the spinal cord is the seat of the disease ; yet occasionally serious injury is done to the DIPHTHERITIC PARALYSIS. 295 nerves or nerve-centers, and recovery is imperfect, the patient remaining more or less helpless during the rest of life, with atrophy of the paralyzed muscles. The treatment is such as has been already indicated in speaking of peripheral paralysis, or such as is re- quired in corresponding cases where the nerve-centers are affected. DIPHTHERITIC PARALYSIS. Diphtheritic paralysis requires rather more atten- tion than has been given to those arising from other acute diseases. It occurs after the primary disease has ceased. The patient is thought to have recovered health, and from eight to thirty days afterward the nervous disturbance is first noticed. The paralysis may appear after either severe or light cases of diph- theria. When it occurs soon after the primary disease, it is more gradual in its onset, and successive nerve- regions are affected one after the other. Diphtheria is most common between the ages of two and twelve. The paralysis following diphtheria is most common between the ages of ten and eighteen. It is impossible to foretell whether or not the patient will have paralysis following diphtheria. Symptoms. — The temperature often rises for a short time before the occurrence of the paralysis. In the ma- jority of cases there is first a slight change in the voice, which becomes nasal. The velum palati and the mus- cles of the larynx being paralyzed, there is regurgita- tion in swallowing liquids. When the attempt is made to swallow food, a portion passes down the wrong way into the larynx, causing choking and coughing. Sometimes disturbance of sight is the first symp- tom, there being dimness or partial loss of vision on account of paralysis of the muscles of accommodation. Strabismus may be caused by paralysis of the motor muscles of the eyeball. Frequently the legs lose the power of motion ; the 296 DISEASES OF TEE PERIPHERAL NERVES. patient is unable to walk. Next in frequency the arms and hands are affected. Occasionally there is paralysis of the diaphragm, and less frequently of the heart. It is rare to have a case in which the paralysis is general. Usually one or two limbs are most affected, the others being only slightly affected, or escaping entirely, and in the majority of the cases the paralysis is limited to the velum palati and the larynx. The reaction of degeneration is very common in diphtheritic paralysis ; indeed, in the majority of cases the loss of power is due to a lesion of the ante- rior roots of the spinal nerves. It is supposed, how- ever, that the disturbance in the throat is due to a lesion of the nerve as it passes near the seat of the original disease. Sensation is only exceptionally disturbed. Very rarely, instead of loss of motor power, severe pain is felt in the course of certain nerves. Diagnosis. — The history of a previous sore throat or attack of diphtheria is sufficient to show the nature of the subsequent nerve-lesion. Without such his- tory it would be impossible to recognize the cause of the paralysis, though the nasal voice, the regurgitation of food, and the choking in swallowing, might lead one to suspect that there had been a diphtheria which had been overlooked. Prognosis. — The prospect is generally favorable, although occasionally patients die from an extension of the paralysis to the heart or muscles of respiration, and sometimes from inhalation's pneumonia, due to the passage of food into the bronchi. Except in such cases, the patients almost invariably recover under proper treatment. Treatment. — Where deglutition is seriously inter- fered with, the greatest care will be necessary in the treatment of the patient to avoid the passage of food into the trachea. Usually a soft solid can be swallowed better than i DIPHTHERITIC PARALYSIS. 297 liquid food ; but in many cases it is necessary to omit feeding the patient by the mouth for a while, and in that case food should be given by enemata, in the way which has already been described. If necessary, a tube may be passed down the throat into the stomach, and the patient can be thus supported by artificial feeding. Paralysis of the limbs should be treated by keeping the limbs warm, by massage, by stimulating bathing, as with salt-water, warm rather than cold, and by the use of electricity. Iodide of iron is one of the most valuable tonics for such patients, and cod-liver oil, if it can be taken, is of great use. Otherwise, except as indicated by the pa- tient's general condition, no special treatment is neces- sary. CHAPTER XXV. SPASM. Nothnagel, Zur Lehre von klonische Krampf e. Virch. Arch. , xlix, pp. 267, 290.— Mitchell, S. W., On Functional Spasm. Am. Jour, of the Med. Sci., Oct., 1876, p. 321.— Mills, C. K, Spasms of the Muscles supplied by the Spinal Accessory Nerve. Am. Jour, of the Med. Sci., Oct., 1877, p. 425.— Remak, E., Zur Pathologie und Therapie localisirte Muskelkrampfe. Berl. kl. Wochenschr., May 23, 1881, p. 289.— Jones, C. H., Clinical Lecture on a Case of Spasmodic Disorders of the Lower Limbs. Brit. Med. Jour. , July 2, 1881, p. 41.— Robinson, E., Cases of Telegraphists' Cramp. Brit. Med. Jour., Nov. 4, 1882, p. 880.— Sinkler, Spinal Accessory Spasm. Med. News, April 19, 1884, p. 453.— Poore, G. V., An Analysis of Seventy-five Cases of Writers 1 Cramp. Med.-Chir. Trans., 61, 1878, p. 111. — Ibid., Writers' Cramp. Practitioner, 1873.— Althaus, J., On Scriveners' Palsy. London, 1870.— Vigou- roux, R., Du traitement de la crampe des ecrivains par la me- thode de Wolff. Le prog, med., x, 1882, p. 37.— Thomsen, J., Tonische Krampfe in willkiirlich beweglichen Muskeln in Folge von ererbter psychischer Disposition. Arch. f. Psych., vi, 1876, p. 702. — Ballet et Marie, Spasme musculaire au debut des mouvements volontaires. Arch, denevrol., Jan., 1883, p. 1.— Rin- ger, Sydney, On the Nervous or Muscular Origin of Certain Spastic Conditions of the Voluntary Muscles. Lancet, Nov. 1, 1884, p. 767 et seq. The convulsive actions included under the name spasm are of several varieties. Tremor is a very fine spasm of the muscles, which produces a trembling of the limbs, sometimes scarcely perceptible. It is rather a symptom of several morbid conditions than a disease of itself. Tonic spasm is a name given to the spasm when a muscle is contracted continuously without relaxation. SPASM. 299 This, also, is rather a symptom than a disease, being found more especially in tetanus and spinal meningitis. It is sometimes difficult to recognize the difference be- tween a tonic spasm and what is called contracture of the muscles ; in fact, the latter may be looked upon in its earlier stages as simple tonic spasm, but later there is usually a change of structure in the muscles, and, the contracture becoming permanent and depending in large measure upon this change of structure, can no longer be called a tonic spasm. Clonic spasm is a name given to the convulsions which are attended with a rapid contraction and relax- ation of muscles. When these clonic spasms are ex- treme, and large groups of muscles are attacked, the name convulsions, or eclampsia, is used rather than clonic spasm, the latter name being reserved for the less severe and less extensive convulsions. In the following descriptions, clonic spasms will be chiefly considered. These are generally reflex in their origin, depending upon the irritation of some sensitive peripheral nerve, possibly far from the seat of the spasm. They many times, also, depend upon lesion of the central nervous system, in which case they are simply symptoms of the disease which gives rise to them. All such cases of spasm of central origin have been considered under diseases of the nerve-centers. It is not necessary to mention in detail spasms of all the various nerves. A few have such peculiar charac- teristics, and occur so frequently, as to be deserving of a separate mention. SPASM OF THE FACIAL NERVE. Irritation of the facial nerve in its course through the temporal bone, or at the base of the skull, may give rise to a spasm of the muscles supplied by it. Slight spasm of the muscles of the face is sometimes seen after facial paralysis. Irritation of the fifth nerve may, 300 DISEASES OF THE PERIPHERAL FERVES. by reflex means, also produce spasm of the facial mus- cles. Very severe convulsive action of these muscles may accompany the pain in severe cases of trifacial neuralgia ; or, without pain, decayed teeth, inflamma- tion of the conjunctivae, abscesses about the face or in the cavity of the mouth, the influence of very bright light upon the eyes, as from the molten metal in a blast-furnace, may be causes. An irritation of distant organs, as the intestinal tract, or the uterus, seems sometimes to be the starting-point of facial spasm. This spasm is generally unilateral. All the mus- cles of one side of the face may be thrown into violent convulsions, producing the most ludicrous grimaces, lasting for a few seconds, relaxation being followed soon by another attack. The series of attacks may continue for several sec- onds or minutes, when there is a period of rest until the next attack occurs. Or, instead of general spasm, one or a few muscles may be affected. There may be slight twitching about the mouth or face. It may seem almost as if the patient had simply acquired a habit of which he might be readily broken. These spasms, how- ever, are very frequently involuntary and entirely be- yond the control of the will. Sometimes the orbicularis palpebrarum is exclu- sively affected ; then the patient closes the eye violent- ly, or simply winks rapidly. Occasionally the muscles of the forehead are also implicated. Blepharospasm is a tonic spasm of the eyelids, the contraction of the orbicular muscle persisting some- times for many minutes, or even hours. A bright light, an attempt to use the eyes for near vision, especially where great care is necessary in seeing small objects, as fine print, is sufficient to bring on an attack in those who are subject to this form of spasm. Sometimes a simple mental emotion will cause an attack. Pressure upon certain parts of the face may have TORTICOLLIS. 301 the effect of relaxing this spasm, and occasionally such pressure will cause other facial spasms to cease. These points correspond to the painful points in facial neu- ralgia ; or such points may be found within the cavity of the mouth, or over the back of the neck, or even in regions supplied by the brachial plexus of nerves. Pa- tients frequently learn where these points are, and are able to cut short the spasm themselves. TORTICOLLIS, OR. WRY-NECK. Slight attacks of wry-neck may follow exposure to cold, and is spoken of as stiff-neck. This may also be the cause of more severe attacks ; it is said to arise also by reflex influence from irritation of the abdominal and pelvic viscera; in very many cases the cause is unknown. Symptoms. — The muscles affected in this form of spasm are those supplied by the spinal accessory nerve, the trapezius, and the sterno-cleido-mastoid. When the latter is contracted, the head is drawn over so that the occiput approaches the shoulder of the affected side ; the chin is turned toward the opposite side, and slightly upward. When the trapezius is affected, the head is drawn backward, and inclined toward the affected side. There is no rotation. Sometimes the shoulder is raised. The spasm usually begins so qui- etly and mildly that the motion at first is not notice- able. Soon the action of the muscle becomes stronger, and then the head is turned and jerked in a very dis- tressing manner. The spasms occur in separate paroxysms, lasting for a few seconds or minutes, frequently repeated, at times, with long intervals of rest. Sometimes other muscles are also affected besides those above mentioned. Patients learn to support the head by their hands, and forcibly to restrain the unpleasant action of the muscles. In violent cases, however, this manoeuvre is only partially successful. 302 DISEASES OF TEE PERIPHERAL SERVES. Sleep may be interfered with. It may be difficult for the patient to take food. The mental influence of the affliction is such as to cause depression of spirits and diminish the appetite ; the patients may become thin and emaciated in consequence. Slight cases, how- ever, have no effect upon the general health. These muscles are occasionally affected with tonic spasm, in which case the head is firmly fixed in the po- sitions above mentioned. Diagnosis and Prognosis. — The diagnosis of these spasms is not difficult. The principal mistake would be, in cases of tonic spasm, to consider that the antago- nistic muscles were paralyzed. Spasm of other mus- cles of the neck may be mistaken for those already mentioned. When the splenius capitis is affected, the head is drawn backward and toward the affected side, the chin is somewhat depressed and directed toward the side of the spasm, and a hard ridge can be felt where the splenius appears beneath the anterior border of the trapezius. Spasm of the obliquus capitis infe- rior turns the head around its vertical axis without ele- vation of the chin or depression of the mastoid process. Spasm of the deep muscles of the neck draws the head strongly backward if bilateral, or toward the affected side when unilateral. (Ross.) In both facial spasm and torticollis the prognosis is very unfavorable. Very few cases recover. Treatment seems to be of very little value. In some cases electricity is successful. The galvanic cur- rent should be applied to the affected muscles, and the faradic current to their antagonists. Apparatus to produce permanent compression over the points of arrest has been tried, in some cases with success. Stretching of the spinal accessory, as it runs along the posterior edge of the sterno-mastoid, has been em- ployed with success in curing the spasm of torticollis. Division of muscles, or their tendons, has been em- SPASM. 303 ployed in some cases with advantage, especially in the tonic form of spasm. Counter-irritation over the nerves supplying the affected muscles, by means of blisters or the actual cautery, may be of value. Of internal remedies, the most successful have been phosphate of zinc, sulphate of zinc, bromide of potas- sium, arsenic, and especially subcutaneous injection of atropia. Spasm of the Diaphragm, if tonic, may be the cause of death, and is always a serious affection. It rarely occurs independently of other disease. Clonic Spasm of the Diaphragm, or Hiccough, may be a light affection, with which every one is fa- miliar, or it may be a serious and obstinate symptom of disease of the viscera or of the nervous system. It is frequently associated with gastric, intestinal, and hepatic diseases, and in many cases is a symptom of bad omen, indicating the approaching fatal termi- nation. When existing independently of serious dis- ease, it is often obstinate, resisting treatment. The galvanic current applied along the course of the phrenic nerve, or, locally, over the insertions of the diaphragm ; the faradic current applied to the epigas- trium ; hot applications over the epigastrium — may be of benefit. Subcutaneous injections of atropia are especially useful, and those of morphia are of benefit. Thomsen's Disease.— A form of spasm has lately been described which is of more interest as a curiosity than practically as a disease. It consists of a stiffness and rigidity of the limbs, especially the legs, appear- ing only when an attempt is made to change the posi- tion, as in rising from a sitting posture, or commencing to walk after standing still. When the patient wishes to take a step, the leg is raised slowly, and with evident exertion, to an angle of about 120°. Standing very un- steadily on the other, the patient sets this down in nearly the same angle. If he then tries to raise the 304 DISEASES OF THE PERIPHERAL NERVES. other leg, lie will fall, generally on the knee, rarely backward; or, if lie does not fall, he will walk un- steadily, the hips and knees bent at an angle of 120°, and remaining flexed while walking. After a few steps the gait improves, and soon the patient can walk natu- rally. Passive motion meets with resistance which is more marked the more rapid the motion. The arms and hands, or even face, are sometimes affected, and there is a similar difficulty in executing any movement as is found in the legs. The affected muscles are unnaturally large and hy- pertrophied ; there is no increase of fat ; no reaction of degeneration, though the electrical reaction may be less than normal. There is, as a rule, no pain, no cramp. The disease usually commences very early in life, perhaps is congenital, and in Thomsen's case seemed to be a family trait. Several authors locate the affection in the muscles. PROFESSIONAL CRAMP. Under this term may be included the difficulty which is found by writers and pianists, telegraphers, and oth- er persons in performing the various acts required by their profession, in consequence of spasm or weakness of the muscles engaged. ^Etiology. — The cause of this affection is usually an excessive use of the hands and fingers, long con- tinued, in persons of a neurotic temperament, or who have been weakened by previous disease or debility. Occasionally injuries, sprains, blows upon the hand or arm, and exposure to cold, act as causes. Symptoms. — At first the difficulty experienced is very slight, consisting simply in a little awkwardness of motion or stiffness of the fingers ; sometimes a mere unpleasant sensation, hardly sufficient to be called pain, indicates the approach of the trouble. The arm and hand become more easily and quickly tired. Gradu- ally these symptoms become more marked ; the hand- PROFESSIONAL OR AMP. 305 writing becomes decidedly poor ; spasms appear in dif- ferent muscles, and sometimes the thumb and fingers are so strongly flexed that the pen is pressed against the paper and broken ; at another time the extensor muscles are affected, and the fingers open, allowing the pen to drop. There is rarely decided pain, but a sense of weari- ness and exhaustion. Sometimes, however, the dis- comfort is very great, and extends up the arm as high as the shoulder. Occasionally pain is felt along the course of the nerve-trunks. When the disease is well advanced, the patient can write at most only one or two words — perhaps can not even sign his name. The arm and hand can be used for the ordinary pur- poses in life ; even laborious manual work can be per- formed without difficulty ; but, as soon as the patient undertakes to employ the fingers for any delicate opera- tion, as writing, playing the piano, or sewing or knit- ting, the symptoms immediately reappear. The electrical reaction of the muscles is increased in the early stages of the disease, and it is only after a long time that any diminution of the reaction can be recognized. Persons affected with this disease may learn to write with the left hand : but in so doing should be careful not to overtax that hand ; if they do, the same symp- toms may appear on the left side ; if careful, they may be able to use the left hand without difficulty. Views differ somewhat as to the nature of this af- fection. Althaus looks upon it as due to fatigue and functional irritability of the co-ordinative centers in the upper portion of the spinal axis. Ross is inclined to look upon the main lesion as situated either in the gan- glion-cells of the spinal cord, or the nerves when the electrical reactions are diminished ; in the cortex or conducting-path above the spinal level when the elec- trical reactions are increased. Others consider that the 20 306 DISEASES OF THE PERIPHERAL NERVES. seat of the disease is in the muscles or the terminal nerve-apparatus. The diagnosis presents no special difficulties. The prognosis is far from favorable except in very recent cases. Treatment. — Entire rest from the cause of the dis- ease is absolutely necessary for recovery. This rest must continue for many months — six at least. The galvanic current frequently gives good results. It is applied in various ways by different observers. One pole should be placed on the neck over the spinal column, and the other applied over the affected mus- cles and nerves of the arm. Erb recommends the application of the galvanic cur- rent to the head (transversely, longitudinally, oblique- ly) ; also to the cervical sympathetic. Showering the arm with hot or cold water some- times gives relief. Wolff has obtained excellent results by the combi- nation of gymnastics and massage. He uses both act- ive and passive motion, exercising the affected mus- cles until they are fatigued. The massage is applied to the fingers, hand, wrist, and arm. He uses percussion with the ulnar border of the hand over the affected muscles. His method has attracted much attention, and several articles have appeared in recent medical journals describing the process. CHAPTER XXVI. DISEASES OF THE SYMPATHETIC. Wright, H. G., Headaches : their Causes and their Cure. London, I860.— Smith, A. A., The Therapeutics of Headache. Med. Record, Aug. 5, 1876, p. 503.— Woakes, E., The ^Etiology and Treatment of Occipital Headache. Practitioner, April, 1878, p. 263. — Warner, F., Recurrent Headache in Children. Brit. Med. Jour., Dec, 6, 1879, p. 889 ; Brain, Oct., 1880, p. 309.— Day, W. H, Headaches : their Nature, Causes, and Treatment. Philadelphia, 1883. Liveing, E., On Migraine. London, 1873.— Allbutt, On Mi- graine. Practitioner, x, 1873, p. 25— Seguin, E. C, A Contribu- tion to the Therapeutics of Migraine. N. Y. Med. Rec, Dec. 8, 1877. — Spender, J. K., The Treatment of Migraine. Lancet, June 14, 1884, p. 1144.— Hughes, C. H., Migraine. Alienist and Neu- rologist, April, 1884, p. 277.— Brunton, T. L., On the Pathology and Treatment of some Forms of Headache. St. Barthol. Hosp. Rep., 1883, p. 329.— Jewell, J. S., The Nature and Treatment of Headaches. Jour, of Nervous and Ment. Diseases, Jan. -April, 1881. CEPHALALGIA.— HEADACHE. It is not necessary to consider headaches occurring as one of many symptoms in various constitutional and inflammatory diseases, nor as an attendant upon or- ganic cerebral diseases. Even when not thus associ- ated, it is frequently only one of several symptoms, but the one which gives most distress, and requiring relief. Whatever seriously lowers the tone of the nervous system or the general health may be an efficient cause. Neurasthenic patients usually suffer from some form of headache, most frequently of a dull or heavy kind, which is almost continuous. 308 DISEASES OF THE SYMPATHETIC. Defective sanitary conditions, bad drainage, or poor ventilation, may cause the disturbance ; frequently a morning headache may be traced to sleeping in an illy- ventilated room. Anaemia and hyperemia of the brain are said to cause headache. I doubt whether the variety of pain will help to distinguish between these two conditions : the diagnosis must be made from other symptoms or conditions. It is to be kept in mind that an anremic patient may have a sudden flow of blood to the head, giving rise to headache of the congestive variety. Alcohol, tobacco, various deleterious gases, as sul- phureted hydrogen, carbonic oxide, or the gas used for lighting, may cause headache ; chronic lead-poisoning is another cause. Headache is sometimes the only symptom of tertiary syphilis ; it is frequent in Bright's disease, and may be the first sign of trouble. There is also, apparently, a connection between headache and rheumatism and gout. A very large class of cases are reflex in origin, de- pending upon disease or derangement in distant or- gans ; the digestive and urino-genital organs are most frequently the seat of such disturbance. Differences in the refractive power of the eyes may be the exciting cause of headache, and in every doubt- ful case an oculist should examine the eyes. A careful examination of all the possible derange- ments is necessary to form a correct diagnosis ; but with care there is usually not much trouble in arriving at a reasonable conclusion : in some cases, however, it will not be possible to discover the cause or nature of the affection. Headache is rare in early childhood, and, when pres- ent, may be of serious import ; it ought to lead to a watchful care lest it should be the forerunner of some serious disease. About the period of second dentition, and until puberty, headache may be more common, HEADACHE. 309 and is sometimes severe and continuous, with remis- sions, but few intermissions. It is not then of a sharp, piercing character, but rather heavy and .dull, increased by mental exertion and confinement. In old age it is not common, and is of more impor- tance than in middle life. Tkeatment. — It may be necessary to change the patient's mode of life or residence. If there is any unfavorable influence about the house, it should be remedied, or, if that is not possible, the patient should change his residence. Too severe mental application, whether in study or in business, must be moderated, and this is not always easy to accomplish. Sedentary habits must be broken in upon, exercise out of doors must be insisted upon, and late hours, whether for business or amusement, must give place to early retiring. High heels and tight lacing, and insufficient clothing, need to be looked after, even if the contest with what is thought fashion- able seems well-nigh hopeless. The diet should be regulated ; the high and gener- ous liver may expect to suffer until he can reduce his diet. An occasional saline cathartic may give tempo- rary relief; or, if there is a gouty tendency, colchi- cum may be used ; but more than that is needed, and while the patient persists in indulgence not much will be gained. In gouty cases, citrate of lithia, five grains or more three or four times a day, promises well. Alcohol and tobacco should, of course, be given up ; if there is any suspicion of lead-poisoning, iodide of potassium should be given to eliminate the poison. Dyspepsia, or other affections which may act as causes, must be treated by appropriate means if pos- sible. During the attack, in cases of excessive blood-sup- ply, counter-irritation to the back of the neck, cold to the neck, or an ice-bag to the lower part of the spine, ergotin in three-grain doses, bromide of potassium in 310 DISEASES OF THE SYMPATHETIC. thirty to sixty grains ; if the pain is severe, wet cups to the back of the neck, or leeches behind the ear — may be tried. In nervous headaches, or those caused by exhaus- tion or overwork, citrate of caffein, two to five grains, is frequently sufficient for its removal; yet the caffein sometimes causes nausea. Aromatic spirit of ammonia and sweet spirit of niter are excellent remedies ; a tea- spoonful of each can be given, and repeated in one or two hours if necessary. Valerianate of ammonia, spir- it of lavender, camphor, or asafoetida, may serve when other remedies fail. Hot water to the head is usually more grateful than cold. Between the attacks, ergotin, in tendency to a con- gestive condition, with care as to habits. In other cases, the various tonics, cod-liver oil, and good feed- ing. Extract cannabis Indica, in third to half-grain doses three times a day, has proved very useful, not merely in migraine, as advised by Seguin, but in more common forms. The drug should be continued several weeks. Iodide of potassium seems to be useful in other cases than where there is a rheumatic or syphilitic taint. Dr. Haley found that it relieved a dull, heavy headache over the brows accompanied by languor, chil- liness, and feeling of discomfort. He gave it in two- grain doses, in half a wine-glass of water, to be sipped slowly. Massage to the head will often relieve the pain in a few minutes ; in chronic cases, the massage should be given for a long time, and may be general. The galvanic current, passed from the forehead to the back of the neck, or transversely, may be tried, or the faradic current from forehead to neck. It is better to use the operator's hand as the electrode on the fore- head, the battery-electrode being held in his other hand. The hand fits the shape of the forehead better than the common metallic electrodes, and the operator SICK HEADACHE. 311 can thus judge more correctly as to the strength of the current, which needs to be very mild. MEGRIM.— SICK HEADACHE.— MIGRAINE. Megrim, or sick headache, is a paroxysmal head- ache, usually limited to one side, frequently attended with nausea and vomiting ; the intervals between the attacks are usually free of pain. .ZEtiology. — Heredity is even more evident in this than in many neuroses. Frequently it occurs in several successive generations in the same family. Women are slightly more liable than men ; Liveing says as 5 to 4, Eulenburg says as 5 to 1. The first attack occurs most frequently before ten, or at puberty. It rarely begins after twenty-five. Certain influences, as imprudence in diet, exhaust- ing exertions, excitement, late hours, noise and confu- sion, will give rise to an attack : and these may occur more frequently at the catamenial period ; but why it is so we do not know. Symptoms.— As in other "explosive" neuroses, the patient is usually free from pain, and in the enjoyment of good health, between the attacks. Sometimes the paroxysm is preceded by a warning ; perhaps an un- usual buoyancy of feeling and sense of exhilaration are noticed on the preceding day, and the patient knows he is about to be sick because he feels so well. Or, again, an indisposition begins the day before, and gives notice of the coming storm. In almost every case, pain is the most prominent symptom. The pain is felt on waking ; usually it is mild at first, but increases as the day advances until it reaches its greatest intensity. Sometimes the pain be- gins later in the day, and occasionally it is absent throughout the attack, the other symptoms alone ap- pearing. The pain varies much in character and se- verity in different attacks, even in the same person. It is usually unilateral, the side affected varying, at one 312 DISEASES OF TEE SYMPATHETIC. time the left, and the next time, perhaps, the right side suffering. Sometimes it is bilateral, though then one side may suffer the more severely. At the beginning of the attack the pain is limited to one region, gener- ally the forehead or the temple ; as it becomes worse, it spreads over the whole side of the head. The pain continues throughout the paroxysm, six or eight to twenty-four hours, rarely longer, though a sense of heaviness or depression may remain for a while longer. There is general tenderness of the scalp over the region affected, rather than any special tender points. Almost from the commencement of the pain there is a loss of desire for food, or absolute loathing of it. As the headache continues, this feeling changes to nausea, and at length vomiting sets in. One severe spell of vomiting may close the attack, and the pain cease, drowsiness or sleep following or not. Generally, how- ever, more than one fit of retching and vomiting occurs, and the prostration is correspondingly severe, as the pallor, sweating and weakness show. The drowsiness or heavy sleep which sometimes follows the vomiting may be in part the result of the exhaustion caused by the pain and the vomiting. It is not like the quiet, natural sleep which sometimes closes the attack ; it rather resembles the stupor follow- ing an epileptic fit. Other symptoms are less common than the pain and nausea. Visual disturbances are next in frequency, and, when present, generally appear before the pain. They consist in partial or total loss of sight, and in va- rious luminous appearances, of greater or less brilliancy, and sometimes colored. The loss of vision is sometimes central and sometimes lateral ; there may be true lat- eral hemianopsia. The luminous phenomena may con- sist simply in the perception of a bright light, without definite form, or there may be zigzag lines of light, sometimes colored, resembling fortifications. A small point of light is first seen, which gradually expands, SICK HEADACHE. 313 increasing in size, assuming the above zigzag form, un- til it extends beyond the field of vision and disappears. Meanwhile, a new spot appears, and goes through the same changes ; the lines of light have tremulous mo- tion. Disturbances of common sensation, anaesthesia, and sometimes of the special senses, on the same side with the headache, are less frequent. When the numbness is on the right side, there may be with it one of the forms of aphasia. In severe cases it is impossible for the patient to apply himself mentally ; but sometimes more than this mental disturbance is noticed, though not to any serious extent, even during the seizures. Pathogenesis. — It is often assumed by the patient that the attacks of migraine are due to gastric disturb- ance ; as the nausea and vomiting are so frequent, this is not strange, and too often the physician falls in with this view. While imprudence in diet may sometimes be the exciting cause of an attack, it is only incident- ally so ; other causes are equally as effective. The phe- nomena are all referable to cerebral influence ; the nausea is from the encephalon, not from the stomach. Any one interested in the different theories will find them fully discussed by Liveing. There seem to be two conditions of the cerebral circulation during the attacks ; in some the vessels seem to be in a state of spasm, contracted ; in others dilated. Liveing refers the attacks to the explosive tendency to be found in the nervous system even in health. There is usually no anatomical change possible, as the attacks are so fugitive. Occasionally certain of the sensory disturbances, as numbness or visual change, are more permanent, so that a slight structural change in the brain might be possible. A change in the circu- lation, and, in the above rare cases, in the structure of the posterior part of the inner capsule and adjoining portion of the optic thalamus, would explain the symp- 314 DISEASES OF THE SYMPATHETIC. toms, except, perhaps, the headache and nausea. Pro- visionally, we may imagine this to be the seat of the change, though our actual knowledge in this regard is very slight. There is a resemblance between the attacks of mi- graine and those of epilepsy, which it is not necessary to specify minutely. A few cases have been observed in which migraine in early life was later replaced by epilepsy. Peog^osis. — The prospect is very slight of com- plete immunity from the attacks during early life ; with advancing years the frequency of the paroxysms diminishes, and finally the patient is free. Yet much benefit may be derived from treatment in diminishing the severity and frequency of the attacks. Teeatment. — Such hygienic measures should be adopted as will most effectually remove the exciting causes ; over-exertion of the brain, neglect of proper exercise and out-door life, late hours, excitement — such influences can be avoided by sufficient self-denial on the part of the patient except in the cases where the struggle for the necessaries of life demand the sacrifice. Much can be done, also, by means already alluded to, to increase the strength and vigor of the nervous sys- tem. During the attack the patient will instinctively take the precautions as to rest and posture which are most favorable. The friends may, however, be too fussy. Quiet, i. e., freedom from noise, motion, jarring, and from conversation ; exclusion of light ; coolness in the atmosphere of the room, not chilliness ; abstinence from food — these conditions may be obtained by the aid of friends, or officious friends may render it impossible for the patient to have them. Drugs taken early in the attack may diminish its severity. Sometimes a large dose of quinine, ten to twenty grains, is of benefit ; caffein, or citrate of caf- fein, in two- to five-grain doses, is more effectual ; prep- SICK HEADACHE. 315 arations of guarana have an effect similar to caffein. In cases of paralysis of the vaso- motor constrictor nerves, ergot is of value ; where there is spasm of those nerves, the inhalation of nitrite of amyl proves of value, but it may be necessary to repeat it several times at short intervals ; one to three drops may be inhaled ; when a patient's peculiarities and susceptibility to the drug are known, larger doses may be used ; belladonna or atropia may be of use in the same class of cases ; nitro-glycerine, or glonoin, as it is also called, has been recommended, one drop of the one-per-cent solution be- ing used in water, but its value is doubtful. Chloride of ammonium, twenty to forty grains, may diminish the severity of the pain. Copious draughts of hot water have been of value with some patients. After the nau- sea has become marked, internal remedies are likely to increase it, and add to the distress by causing vomiting ; though, in rare cases, the emesis relieves the pain and shortens the attack. Several remedies have a value in diminishing the frequency of the attacks. Extract of cannabis Indica in one-third- to one-half-grain doses three times a day is very valuable, but it must be continued several weeks. Valerianate of zinc, three grains three times a day, is also useful ; and in larger doses, five or six grains every three hours, it may shorten the attack. Liveing found iodide of potassium, five grains three times a day, of advantage, and he also recommends bromide of potassium. It should be given in ten- to twenty -grain doses three times a day for several months. The galvanic current may be used with advantage. In cases where the vessels are contracted, the negative pole should be held in the hand, or on the back of the neck, while the positive pole is placed over the cervi- cal sympathetic without interruptions. In cases with paralysis of the constrictor vaso-motor nerves, Erb ad- vises the cathode over the sympathetic, and that the 316 DISEASES OF TEE SYMPATHETIC. current should be repeatedly opened and closed, avoid- ing, however, too strong irritation. The faradic current, used as advised for simple headache, sometimes gives relief. Many times these applications can not be made dur- ing the attack, as the pain is increased by the simple manipulations necessary, and not relieved by the elec- tricity. Between the attacks, general faradization or galvani- zation may be of great service, as in other cases of di- minished nervous power, in restoring the system to a normal condition. Massage would rarely be of value during the attack, but in its incipient stage, and between the attacks, may be of great benefit. GRAVES'S DISEASE (Exophthalmic Goitre). Eulenburg und Guttmann, Die Basedow'sche Krankheit. Arch.f. Psych., i, 1868, p. 430.— Wilks, S., Exophthalmic Goi- tre. Guy's Hosp. Rep., 1870, p. 7.— Russell, J., Clinical Illus- trations of Graves's Disease. Med. Times and Gaz., Sept. 2, 1876 et seq. — Chvostek, Die Therapie der Basedow'sche Krankheit. Zeitschr. f. Therapie, No. 8, 1883. Exophthalmic goitre is an affection attended with three prominent symptoms — palpitation, goitre, and exophthalmos. Symptoms. — The disease usually begins by a nerv- ous irritability and change of character, feeling of fullness in the head and eyes and neck, and palpita- tion. In most cases the palpitation is spoken of as the first symptom, perhaps because it first attracts atten- tion. The heart's action rises to 100 or 150 ; but there are no signs of organic disease of the heart. The projection of the eye is usually attended with a diminution in the motion of the upper lid, so that, if the eyeball is rolled upward, the lid does not move in harmony therewith. Sight is not affected, and accommodation is not dis- GRAVES'S DISEASE. 317 turbed. The ophthalmoscope generally shows nothing abnormal, though optic neuritis has been seen. The thyroid gland slowly increases in size until it becomes quite prominent ; even the middle lobe may be enlarged. In consequence of this enlargement, the voice may be somewhat changed in character, and res- piration may be disturbed. Various general symptoms may be associated with the above. The appetite suffers; diarrhoea sometimes sets in ; there may be extreme emaciation ; anaemia is not uncommon. Among women, the catamenia may cease, or there may be dysmenorrhcea. There is sometimes unilateral sweating. Sometimes one of the three prominent symptoms may be absent. As a rule, the symptoms are very slightly marked at first, but gradually increase in severity, the disease be- ing chronic in its course. Occasionally an acute case appears, in which all the symptoms are rapidly devel- oped. Pathology. — The pathology of this disease is by no means easy to explain. Panas is inclined to think that the disease depends upon a disturbance of the medullary oblongata, an irritation which would excite the sympathetic fibers passing to the heart, and the vaso-dilator nerves would explain the symptoms. Or, on the contrary, a paralysis of the inhibitory nerves, and of the vaso-constrictures. Panas is inclined to the belief that the latter is the correct explanation. Anatomical changes have been found several times in the cervical sympathetic, especially in the lower ganglion. Prognosis. — Prognosis is not very favorable, though several cases of recovery have been reported. Treatment.— Digitalis has but little influence in moderating the rapidity of the heart's action. Bella- donna has sometimes been of use. Quinine and iron 318 DISEASES OF THE SYMPATHETIC. have also proved serviceable. The best results have been obtained by Chvostek from the use of electricity. He used the ascending galvanic current to the cervical sym- pathetic, and on each side, stabile, one minute ; to the spinal cord the positive pole on the fifth dorsal, the negative on the cervical vertebrae ; he also passed a cur- rent transversely through the head from one mastoid process to the other ; or in some cases applied it to the temples. The application was about one minute in each place. He used a very weak current, which caused no sense of heat, and applied it daily. Meyer and Leube have both obtained good results from galvanism. ANGINA PECTORIS. See, G., De l'angine de poitrine. France med., 1876, p. 197 et seq. — Balfour, G-. W., Upon Paroxysmal Angina Pectoris. Edinburgh Med. Jour., March, 1881, p. 769.— Huchard, H. Le concours med., No. 6, 1884. Angina pectoris is a disease characterized by pain- ful paroxysms, the pain being situated in the neighbor- hood of the heart, and radiating thence to the left side of the chest and left arm. The attacks are accompa- nied with great anxiety and a sensation of impending dissolution. JEtiology. — The disease attacks males by prefer- ence, and occurs most frequently after the age of forty. It is uncertain whether heredity plays any part in the aetiology of this disease. Gout, rheumatism, and alco- holism are supposed to be important as causes. Ex- cessive tobacco-smoking is also spoken of as predispos- ing to the disease. Many cases of angina pectoris are found in persons who have organic diseases of the heart, and these are naturally looked upon as giving rise to the pain. Especially is this true in regard to changes in the coronary arteries, or such changes at the com- mencement of the aorta as are likely to interfere with ANGINA PECTORIS. 319 the circulation of the blood through the substance of the heart. As directly exciting to the attacks may be men- tioned exposure to cold, unusual mental emotions and bodily exertion, especially walking against a strong wind, or walking rapidly up hill, or ascending a flight of steps rapidly. Yet many cases occur in which there has been no special exciting cause, as is particularly true of those attacks which occur during sleep. Pathological Anatomy. — The anatomical changes found are such as belong to the organic diseases of the heart, which may be supposed to exert an influence as predisposing causes. Otherwise than these changes, which need no special description, there is no anatomi- cal lesion discoverable. Symptoms. — The prominent symptom of this dis- ease is pain, which is situated usually along the left border of the sternum, and more especially near the apex of the heart. Thence the pain may radiate over the whole chest, may descend along the left arm, rarely going below the elbow. The pain is not so sharp and acute as some other species of neuralgia, but it is at- tended with such anxiety and distress, such a sense of danger to life, that it is much less bearable than almost any other variety of pain. During the attack the pulse is often increased in rapidity, but is rarely irregular unless there is organic cardiac disease. The respiration is sometimes unaf- fected, though very often the patient instinctively holds his breath, and remains immovable, supporting himself by his arms, as if afraid even to breathe. Each attack of severe pain is usually of but short duration ; but they may succeed one another rapidly, and the duration of the whole attack is very variable, sometimes extending over days, though when so long there are generally pe- riods of remission almost amounting to intermission. When the attack has finally ceased, the patient is usually free from pain until the recurrence of the next, 320 DISEASES OF THE SYMPATHETIC. which may not be for many months ; but, as the at- tacks recur, their frequency becomes greater, until the intervals between are very short. Prognosis. — When the disease depends upon an organic change of the heart, death usually follows after a longer or shorter interval. Where there is no organic change of the heart, the patient may recover, and live long without a recurrence of the disease. The nature of the disease is but imperfectly known. It is generally considered as belonging to the neural- gias. Some cases are referable to gout or rheumatism ; some are probably due to fatty degeneration of the walls of the heart. Some again, perhaps, depend upon an imperfect supply of blood to the heart, in conse- quence of disease of its nutrient arteries. It has also been referred to a neuritis of the cardiac nerves. As has been remarked : "It is very difficult to choose an opinion out of the midst of this labyrinth of explana- tions, which contradict each other and destroy each other." Diagnosis. — The chief danger of mistake lies rather in considering a simple neuralgia, affecting the inter- costal nerves, as angina pectoris. The character of the pain is different, the anxiety and distress attending it are much less in intercostal neuralgia, or are entirely wanting. Embolism of the pulmonary artery is attended with much greater dyspnoea, and the circumstances asso- ciated with it will assist to a diagnosis. It is of primary importance to learn whether the pain is associated with organic disease of the heart. To do this, it would be necessary to examine the heart between paroxysms. And even a careful physical ex- amination may not settle the question without doubt. Treatment. — Eulenburg says : " The remedies are many, the cures few." During the paroxysm it is most important to relieve the pain and distress. Nitrite of amyl will sometimes cut the attack short. ANGINA PECTORIS, 321 Five or six drops on a handkerchief, inhaled by the pa- tient, repeated if necessary, may suffice to relieve the paroxysm. The subcutaneous injection of morphia, with a small amount of atropia, will often give relief. With other patients, the most speedy relief is experienced from the application of ice immediately over the heart. M- tro-glycerine (glonoin), in the dose of one or two drops of the one-per-cent solution, has been recommended, and has, in some cases, proved very efficacious, not only in relieving the pain of the attack, but in warding off a recurrence. Acomtia, by preference Duquesnil's, in dose of from rro- to 2-fo- °f a grain, repeated, if necessary, every hour or two hours, until there is tingling of the lips, or tongue, or fingers, will often give relief, but is less rapid in its action than the remedies previously men- tioned. The benefit derived from this drug is, however, of longer duration. Tincture of aconite-root may be used instead. Between the attacks means should be taken to di- minish the danger of a recurrence. If there is any gout or rheumatic tendency, appropriate remedies should be used. In other cases the general health should be maintained, the patient cautioned against over-exertion of any kind, and, as many of these pa- tients are run down in general health and overtaxed, a large proportion of rest is absolutely necessary. Smoking should be given up. Among the drugs which may be used with the pros- pect of greatest benefit is arsenic. Besides this, prepa- rations of iron and zinc may be used. Nitrate of silver has been recommended. Digitalis, combined with the arsenic, is also mentioned as valuable. 21 322 DISEASES OF THE SYMPATHETIC. SYMMETRICAL GANGRENE. Raynaud, M. , Nouvelles recherches sur la nature et le traite- ment de l'asphyxie locale des extrernites. Arch. gen. de med., 1874, Jan., p. 1 ; Feb., p. 189.— Warren, J. C, Symmetrical Gan- grene of the Extremities. Boston Med. and Surg. Jour., Jan. 16, 1879, p. 76. — Weiss, M., Ueber sogenannte symmetrische Gan- gran. Zeitschr. f. Heilk., iii, 1882, p. 233. The causes of this peculiar affection are not known. The disease consists in a disturbance of the circulation, especially in the extremities, probably an affection of the vaso-motor nerves, by which the supply of blood is cut off, and hence the nutrition suffers ; and, when car- ried to an extreme, gangrene sets in, and the affected parts slough off. Fingers and toes are the most fre- quently affected ; but limited spots on the body, and even the face, may suffer. The disease is almost al- ways symmetrical, and is paroxysmal. In many patients there is a prodromic period of un- rest, with change of character. The patient becomes peevish, fretful, surly, withdraws within himself, and avoids contact with those whom he formerly sought, even his own children. He sighs, and frequently sheds tears. Sleep is restless, broken by dreams. Appetite poor, digestion difficult, and the slightest excess is fol- lowed by severe gastric crises, similar to those seen in ataxia. Hearing, sight, and taste may be diminished. A disagreeable sensation is felt in the limbs ; the circulation is sluggish ; the surface becomes cyanotic, perhaps almost black ; generally, severe pain, of a neu- ralgic character, sets in, which is without intermission, almost without remission. The affected parts are an- aesthetic, and this may cause the gait to assume an ataxic character. After reaching this stage, the symptoms may sub- side and the normal condition of the parts return. Otherwise, the disturbance of nutrition increases, and there is gangrene affecting the fingers and toes, or su- SYMMETRICAL GANGRENE. 323 perficial spots of the skin, and after fonr or five days the dried epidermis falls off, leaving a superficial ulcer, which heals slowly. If a whole phalanx of finger or toe is affected, this drops off, and the stump cicatrizes slowly. There is no fever attending the above phenomena. The heart is unaffected ; the pulse is not disturbed, even in the arteries near the cyanotic parts. The tempera- ture is lowered in the affected limbs. Occasionally there is no pain. Raynaud found the circulation of the fundus of the eyes affected, arteries contracted, and venous pulsation ; in one case he found these changes between the attacks ; in another case at the same time with the attacks. The diagnosis is not difficult when the whole series of symptoms is before one ; but at the beginning there might be some doubt as to the nature of the affection, and it would be excusable to suspect locomotor ataxia, or disease of the spinal membrane. Teeatment. — Warmth and rest are indicated ; some of the symptoms might be relieved by gentle massage. Raynaud obtained excellent results from the use of the galvanic current applied over the spinal column. He used from twenty-five to thirty cells, the positive pole over the fifth cervical vertebra, the negative pole over the sacrum. After a short time he slid the nega- tive pole up to the eighth dorsal vertebra. The appli- cation was continued ten to fifteen minutes daily. The circulation became more rapid ; abundant sweat ap- peared ; the hands became moist ; in some cases head- ache followed the application, and then it was neces- sary to reduce the number of cells. He also applied the positive pole over the nerves in the upper part of the limb, and the negative pole over the affected sur- face. He was able to use in this way from thirty to sixty cells. As improvement appeared, sensation be- came more acute, and it was necessary to reduce the number of cells. 324 DISEASES OF THE SYMPATHETIC. UNILATERAL FACIAL ATROPHY. Guttmann, P., Ueber einseitige Gesiclitsatrophie. Arch. f. Psych., i, 1868, p. 173.— Bannister, H. M., Progressive Facial Hemiatrophy. Jour, of Nervous and Mental Diseases, Oct., 1876, p. 539.— Hammond, Wm. A. Ibid., April, 1S80, p. 250.— Flashar, Ein Fall von bilateraler neurotischer Gesiclitsatrophie. Berl. hi. Woch., Aug. 2, 1880, p. 441.— Wette, H. CM. f. d. m. Wissen., July 8, 1882, p. 491.— Mendel. Berlin. Jcl. Wochenschr., Sept. 17, 1883, p. 588.— Jessop and Browne. St. Barthol. Hosp. Rep., xviii, 1882. — Wolff, Ueber doppelseitige fortschreit. Gesiclitsatrophie. Virch. Arch., 94, 1883, p. 393. The cause of unilateral atrophy of trie face is not certain ; more cases have been noticed in women than in men ; frequently injuries have preceded the atro- phy. Symptoms. — Preceding the change in the tissues of the face there may be a prodromic period, during which there is pain in the face and head, with perhaps hyperesthesia. Bannister noticed absence of perspira- tion on the affected side of the face, without pain. Before the atrophy, there is usually a whitish dis- coloration of the skin at the point where the change is about to take place. Two or three of these spots may appear at a moderate distance from one another, and run together. The hair becomes white, and may fall out. The atrophy affects the skin and subcutaneous tis- sues ; the bones rarely undergo atrophy, though their growth may be retarded if the patient has not reached adult years. The muscles of the face are not subject to any fatty degeneration. Hammond found the muscu- lar fibers diminished in size. Owing to the loss of fat tissue and change in the skin, the cheek is hollowed in ; the skin, lacking in elasticity, seems to be closely ad- herent to the bone. Sometimes the tongue, the hard and soft palate, are affected ; the eye seems to be sunken deeper into its socket, and the lids are partially closed. There is no muscular paralysis ; the electrical reac- tions are normal ; the circulation is rarely disturbed ; UNILATERAL FACIAL ATROPHY. 325 there is no change of temperature on the two sides of the face ; tactile sensation is not diminished. The disease does not lead to a fatal result, and no au- topsies have been made. Several theories have been advanced to explain the singular phenomena. It has been thought to be a disease of the cervical portion of the sympathetic, or of the nuclei of the facial or other cranial nerve ; of the spheno-palatine ganglion, or a primitive atrophy of the adipose tissue. ~No treatment has been of permanent benefit. Elec- tricity has been thought to give a slight relief. Both the galvanic and faradic current have been applied locally to the face, but no permanent improvement fol- lowed. UNCLASSIFIED. CHAPTER XXVII. VEETIGO. Eussell, J., Illustrations of Stomachic Vertigo and Allied Af- fections. Med. Times and Gaz., July 3, 1880.— Jackson, J. H., Lecture on Auditory Vertigo. Lancet, Oct. 2, 1880, p. 525. — Fere, Ch., et Demars, A., Note sur la maladie de Meniere et en particulier sur son traitement par la methode de M. Charcot. Revue de med., No. 10, 1881. — Leven, Du vertige. Gaz. des hop., May 23, 1882, p. 468.— Woakes, E., Remarks on Vertigo. Brit. Med. Jour., April 28, 1883, p. 801. Frank defines vertigo as "an illusional turning, painful and sudden, which seems to affect the person himself and external objects, whether they are in re- pose or moving in their ordinary manner." Vertigo is really a symptom, not a disease. It may be reflex or sympathetic, or the cause may escape our observation, and then it is spoken of as idiopathic. Axenfeld has said that vertigo is caused by a change in the intra-cranial circulation, either a lack of suffi- cient arterial blood, or hyperemia, causing the symp- tom. In both these conditions the molecular inter- change in nerve-cells is incomplete ; their nutrition suf- fers ; their functions are exalted, exhausted, or per- verted. Causes. — Vertigo is sometimes caused by dyspep- sia. It is one of the symxotoms of exhaustion, of cere- bral anaemia, of intestinal or uterine disturbance. Va- rious poisons may produce vertigo, as tobacco, alcohol, opium, oxide of carbon, lead, prussic acid, or urremic poisoning. It is very common in certain cerebral dis- eases,, especially those affecting the cerebellum. Heart 330 UNCLASSIFIED. disease is sometimes accompanied by vertigo. It may- be premonitory of various acute diseases, as the exan- themata. The petit mat of epilepsy is often simply vertigo attended with impaired consciousness. A disturbance of accommodation in the eyes, espe- cially if the eyes differ one from the other, may give rise to this disagreeable symptom. A slight weakness of some of the motor muscles of the eye, producing slight strabismus, may have the same effect. Of these, the causes are comparatively simple, and require little more than a mention. There is, however, a series of symptoms, due to disturbances of the ear, which de- serve more extended mention. Disease of the semicircular canals, or even a slight increase of pressure upon the fluid contained in these canals, is attended with vertigo. Even an accumula- tion of wax in the ear, or the closure of the Eustachian tube, may be sufficient to give rise to the symptoms. Vertigo, when caused by affection of the ear, was carefully described by Meniere, and hence has been called, from him, Meniere's disease. Besides vertigo, there is usually tinnitus, also deaf- ness, which in severe cases is complete. The attack is often sudden, the patient being obliged to stop, immediately seize hold of some object to sup- port himself, or perhaps he falls, as if suffering from an attack of epilepsy. There is, however, no loss of con- sciousness. His face is pale, his skin is cold, he is bathed in perspiration. There is nausea, vomiting, and headache. Many times the attack is less severe — the patient simply staggers instead of falling, and suffers severely from the accompanying symptoms. As a rule, the attack is not of long duration. The patient regains his steadiness and his usual health ; but, so long as the affection of the ear continues, there is danger of a re- newal of the vertigo. The treatment of auditory vertigo is, of course, first to remove any affection of the ear, any cause of press- VERTIGO. 331 nre upon the semicircular canals. Charcot found great benefit from the use of seven to fifteen grains of qui- nine daily for nearly three months. If necessary, the quinine, after having been omitted, can be repeated when the symptoms recur. Sometimes electricity may be of benefit, though very rarely. It is important to make a correct diagnosis as to the cause of vertigo. Auditory vertigo is very likely to be mistaken for epilepsy, or for vertigo associated with dyspepsia. Unless a correct diagnosis of the cause is made, the treatment is likely to be futile. The treatment of other forms of vertigo must be di- rected, according to the cause, to the primary disease. CHAPTER XXVIII. CHOREA. Stukges, O., Some Statistics of Fatal Chorea. Lancet, July 17, 1880, p. 85.— Mitchell, S. Weir, Lectures on Diseases of the Nervous System. Lectures VII, VIII. Philadelphia, 1S81.— Strange, W., Notes of 100 Cases of Chorea. Brit. Med. Jour., July 16, 1881.— Sturges, O., The Heart Symptoms of Chorea. Brain, July, 1881, p. 164.— Chapin, H. D., Points of Interest in Chorea. Med. Record, Dec. 15, 1883, p. 648.— Santini, G., Sulla patogenesi della corea. Rivista Sperimentale, ix, 1883, p. 449.— Sturges, O., Chorea with Rheumatism. Lancet, Aug. 31, 1878, Nov. 29, 1879, Sept. 20, 1884.— Houghton, J. H. Brit Med. Jour., Dec. 9, 1882.— Rickards, E. Ibid., Nov. 11, 1882, p. 932.— Fra- ser, T. R Ibid., Dec. 9, 1882, p. 1132. Chorea (Saint Titus's dance) may be denned as a neurosis affecting the voluntary muscles, generally pre- ceded and attended with slight mental disturbances, the motor phenomena consisting in irregularity of vol- untary motions, or, when severe, the spontaneous de- velopment of irregular motions apart from the inter- vention of the will. JEtiology. — Certain constitutional conditions un- doubtedly predispose to chorea. Heredity seems in some cases to be one of the predisposing causes ; the instability of the nervous system at certain periods of life, as during second dentition, and at puberty, are also to be taken into account, many more cases occur- ring from six to eleven years of age than at any other equal period. The disease is extremely rare after twen- ty-five years of age. The debility following scarlatina, diphtheria, typhoid fever, etc., frequently seems to predispose to the disease. Rheumatism appears to be- CHOREA. 333 long rather to the exciting causes, considering the fre- quency with which it is followed by chorea. The re- lation which the two diseases bear one to the other is still an undecided question ; they occur together too frequently to justify us in considering the relation purely accidental. Chorea may appear before the child recovers from the rheumatism. The restraint and discipline of school life, especially public-school life, with its ambitions, oftentimes has an injurious influence. Among the more immediate causes of chorea may be mentioned sorrow, care, anxiety, fright, and irrita- tion. Occasionally chorea occurs during pregnancy, especially among primiparse, and most frequently dur- ing the twenty-first and twenty-third years of age. Symptoms. — The earliest symptom is a change of disposition. The child becomes restless, irritable, is thought to be getting nervous, or to have the fidgets. It loses its temper more easily, gives impertinent and saucy replies to its parents ; in fact, the whole nature of the child seems to have undergone a decided change for the worse. Much too frequently the parents and teachers consider the child disobedient and naughty, whereas it is entirely irresponsible for its conduct, and, instead of taking the proper measures to stop the dis- ease at its very beginning by curing a physical malady, they make it worse by employing reproof, punishment, and harshness to correct a moral delinquency that does not exist. This change of disposition may continue throughout the disease, and even extend beyond the time when motor disturbances have ceased. During the severest attacks there may be lack of mental pow- er, and inability or disinclination to apply the mind vigorously ; the expression of the patient may be al- most idiotic. After the above mental symptoms have existed a variable length of time, motor disturbance makes its apx^earance, as a rule beginning on one side and ex- 334 UNCLASSIFIED. tending to the opposite side. Some authors say that the left side is the more frequently affected. Occa- sionally the motor disturbance is confined to one side during the entire disease. At first the irregular motion is slight, scarcely perceptible to an ordinary observer ; this irregular action of the muscles becomes more marked and constant. The face and upper extremities are in constant motion ; the patient is continuously making grimaces^ which at first may be thought volun- tary, and the child may be unjustly punished for " making faces." The fingers are flexed and extended, one or several at a time ; the child picks at its clothing, pulling and perhaps tearing it. When the lower ex- tremities are affected, the toes and legs are in constant motion, like the hands. Voluntary motion is inter- fered with ; the child is unable to write or sew ; often can not feed itself. Walking may also be difficult, or impossible. In extreme cases, not only are the limbs and face affected, but the body may also be turned and twisted and bent in various directions by the involun- tary action of the muscles of the trunk. The patient is unable to be up, is tossed about in bed ; the constant and violent motion causes excoriation of the skin ; he has a wan and haggard, perhaps a half-idiotic look, and is a pitiable sight. The respiration in severe cases is sometimes affected, acquiring a jerky character; speech may partake of the same jerky character, and it may even be almost impossible for the patient to speak. Except in very severe cases, sleep is not disturbed, and almost invariably the involuntary motions cease during sleep. In cases of moderate severity the pa- tients do not complain of being tired, and there is no appearance of exhaustion. Of course, this is not true of the severest cases. Sensation is but little if at all affected ; once in a while there may be pain, and sometimes tenderness, on pressure over the nerves. CHOREA. 335 M. Rosenthal found that the reaction of the muscles to both the faradic and galvanic current was frequently increased. It is very common to find a cardiac murmur in cases of chorea, even where there has been no rheumatism preceding. It is not very rare to find an irregular in- termission of the pulse. As the patient recovers, the cardiac symptoms disappear, unless caused by organic lesion. A so-called post-hemiplegic chorea is one of the sequelae of cerebral disease. The motions may very closely resemble those of chorea. This has been de- scribed in connection with cerebral diseases. When the disease is caused by fright, and occasion- ally under other circumstances, the motor symptoms show great intensity at the commencement, the most violent irregular action appearing in the course of a few hours. These cases, however, are exceptional. Duration. — The duration of chorea differs greatly in different cases. Some patients recover in three or four weeks ; in others the disease is extended over several years ; the average duration is said to be two or three months. It is not uncommon for a child to suffer from two or even three attacks. Between these attacks the child is considered well, and is thought to have been cured ; but many times a careful observation will show that the irritability of the temper and changed disposition persist ; also, if the child' s hand is quietly held, a very slight spasmodic action of the fingers can be felt — too slight, perhaps, to be seen. Many cases, therefore, spoken of as recurrence of chorea, are in reality simply cases of remission of the severer symptoms. Dr. Mitchell mentions the greater frequency of chorea in the spring, and a tendency to recur the succeeding spring. Diagnosis. — The milder cases of chorea can hardly be mistaken, especially if their history is learned ; the description of the disease already given is sufficient for 336 UNCLASSIFIED. diagnosis. There is a form of choreic disturbance which occurs after apoplexy, affecting the paralyzed side, which might be mistaken for genuine chorea. Charcot has well described this, and named it post-hemiplegic chorea. A history of the case showing the previous attack of paralysis, the fact that the affected limb still suffers from impaired power, and the difference between the involuntary motions in these cases and the irregu- lar action seen in genuine chorea, together with fre- quent presence of contraction, would assist in forming a diagnosis between the two conditions. In a few cases of cerebro-spinal sclerosis the irregu- lar involuntary motions become so general, and reach such a grade of severity toward the close of the dis- ease, that it is possible to mistake the affection and consider that the patient is suffering from chorea. In these cases the history of the disease and the general character of the motions, the fact that sensation is often affected in sclerosis, that contraction of the fingers and hand are more frequent, will aid in forming a correct diagnosis. These cases are, however, often very diffi- cult to distinguish from chorea. Pathological Anatomy. — The nature and seat of the lesion causing chorea are still undecided questions. Mild cases recover, leaving no disability ; only severer cases result in death : and therefore it is not without reason that many authors object to ascribing the milder cases to the same lesion as is found in the severer cases. In many autopsies the smaller blood-vessels of the brain have been found plugged. In some cases minute vege- tations have been found on the valves of the heart, ac- counting for the embolisms in the brain ; but these changes are not constant. The optic thalamus and cor- pus striatum are the parts chiefly or exclusively affected. It is specially interesting to recall the fact that in post-hemiplegic chorea, and in so-called athetosis, the lesions preceding these irregular motions are situated in the same portions of the brain in which these dis- CHOREA. 337 eased arteries are found in chorea. Whether this por- tion of the brain is affected in sclerosis with exagger- ated tremor has not, to my knowledge, been a subject of investigation. It is also an interesting fact that bun- dles of nerve-fibers, passing through this region from the cortex, may be irritated so as to produce move- ments in the limbs similar to those produced by irrita- tion of the motor centers in the cortex. There is, therefore, a presumption in favor of a simi- lar causation of the irregular movements in all these affections. Whether the mild cases of chorea, ending in complete recovery, can ever be referred to an organic lesion of the brain, is extremely doubtful. A simple functional disturbance is sufficient to account for all the symptoms. Considering the mental phenomena, and the frequent hemiplegic character of the disease, af- fecting the face as well as the limbs, it must be looked upon as primarily of cerebral origin. Prognosis. — There is very little more to be said in regard to prognosis ; the milder cases always recover after a variable length of time, perhaps after two or three relapses. The older the child at the beginning of the disease, the more severe will it probably be, and the longer its duration. Death seldom occurs. In every case where I have seen such a result it has seemed to me that there was organic cerebral disease which caused the choreic symptoms and the fatal termination. Treatment. — The most active and meddlesome treatment has been advocated by some, and entire ab- stinence from medicine by others. In reality, mild cases probably do well without drugs. Hygienic and moral treatment is necessary in every case. The child should be noticed as little as possible ; its attention not called to its infirmity, unless it can be praised for improvement. Nothing more should be de- manded of the child than can be possibly helped ; the desires and wants of the child should be anticipated, and gratified as far as may be without over-indulgence. 22 338 UNCLASSIFIED. Of course, the child should be taken out of school, and, if necessary, removed from the society of playmates and the care of servants, who may irritate and annoy it by reference to its irregular movements. Common sense and knowledge of child nature will serve better than any written directions to guide this part of the treatment. Except in the severer cases, confinement to the bed and house is unnecessary. Arsenic has proved a most successful medicine. This should be given at first in moderate doses, then the dose rapidly increased to the limit of toleration. Thus, beginning with three or four drops of Fowler 1 s solution three times a day, the dose may be increased, by one drop every second or third day, until the child takes twelve or fifteen drops, or even more, at a dose. This remedy is to be thus continued, increasing the dose until either nausea follows or oedema below the eyes shows the approach of toxical effects. If nausea re- quires the drug to be discontinued, it should be re- sumed in the same dose as when omitted so soon as the nausea ceases. Unless given in large doses, no benefit can be expected. Many times it is of benefit to use iron also, and other tonics. Sulphate of zinc, in doses of three to five grains three times a day, has also been highly recommended. I have generally, however, found the arsenic sufficient. In severe cases, where the spasmodic action inter- feres with sleep, it may be necessary to give remedies to procure the needed rest. Of these, chloral is much the best. Perhaps paraldehyde would be as service- able. It is not desirable to give opium, or any of its preparations, if it can be avoided. Hyoscyamus, coni- um, and belladonna may be used as occasion requires. Calabar-bean has been used by Bouchut ; he employed •003 to "005 grm. three or four times a day subcutane- ously, with benefit to the patient. In many cases re- lief follows the application of ether spray to the back ; or ice along the spine may be used instead of the ether. CHAPTER XXIX. PARALYSIS AGITANS. Luys J., Contribution a l'etude anatomo-pathologique de la paralysie agitante. L'encephale, 1882. — Berger, Ueber Paralysis Agitans. Schmidt's Jahrb., 195, 1882, p. 246.— Buzzard, A Clini- cal Lecture on Shaking Palsy. Brain, Jan., 1882, p. 473. — Erlen- meyer, A., Beitrag zur symptomatischen Behandlung der Pa- ralysis Agitans. Cbl. f. Nervenheilkunde, Psych., etc., May 1, 1883, p. 193. PARALYSIS AGITANS.— SHAKING PALSY.— PARKINSON'S DISEASE. Paralysis agitans is most common in old age, the name very well expressing its character — a tremor, more or less severe, attended with a weakness of the muscles, and a certain degree of stiffness. Violent emotions have sometimes been thought to be the cause ; but it is very doubtful whether such is the case. Otherwise we know nothing as to its aetiology. Symptoms. — The tremor is peculiar and character- istic, showing itself when the limbs are at rest, dimin- ishing or ceasing during voluntary motion, in this re- spect contrasting strongly with the tremor of sclerosis. The temperature is not increased, although there is such constant muscular action. Occasionally the trem- bling entirely ceases just before death. In the early stages of the disease the tremor is very slight, and is usually confined to the hands and fin- gers, often to the thumb and index-finger, which are rapidly adducted and abducted. At first this is a slight annoyance to the patient, and does not interfere seriously with his comfort or his ordinary pursuits. As the disease advances, however, the tremor affects 310 UNCLASSIFIED. other muscles, becomes more marked, and greatly an- noys the patient. It does not cease entirely during voluntary motion of the parts, and so may interfere more or less seriously with the use of the hands. Opinions differ somewhat as to whether the head is affected ; it certainly is in some cases. After a while, to the tremor is added a weakness of the muscles — partial paralysis. There is also stiffness of the joints, the hands take a peculiar position, the thumb and index-finger being approximated, as if hold- ing a pen, and occasionally there is a slight claw-shape position of the fingers. The electrical reaction of the muscles is normal. In walking, the patient's head and body are bent forward, so that it seems almost as if he would fall upon his face. Instead of walking naturally, the pa- tient trots forward with short steps, as if the position of the body produced a sensation of falling, and he found it necessary to run in order not to pitch on his face. Sometimes there is compulsory motion back- ward instead of forward. The tendon reflexes have been noticed to be exaggerated in both the upper and lower extremities. Sensation is variously modified in some cases, and, when the disease is advanced, the mental powers suffer. There is sleeplessness and loss of memory, sometimes melancholia. Pathological Anatomy. — No satisfactory explana- tion of this disease has been proposed. Many careful autopsies show no change at all of the nervous system, and the pathological changes, if any, remain to be dis- covered, though there is a tendency among authors to refer the disease to some disturbance of the medulla oblongata. Diagnosis. — The diagnosis must be made from scle- rosis of the nerve-centers, with which this disease was formerly confounded. The difference in the character of the tremor, the positions of the hands in an ad- vanced case, are sufficient to distinguish the two. The PARALYSIS AGITANS. 341 progress of the disease is also different. The cerebral symptoms are similar in only a few cases. They occur earlier in sclerosis than in paralysis agitans. The tremor of metallic poisoning, or of acholismns, may be diagnosticated by the history of the patient and by the progress of the disease. It is scarcely possible that post-hemiplegic chorea should be mistaken for paralysis agitans if the phy- sician is sufficiently careful. Prognosis. — Recovery is not to be expected. In- termissions may occur, but the course of the disease is generally forward. Treatment. — Very little can be said in regard to treatment. Some few drugs are of value as long as they are used ; but when given up, the tremor returns. Erlenmeyer found that chloral produced sleep, but had no influence upon the tremor. An infusion of valerian with bromide of potassium had a marked effect upon the tremor so long as it was used. Atropia always diminished the tremor, but he found it necessary to omit the drug on account of a slight toxic effect. Curare, when given subcutaneously in a dose of - 033 of a gramme, caused the tremor to diminish. This improvement continued about three days. Eulenberg recommends very highly the subcutane- ous injection of arsenic. He uses Fowler's solution diluted with two parts of distilled water, giving six to ten minims for a dose. These injections were continued daily, without unpleasant symptoms. In one case, fifteen injections, in another four, produced a very marked diminution of the tremor, lasting two months. Hyoscyamia has been recommended, but Erlen- meyer found that it had no effect unless given in toxic doses. The galvanic current may give relief, applying it to the head and neck ; but when the treatment is discon- tinued, the tremor returns. Static electricity has also been used with temporary benefit. CHAPTER XXX. EPILEPSY. Echeverria, M. G., On Epilepsy. New York, 1870.— Ben- nett, A. H., Analysis of 100 Cases of E. Brit. Med. Jour., March 22, 1879, p. 419.— Jackson, J. H., Lectures on the Diagnosis of E. Med. Times and Gaz., Jan. 11, 1879, p. 29.— MacDonald, C. F., Feigned E. Am. Jour, of Insanity, July, 1880 ; Boston Med. and Surg. Jour., Dec. 30, 1880.— West, J. F., On Trephining for Traumatic E. Trans. Med.-Chir. Soc, 1880, p. 23.— Seguin, E. C, Importance of the Early Recognition of E. Med. Record, Aug. 6, 1881. — Lunier, Des epileptiques ; des moyens de traite- ment, etc. Annates med psycholog., March, 1881, p. 217.— Gow- ers, W. R., Epilepsy. London, 1881.— Marie, P., Note sur l'etat de la pupille chez les epileptiques. Arch, de nevrol., iv, 1882, p. 42.— Beevor, C. E., On Knee- Jerk, etc., in E. Brain, April, 1882, p. 56.— Alexander, W., The Treatment of E. by Ligature of the Vertebral Arteries. Brain, July, 1882, p. 170.— Russell, J., The Remedies in the Treatment of E. before the Introduction of the Bromides. Practitioner, Feb., 1883, p. 81.— Weiss, J., Ueber E. und deren Behandlung. Wiener Klinik, April, 1884. — Ralfe, C. H., Seventeen Cases of E. treated with Sodium Nitrite. Brit. Med. Jour., Dec. 2, 1882, p. 1095.— Walsam, W. J., On Trephin- ing the Skull in Traumatic Epilepsy. St. Barth. Hosp. Rep., 1883, p. 127. Epilepsy is a name given to an affection whose chief characteristics are attacks, recurring with more or less regularity, in which the patient partially or entirely loses consciousness, and is generally more or less con- vulsed, there being no organic disease to which these convulsions can be referred as a cause. Symptoms. — In about half the patients there is a warning aura, indicating the near approach of a con- vulsion. This aura may consist in an involuntary mo- EPILEPSY. 343 tion, or a sensation in any part of the body or limbs, most frequently in the stomach; occasionally it is a sound, a sight, an odor, or it may be a confused mental action ; it precedes the attack a few seconds or minutes only. The attack may begin by a peculiar shrill cry, upon which the patient suddenly drops unconscious ; or, without this, consciousness is lost, and the patient falls, perhaps injuring himself. If the aura has given suffi- cient warning, he may be able to sit or lie down before the attack. In a very large proportion of cases the countenance changes, the face becomes pale, the eyes have a pe- culiar vacant look; tonic spasms seize the limbs and body ; the patient stiffens. The attack may begin in one limb and extend to the whole body, or it may be unilateral or bilateral throughout. During the tonic stage the limbs, face, and head may be drawn into un- natural positions ; there is frequently conjugate devi- ation of the eyes, with rotation of the head to one side. After a few seconds or minutes clonic spasms gradu- ally take the place of the tonic rigidity ; the limbs are jerked about, the muscles of the face and mouth are affected, there is frothing at the mouth, the tongue may be bitten. The patient is not tossed about much, as occurs in hystero-epilepsy. The countenance changes from pale to livid through venous congestion. The pupils are dilated, and do not react to light. There is conjugate deviation of the eyes, with rotation of the head to the opposite side from what it was during the tonic stage. Cutaneous reflexes, even of the conjunctiva, are abolished during the attack. The urine may be voided involuntarily, especially during nocturnal fits ; the faeces are less commonly passed during the attack. The spasms gradually de- crease in frequency ; the intervals between the contrac- tions are longer and longer, until there is quiet. 344 UNCLASSIFIED. Immediately after the clonic stage, before return of consciousness, the patellar tendon reflex is increased, and ankle clonus is present in rather more than half the cases ; the tendon reflex is occasionally abolished. Dur- ing this period the pupils may oscillate, the eyes roll in unison from side to side. After lying quiet for a few minutes, the patient gradually comes to himself, being confused for a while. Often a heavy sensation in the head, or headache, suc- ceeds the attack, continuing a few hours or days. Some- times unilateral paralysis, or weakness, is noticed af- terward, and may persist several days. Unilateral anaesthesia after the spasm is probably found only in hystero-epilepsy. Many patients fall asleep immediately after the at- tack, sometimes before recovery of consciousness. This is scarcely natural sleep ; it rather resembles stupor. If the fit occurs during sleep, the patient may not awake, and in the morning be entirely unaware of what has occurred. Others will recover full possession of their faculties as suddenly as they lost them, without the least discomfort in the head or elsewhere. Sometimes the pulse is abnormally slow for several days, or even weeks, after the attack. In the full, complete attack of epilepsy, the loss of consciousness is absolute and entire. Attacks may be much less severe than those just described, consisting simply of a momentary loss of consciousness, without spasm of any kind ; or they may be reduced to the aura, consciousness not being interrupted, though mental activity and ability are un- doubtedly somewhat impaired. These attacks without convulsions are called petit mal ; those with convul- sions, grand mal. Every grade of severity is found, from the slightest ephemeral sensation to the severest convulsive attack. Many authors consider loss of consciousness neces- sary to constitute epilepsy. Nothnagel is right, how- EPILEPSY. 345 ever, in saying that complete abolition of conscious- ness is not necessary to characterize the disease as epi- lepsy, " but that simple dizziness is sufficient ; in fact, any alteration whatever of the mental activity occur- ring paroxysmally, such as hallucinations and the like." Various unusual and exceptional manifestations of epilepsy deserve mention. Occasionally during the at- tack patients will perform acts which it would seem must be voluntary and conscious. In these the patient may simply perform some inoffensive act, as walking rapidly to a distance, or, as in one of my patients, a workman began to gather together pieces of wood, as if to carry home ; or the acts may involve more serious consequences, as pocketing various articles not belong- ing to himself, or making an attack upon by-standers, and, if the impulse is strong, the patient may be thrown into a frenzy, and may commit homicide. After these acts there is no recollection of what has been done dur- ing the attack ; there may be the same oppression in the head, and even the same tendency to sleep as after other attacks. Occasionally the patient seems to see objects which do not really exist ; there are hallucina- tions of sight. These unusual forms of epileptic seizures may co- exist in the same individual with the more common, or may precede the outbreak of the latter by several months or years, or may follow after a course of reme- dial treatment. The attacks vary greatly in frequency ; they may be separated by an interval of months, or even years. The earlier attacks occur usually at much longer inter- vals than the subsequent, when the disease is left to run its course without treatment. The attacks may occur many times a day. H. Hayes Newington reports (" Journal of Mental Sciences," April, 1877, p. 89) a case in which there were six hundred and twenty-two true epileptic fits in twenty-four hours. This great number 346 UNCLASSIFIED. was excessive and unusual. Often from three or four to ten or a dozen may occur in the course of the day. It is very common to have the attacks recur in groups, several within a few hours or days ; then there is an interval of variable length free from attacks, and again a series of several in rapid succession. Epileptic fits may take place either during the day or in the night ; a large proportion occur in the early morning hours, just before or just after waking. It is impossible to estimate exactly the proportion of cases occurring during the night, as patients are often entirely ignorant of having had an attack. If one wakes with tongue bitten, bedclothes stained with blood and in much disorder, if the bed is wet, and there is discom- fort in the head in the morning, it is more than likely that there has been an attack. Any one of the circum- stances should give rise to suspicion in the case of an adult. After the attacks, small subcutaneous haemor- rhages may be seen, especially about the eyes and the rest of the face. These disappear in a few days. The patient' s limbs, and even his life, are not safe so long as he has the attacks. The fact of being in a po- sition of iminent danger sometimes seems to prevent the occurrence of the fit ; thus workmen, whose duty it is to ascend ladders or be on stagings, will sometimes be entirely free from fits in these exposed situations. It is, however, never safe to trust to such exemption. Epileptics suffer many times from bruises, and even from fractures or dislocations, as the effects of their at- tacks. They may also fall into the fire and receive severe burns. Death does not often occur during the fit. Some- times, however, cerebral haemorrhage is the direct re- sult of an attack. Occasionally the attacks recur with great rapidity, with scarcely a perceptible intermission ; the patient is in a state of epilepsy, status epilepticus, as it has been called, in which the fatal termination may occur. EPILEPSY. 347 Between the attacks the patient may enjoy the most perfect health, and if the attacks are nocturnal, or occur in the early morning, he may be able to attend to all the duties of life — may even manage a large business without any one suspecting his infirmity. On the other hand, it is possible that the affection may lead to an impairment of mental powers, the memory at first be- ing weakened, finally imbecility or dementia closing the scene. This is more common when the disease be- gins in early life. A few rarely occurring very severe attacks have generally little influence upon the mental powers ; frequently recurring petit mal, giving friends much less concern, may more seriously undermine the intellect. The paralysis, which occasionally appears after the attack as an ephemeral symptom, may become perma- nent, continuing from one attack to the next. In such cases it is probable there is some organic cerebral le- sion. ^Etiology. — Among those causes which give rise to a state of the nervous system predisposing to epilepsy may be mentioned heredity ; not that the ancestors have necessarily had fully developed epilepsy ; they may have shown only oddities of character, or mental extravagances, or they may have suffered from neural- gia or other neuroses. Parents addicted to the exces- sive use of alcoholic drinks may transmit to offspring a tendency to epilepsy. The frequency with which hereditary influence can be shown to exist in this affection — eighty times in three hundred and six, according to Echeverria — should lead to caution in regard to the marriage of epileptics. The excessive use of alcoholic drinks may develop a tendency to epilepsy in the subject ; such indulgence may also be the direct cause of the attacks. Some epi- leptics have the attacks only after a course of rather hard drinldng. The period of puberty is that in which the disease 348 UNCLASSIFIED. is most likely to be developed ; much the larger num- ber of cases begin between ten and twenty -five years of age, or even between ten and twenty. Severe and prolonged convulsions in infancy are very frequently followed by epilepsy later in life. Ap- parently the cause of the earlier convulsions leads to changes in the brain, which favors their subsequent re- turn. Various depressing agents may be classed as pre- disposing causes, as worry, anxiety, grief, or excessive mental work ; but it is quite likely that many times there has been in these cases a predisposition to the disease in addition to the above depressing agents. Syphilis, especially if the bones of the skull are dis- eased, may be a cause of epilepsy. Disease of the bones, induced by injuries or by other causes than syphilis, may also give rise to at- tacks. The causes which may be more properly called ex- citing causes are blows or falls upon the head, whether giving rise to fracture of the skull or not, injuries to peripheral nerves, sunstroke, fright, anger or other vio- lent emotion, and lead-poisoning. Phimosis may be the cause of such an irritation as to give rise to epilepsy ; it would seem to be a pre- disposing cause, as giving rise to such a state of the system as to favor the occurrence of epilepsy, and it also may alone excite the attacks. The same reflex in- fluence may depend upon other sources of irritation, as that caused by teeth cutting through the gums. Occasionally serious disorders of digestion or im- prudence in diet seems to give rise to the attacks. At the best, however, it is often impossible to dis- cover the causes which lead to the development of the tendency, or give rise to the fits. Brown- Sequard found that after certain lesions of the nervous system, especially in Guinea-pigs, a por- tion of the face suffered a change in its nutrition such EPILEPSY. 349 that irritation of the cheek would excite an epileptic attack ; such Guinea-pigs might transmit the tendency to epilepsy to their offspring. Several times a similar epileptogenous zone has been found in epileptic pa- tients. Otto reports a case of a patient the snapping of whose hat-elastic caused an attack. Diagnosis.— The diagnosis of epilepsy from hysteria and hystero-epilepsy will be more clear after their de- scription in the next chapter. The lighter attacks, the petit mal, may be recog- nized from common fainting or vertigo, by the regu- larity or frequency of their recurrence, by the brevity of the attack in epilepsy, by the occasional presence of an aura, by the occurrence of the grand mal at long in- tervals. The possibility of vertigo due to Meniere's disease, or the lithemic vertigo, should be kept in mind. Criminals and others try to simulate epilepsy to es- cape punishment or gain profit. A well-trained impos- tor is not easily discovered. The pallor of the face, the dilated pupils, reacting suddenly to light, can not be counterfeited, and it is scarcely probable that the cornea would be insensible to touch. A careful watch- ing of all the symptoms would lead to detection of impostors, unless they were remarkably well trained. (See MacDonald's case.) Prognosis. — Most patients with epilepsy are capa- ble of improvement ; few can be expected to recover. The earlier in life the attacks begin, and the longer they have persisted, the less favorable is the prospect. If a definite cause can be discovered, as teething, sunstroke, lead-poisoning, syphilis, etc., the chances are in favor of recovery in proportion to the readiness with which these causes can be removed, if the disease has not been of too long duration. Mental failure is rare when the attacks begin after puberty, except in syphilitic cases ; when they com- mence early in life, the mind is much more likely to fail. 350 UNCLASSIFIED. Teeatment. — If any source of peripheral irritation can be discovered which may act as cause of the fits, that should be removed, as cicatrices, phimosis, or irri- tation of gums by teeth. If fracture of skull or de- pression, fragments should be removed or raised. The remedy which has been found most useful is the bromides. It is rather a matter of taste as to which bromide should be employed ; the potassic, sodic, calcic, and lithic salt act very nearly alike. Sometimes an idiosyncrasy on the part of the patient will be a guide in the choice. G-owers's method of giving the bromides is somewhat different from the ordinary way, and is of value. He gives very large doses at the beginning of treatment — two or three drachms every second or third morning, increases the dose to four drachms every fourth morn- ing, and six drachms or an ounce every fifth morning. These large doses should be given after breakfast, in a tumblerful of water. When drowsiness and mental dullness follow during the rest of the day, he does not increase the dose. More than an ounce is rarely borne. The maximum dose should be reached in two or three weeks and repeated three or four times, and the doses then gradually reduced ; the whole course lasts six or seven weeks. Unless the attacks cease entirely when a dose of four drachms is reached, he gives up the effort to cure the patient. After omitting the bromide a week or two, he gives it again regularly in smaller doses, twenty grains or more three times a day. The usual method of giving bromide is to give a dose three times a day ; usually the dose is too small. It is necessary to begin with at least fifteen or twenty grains three times a day, and the dose should be in- creased rapidly till some evidence of its action is ob- tained. Patients may take sixty to ninety grains of bromide a day for six or ten years without injury. When large doses are given, acne appears on the face, back, etc. ; three to five drops of Fowler's solu- EPILEPSY. 351 tion with each dose of the bromide will tend to prevent this. In very large doses patients sometimes find their legs getting weak, or lose their memory. If the dose is diminished or omitted for a few days, these symp- toms disappear. In excessive doses, delirium and symptoms resembling meningitis may be produced. Of course, this ought to be avoided. Iron, cod-liver oil, and quinine may be given to ad- vantage with the bromides. Occasionally the bromides seem to lose their bene- ficial effect, or the patient becomes disgusted with the drug. Ralfe recommends then the use of sodium ni- trite, free from the nitrate. Atropia is frequently used, either with the bromide or alone, sometimes with benefit. With it, or the ex- tract of belladonna, may be used valerianate or oxide of zinc, and extract of hyoscyamus. Digitalis is sometimes combined with the bromides. Kunze * used curare subcutaneously, in 0*03 gramme doses, every fifth day for three weeks, then waited for the next attack, and repeated. The first sign of toxic action is a blurred vision. Wildermuthf gave, with bromide, osmic acid 0*002 gramme in watery solution or pill, or 0*004 gramme potassic osmate, with benefit in an old, obstinate case when bromides alone failed. During an attack the patient's clothes should be loosened ; he should be prevented from injuring himself if the clonic convulsions are violent. A towel rolled firmly into a cone, or a piece of cork or rubber, should be put between the teeth, to prevent biting the tongue. When an aura gives opportunity, the inhalation of nitrite of amyl may cut the attack short. Patients sometimes learn that by firmly seizing the limb in which the aura is felt, or by tightly bandaging it, they can arrest the lit. * " Wien. med. Presse," Oct. 20, 1878. t "Berl. kl. Wochenschr.," June 9, 1884. 352 UNCLASSIFIED. In the status epilepticus, inhalation of nitrite of amyl sometimes is beneficial. Gowers finds the most good from repeated doses of chloral, morphia subcu- taneously, and the application of ice to the spine. The diet should be simple and unstimulating. It is well to restrict the use of animal food to a small amount once a day, or forbid it entirely. This diet is most valuable with young patients. CHAPTER XXXI. HYSTERIA AND HYSTEEO-EPILEPSY. Richter, Ueber psychische Therapie motorisclier Storungen der Hysterie. Berl. M. Wochenschr., June 14, 1880, p. 341. — Mitchell, J. Weir, Lectures on Diseases of the Nervous System, especially in Women. Philadelphia, 1881. — Debove, L'hysterie chez l'homme. Gaz. des hop., Nov. 20, 1882, p. 1070. — Huchard, H., Caractere, moeurs, etat mental des hysteriques. Arch, de nevrol., iii, 1882, p. 187. — Axenfeld, Traite des nevroses. Paris, 1883.— Dujardin-Beaumetz, On the Treatment of Hysteria. Med. News, Aug. 4, 1883, p. 113.— G-rasset, The Eelations of Hysteria with the Scrofulous and the Tuberculous Diathesis. Brain, Jan., July, 1884. Richer, P., Etudes clinique sur l'hystero-epilepsie, ou grande hysterie. Paris, 1881. — Mills, 0. K., Hystero-Epilepsy. Am. Jour. Med. Set., Oct., 1881, p. 392.— Welponer, E., Exstirpation beider Ovarien wegen Hystero-Epilepsie, Heilung. Wien. med. Wochenschr'., No. 30, 1879.— Walton, G-. L., Hysteria, as affected by Removal of the Ovaries. Boston Med. and Surg. Jour., June 5, 1884, p. 529.— Peckham, G-., Metallotherapy, Theoretically and Practically Considered. Archives of Med., Dec, 1883, p. 283. — See, also, on Metallotherapy, Charcot, Lancet, 1878, i. — West- phal, Berl. Tel. Woch., 1878, p. 441.— Wilks, Brit. Med. Jour., July 20, 1878. HYSTERIA. Hysteria is often described as a functional disease of the nervous system ; it would be more exact to speak of it as a diseased or abnormal state of the nerv- ous system, revealing itself by peculiarities of tempera- ment, of thought, action, and affection, with occasional outbreaks of motor or emotional disturbance. Formerly the convulsive phenomena were considered as essential ; but, while their importance is still recog- 23 354 UNCLASSIFIED. nized, more attention has been recently given to the state of the nervous system, which renders these phe- nomena possible. ./Etiology. — Briquet says half the women have a predisposition to hysteria — that is, they are very im- pressionable. This predisposition is also seen in a few men, and a small number of males are attacked. The age at which the affection is most common lies between puberty and twenty years. After that age there is a gradual diminution in the proportion of pa- tients. Among young girls Briquet found about a quarter or a fifth as many cases as among those who had commenced to menstruate. There are many cases reported as occurring in boys. Heredity plays an important part in predisposing to hysteria. It will often be found that some form of nervous disturbance is prevalent among the relations of such patients. Huchard says that in hysterical women it will be found thirty times in one hundred cases that the parents have been hysterical, but in women not thus affected only four times in one hundred cases will this be found to be the case. Briquet found that a little more than half the hysterical mothers had transmitted the affection to their daughters. It can not be doubted that the training to which young girls are subjected influences the predisposition to hysteria ; their home training and school training, their food, exercise, clothing, the amount of sleep ob- tained, the amusements allowed, the self-restraint which they may be taught — these and many other conditions either increase their natural predisposition or dimin- ish it. And not only do children show the effect of their mode of life ; older women show it also, and a tendency to hysteria may be created, or, if existing, may be neutralized, by the surroundings of the patient and by those indulgences which she allows herself, or by those privations to which she may of necessity be exposed. HYSTERIA. 355 Whatever lowers the healthy tone of the system, as a whole, may serve indirectly as a cause of hysteria : the depressing passions, care and worry, disease of any or- gans, but more especially of the uterus and its append- ages, may give rise to the state of the nervous system which favors the development of the affection. Accidents and bodily injuries must be counted among the predisposing causes of hysteria. Those ac- cidents which are accompanied with nervous shock and fright, as when a horse runs away with the carriage in which the patient is riding, or railroad accidents, are most likely to give rise to this state of the nervous sys- tem. Some of these causes which act as predisposing to hysteria may become the direct cause of an attack in patients who are otherwise predisposed thereto. Imi- tation may give rise directly to an attack. Symptoms. — In hysteria there is found a perversion of certain faculties and characteristics of the patients. There is a paralysis or weakness of the moral sense and of the will, an exaggeration of the emotions and the af- fective faculties, with irregular and perverted action of the cutaneous, visceral, and special senses. Nearly, if not quite, all the phenomena of hysteria can be ex- plained by supposing the above changes. The special manifestations of hysteria in different patients are almost as varied as are the diseases to which humanity is liable. Even in ordinary health these patients show a nervous mobility, a habit of ex- aggeration, a morbid desire for sympathy, an excessive sensitiveness and ardent imagination which is charac- teristic. The disturbance of the moral sense may show itself simply by persistent exaggeration of symptoms — an ex- aggeration which almost amounts to simulation ; or there may be deliberately planned simulation. The patient will pretend to have symptoms which do not exist ; she will produce haemorrhage from some portion 356 UNCLASSIFIED. of the mouth, and pretend to have haemoptysis ; she will pretend to vomit urine instead of secreting it by the kidneys ; and perhaps, in order to keep up the illu- sion, she will drink her urine immediately after passing it. The patient may pretend that she is paralyzed, or is so weak that she is unable to rise ; yet, when she thinks herself alone, she may be seen to rise and cross the room. A more serious and important exhibition of this propensity for lying is occasionally met in hysterical women ; they will accuse a physician or dentist or priest of taking improper liberties with them, or of vio- lating them. The records of legal medicine contain many such instances. The foundation for some of the complaints of the hysteric may be a real discomfort ; this discomfort or pain is exaggerated by the patient. A slight pain in the eyes, when open to the light, is exaggerated into severe photophobia, and the patient must remain in a dark room ; yet when the oculist wishes to examine the eyes the light is born without complaint, and even the ophthalmoscope can be used without the patient's com- plaining. A slight discomfort in swallowing is exag- gerated into entire loss of power to take food, and, if a sound is passed, a very persistent spasmodic stricture may be found. So it may be in regard to other symp- toms ; but it will often be very difficult to judge wheth- er there is any foundation at all for the pretended ina- bility. The disturbance of the emotions and affections is sometimes very marked in hysterics. Huchard thinks it is not common to find excessive sexual excitement in hysterical patients ; that sexual desire may be entirely lost. Other passions may be exaggerated ; they easily acquire a repugnance for persons ; they long for atten 7 tion and manifestations of love from others. This pe- culiarity may lead to the simulation of disease ; but in much the greater proportion of hysterical patients it is HYSTERIA. 357 shown only by a claim upon the attendants or members of the family for care and attention. Self is elevated to the highest place in these patients, and self must be served first and always. A mother may exact from a daughter constant attendance, even at the price of ruin- ing that daughter's health ; a daughter may be jealous of brothers and sisters, and become worse whenever the mother tries to give care to other members of the family. Sometimes the patient has only one class of symp- toms ; probably, in such cases, there is real disease, pain, or discomfort, as a foundation for her complaints. At other times the complaints and symptoms vary from week to week, or in different attacks ; even during the physician's visit she may recite a long list of ill- con- nected symptoms, inconsistent with one another. " They love to carry everything to extremes, do not know how to live in simplicity ; they exaggerate all their feelings, indifference as well as enthusiasm, affec- tion as well as antipathy, love as well as hate, joy as well as despair, and they dramatize everything on the great stage of the world, where they are, and always remain, true comedians." The intellectual condition of hysterics is generally unnatural. They are not able to turn their minds to the more serious occupations in which they may have once engaged ; those who have been familiar with their mental power when in health will probably find that there has been a loss therein. Though this is true of the higher and more complicated processes of thought, yet in the ordinary round of daily life, and on a lower plane, their mental activity may be exaggerated, their conversation may be lively, animated, witty, and en- tertaining ; they may appear even brighter than is natural, perhaps relapsing soon into silence and indif- ference. The special senses, particularly hearing and smell, may be abnormally acute ; occasionally hallucinations 358 UNCLASSIFIED. of sight, hearing, or odor may be noticed, though it is necessary to guard against error as to the two last senses, the patient noticing sounds and odors which are not perceived by the attendants. Perversion of taste may lead to a distaste for certain articles of diet, or a desire for abnormal articles. Ordinary sensation may be diminished or increased in acuteness ; such changes are more frequent in the form called hystero-epilepsy than in simple hysteria, yet even this will show at times abnormal conditions of sensation. Pain may be felt in different regions, and, as has been noticed, the acuteness of the pain may be much exaggerated by the patient. Headache is not uncom- mon, and backache is often met in these patients. The pain may be very severe just below the breast, espe- cially on the left side. There may be severe pain and tenderness in the joints, simulating arthritis. It would, however, require much too large £ space to enumerate all the changes of this nature which may be found in hysterics. Sometimes there is a great diminution of the urinary secretion ; and there may be even a temporary suppres- sion, which has been known to extend over some days. Charcot reports a case, observed during four months, in which there was a great diminution in the amount of urine, an average of three grammes during August ; on several occasions there was total suppression, once for eleven days. The patient vomited much, and the vomitus contained urea. Among other abnormal conditions may be mentioned excessive sweating, disturbance of the gastric secre- tions, enormous secretion of gas in the stomach and in- testines. Paralysis affecting various parts of the motor sys- tem is sometimes seen, affecting an entire limb, or only a few muscles. Muscles thus affected give a normal reaction to the electric current. It is said by some that EYSTEBIA. 359 normal response to the motor irritation, with loss of sensitiveness to the current, is diagnostic of hysterical paralysis. If the anaesthesia is extreme, and the reac- tion perfect, this may be an aid to diagnosis, but it is not alone sufficient to found a diagnosis upon. Instead of total paralysis, there may be contraction, persisting for months or years. Aphonia may be hysterical in its origin ; the patient may lose her voice entirely, and be obliged to have re- course to signs to make herself understood, or there may be an ability to whisper. This hysterical aphonia is rather intractable, and is very likely to recur. The symptoms above noticed may appear in dis- tinct attacks, between which the constitutional pecul- iarities are still to be noticed, but in less marked de- gree. There are other attacks, attended with more or less violence, which are more generally known as hysterical attacks. These crises are attended with spasmodic ac- tion, or with excessive emotional disturbance ; often begin with a sensation as if a ball rose from the epi- gastrium to the throat {globus hystericus), or that may be the whole of the spasmodic attack. Then, when this sensation has reached the throat, there is a general spasm, attended with screaming, with crying and sob- bing, mingled with wild laughter. Sometimes this spasm commences suddenly, without the preceding aura. During the attack the patient seems to be un- conscious, yet afterward may have a recollection of most that occurred. The heart may beat rapidly and strongly ; the respiration is accelerated ; the patient, feeling a sense of suffocation, may clutch at her throat, and try to tear her clothing. Muscular movements in these attacks are generally co-ordinated to accomplish some purpose, and are semi- voluntary, or entirely un- der the control of the will, though that will may be perverted. These attacks last from a few minutes to a few hours. 360 UNCLASSIFIED. After the attack the patient is usually exhausted, lies still, with eyes shut, is disinclined to speak, and may seem more than half ashamed. Commonly a large amount of pale urine, of low specific gravity, is voided soon after an attack. HYSTERO-EPILEPSY. Charcot first, and later his pupils and others, have given descriptions of attacks occurring in hysterical patients which seem to be combinations of epilepsy and hysteria. Gowers, indeed, considers these to be hysteria added to and occurring after epileptic at- tacks. In this manifestation of disordered nervous action there are more or less distinct attacks, with periods of remission, or rarely intermission of symptoms. The convulsive attacks never occur without warn- ing. The patient shows a change in her disposition, becoming irritable, moody, gay and lively, or sad and desponding. She may be quiet or restless ; she may com- plain of headache, or of pain elsewhere, especially in the ovarian region. There may appear also, before the fully developed attack, the hypersesthesia and the an- aesthesia of one side or the other, as is seen between the convulsive attacks. These prodromes, especially the psychical, may appear even several days before the attack. The attack is divided by Richer and others into four periods : 1. The epileptoid. 2. That in which contortions prevail. 3. Period of emotional attitudes. 4. Period of delirium. The epileptoid period is immediately preceded by slight convulsive movements, as winking the eyelids with extreme frequency, general tremor, and rapid respiratory movements ; during this prodromic stage consciousness is retained ; it seems sometimes as if un- HYSTERO-EPILEPSY. 361 usual interest in the phenomena hastens the advent of the convulsions, during which consciousness is lost. The fully developed epileptoid attack very closely resembles an attack of true epilepsy ; first there is a rigidity of the body and limbs, with a slow motion of different parts, the body is slowly bent back, the neck is swollen, or the head slowly turns to one side. The face is pale, then congested ; the features are distorted ; the limbs are slowly and stiffly moved, usually turned on their axis, or flexed and extended ; the arms assume the position of extreme pronation ; the legs are strong- ly adducted ; the feet turned inward or outward. This is followed by a short stage of rigidity, with- out motion ; the patient remains immovable in the position in which she is found at its beginning ; usual- ly the body is extended, in dorsal decubitus, with the head bent back slightly, the arms extended, pronated ; or other postures may be assumed. The whole dura- tion of this stage may be a minute. Next follows a stage of clonic convulsions of limited excursion, sometimes general, sometimes unilateral ; these resemble the clonic convulsions of epilepsy. Muscular resolution is next seen, with stertorous res- piration, and frothing at the mouth. The clonic stage lasts about a minute ; that of muscular resolution a few minutes. The second of Richer' s periods may be divided into that of illogical attitudes and that of great movements. In the first of these the patient assumes the most varied, extraordinary postures with great force, ex- treme opisthotonus being the position most frequently assumed. The stage of great movements is characterized by rapid, alternating motions of flexion and extension of the body ; the limbs may also be moved about. At the beginning of this stage the patient may utter a pierc- ing cry, or she may strike herself, or tear her hair or clothing. 362 UNCLASSIFIED. In the second period the loss of consciousness is not complete. The contortions are of longer duration than the epileptoid spasms, sometimes five or ten minutes ; there is no foaming at the mouth, no suspension of the respiration, no inspiratory spasm, and, consequently, no turgescence of the face. The third period is that of hallucinations. The pa- tient's words and gestures are in harmony with her hal- lucinations. General and special sensibility are abol- ished. This third period may imperceptibly merge into the fourth, or that of delirium, in which the patient seems to review the events of her past life. With this the attack may cease, the patient often passing a large amount of pale, clear urine. Curious and important phenomena in these patients are connected with the effects of pressure over certain areas of the body. This pressure may give rise to an attack ; these spots differ in different patients, and sometimes corresponding spots on both sides of the body must be pressed. These regions are just above the breasts, just below the breasts, under the axillae, just over the crests of the ilia, between the scapulae, and over the ovaries. Immediately after an attack, pressure over the hysterogenic zone may not induce another. Another phenomenon is that pressure over one ova- ry — that which between the attacks is hyperkinetic — will often cause the attack to cease immediately. The patient, though violently convulsed, falls on the bed entirely relaxed, and may soon recover consciousness ; sometimes, however, another attack succeeds before consciousness is fully restored. This pressure must be directed so as to affect the ovary, and it may be neces- sary to use great force to obtain the result. When the hysterogenic zone is not in the ovarian region, pressure over that zone may cause the attack to cease, or it may cease from pressure only when that is exerted over the ovary. HYSTERO-EPILEPSY. 363 During tlio attack the eyes are ansesthetic, even dur- ing the period of delirium, and the cornea may be touched without exciting reflex movements of the lids ; sometimes tears will flow after such a test, and some- times the eye remains dry. The variations of the pupils have been studied late- ly by Fere. During the attack the pupils are, as a rule, only slightly influenced by the light. During the first part of the first period the pupils remain contracted ; immediately at the commencement of the second part of this period, when the clonic spasms set in, they are widely dilated, and remain so until the period of emo- tional attitudes ; during that, and the period of deliri- um, the pupils contract and dilate according to the nature of the hallucinations, whether the objects pre- sented to the mind seem to be near or remote. Of course, in imperfect attacks, all these phases of the pupils may not be seen. Yet Fere noticed in one instance, where the attack consisted only of the great movements, in which the pupils are dilated, that before the attack the pupils contracted with great energy, though there was no sign of other contraction. The condition of patients between the attacks is peculiar and interesting. As a rule, there is hemian- esthesia, affecting the side opposite the tender ovary, yet there are exceptions to this rule where the loss of sensibility is on the same side. The side which is not hemianesthetic is in a state of hyperesthesia. Not only is there loss of general sensation, of touch, and pain, but the special senses are affected on the same side with the general sensibility ; sight, hearing, smell, and taste may all be diminished on that side. Fere has carefully studied the condition of the eyes in these patients. He finds the field of vision limited, almost reduced to nothing, with complete loss of per- ception of color. In such patients there is complete anaesthesia of the conjunctiva and cornea; the reflex action of pupil and lids is also much interfered with. 364 UNCLASSIFIED. In other patients there may be only a moderate limita- tion of the field of vision, and partial loss of perception of color. These two kinds of visual defect generally show a direct relation and harmony between them- selves. Where there is only partial loss of visual pow- er, the anaesthesia of the eyeball varies according to the amount of visual disturbance. Diagnosis. — Sometimes the general physiognomy of the patient reveals to the physician that he has to do with a hysterical case ; again, the singular combi- nation of symptoms presented is sufficient to give a clew to the nature of the affection. Where there are no convulsive attacks, when the patient imagines disease of some organ, the physical examination of that organ, and a comparison of the symptoms with those which ought to be present, will often be sufficient for a diagnosis. It may not be pos- sible to arrive at a conclusion immediately, but careful observation of all the symptoms will generally lead to a correct diagnosis within a few days. When the hysterical simulation takes the appear- ance of nervous diseases, it may not be easy to decide whether there is real disease. If the history of the pa- tient and of the attack can be obtained, the task will be less difficult. As it would be awkward, to say the least, to treat as hysterical a patient who has a real or- ganic lesion, great care in the first examination, and careful watching of changes, is essential. If the pa- tient, by inheritance, age, and temperament, seems to be predisposed to hysteria, if the disease can be re- ferred to some disturbing emotion, if its symptoms are singular and in striking contrast to those arising from any organic lesion, and if there is much variation from time to time in the symptoms, such as renders the exist- ence of organic disease almost impossible — if these con- ditions exist, it may be safe to diagnosticate hysteria. The diagnosis of the convulsive hysterical attacks from epilepsy is not always easy. The fully developed HYSTERIA. 365 attack of hystero-epilepsy is not to be mistaken ; bnt the imperfect, partial attacks may not be at once rec- ognized. The aura is not the same ; the globus liystericus is rarely met in true epilepsy. The manner in which the patient tells about the aura will sometimes aid in form- ing an opinion as to the nature of the attacks. The hysteric almost never falls suddenly, as the epileptic ; there is a gradual sinking, and ability to save one's self from injury. Except in hystero-epilepsy, con- sciousness is not totally abolished in hysteria ; the pa- tients will remember somewhat of the events during the attack. The convulsions last longer in hysteria, and are more varied ; they are also of wider excursion ; the patients throw themselves about more. As the at- tack ends, its hysterical nature is sometimes clearly re- vealed by the sobbing and crying, or by the attack of laughing which follows. The state of the patient be- tween the attacks will be an important aid to diagnosis. The epileptic, after the heaviness and dullness, or pa- ralysis, which is sometimes seen after an attack, has passed, is as well as ever, and shows no sign of disturb- ance, unless the disease has begun to affect the mind. The hysteric has the psychical peculiarities between the attacks which have been previously described. If a large amount of pale urine, of low specific gravity, is passed immediately after an attack, the chances are de- cidedly in favor of hysteria. Peognosis. — Life is not in any special danger from hysteria. When once the predisposition has developed into the actual hysterical state, recovery is at best a distant possibility. The favorable termination will de- pend upon how thoroughly the patient's constitution has been undermined by early education and trials, and upon how much can be done to restore a natural vigor to the nervous system. When the predisposition is slight, or absent, treat- ment is much more likely to be successful. 366 UNCLASSIFIED. Relapses are very likely to occur ; a patient may be well for many months, until some excitement or emo- tion awakens again the symptoms. In hystero-epilepsy the prospect of recovery from the earlier attacks is the more favorable. As the fre- quency of the attacks increases, the prognosis becomes more grave. Tkeatment. — Treatment should begin with children of neurotic parents about as soon as they are bom, to prevent, if possible, the development of the hysterical predisposition. Care in regard to the child's surround- ings, its food, exercise, sleep, study, and government, is to be continued throughout childhood and youth. Sometimes the mother is not suitable to look after the child, and the care must be given to others. In all such cases the family physician has it in his power to do much by advice and warning. Huchard formulates this line of treatment thus : "To favor the physical de- velopment at the expense of the moral and intellectual development." After the disease has once shown itself, it will be necessary to use all the hygienic means at one's com- mand to counteract the predisposition, and the pa- tient's life may need to be watched and regulated for months or years. Often this can be done better away from home. The patient is self-willed, and needs to be under control, which will not be exercised at home. As disease of one of the viscera may be a principal cause of hysteria, every organ should be examined, and, if really diseased, the disorder should be corrected if possible. The physician will, of course, bear in mind the fact that functional disturbances may be found in any part of the system. He will also do well to bear in mind that too much notice given by him to any organ may call the patient's attention to that part of the body, and so its condition be made worse. This tendency of the patient may be utilized by the physi- cian to turn the patient's attention away from the dis- HYSTERIA. 367 eased organ while he really administers medicine for that. ' The management of the patient between the attacks is of great importance ; or, if there has been no fully developed attack, but only such an unstable nervous condition as to give rise to fear of an attack, the gen- eral management is important. This will include hy- gienic and dietetic agencies ; but care must also be given to develop the patient's power of will, of self- restraint, and her ability to meet and resist* the ordi- nary little disturbances which arise in daily life, as well as the more serious trials. The physician would not be wise to entirely ignore the patient's complaints ; he should not set aside the symptoms mentioned as en- tirely imaginary, but, while letting the patient feel that she has his sympathy, and that he understands her troubles, he should also show her that, by a resolute effort of will, she can do much to help herself. He can not do this on the first visit, nor perhaps until after he has allowed time enough to elapse to win her confi- dence. In other cases, comparative harshness and dis- regard of complaints from the first will have a better effect. It will sometimes be necessary to remove the pa- tient from home, and to seclude her in a measure, or en- tirely, giving her into the care of kind but firm nurses. The boundary between hysteria and insanity is by no means well defined, and the question may arise as to the propriety of asylum treatment. Each case must be judged upon its own merits. Of drugs which may be used, those which will act as tonic to the nervous system, and increase the vigor of the health generally, should be given, in order to remedy the natural predisposition of the patients. Be- sides the ordinary tonics, arsenic, zinc, and phosphorus, in their different pharmaceutical forms, may prove of benefit ; valerianate of zinc, in two- or three-grain doses, is specially valuable. Cod- liver oil, or, if that can not be taken, cream, is a useful addition to the diet. If the 368 UNCLASSIFIED. heart is irregular or feeble, a short course of digitalis may be of value. Hysterical patients are very often addicted to the use of preparations of opium to relieve real or imagi- nary pain. Opiates should be used with extreme cau- tion. A patient who has taken much opium loses her power of bearing pain, and when to the slight discom- fort is added the craving for the drug, she can not or will not distinguish between the two sensations, and calls loudly for the opiate. If it is withheld, the need of it ceases after a while. Of course, if the patient is a confirmed opium-taker, the task of weaning her from the habit becomes the more difficult. As a substitute for opium, recourse may be had to external applications, to atropia, hyoscyamus, conium, and cannabis Indica ; subcutaneous injections of water will sometimes be of advantage. Bromide of potassium and chloral had better be used only occasionally. If their use is habitual, the result is bad. Sleeplessness can be remedied often by massage, by exercise, by healthy occupation of the mind, by removing digestive disturbances, sometimes by a meal or a slight stimulant given at bed-time. Care should be exercised in using alcoholic stimulants, as hysterical patients easily acquire a craving for such. During an emotional attack, various preparations of valerian, asafcetida, musk, etc., can be given ; yet they are by no means always successful. Inhalations of nitrite of amyl, ammonia, and ether can be tried. The convulsive attacks can sometimes be cut short by a command given in a sudden and authoritative man- ner ; at other times a slap, or a glass of water thrown in the face, may stop the attack. There are some ob- jections to this procedure, especially as the water wets both patient and bed. In hystero-epilepsy, compression of the ovary will almost always cut short the attack ; the compression must be directed toward the ovary, and be quite strong. HYSTERIA. 369 An ice-bag placed over the hypersesthetic ovary for half an hour, or longer, morning and evening, may have a beneficial effect in diminishing the frequency of convulsive attacks. Blisters may produce a similar effect. Fere has caused an ovarian compressor to be made which can be worn by the patient ; this causes the at- tacks to be postponed. Inhalation of ether may cause the attack to cease. An indifference to attacks, in which the patient does not lose consciousness, is a useful means of diminish- ing their frequency and their violence, while too much curiosity an^L attention will cause the attacks to be more frequent and more severe. The question of removal of the ovaries has been somewhat discussed. Several cases of recovery have been reported. The operation should be kepfr in mind with reference to severe intractable cases where there is evident disease of the organs. The phenomena called metallotherapy are of con- siderable interest. In some cases of hystero-epilepsy, if a metal disk is bound upon an anaesthetic part, in ten to twenty minutes sensation returns ; the return of sensation is preceded or accompanied by a pricking sensation. The return of sensation is not confined to the area covered by the metal, but extends beyond the disk, mostly parallel with the axis of the limb, if the metal is on a limb. Patients are not all susceptible to the same metal ; one may be influenced by iron, an- other by copper, another by lead, and so on. When sensation returns in a part of the anaesthetic side in consequence of the application of metal, it will be found that a corresponding spot of skin on the sound side has lost its hyperesthesia. There may be a similar transfer of muscular power, of vision, of hearing, taste, and smell. The circula- tion is affected, and the temperature may be altered. When the metal disk is removed, the anesthesia, 24 370 UNCLASSIFIED. etc., oscillates for a short time between the two sides, until finally the parts recover their previous condition. Only a small proportion of the patients affected receive any permanent benefit from these applications. Burq first, in recent times, called attention to this influence of metals. Charcot, his pupils, and many others, have followed up these investigations. Many curious and interesting facts have been learned which can not be given here. Among agents which have been experimented with, and which may be used with some benefit, especially in hystero-epilepsy, may be mentioned the magnet, the application of which, to the skin, causes a transfer of sensation. Static electricity, in the form of direct dis- charges, or discharges from Ley den jars, will cause a transfer ; prolonged static baths are said to have a per- manent effect. The application of both the galvanic and inter- rupted currents are often of value. The application may be made to the affected parts : if there is anaes- thesia, the wire brush to the skin ; if paralysis, the skin should be moistened, so that the electricity can pass through to the muscles. Beard and Rockwell's method of general electrization may be used ; the feet of the patient are put in a basin of water (not a metallic basin), in which one pole is placed ; the other pole may be passed over the patient's neck and shoul- ders, or may be placed in another basin of water, in which his hands are dipped. CHAPTER XXXII. 15TEUKASTHENIA. Mitchell, S. Weir, Fat and Blood. Philadelphia, 1884.— Beard, G. M., A Practical Treatise on Nervous Exhaustion. New York, 1880. — Mitchell, Lectures on the Diseases of the Nervous System. Philadelphia, 1881.— Playp air, W. S., The Systematic Treatment of Nerve-Prostration and Hysteria. London, 1883. — Clark, F. le Gros, Some Remarks on Nervous Exhaustion and on Vaso-Motor Action. Jour, of Anat. and Physiol. , April, 1884, p. 239. Neurasthenia means simply an exhaustion, and con- sequent weakness, of the nervous system in general. During the last few years this condition has attracted much attention, and has been looked upon as a sepa- rate, independent affection. Beard led the attention in recent years to the many various disturbances which can be classed under this head. JEtiology. — The causes of neurasthenia are very numerous, the most important, perhaps, being the mode of life, habits, and customs of the present generation. Heredity certainly plays an important part in the aetiology, many of the patients having a father or moth- er, or both parents, similarly affected, or suffering from some debilitating disease, as phthisis. Women are the most subject to the disease, although men are by no means exempt. Of other causes, the training which the child re- ceived in its infancy and early years acts powerfully ; the school-life and the home-life both aid in develop- ing a weakened nervous constitution. In adult years, the wear and tear of business and of social life, the 372 UNCLASSIFIED. anxieties and worries, the disappointments frequently met in the struggle for existence, aid also in the same direction. The way houses are built, the way they are warmed and ventilated, habits in regard to diet, in re- gard to sleeping, exercise, employment, and amuse- ment, must be reckoned as favoring the development of this affection. To go into particulars would require an enumeration of every violation of the laws of health and hygiene which are so common at the present time. Pathological Anatomy. — There is probably no special pathological change to be discovered on inspec- tion, or the minutest examination of the nervous sys- tem. In the vast majority of cases the disturbance is purely functional, at least in the commencement. In a few cases there is a strong suspicion or probability that the nervous exhaustion leads finally to structural changes, as sclerosis ; this is, however, by no means positively proved. Most patients, however, have an unhealthy complexion. There is an expression about the eyes and mouth which is characteristic. The gait and other movements of the patient are also more or less characteristic of the languor and discomfort expe- rienced. These peculiarities can not be well described, but can be learned by observation. Symptoms. — A patient usually comes only gradu- ally to realize that his health is impaired. The first symptoms are those of languor, of disin- clination for exertion. The patient finds it necessary to rouse himself by an effort of the will to perform his daily duties. This languor and lassitude may be ac- companied with more or less discomfort in the head, perhaps amounting to pain ; or there may be a sense of weakness across the back, and pain along the spine. Sometimes there are various abnormal sensations in the limbs. Attending the pain in the head or back, there is usually more or less tenderness on pressure over the scalp, or the spinous processes of the vertebrae. The NEURASTHENIA. 373 back of the head and upper part of the neck are very- likely to be the seat of the pain. This tenderness may be excessive. This is the condition which has been called "spinal irritation." It is often attended with motor and sensory disturbance of the limbs, according to the level at which it may be. There is no need to raise this symptom to the dignity of a separate affec- tion ; it is merely the result of the general nervous ex- haustion localized. Noises in the ears, of various kinds, may also be noticed. The pupils may be widely dilated, or have an unusual mobility. Loss of sleep is sometimes very distressing ; the pa- tient may find it difficult to get asleep, and lie awake half the night, or he may have no difficulty in dropping to sleep when he first goes to bed, but, waking up after an hour or two, lies awake for several hours. Some- times, when the sleep seems to be sound during the whole night, the patient awakes unrefreshed, feeling as tired as when he went to bed. It is no uncommon thing to have the patient feel sleepy before going to bed, unable to do anything on account of the extreme drowsiness, and then, on retiring, he is as wide awake as possible. When the disturbance has continued some time, and advanced considerably, there may be an irritability of temper and a change of disposition, which renders it very trying to get along with such patients. He may be unable to control his mental operations. Reading even a few sentences is fatiguing, or it is impossible to understand anything that is read, so that all intellect- ual work must perforce be abandoned. Various disturbances of the secretions, either a de- ficiency or an increase of perspiration, or of the saliva, or of urine, show that the secretory functions are inter- fered with. Many patients cry very easily in a hys- terical manner. The voice may be changed and peculiar. A com- 374 UNCLASSIFIED. plaining, weak, high-pitched voice is sometimes met. The vaso-motor system shows a certain amount of in- stability. It is common for patients to blush easily on the slightest provocation. There is also frequently a sensation of heat, flushing of the face and head, which at times is extremely disagreeable, almost painful. This sense of heat may also be experienced through the back and limbs, and alternate with chills creeping over the body. Perhaps, owing in part to the instability of the vaso- motor system, these patients are very susceptible to changes of weather ; especially, dull, cloudy, and cold weather is found to be disagreeable. Many times, also, the heat of summer is oppressive, though the patients very often desire the rooms in which they dwell during the winter to be kept at a high temperature. The strength is very easily exhausted. Having no reserve force, if there is an extra demand for exertion they find themselves unable to meet the emergency, and hence are quickly tired. They may be entirely inca- pacitated for the ordinary duties of life, in consequence of lack of power for sustained exertion. The symptoms in neurasthenia change and vary from time to time even in the same patient. There are no two patients in whom the group of symptoms is the same. Also, the symptoms can not be reconciled with an organic change in any part of the nervous sys- tem. They are too variable and too contradictory to have any such sound basis. Many of these patients are more or less hysterical, and it is sufficient that the physician should mention symptoms for the patient to have them at the next examination. Diagnosis. — The diagnosis of nervous exhaustion can be made only after a careful study of the symp- toms, both subjective and objective. The accounts already given of various organic dis- eases, with their symptoms, will be sufficient to enable any one, after a careful examination, to decide whether NEURASTHENIA. 375 there is any such organic change. If not, and if the symptoms are frequently changing, and if the patient has a semi-hysterical appearance, seems to be dwelling a great deal upon his own symptoms, over -anxious about himself, it will be pretty safe to decide that there is no organic change, but that the disturbance is simply nervous exhaustion. Prognosis. — The chances of recovery in these pa- tients depends a great deal upon whether the exhaus- tion is excessive, and whether the patients have, through several years, gradually reached the condition in which they are found. At the very best, it will require many months, per- haps years, for a satisfactory recovery ; and, if the pa- tient is somewhat advanced in years, he can never regain the vigor of earlier life. Death almost never results as a consequence of nervous exhaustion, though it is possible that, after several years, organic changes may be set up in the nervous system, which may then lead to a fatal termination. Insanity, especially melancholia, is not very likely to occur as the sequel of neurasthenia. Many patients neither get well nor grow worse, but live an invalid life, suffering greatly, having very little comfort in themselves, and feeling that they are a burden and care to their friends, until some intercurrent disease ends their life. Treatment. — One of the first requisites in treat- ment of such patients is rest, and many of the patients require bodily as well as mental rest. If the disease is but slightly advanced, it may be sufficient to send the patient away from home to get him out of the regular ruts of life, away from business and its cares, or, in the case of women, away from household duties and anxie- ties, or the excitement of fashionable life. Traveling is rarely of benefit. It is better for the patient to go to some retired place where recreation and amusement can be obtained sufficient to make the time 376 UNCLASSIFIED. pass pleasantly, and, settling down, lie should deter- mine to obtain the greatest amount of rest possible. In cases where the disease is rather advanced, it is much better that the patient should be taken away from home, away from the care and the sympathy of friends, placed among comparative strangers, and subjected to the treatment which Weir Mitchell has so ably de- scribed in his two little books. This treatment con- sists in putting the patient to bed, feeding systematic- ally at first with milk, and later with other easily assimilated food, supplying the place of exercise by- massage and electricity. These patients usually have much trouble in sleep- ing. It may at first be necessary to give various reme- dies in order to obtain quiet rest at night. A good dose of opium, or occasionally bromide of potassium, may be of advantage. The bromide, however, should be given in divided doses, beginning about the middle of the day, so that the patient will take three doses before night. Chloral should rarely be given ; paraldehyde in doses of thirty to fifty minims is much better. Vale- rianate of zinc, combined with extract of hyoscyamus and extract of conium, as in the following prescription : ]jfc Zinci valerianatis gr. ij ; Ext. hyoscyami, ) ' M Ext. conn, ) ° Ft. pil. given three times a day, will sometimes quiet the nerv- ous restlessness, and favor sleep better than anything else. This combination also has the advantage of be- ing slightly laxative. If there is instability of the vaso- motor system, flushings, and chills, it may be an ad- vantage to combine with this ergot, cod-liver oil, and other tonics ; arsenic, iron, strychnia, etc., may be given as seems most desirable. Electricity is useful, not only to obtain the passive exercise of the muscles, but, given in the form of gen- NEURASTHENIA. 377 eral faradization, as described by Beard and Kockwell, is often of very great advantage, acting as a general tonic ; the static form is also useful. It may be well to say a few words in regard to feed- ing. Most of these patients are underfed. In many there is nervous dyspepsia, and the stomach will bear but a small amount of food at one time. It is neces- sary, therefore, to feed frequently. Occasionally as often as every half-hour a few spoonfuls may be given. Milk, or some of the various preparations, as Eidge' s Food, or Mellin's Food, can be given at first, but soon other things may be joined with it, as has been already mentioned in regard to the feeding of patients. To carry out a successful treatment of these patients requires a great deal of tact and perseverance on the part of both the physician and the patient. The pa- tient must stay in bed long enough. The mistake is more frequently made of not keeping the patients con- fined as long as is necessary rather than of keeping them in bed too long. The methods of treatment while the patient is in bed must be changed and varied as circumstances re- quire. "Where there is extreme exhaustion, very little attention needs to be paid to the amusement or the recreation of the patient while thus confined. As the patient, however, gains strength, it may be well to al- low some reading. After a while the patient may be allowed to read a little himself. Then other light em- ployments may be gradually taken up ; but it is neces- sary to remember that sewing, knitting, crocheting, etc., are really a severe tax upon the muscular system, and will often of themselves produce pain in the back and head, so that it is necessary to limit the time of such employment. When the patient begins to get up, it will be neces- sary to carefully regulate the amount of exercise and exertion, in order that he may not overtax himself, and so be put back and delayed in recovery. 378 UNCLASSIFIED. Many times it is necessary to confine the patient to the bed all day long. He can change from bed to lounge, or couch, and back again. At first it may be necessary to exclude friends ; but, later, a friend, who has the wisdom not to stay too long and not talk too fast or much, and who does not tire the patient, may be admitted as may seem most desirable. CHAPTER XXXIII. TETANUS AKD TETANY. Aufrecht, Zur pathol. Anatomie des Riickenmarks beim Te- tanus. Deut. med. Wochen., No. 14, 15, 1878, and London Med. Bee., June 15, 1878, p. 238.— Coats, J., On the Pathology of Tet- anus and Hydrophobia. Med.-Chir. Trans., 61, 1878, p. 79. — Woods, G-. A., A Contribution to the Pathology of Tetanus. Lan- cet, Sept. 7, 1878, p. 326.— Wood, H. C, Abstract of a Lecture on a Case of Idiopathic Tetanus. Philadelphia Med. Times, March 15, 1879, p. 273. — Knecht, Beitrage zur Lehre vom Tetanus. Schmidt's Jahrb., 181, 182, 1879.— Macdougall, J. A., The eti- ology of Tetanus, etc. Lancet, July 19, 1884, p. 98.— Bowlby, A. A., Five Cases of Tetanus, with some Remarks on its Pathology. St. Barth. Hosp. Bep., 1883, p. 85. Tetany. — Trousseau, Lectures on Clinical Medicine. New Syden. Soc, 1868, vol. L— Erb, W., Zur Lehre von Tetanie. Arch. f. Psych., iv, 1874, p. 271.— Chvostek, Beitrag zur Tetanie. Wien. med. Presse, 1876, 1878, 1879.— Weiss, N., Ueber Tetanie. Volkmann's Sammlung, No. 189, 1881.— Gowers, W. R., Clini- cal Lecture on Tetany. Lancet, July 21, 1883, p. 92. TETANUS (Locked- Jaw). Tetanus is a continuous tonic spasm of the muscles, due to an increase of the reflex irritability in conse- quence of an injury, though sometimes apparently the result simply of a chill. JEtiology. — Injuries of the extremities are more frequently the cause of tetanus than those of the trunk. Both severe and slight wounds may be followed by the spasms, which may occur before the wound is healed, or only a long time afterward. Exposure to the inclemency of the weather, and various hardships, also lack of cleanliness in the care 380 UNCLASSIFIED. of the wound, are more likely to be associated as causes of the attack. The disease is somewhat common in military sur- gery, and the soldiers of the vanquished party are more likely to be affected than the victors. In civil life, men are more commonly affected than women, being more exposed to injuries. The disease is very common in certain countries in new-born children, especially during the first nine days of life. Children are more likely to be affected in warm cli- mates ; and there are also districts in temperate zones where the disease is more likely to occur, as along the southern and eastern shore of Long Island. It is said that the colored races are more likely to be attacked than whites. Symptoms. — The first symptom is usually a stiffness of the jaws (trismus), which renders it somewhat diffi- cult to open the mouth. Then there is a slight spasm in the muscles of the neck, and later this spasm ex- tends to the muscles of the back and of the trunk. The severity of the contraction steadily increases, and, the extensors being the most powerful, the body is gen- erally drawn backward, so as to form an arch, and, when the spasm is extreme, the patient rests upon his head and heels, the body being arched above the bed (opisthotonus). The arms and hands are often unaffected, though they may be rigid in extension. The contraction of the muscles is attended with se- vere, cramp -like pains, producing extreme distress. The skin is frequently covered with perspiration dur- ing the spasm. The contraction of the respiratory muscles interferes with breathing, so that at the height of the spasm the patient has a sensation of impending suffocation. Owing to the closure of the jaws, the-pa- tient finds great difficulty in speaking, and it is almost impossible to feed him. TETANUS. 381 The muscles are continuously in a state of contrac- tion, but are not always contracted to such an extreme degree, remissions occurring, during which the patient may resume the ordinary position in bed, be able to take food, and converse ; yet the slightest irritation, even breathing upon the patient, or a slight jar of the room, or an attempt to swallow, will cause a recurrence of the extreme spasm. The temperature is but little affected except just be- fore death, when it may rise as high as 112° or 113°. The pulse, also, is nearly normal, except toward death it may, with the rise of temperature, become very rapid. The mind is usually unaffected, except toward the close of life, when there may be delirium. Occasion- ally the patient dies in consequence of the disturbance of respiration ; but this is not very common. Many times the patient dies in the interval between the spasms, apparently worn out by the disease. Pathological Anatomy. — The pathological changes found in tetanus do not explain the symptoms, nearly all being apparently the effects of the disease rather than the cause. In many cases, however, inflammation of the nerves leading from the seat of the wound have been recog- nized, and occasionally there have been found changes in the spinal cord, the blood-vessels being surrounded by leucocytes. Ross mentions finding these bodies in the gray and white substance, around the vessels, though not usually aggregated in the perivascular spaces, as in hydrophobia. He also found some changes in the ganglion -cells of the anterior cornua. Diagnosis. — It is scarcely possible to mistake teta- nus when well marked. It is important to make a diagnosis as early as pos- sible, even when there is only the first symptom of tris- mus. Strychnia-poisoning resembles tetanus in some re- spects, but the spasms are less continuous, having pe- 382 UNCLASSIFIED. riods of entire intermission ; also the reflex irritability is somewhat less marked, and the disease begins more abruptly, affecting the limbs first rather than the mus- cles of mastication and the neck. Prognosis. — The disease is always a grave affection ; seventy per cent or more die. It is less serious when the result of cold than when there has been a previous wound or injury. The longer the time after the injury when the first symptom ap- pears, the more favorable the prognosis. Infants al- most always die. Treatment. — The patient should be put in a dark room, kept as quiet as possible, and every possible effort made to prevent any impressions which would excite the spasm. One of the most difficult problems is how to feed the patient. It is absolutely necessary to keep up his strength, and the feeding should be done, in the most quiet way, with liquid nourishment, so as to re- quire as little effort on the part of the patient as pos- sible. The jaws being closely locked, it may be necessary to pass the food in by a tube behind the teeth. It has been recommended to feed the patient, while under the influence of ether, by means of a tube passed through the nostril into the stomach. Of antispasmodic drugs, almost all in the Pharma- copoeia have been used at different times. Curare and calabar-bean have been used to diminish the reflex irri- tability. Chloral and bromide of potassium together are of great advantage, but it is necessary to give large doses. As high as sixty grains of chloral have been given, repeating it as may be necessary. Generally, twenty or thirty grains, with the same amount of bro- mide of potassium, given every two or three hours, would be sufficient. Thompson gave three grains daily the first three days, ten grains daily the next ten days, five grains daily the next seven days, after that gradu- ally reducing the quantity so that in twenty-six days TETANY. 383 one hundred and thirty-three grains were taken, the patient being a child seven years old. Read gave twenty drops of gelsemium every two hours, and the next day forty drops every two hours, the patient recovering. The patient may be kept under the influence of ether, so as to prevent the spasms, when other means fail. Various surgical expedients have been tried; the nerves have been divided above the seat of the wound. Unless this is done very soon after an injury, it would probably have but little influence. Stretching the nerve leading to the wound has proved of benefit in a few cases. TETANY. Tetany has been sometimes spoken of as intermit- tent tetanus, sometimes as an intermittent cramp. It consists of spasms affecting more generally the upper extremity, in severe cases extending also to the legs and body, intermittent, recurring at irregular inter- vals. Symptoms. — Trousseau speaks of three varieties, the mildest, which is local in its manifestations, being confined to the extremities, usually the upper, some- times affecting the lower. The spasm consists chiefly in a partial flexion of the fingers, the thumb and fin- gers being approximated so as to form a cone. The wrist is flexed and pronated and the forearm flexed upon the wrist. In the lower extremities, the toes are flexed, the foot and leg extended. The spasm is attended with severe pain, and any effort to overcome it is painful. The convulsions may last for from five to fifteen or twenty minutes ; the less severe convulsions may con- tinue two or three hours. These attacks may be repeated once a day, or sev- eral times a day, for several months, and then the pa- 384 UNCLASSIFIED. tient may be entirely free, until after some months the attacks reappear. One of my patients had these at- tacks regularly twice a year, lasting each time three months. Trousseau has mentioned that in the interval be- tween the spasms a compression over the track of the nerves or the vessels will cause the attack, which con- tinues as long as the compression is maintained, ceas- ing as soon as the pressure is removed. After the attack there is for a short time loss of power in the limbs affected. Sensation is likely also to be diminished. Trousseau's middle form of the disease combines with the spasms already mentioned other general symptoms, which he mentions as feverishness, head- ache, loss of appetite, slight congestions in different parts of the body ; the spasms are more severe, return more frequently, and affect the muscles of the trunk and face, as well as those of the extremity. He has also enumerated a third and more grave form of the disease, which differs in nothing from the other except in being more severe. Sometimes the patients recognize that an attack is approaching, by unpleasant sensations in the hands and feet, and slight stiffness in moving. Several authors have recognized a very great in- crease of electrical irritability in both the nerves and muscles of the affected limbs during the attack. The disease is of long duration when once it appears, extending, with the intermissions, through many years. ^Etiology. — Very little is known as to the cause of this disease. " Catching cold " is often mentioned as the starting-point of the spasms. Various exhausting influences seem to act as causes. One patient stated that eating and drinking would bring on an attack dur- ing the time when he was liable to have them. Pathological Anatomy. — Very few autopsies have been made, and but little is known as to the changes in TETANY. 385 the nerves or their centers. Weiss found swelling of the ganglion- cells of the anterior cornua, with a lateral position of their nuclei and vacuoles in the cells and their processes ; also atrophy of the cells, with loss of their protoplasmic processes. Diagnosis. — The character of the spasm, the inter- mission of the attacks, and especially Trousseau's ma- noeuvre of pressing upon the nerve or vessel of the limb, are sufficient to determine the nature of the disease. Prognosis. — The disease is rarely fatal, though a few cases of death have been reported. The patient, having passed through one attack, is not safe from sub- sequent attacks. Treatment. — It seems as though very little could be done to cut short the spasms. Opium, belladonna, chloral, and inhalations of ether may be used as indi- cated. Electricity may be tried, either by faradizing the muscles that are not affected, or the use of galvanism to the nerve-centers. Erb saw a recovery take place from the stabile ap- plication of the anode to the vertebral column and the nerve-trunks chiefly affected. I used electricity in one case in every way I could think of, without a par- ticle of benefit. I have obtained more benefit from the use of the fluid extract of conium, twenty drops every two hours, than from any other remedy. Between the attacks, quinine, arsenic, and valerianate of zinc, and other nerve-tonics, should be given. CHAPTER XXXIV. MYXCEDEMA. Ord, On Myxoedeina. Med.-Chir. Trans., lxi, 1878. — Cushier, Elizabeth, M., A Case of Myxoedema. Archives of Med., Dec, 1882, p. 203.— Oliver, T., Clinical Lecture on Myxoedema. Brit. Med. Jour., March 17, 1883, p. 502.— Edes, R. T., Clinical Lecture on a Case of Myxoedema. Boston Med. and Surg. Jour., April 24, 1884, p. 385.— West, E. G., A Case of Myxoedema, with Au- topsy. Boston Med. and Surg. Jour., July 17, 1884, p. 50. Myxoedema consists essentially in an increase of the subcutaneous tissue, which is infiltrated with mucin, so that the general appearance is that of oedema, yet the skin does not pit on pressure. Symptoms. — The patient's appearance is very pecul- iar. The eyelids are thick, as if swollen with crying, or infiltrated with serum ; the nose is very broad, the lips thick, the hands are large and misshapen, the fin- gers being club-shaped. The feet are usually affected the same as the hands ; the swelling sometimes extends to other parts of the body, especially to the arms and legs, and even to the trunk itself. The tongue is usu- ally very much swollen. The patient has many times a waxy or anaemic complexion, the red-blood corpuscles being diminished in number. The infiltrated tissue has a semi-translucent appearance. The motions are necessarily slow and difficult. The patient manages his large fingers in a clumsy way, so that the more delicate manipulations of writing or sew- ing are illy performed. The gait of the patient in walk- ing is slow, as if great exertion were required. Ordinary sensation is diminished, and the special MYXCEDEMA. 387 sensations of taste and smell may also be diminished, probably on account of the swelling of the mucous membrane of the nose. In some cases the temperature has been noticed to be above normal, but it is usually diminished. The pulse is generally slow. In most of the cases observed the intelligence has seemed to be affected. The patient answers questions slowly, as if it were an effort to think or speak. She seems indifferent to her surroundings. Memory may be weakened. The simplest operations of arithmetic are performed with difficulty, or the patient is unable to give correct answers. Sometimes the hair falls out. The nails become brittle and furrowed. The digestion is affected only when the disease has reached an extreme degree. Constipation is very common. Menstruation is often irregular. In some cases the thyroid gland has been very much diminished in size. The succession of these symptoms may vary some- what in different cases. Sometimes the mental depres- sion, even reaching the degree of melancholia, may ap- pear early ; or, on the other hand, there may be a very great amount of swelling, with the mind almost entirely unaffected. ^Etiology. — The causes of this disease are very ob- scure. In several cases worry or anxiety, or some men- tal shock, has preceded the attack. We, however, in fact, know almost nothing in regard to the real cause of the affection. The course of the disease is very slow, most of the cases extending over several years. Pathogenesis. — The nature of this disease is as yet imperfectly known. On the one hand, it is sup- posed that the changes in the skin are primary, and that, owing to defective sensation, the cerebral disturb- ance follows as a result of the cutaneous change. 388 UNCLASSIFIED. Another view is that the disease is due to disturb- ance of the nervous system, either the sympathetic or a more general disturbance involving other than the sympathetic system, and the cutaneous changes are looked upon as secondary. In the few autopsies which have been made, the ex- amination has not been, as a rule, complete ; in each case some important parts were overlooked, and not ex- amined. Changes have been found in the spinal cord, in the blood-vessels, and nerve-cells. Dr. E. M. Cushier ("Archives of Medicine," 1882, p. 216) says: "The disease in question can only be described as a nutritive disturbance, resulting in the presence, in the connective tissue, of a substance com- mon in embryonic tissue, but not existing normally, ex- cepting in very small amounts, in adult life." Teeatment is comparatively unsatisfactory ; almost every means of arresting the progress of the disease has failed. A few cases have been reported in which the use of tonics, such as iron, quinine and strychnia, warm-air baths, massage, and general hygienic treat- ment, have seemed to be of some advantage. The dou- ble chloride of gold and sodium has been recommended. Dr. Edes refers to a curious case, in which abdominal dropsy occurred, and became so severe as to require tapping, after which operation both the ascites and myxcedema disappeared. CHAPTEE XXXV. TOXIC NEUROSES. Lead.— Bernhardt. Arch. f. Psych, u. NervenJc., iv, 1874, p. 601.— Westphal, C. Ibid., p. 776.— Riegel, F. Deut. Arch. f. Tel. Med., 1878, p. 175.— De Watteville, A. Lancet, July 10, 1880, p. 44.— Monakow. Arch. f. Psych., x, 1880, p. 495.— Zunker. Zeitschr.f. M. Med., 1880, p. 496.— Birdsall, W. R. Amer. Jour, of Neurol, and Psych., May, 1882, p. 176.— Webber, S. G. Arch, of Med., Aug., 1882.— Putnam, J. J. Boston Med. and Surg. Jour., 1883, p. 315. Arsenic. — Seeligmuller, A. Deut. med. Wochenschr., No. 14, 1881.— Popow, N. St. Petersb. med. Wochenschr., 1881, p. 311.— Da Costa, J. M. Philadelphia Med. Times, March 26, July 2, 1881.— Mills, C. K. Med. News, March 3, 1883, p. 257. — Seguin, E. C. Jour, of Nerv. and Mental Dis., Oct., 1882 ; Opera Minora, 1884. Alcohol.— Hutchinson, J. E., Symptoms and Treatment of Alcoholism. Phila. Med. Times, July 30, 1881, p. 687.— Pepper, William, On Acute Diseases in Drunkards — Delirium Tremens. Phila. Med. Times, June 17, 1882, p. 621.— Atkinson, F. P., The Treatment of Delirium Tremens. Practitioner, Jan., 1883, p. 38. — WlLLE, Ueher einige klinische Beziehungen des Alcoholismus Chronicus. Zeitschr. f. Psych., 1884, Bd. xl, p. 827. Hydrophobia.— Benedikt, M., Zur pathologischen Anatomie der Lyssa. Virch. Arch., Bd. lxiv, 1875, p. 557 ; Bd. lxxii, 1878, p. 425. — Bollinger. Ziemssen's Cyclop., Am. Trans., vol. iii, 1875.— Curtis, T. B., A Case of H. Boston Med. and Surg. Jour., Nov. 7, 1878, p. 581 et seq.— Putnam, J. J., The Physiological Pa- thology of the Hydrophobic Paroxysm. Ibid., Nov. 21, 1878, p. 650.— Gowers, W. R. Ibid., Feb. 6, 1879, p. 178.— Foot, A. W., Report on H. Dublin Jour. Med. Sci., Oct. 1, 1879, p. 287.— Col- lins and Mills, C. K., Cases, with Microscopic Report. Proc. Phila. Co. Med. Soc, 1880, ii, pp. 107, 117.— Colin, L., Annales d'hygien pub. May, 1881, p. 408.— Ruxton, John, A Case of Hy- drophobia ; Recovery. Brit. Med. Jour., Nov. 19, 1881, p. 811.— 390 UNCLASSIFIED. Broadbent, Cases of Supposed Hydrophobia treated by Chloral, one of which recovered. Med. Times and Gaz., March 17, 1883, p. 308. CHRONIC LEAD-POISONING. Lead may be taken into the system through the skin, by the mouth with food, or, inhaled as dust, may be swallowed with the saliva. The occupations in which lead is used are readily recognized in most cases ; among those less known as dangerous may be men- tioned file-cutters, brush-makers, workers in enamel, in colored papers, in lace, and in rubber-factories. Food preserved in tin, or drink passing through lead pipes, or stored in lead-lined cisterns, not only or- dinary drinking-water, but mineral-waters, ale, beer, etc., are likely to contain lead. Symptoms. — The time when the symptoms appear after exposure varies from a few days to several years. Ancemia is one of the earliest and most common effects of lead. The red corpuscles may be reduced one third in number ; their size is also slightly in- creased. The patient is sallow ; the skin is dry and harsh, sometimes oedematous. A narrow line of bluish- purple color may be frequently noticed at the edge of the gums in patients who do not cleanse their teeth. Lead colic is a well-known symptom. Preceding the attack, the appetite may have failed for some days, there may have been a sweetish or disagreeable me- tallic taste, and a general feeling of ill-ease. Consti- pation is usually present. The pain is light at first ; gradually increases until it is of extreme severity. The spasms of pain are usually of short duration, but recur frequently, so as to be almost continuous. The patient can not keep quiet ; he tosses about. Generally there is no tenderness of the abdomen ; pressure may give temporary relief ; nausea and vomiting may occur. The pulse is hard ; vascular tension is increased. The sphygmograph shows a slight notch at the apex of TOXIC NEUROSES. 391 the curve, a peculiar cupping, by which two points or teeth are produced. Arthralgia is said to be next in frequency to colic as a symptom of lead-poisoning. The pains resemble neuralgia ; the joints are somewhat swollen, and may be red ; sometimes there are cramp-like pains in the muscles. The paralysis of lead-poisoning usually affects the extensor muscles of the fingers and wrists ; is almost always bilateral, though it may begin on one side ear- lier than the other. One or more attacks of colic, or arthralgia, may have preceded, and there has generally been abnormal sensation in the parts, pricking and tingling, as if the limb were asleep. The supinator longus is rarely affected ; the deltoid is paralyzed rath- er than the biceps. The flexors of the fingers always seem weak when the extensors are paralyzed. The legs are much less frequently affected than the arms ; some- times the loss of power is noticed in all four limbs. When cosmetics are the cause of the poisoning, the muscles of the face may be paralyzed, otherwise they are usually exempt. The onset of the paralysis is gradual ; sometimes, however, a day or two is sufficient to render the hands helpless. The muscles undergo atrophy, which may be extreme. The electrical reaction is diminished, or lost ; the reaction of degeneration may be recognized, unless the atrophy has progressed too far. There may be partial loss of sensation on one or both sides ; this, however, is rare. Tremor, resembling paralysis agitans, is occasion- ally seen. Instead of symptoms of peripheral paralysis, those of myelitis may be the only evidence of lead-poison- ing. So close is the resemblance that it may be im- possible to form a diagnosis from the symptoms alone. In order to form a correct opinion, it will be necessary to give iodide of potassium, and after a week or so ex- 392 UNCLASSIFIED. amine the urine for lead. Every case of chronic mye- litis should be thus examined for lead. The severest form in which lead-poisoning shows itself is seen when the brain is affected — encephalo- pathia saturnina. The symptoms are headache, or simply discomfort in the head, incapacity for mental exertion, amblyopia and amaurosis, delirium, or even maniacal excitement, and epileptiform attacks. Be- ginning -with the milder manifestations, the severe symptoms may follow within a few days, until a fatal termination is reached. Many times albumen will be found in the urine, and hyaline casts are not uncommon. Pathological Anatomy. — Lead has been found in nearly all the tissues of the body ; but its presence is not constant, and the symptoms do not seem to depend thereupon. The nerves supplying the paralyzed muscles have been found atrophied and degenerated. Changes have been found in the nerve-cells of the anterior cornua of the spinal cord, also in the vessels of the cord. In many autopsies no such changes have been found. The muscles undergo fatty granular degeneration. Prognosis. — It is very rare for lead colic and arth- ralgia to terminate fatally ; relapses, or repeated at- tacks, are usual, if the patient continues exposed to lead. Lead paralysis is also seldom fatal unless the ex- posure to the poison has been very prolonged, and the symptoms have been neglected. Under proper treat- ment, recovery is the rule ; but many months or years may be necessary for restoration of function. The prognosis in tremor from lead is favorable. When the cerebral symptoms are slight, chiefly headache and mental inertia, the chances of recovery are good ; the same is true even in cases of delirium and mania, though then the prospect is more serious. In eclampsia saturnina the patient almost invariably dies. TOXIC NEUROSES. 393 Treatment. — It is scarcely necessary to say that means should be taken by all workers in lead to pre- vent its introduction into the system, or that, with the first symptoms of poisoning, there should be yet greater care. Iodide of potassium should be given to remove the lead from the system. During treatment the physician must watch lest the liberation of lead from the tis- sues should give rise to a recurrence of acute symp- toms. Warm baths are of value, by maintaining the ac- tivity of the skin and favoring metamorphosis of tis- sues. Iodide of iron is of value to improve the quality of the blood. During the attack of colic, morphia should be freely used ; it will aid in relaxing spasm, and, with a cathar- tic, aid in opening the bowels ; atropia may be com- bined with it to advantage. Nitrite of amyl inhaled may often relieve the pain and shorten the attack ; it also restores the normal ten- sion of the vessels aud the normal character to the sphygmographic tracing of the pulse. To relieve the arthralgia, warm baths, sometimes cold packing, and the galvanic current applied locally to the affected joint, are of value. Sometimes tincture of iodine, though increasing the pain temporarily, may give relief subsequently. Paralysis should be treated by massage, warm baths, and electricity ; the interrupted galvanic cur- rent, if the muscles do not react to the faradic. In ob- stinate cases, strychnia by the mouth, or subcutane- ously, is said to be of advantage ; comparatively large doses are required. TJie treatment must be persevered in for months or years, and not hastily abandoned. In cases where there seems to be myelitis, and in cerebral cases, the same course should be pursued for eliminating lead. The galvanic current to the head will sometimes relieve headache. 394 UNCLASSIFIED. ARSENIC. Arsenical poisoning is found among the various ar- tificers in that metal ; also among those who use fabrics containing arsenic in the dyes, as artificial - flower makers, seamstresses, and paper-hangers. Wall-papers, cretonnes, etc., bring others in contact with the poison. Among some of the more common symptoms are disorders of the digestive organs, gastric catarrh, weak- ness of the eyes, conjunctivitis, and cutaneous erup- tions. A condition of general debility, or even paraly- sis, anaemia, and nervous weakness, resembling neu- rasthenia, can sometimes be traced to wall-papers containing arsenic. After acute poisoning by the ingestion of large doses of arsenic, when the gastro-intestinal symptoms are passing off, those pertaining to the nervous system ap- pear. There is first pain in the back and limbs, accom- panied with numbness or a sleepy sensation. With this, a weakness which increases progressively till there is total paralysis. These phenomena occur within a week or two after the poisoning. Sensation may be almost lost, or scarcely impaired. Atrophy of the affected muscles follows, and the reaction of degeneration is found. The patellar tendon reflex has been found absent, the plantar cutaneous reflex absent, while the cremaster reflex was normal. The paralysis begins in the legs, and is most severe in them ; may also affect the arms, usually in a less de- gree. Cutaneous trophic and vaso-motor changes are not infrequent. In some cases albumen has been found in the urine. Generally, improvement begins within a month, and steadily progresses to perfect or nearly perfect recov- ery ; a slight weakness may remain a year after the poisoning. In a few cases the paralysis may be per- manent. TOXIC NEUROSES. 395 SeeligmuQer gives several diagnostic points : 1. The acute origin of the paralysis as contrasted with the chronic nature of lead paralysis. 2. The severe sen- sory disturbance. 3. Arsenic affects primarily, and most frequently, the legs. 4. Atrophy and reaction of degeneration appear earlier in arsenical poisoning. 5. Other trophic changes are not seen in lead. The evidence is sufficient to prove that the symp- toms are due to a diffused myelitis affecting especially the anterior gray substance. Treatment. — It does not seem to be certainly as- certained that any special medication hastens the elimi- nation of arsenic. As it leaves the system chiefly through the kidneys, their action should be main- tained, as well as that of the skin, by baths and proper clothing. Morphia, or other anodynes, may be necessary on account of the pain. Electricity and massage must be used to restore the use of the muscles, as in other affections with similar loss of power. ALCOHOL. The symptoms of acute alcoholism, as seen in sim- ple drunkenness, need not be described here. Those of chronic poisoning vary considerably. The more common effects are a gradually undermining of the health and a change in important viscera, as liver and kidney, giving rise to diseases of those organs. The most common nervous disturbance is found in that condition known as delirium tremens. This is the final result of a long debauch. Patients vary greatly as to the ease with which they have an attack. It is the common belief that the sudden leaving off of drinking is the cause of delirium tremens. Some- times this is so, but many times the patient gives up the liquor because he can not take it ; the system will not longer tolerate the poison, and then the cessation 396 UNCLASSIFIED. from drinking is the first symptom of the disease, not the cause of its outbreak. Besides the influence of alcohol, it will be found that there has been abstinence from food and loss of sleep, aiding to produce the final outbreak of delirium. In severe cases, it will be found that patients have not slept for a week or more, and have eaten nothing for several days. Preceding the attack there is a tremor of the hands, tongue, and sometimes a general tremor whenever the limbs are moved. Vomiting may appear a day or two before the delirium. At first there is only an inclina- tion to start suddenly ; there is a watchfulness in the patient's expression, and he is evidently divided in his attention to the physician and his unexpressed fears. He fingers the bedclothes with trembling hands. Per- haps he is covered with a cold perspiration. The eyes are red and watery ; he has a haggard expression. After a while the delirium may become more active ; various hideous and repulsive shapes present them- selves to the disordered brain. The patient starts up, and struggles violently to escape from his tormentors. Hallucinations of hearing are much less common than those of sight. It is very seldom that patients ever attempt to in- jure themselves or others. If attacks are made upon attendants, it is in connection with some hallucination, or in an endeavor to escape from imaginary specters. So, also, efforts to jump out of windows, etc., are made for the purpose of escape. The temperature varies ; it is often normal, is some- times subnormal, and may be elevated. It is almost impossible to take the temperature in an excited pa- tient. The pulse is rapid and weak where there is much excitement, or it may be only slightly increased in fre- quency when the excitement is moderate ; it ranges from 80 to 150, or even more. TOXIC NEUROSES. 397 Disgust for food, and vomiting of everything taken into the stomach, are quite common. If the patient does not obtain sleep, the tremor, delirium, feebleness of the pulse, and general prostra- tion increase until death. Near the^close of life the temperature may rise to 106° or 107°. A fatal termination is rare if the patient is seen early and properly treated, unless there is organic dis- ease of one of the important organs. Instead of delirium tremens, or after an attack, the victims of alcoholism may have serious cerebral symp- toms, resembling meningitis, or there may be organic disease of the brain ; sometimes there is insanity, usu- ally mania, often general paralysis. The prognosis in such cases is unfavorable. Teeatment. — A quiet room is desirable, with as little disturbance from attendants as may be. It is better in some cases to have the room darkened ; but many times the uncertain, fitful shadows in a dimly lighted room disturb the patient more than a bright light. His imagination transforms the shadows into grotesque or horrible shapes. Some authors object to mechanical restraint, advis- ing that there should be attendants enough to keep the patient quiet and prevent his injuring himself or oth- ers. Those who need restraint are excited by the op- position of other men ; they will struggle against those who, they imagine, are about to injure them. If put into a strait-jacket, their struggles soon cease, or are much less violent, and there is no danger of injury from too great force applied by injudicious, tired, or excited (not angry) attendants. Of course, a patient in a strait- jacket needs to be watched lest he should work himself into a dangerous position, or roll out of bed, or other- wise harm himself. If there is vomiting, tincture of capsicum should form a part of every prescription ; sometimes it is sufficient alone to produce sleep, and enable the stomach to retain food. 398 UNCLASSIFIED. If the pulse is very rapid and weak, if there is much excitement and tremor, that is, in the worst cases, tincture of digitalis, with or without capsicum, is the best drug. According to the pulse, from one to four drachms should be given. If the pulse is strong and only moderately rapid, one drachm, or perhaps half a drachm, will be sufficient. In very severe cases the larger doses are needed. One dose, sufficient to strength- en the pulse, is better than to repeat small doses. Sleep may follow in half an hour. The digitalis, not in the largest doses, may be repeated after twelve or twenty- four hours if it is necessary to procure sleep again. Often only one dose is required. It must be kept in mind that the patient receives considerable alcohol with large doses of the tincture. Chloral and bromide of potassium are valuable in the milder cases, and in the severer after digitalis has reduced the pulse. One or two large doses, thirty to forty grains of chloral, with as much bromide, is better than repeating small doses frequently. The latter may increase the excitement. If the stomach is very irri- table, it is better to give only the capsicum by the mouth ; chloral, if necessary, can be given by enema. Paraldehyde, in drachm doses, may be sufficient in very mild cases, or after one or two nights' sleep ob- tained by other means. I have not used it in severer cases. Formerly opium, or its preparations, were generally used. In some cases the hypodermic injection of a quarter of a grain of morphia is the best treatment. After the patient has become quiet, the oxide of zinc, two or three grains, or sulphate of quinine, three to five grains, given three times a day, will prove most useful tonics. It is important that the patient should be well fed ; at first milk, hot or cold, as best suits the patient, or animal broths, are best ; when the stomach will digest solid food, it should be given. TOXIC NEUROSES. 399 HYDROPHOBIA.. Hydrophobia is always caused by the bite or the in- oculation with the saliva of a rabid animal. It never arises spontaneously. Domestic animals, dogs, cats, cows, etc., and wild animals, as foxes or wolves, may communicate the disease. About half those bitten are attacked with rabies ; bites on unprotected parts, hands, face, and neck, are most dangerous. Early cauterization of the wound diminishes the danger. Slight wounds, like scratches, are more likely to give trouble than severe bites which bleed freely. There is a stage of incubation, continuing from two weeks to five years (Colin), during which the wound heals, the patient appears in usual health, though often he has a serious apprehension, a dread of the conse- quences, which he can not explain. Often the first symptom of the approaching attack is a pain shooting from the seat of the wound toward the nerve-centers ; the cicatrix may become livid. The patient's disposition may show a change — he may be- come moody or irritable. With or without the above symptoms there arises a peculiar difficulty in swallow- ing. All the motions can be made, but, so soon as the liquid or food touches the mucous membrane of the mouth, the irregular or spasmodic action of the throat interferes with deglutition. Generally, speech is also hindered. At first the patient can overcome this irregular ac- tion of the muscles, but soon he loses that power, and the reflex excitability becomes so excessive that any noise suggesting food or drink excites the spasm. Oth- er regions also acquire this abnormal excitability, so that a slight draught of air over the face, the glitter of a bright light on the eye, or a sharp sound heard, has the same effect. The patient is unable to swallow his saliva, which 400 UNCLASSIFIED. becomes thick, tenacious, and ropy. The irritation thus produced gives rise to violent paroxysms ; the pa- tient starts up, hurling violently back his attendants, clutches at his throat, tries to clear his mouth of the mucus, and spits it far from him with extreme violence. His whole effort seems to be to expel the saliva which so distresses him and interferes with reflex respiration. Delirium, hallucinations, and delusions are some- times noticeable during these paroxysms, and occasion- ally in the intervals. After such an attack the patient lies quiet, or may sit up at his ease ; can usually walk if desirable. He knows when the attack is about to be repeated, and may warn his attendants. There is almost never any effort to bite or scratch. The stories of patients bark- ing like dogs, etc., are in a great degree the products of the imagination of attendants. Finally, these paroxysms become more and more fre- quent, the patient is exhausted by his inability to take food, by sleeplessness, and by the violence of the dis- ease. Partial paralysis may occur. Death takes place either during an attack or quietly in the interval ; the power to swallow may return just before death. The imagination, or, perhaps, it would be more cor- rect to say the emotional conditions and the mental influences, seems to exert a great influence over the attacks. The sight of water, even a reference to drink- ing, will cause one ; yet the same patient may immedi- ately after urinate, both seeing the urine and hearing it fall into the vessel without any disturbance. Diagnosis and Prognosis. — The only affection likely to be confounded with hydrophobia is hysteria, which in some of its manifestations slightly resembles the more serious disorder. A careful observation of the patient's condition during the spasm, and in the in- terval, will guide to a diagnosis, as will also the experi- ment of gently fanning his face, or the manner in which he acts when drink is offered, bracing himself for a TOXIG NEUROSES. 401 great effort, seizing the cup, unable to carry it to his mouth, or only succeeding in swallowing a few drops ; the character of the attack is very different from hys- teria. There is no resemblance to tetanus, as has been sometimes claimed. Hitherto death has been the uniform termination, except in a few cases, and in many of these the diag- nosis is doubtful. Pathological Anatomy. — The blood-vessels of the brain and spinal cord are distended, their walls are thickened, and in many places collections of leucocytes surround the smaller vessels, and they may be found quite generally scattered through the gray substance. Sometimes the blood escapes from the vessels, forming small haemorrhages. Ross has found the nerve-cells of the median and central groups in the anterior cornua shrunken and atrophied ; the spinal accessory and pneu- mogastric nuclei were also altered. Teeatment. — As soon as one has been bitten by a dog, whether thought to be rabid or not, the wound should be sucked, either by the person himself or by some one else. If the mucous membrane of the mouth is unbroken, there is no danger in doing this. As soon as possible after this the wound should be thoroughly cauterized. Some advise nitrate of silver, others caus- tic potash ; the latter is probably the better. The hot iron may answer the same purpose, but is less certain in its effect, as it can not so surely penetrate to every part of the cavity. Gunpowder may be poured into or upon the wound and ignited. Or the wound may be excised. When the first symptoms of the disease have shown themselves, there is little chance of recovery. Chloral, morphia, and stimulants given by the rectum may re- lieve the suffering somewhat. Ether can be inhaled to give relief, and while the patient is under its influence a tube may be passed into the stomach and food intro- 402 UNCLASSIFIED. duced. Curare and morphia can be injected subcu- taneously. Ruxton gave six drops of tincture of can- nabis Indica to a boy about six years old each time he awoke. The boy recovered. Broadbent reports a cure from enemata of twenty grains of chloral, one ounce of brandy, and two ounces of beef-jelly every three hours. CHAPTEE XXXVI. SYPHILIS. Zambaco, D. A., Des affections nerveuses syphilitiques. Paris, 1862. — Heubnek, Die luetische Erkrankung der Hirnarterien. Leipzig, 1874. — Fournier, A., La syphilis du cerveau. Paris, 1879. — Savard, P., Etude sur les myelites syphilitiques. Paris, 1881.— Wood, H. C. Am. Jour. Med. Sci., Oct., 1880, p. 384 ; Boston Med. and Surg. Jour., Dec. 20, 1883, Jan. 10, Feb. 28, 1884.— Lancereaux, E., Syphilis cerebral. Gaz. hebd., 1882.— Putzel, L., Syphilis of the Central Nervous System. Med. Rec- ord, April 26, 1884, p. 450.— Seguin, E. C, The American Method of giving Potassium Iodide, etc. Archives of Med., Oct., 1884. Syphilis of the nervous system belongs to the ter- tiary period. The first symptoms may appear as early as two months after infection, or as late as thirty years ; generally between three and twenty years after. The nervous symptoms are much more frequently seen after a very mild primary attack, and in a large proportion of cases there have been no secondary symp- toms. So slight has been the earlier manifestations of the disease that the patient frequently does not know he has had it. SYPHILIS OF THE BRAIN. Pathological Anatomy. — The changes in the brain are similar to those found elsewhere. The membranes and vessels are most frequently affected. Gummatous tumors form in the membranes, varying in size from small grains to the size of a hen's egg ; they are most frequent in the pia mater. They are found on the con- vexity, and especially at the base near the sella turcica. 40i UNCLASSIFIED. Instead of distinct tumors, there may be a diffusion of the new growth over the surface of the membranes closely resembling pus, and this may contain small gummatous tumors scattered throughout its extent. The subjacent cerebral substance is necessarily af- fected, partly by spread of the growth destroying the nerve-elements, in part by closure of blood-vessels, in- terfering with nutrition. The syphilitic new growths may undergo degenera- tion, and their interior become fatty or caseous. They may excite inflammation in their vicinity, acting as any other new growth in this respect. The arteries are also the seat of syphilitic changes. These have been described at length by Heubner. The new growth is developed between the elastic lamina of the intima and the endothelium. The lumen of the vessels is more or less encroached upon by semi-lunar segments or zones of the firm, fibrous new formation. Sometimes the artery is entirely closed by this process, or a thrombus may form at the constricted portion, and thus finally effect its closure. The brain-substance may be primarily affected ; but such cases are rather rare. An important peculiarity of syphilitic lesions of the brain and its membranes is that they are very often multiple ; even distant regions, opposite sides, may be simultaneously affected. They may be present an in- determinate period, and attain considerable size, with- out giving rise to any symptoms. Secondary changes, softenings, and inflammations are found in connection with these morbid products, the same as with those of a different nature. Symptoms. — Syphilis of the nerve-centers gives rise to no special or peculiar symptoms differing from those caused by other lesions of those parts. The diagnosis must be made rather from the grouping of the symp- toms or other peculiarities in the mode in which they show themselves. As in other diseases, the symptoms SYPHILIS. 405 may be divided into those which are due directly to the lesion and those which are dependent upon sec- ondary changes, which are the same as when these changes are dne to other causes. Headaclie is the most common and the earliest symptom, often the only one. The pain is severe, ob- stinate, frequently nocturnal ; it occurs in paroxysms, though there may not be entire relief between the at- tacks. The scalp or parts of the face may be tender, and pressure upon those points may aggravate the pain. The severity of the pain is sometimes excessive — ago- nizing. Relief is obtained generally only from specific treatment ; or, if it seems to follow other means, the pain soon returns. Sometimes external periostitis will cause a swelling over the cranial bones, which will set- tle the diagnosis. Pain may also be felt in other parts of the body, in the limbs, resembling closely neuralgia from other causes. With the pain, or independently, the patient may have a sense of pressure in the head, dizziness or ver- tigo, ephemeral or fugitive attacks of loss of memory, dimness of sight, numbness in the extremities, or slight impairment of motor power or of speech. These symp- toms may be so insignificant that they are ignored until questions recall them to the patient' s mind. The headache, with or without the above symptoms, is of inestimable value as indicating commencing cere- bral mischief at a stage when treatment can be of use. Though a similar train of phenomena may occur in cases of tumor of the brain, in uraemia, and in com- mencing meningitis, the possibility of syphilis should always be kept in mind, even when patients deny the primary or secondary symptoms. The motor phenomena, paralysis and S2?asm, are characterized by the irregularity of the symptoms, the limitation of the paralysis or spasm to a few muscles, and their ephemeral or fugitive character. 406 UNCLASSIFIED. Hemiplegia, differing in nothing from that caused by cerebral haemorrhage, may occur without special warning in syphilis ; but generally the attack is less sudden, the paralysis creeping, as it were, from one set of muscles to another, the patient not losing conscious- ness ; the loss of power frequently does not affect the whole side ; is limited to the arm or face, or spares the leg. Sensibility is rarely affected. Attacks of paralysis of a few muscles or sets of mus- cles may appear and disappear several times before there is permanent loss of power ; these attacks may persist a few hours or days, and be repeated at near or distant intervals. Spasm, local or general, sometimes precedes the pa- ralysis. When the prodromic cephalalgia, and other slight cerebral disturbances, mentioned above, have preceded these paralytic symptoms, there is great reason to sus- pect syphilis, and the proper treatment should be fol- lowed. When individual cerebral nerves are affected, as well as the limbs, if the symptoms are irregular, can not be accounted for by one lesion, the alternate pa- ralysis being such as to show that there must be two or more centers of disease, the probability of syphilis is greatly increased. Among the cranial nerves most likely to be para- lyzed may be placed, first, the third nerve, the motor oculi ; the sixth, the abducens, is next ; the seventh, twelfth, the second, eighth, and fifth follow next in frequency. Paralysis of the third nerve from syphilis is often partial ; it may be combined with paralysis of the sixth or not; whether alone or in connection with disturb- ance of other cranial nerves, there is reason in such cases to suspect syphilis, and careful inquiry for pro- dromic symptoms may add to this probability. It is unnecessary to describe minutely all the vari- SYPHILIS. 407 ous combinations which are frequently found in such cases. Spasm or convulsion limited to a few muscles, as the facial, or those of one arm, of the hand — monospasm, as it is called — is an indication of irritation of the motor centers in the cortex of the brain. Very often the le- sion in these cases is syphilitic. The convulsion may extend to the whole of one side, or it may begin in one region and extend to the opposite side, becoming gen- eral. Many times consciousness is preserved, or it may be only partially impaired. Sometimes severe pain in. the head or in the affected limb may attend the spasm. Convulsions, differing in no respect from true epi- lepsy, may be due to syphilis. If the patient is some- what advanced in age before the attacks commence, their syphilitic origin is the more probable. If mental impairment appears early, and motor weakness follows the attacks, limited to one side or one limb, and per- sisting between the attacks, the probability of syphilis is the greater. - Sometimes the mental phenomena are most promi- nent ; intellectual weakness, loss of memory, inability for consecutive thought, delirium, perhaps mania, may be present. Sometimes the mental disturbance will closely resemble general paralysis. While the above symptoms, or groups of symptoms, individually only give rise to a suspicion of syphilis, the combination of two or more of the groups increases the certainty of the diagnosis. The course of cerebral syphilis, if not properly treated, is steadily downward. The symptoms increase in severity, the spasms become more frequent, the pa- ralysis extends, and the mental powers are gradually lost. Within a comparatively short time a fatal termi- nation closes the scene. 408 UNCLASSIFIED. SYPHILIS OF THE SPINAL CORD. The membranes are most frequently the seat of the morbid changes, the cord being affected secondarily. Sometimes the medullary substance itself is attacked, the lesion being generally diffused throughout the part of the cord which is the seat of the disease. Gumma- tous tumors are also found. The bones are less fre- quently diseased. The lumbar enlargement is more generally attacked than the higher parts. The symptoms are very similar to those produced by other lesions. When meningitis is present there are pains in the back and limbs, perhaps with spas- modic action or contraction. The symptoms are vari- able ; there may be remissions or intermissions, which are not seen in simple meningitis. When the cord itself is affected there is more likely to be irregularity in the course of the disease than in simple myelitis. Locomotor ataxia may be very closely simulated. The earlier symptoms may relate to the genito-urinary organs. Impotence and inability to micturate may precede the paralysis. When the Litter appears, it may begin in one leg, and appear in the other later. Sensation may be unaffected until the paralysis has become well marked ; it may be only slightly disturbed during the whole course of the disease. In other cases both sensation and motion may be lost early. Some- times the paralysis pursues an acute course very simi- lar to the severest form of ordinary acute myelitis. Often the course of spinal syphilis is chronic ; the symptoms develop slowly ; there may be periods of re- mission, or at least no advance is made. The prognosis is unfavorable for complete recovery ; if energetic treatment is followed, the symptoms may recede and a certain amount of benefit be received ; the patient improves, but very often the cord is too serious- ly injured for its functions to be completely restored. SYPHILIS. 409 SYPHILIS OF THE NERVES. The cranial nerves are the most frequently affected by syphilis ; these have been referred to already. Any of the other nerves may be implicated in syphilitic growths. It is probable that the nerves may be direct- ly diseased ; many cases of neuralgia in syphilitic pa- tients are probably thus caused. The symptoms seem to be very similar to those of neuritis. This depart- ment of the subject needs further investigation. Hereditary syphilis may attack the nerve-centers ; cerebral symptoms are not uncommon ; the spinal cord has been the seat of syphilitic changes in very young children. TREATMENT OF SYPHILIS OF THE NERVOUS SYSTEM. There should be no delay in beginning an anti- syphilitic treatment. The more serious the symptoms, the more energetic this should be. As the brain and spinal cord are all-important for life, and as slight lesions produce serious permanent disability, it is necessary to begin at once with large doses of iodide of potassium, and to use mercury freely. If the case is very urgent, from forty to sixty grains can be given at once three times a day ; if less haste is needed, a dose of ten to twenty grains may be given three times the first day ; the doses may be increased by ten or twenty grains each day, or every other day, until some result is obtained. Large doses of forty-five to sixty grains are some- times borne better by patients than small doses of four or five grains. The dose should be increased until the disease is checked, or there is evident intolerance. What is the limit ? Many patients improve when taking one hun- dred and twenty grains a day. I have repeatedly given two hundred and fifty grains daily, and have even gone 410 UNCLASSIFIED. as high as nine hundred grains a day with no disadvan- tage to the patient. The drug should be given in a large amount of wa- ter ; slightly alkaline water is preferable. It is gener- ally better to give it before meals, though with some patients it is better after meals, and some prefer to di- vide the large doses, taking part before and part after meals. If the bowels become too loose from the iodide, the dose may be slightly reduced, more diluted, and then increased more slowly ; or, if there is need for immedi- ate effect, a few drops of laudanum can be added to each dose. Vomiting may seriously interfere with the adminis- tration of the drug. If it does, it will be necessary to omit it for a while, then begin in smaller doses and in- crease more slowly. Or the plan of giving a large dose at once might be tried. Conjunctivitis, coryza, and glossitis are rare in syphilitic patients as effects of the iodide. Acne may be met with Fowler's solution, but is not a contra-indication to the use of the medicine. Mercury may be given by inunction, half a drachm or two drachms being rubbed in daily. Internally, the biniodide or bichloride is preferable, and should be given in doses of from -^ to J of a grain three times a day. Many authorities prefer the inunction. The iodide of potassium and mercury should not be stopped too soon. It is necessary to continue the treat- ment several weeks after the patient seems cured. The largest dose reached need not be continued. Of other treatment, tonics, especially iron and cod- liver oil, are generally indicated. The strength should be maintained by a generous diet. Sequelae and complications should be treated accord- ing to the principles given elsewhere. INDEX. Abscess of the brain, 124. Acute ascending paralysis, 192. JEsthesiometer, method of using, 2. Agrammatism, 48. Agraphia, 47. Akataphasia, 48. Alcoholism, 395. Amaurosis in cerebral lesion, 41. Amblyopic cerebral lesion, 41. Amimia, 47. Amyotrophic lateral sclerosis, 252. Anaemia of brain, 68. acute, 70. chronic, 71. Anaesthesia, 3. Anarthria, 47, in lesion of the pons, 45. locality of lesion in, 49. Angina pectoris, 318. Ankle clonus, 9. in lesion of spinal cord, 144. Aphasia, amnesic, 46. ataxic, 47. locality of lesion in, 48. Apoplexy, 86. in multiple sclerosis, 246. Arsenic poisoning, 394. Arthralgia, lead poisoning, 391. Asphyxia, local, of the limbs, 322. Ataxia, 46, 141. hereditary, 236. locomotor, 224. Athetosis, 98. seat of lesion in, 39. Atrophy, facial, 324. muscmar, in disease of spinal cord, 139. Atrophy, muscular, progressive, 207. Backache, 148. Basedow's disease, 316. Bed-sores, treatment, 10. Beri-beri, 266. Blepharospasm, 300. Brain, abscess, 124. anaemia, 68. anatomy, 18. arteries, anastomoses, 32. blood-vessels, 31. convolutions, nomenclature, 18-21. change of blood-supply, 68. congestion, 74. diseases of, 15. exhaustion in cerebral hyperaemia, 77. haemorrhage, 84. hyperaemia, 74. lesions, destructive, 37. lesions, irritative, 37. malnutrition (see anaemia), 69. membranes, diseases of, 50. motor centers, 33. physiology, 33. sensory centers, 34. symptomatology, general, 37. syphilis, 403. tumors, 116. vessels in cerebral hasmorrhage, 87. visual centers, 35, 37. Bright's disease in meningitis, 59. Bronchial crises, 232. Bulbar paralysis, 215. acute, 222. and muscular atrophy compared, 219. of cerebral origin, 222. Burdach, column of, 135. Caries of vertebrae, 167. Carrefour sensitif, lesion of, 39. Caudate nucleus, 21. functions, 37. lesion of, 39. Cavities in brain from thrombosis, 113. Centrum ovale. 19. Cephalalgia, 307. 412 INDEX. Cerebellar peduncle, lesion of, 46. Cerebellum, haemorrhage, 46. lesion of, 46. tumor, 46. Cerebral abscess, 124. anaemia, 68. Cerebral arteries, occlusion of, 107. thrombosis of, 112. Cerebral haemorrhage, 84, 86. diagnosis from embolism, 110. explanation of phenomena, 95. hyperamiia, 74. secpielae, 97. softening in embolism, 108. tumors, 116. Cerebro-spinal sclerosis (see multi- ple sclerosis), 242. Cheyne-Stokes respiration, 10. Chorea, 332. Chorea, post-hemiplegic, 98, 335. seat of lesion in, 39. Clonic spasm, 299. Clonus, ankle, 9. wrist, 9. Compression of spinal cord, 167. Compulsory movements. 46. Constipation, treatment. 11. Contractures after cerebral haemor- rhage, 97. Convolutions of brain described, 18. Corona radiata, 19. Corpus genieulatum, origin of optic tract, 27. Corpus quadrigeminum anterior, le- sion, 43. origin of optic tract, 27. posterior, lesion. 43. striatum, nutrient arteries, 32. Cramp, professional. 304. Cras cerebri, basis. 22. division of fibers in basis, 23. lesion of, 42. tegmentum, 22. Cystitis, 11. Degeneration, descending, course of, 23, 40. secondary, in lesion of internal capsule, 40. Delirium tremens, 395. Diet. 13. Diphtheritic paralysis, 295. Diplegia contraction, 211. Diplopia, 3. Disseminated neuritis, 266. sclerosis, 242. Dura mater, inflammation of (see pachymeningitis), 50. Dynamometer, 5. Dysarthria, 47. Eclampsia saturnina, 392. Electricity, changes in reaction to, 5. in testing muscular power, 5. Embolism of cerebral arteries, 107. Emotions in cerebral haemorrhage, 99. Encephalopathia saturnina, 392. Epilepsy, 342. diagnosis from cerebral hyper- aemia, 80. Exophthalmic goitre, 316. Eyes, conjugate deviation, 44. examination of, 45. Face, atrophy of, 324. Facial nucleus, lesion of, 217. Feeding, methods of, 13. by rectum, 14. Fibrillary contractions, 210. Front tap contraction, 9. Gangrene, symmetrical, 322. Gastric crises, 231. Girdle sensation, 147 Goitre, exophthalmic, 316. Goll, columns of, 134. Grand mal, 344. Graves's disease, 316. Haematomyelitis, 162. Haematorrhachis, 159. Haemorrhage, meningeal, 84. into spinal cord, 162. spinal meningeal, 159. Headache, 307. Hemianopsia, 4. as localizing lesion, 41. lateral homonymous, 41. nasal, 41. temporal, double, 41. Hemiopia, 4. Hemiplegia, pretended, 101. Hereditary ataxia. 226. Hydromyelus, 176. Hydrophobia, 399. Hyperemia of the brain, 74. Hyperesthesia, 3, 147. Hvpoglossal nucleus, lesion of, 216. Hysteria, 353. Hystero-epilepsy, 360. Infantile paralysis, 195. Internal capsule. 20. course of fibers leading from, 23. fibers, order of, 36. lesion of, 40. INDEX. 413 Internal capsule, sensory fibers, 36. Island of Reil, lesion of, 48. Kak-ke, 266. Labio-glosso-laryngeal paralysis, 215. Landry's paralysis, 192. Laryngeal crises, 232. Lateral sclerosis, 250. Lead colic, 390. poisoning, 390. . poisoning in myelitis, 180, 188, 391. Lenticular nucleus, 21. functions, 37. lesion of, 39. Leptomeningitis cerebralis, 53. spinalis, 152. Local asphyxia of the limbs, 322. Locked- jaw, 379. Locomotor ataxia, 224. Mania in cerebral anaemia, 72. a potu, 395. Megrim, 311. Meniere's disease, 330. Meningeal haemorrhage, cerebral, 84. spinal, 159. Meningitis, cerebral, 50. cerebral, chronic, 58. cerebral, local, 58. spinal, 149. tubercular, 61. Micturition, disturbed, in disease of spinal cord, 144. Migraine, 311. Monospasm in meningitis, 58. Motion, accelerated, 141. retarded, 141. Motor centers, lesion of, 38. spasm in lesion of, 38. Motor power, methods of testing, 5. Multiple neuritis, 266. sclerosis, 242. Muscles supplied by motor nerves, 140. Myelitis, 179. acute, 179. of anterior cornua, 195. of anterior cornua in adults, 199. chronic, 188. from lead, 391. Myxocdema, 386. Nephritic crises, 231. Nerve, eighth, origin, 31. fourth, connection with sixth, 28, 30. fourth, origin, 28. Nerve, seventh, origin, 29. sixth, origin, 29. sixth, paralysis of, in lesion of pons, 45. third, connections with sixth, 28, 30. third, nucleus, lesion of, 43. third, origin, 27. third, disease of, 259. Nerves of medulla, 31. peripheral, distribution to muscles, 140. syphilis of, 409. Nervous exhaustion, 371. cause of anaemia of brain, 69. Neuralgia, cervico-brachial, 275. cervico-occipital, 274. dorso-intercostal, 275. lumbo-abdominal, 276. sciatica, 276. trifacial, 274. Neurasthenia, 371. Neuritis, 261. multiple, 266. Nutrition, 12. Ophthalmoscope, importance of, 4. Optic chiasma, decussation in, 26. Optic nerves, 26. neuritis, in cerebellar lesion, 46. neuritis, in myelitis, 185. neuritis, in tumor of brain, 119. thalamus, 22. thalamus, function, 37. thalamus, lesion of, 39. thalamus, nutrient arteries, 32. tract, 26. tract, central origin, 27. Pachymeningitis, 50. cervical hypertrophic, 149. external, 50. internal hemorrhagic, 51. spinalis externa, 149. spinalis interna, 149. : Painful points, 272. Paralysis, acute ascending, 192. after acute diseases, 294. after diphtheria, 294. agitans, 329. alternate, 43. brachial plexus, 293. bulbar, 215. facial, 289. from pressure, 285, 293. infant ilc, 195. Landry's, 192. lead. 391. local, 285. 414 IXDEX. Paralysis of motion, significance in disease of spinal cord, 139. ocular muscles, 289. peripheral, 285. pseudo-hvpertrophic, 255. reflex, 286. rheumatic, 285. seventh nerve, 289. Paraphasia, 48. Parkinson's disease, 339. Petit mal, 344. Photopsia, 42. Pia mater, inflammation of, 53. Points apophysaires, 272. douloureux, 272. painful, 272. Poisoning, arsenic, 394. lead, 390. Poliomyelitis, anterior acute, 195. in adults, 199. in infants, 195. anterior chronica, 202. Pons Varolii, lesion, 44. sensation in lesion of, 45. Post-hemiplegic chorea, 335. Professional cramp, 304. Progressive muscular atrophy, 207. hereditary, 212. juvenile form, 212. Prosopalgia, 274. Pseudo-hypertrophic paralysis, 255. Pseudo-meningitis in children, 73. Pulvinar, function of, 37. lesion of, 41, 42. Pupil, contracted, in lesion of pons, 45. changes in, 4. reaction in cerebral lesion, 42. Pyramidal columns, 135. Reaction of degeneration, 6. Reflex action described, 6. in lesion of spinal cord, 142. centers in spinal cord, 8. Reflexes, cutaneous, 7. deep, 8. patella tendon, 8. tendon, 8. Respiration, Cheyne-Stokes, 10. Retarded motion, 141. Saint Vitus's dance, 332. Sciatica, 276. Sclerosis, 242. amyotrophic lateral, 252. lateral, 250. multiple, 242. posterior spinal, 224. Sensation, changes in, 3. Sensation changes, lesion of spinal cord, 147. methods of testing, 1. in unilateral lesion of spinal cord, 147. Sense, muscular, testing, 2. of pain, testing, 2. of pressure, testing, 2. of temperature, testing, 2. of touch, testing, 1. Sensory fibers, course of, 36. in pons, 45. Sexual function perverted in dis- ease of spinal cord, 145. Shaking palsy, 339. Sick headache, 311. Sleeplessness in anaemia of brain, 74. Spasm, 298. facial, 299. of diaphragm, 303. svmptom of lesion of motor cen- ters, 38. svmptom of lesion of spinal cord, '129. Speech, disturbance of, 46. in lesion of pons, 45. Spinal anaemia, 158. Spinal cord, anaemia of, 158. anatomy, 132. blood-vessels, 133. cavities in, 176. central canal dilated, 176. changes in blood-supply, 156. compression, 167. general symptomatology, 138. gray matter, 133. groups of cells, 133. haematorrhachis, 159. haemorrhage, 162. hyperaemia, 156. inflammation, 179. length, 133. membranes, 132. meningeal haemorrhage, 159. physiology, 136. pia mater* inflammation of, 152. sclerosis of lateral columns, 250. sclerosis of posterior columns, 224. slow compression, 167. symptomatology, 138. syphilis, 408. unilateral lesion, motion in, 139. unilateral lesion, sensation in, 147. white substance, 134. Spinal dura mater, inflammation, 149. hyperaemia, 156. irritation, 373. leptomeningitis, 152. INDEX. 415 Spinal dura mater, meningeal haemor- rhage, 159. meningitis, 149. pachymeningitis externa, 149. pachymeningitis interna, 149. tumors, 173. Status epilepticus, 346. Symmetrical gangrene, 322. Sympathetic, diseases of, 307. Syphilis of the brain, 403. hereditary, 409. of the nerves, 409. of the spinal cord, 408. Syringomyelia, 176. Tabes dorsalis, 224. Tache cerebrale, 9. Temperature in cerebral haemor- rhage, 94. embolism, 109, 111. Trophic changes in cerebral haemor- rhage, 99. Tendon reflex, 8. absent in lesion of spinal cord, 143. Tetanus, 379. Tetany, 383. Thomsen's disease, 303. Thrombosis of cerebral arteries, 112. Tonic spasm, 298. Toxic neuroses, 389. Torticollis, 301. Tremor, 298. Trismus, 380. Trophic centers in spinal cord, 137. changes in lesion of spinal cord, 145. Tumor of brain, 116. spinal cord, 175. spinal meninges, 174. Tiirck, columns of, 135. Urine, retention, 12. Ventricles, haemorrhage into, 95. Vertebrae, cancer, 167. caries, 167. tender, 148. Vertigo, 329. in cerebellar lesions, 46. Vision, alterations of, 3. mode of examining, 4. Visual centers, lesion of, 42. Vomiting in cerebellar lesion, 46. "Word blindness, 48. deafness, 48. Writer's cramp, 304. Wry-neck, 301. THE POPULAR SGIENCE MONTHLY. CONDUCTED BY E. L. AXD W. J. YOUMANS. The Popular Science Monthly for 1885 will continue, as here- tofore, to supply its readers with the results of the latest investiga- tion and the most valuable thought in the various departments of scientific inquiry. Leaving the dry and technical details of science, which are of chief concern to specialists, to the journals devoted to them, the Monthly deals with those more general and practical subjects which are of the greatest interest and importance to the public at large. 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