BPBB Hi « ^m LIBRARY OF CONGRESS. r, r b ° Shelf -,_B_B_ri3 UNITED STATES OF AMERICA. Kfoika A TREATISE INTRACRANIAL DISEASES: INFLAMMATORY, ORGANIC, AND SYMPTOMATIC. BY CHARLES PORTER HART, M.D., LATE SPECIAL LECTURER ON DISEASES OF THE NERVOUS SYSTEM IN PULTE MEDICAL COLLEGE MEMBER OP THE AMERICAN ASSOCIATION FOR THE ADVANCEMENT OF SCIENCE; HON- ORARY MEMBER OF THE COLLEGE OF PHYSICIANS AND SURGEONS OF MICHIGAN; AUTHOR OF "DISEASES OF THE SPINAL MARROW AND ITS COVERINGS," " DIS- ^^" /\ 3 EASES OF THE NERVOUS SYS- TEM," ETC., ETC. IF jan 59 lassr PHILADELPHIA: F. E. BOEBICKE, HAHNEMANN PUBLISHING HOUSE. 1884. "<, tf* 12* Copyright, F. E. Boericke, 1884. PREFACE The present work on Intracranial Diseases embraces inflam- matory, organic, and symptomatic affections of the brain and its membranes — diseases which are quite as important, and as frequently met with in practice, as those contained in my work on Diseases of the Nervous System. Though intended chiefly as a Supplement to the latter work, I have endeavored to render it so complete in itself, as to present within a moderate compass the leading views of those most advanced in cerebral pathology and therapeutics, and, at the same time, furnish a safe and sufficient guide to those who may be dis- posed to consult its pages for information on these interesting and important subjects. As the diagnosis of intracranial diseases is frequently at- tended with considerable difficulty, I have prefixed a few chapters on matters pertaining to the regional diagnosis of cerebral affections ; for, as M. Charcot has well said in the preface to the American edition of his Lectures, " The exposi- tion of the principles underlying the doctrine of cerebral localization seems to have now become a necessar}^ chapter of introduction to the practical study of diseases of the brain." In conclusion, I desire to acknowledge with grateful feelings the generous appreciation bestowed by the profession upon my former writings, especially those pertaining to the nervous system, and to express the hope that the present addition thereto will be found to possess merits entitling it to a like favorable reception. C. P. H. Wyoming, 0., Jan., 1884. CONTENTS. PART I. Matters Pertaining to Regional Diagnosis. SECTION I. Physiological Considerations. CHAPTER I. Functions of the Cerebrum. Discovery of the cortical centres — Ferrier's experiments on the brain of an ape — Summary of the results obtained by Fritsch, Hitzig, and Ferrier — How the discrepancies between them may be accounted for — Methods employed in the investigation — Situation of the motor centres in man — Goltz's method of re- search — Broca's discovery confirmed — How these discoveries are regarded by Eckhard, Schiff, and others — Lussana and Lemoigne's objections — Brown- S6quard's views — 'Arguments in support of the cortical theory of localization — Objections answered — Confirmed by clinical experience — Law of functional substitution — The sensory centres — Facts which appear to be satisfactorily established — Volition and intelligent consciousness — The seat of intelligent language in man, 17 CHAPTER II. Functions of the Cerebral Ganglia. Meynert's ganglia of the tegmentum pedunculi and pes pedunculi — Effects pro- duced by electric stimulation of the corpora striata — Hemianesthesia — Luy's four divisions of the optic thalamus — Functions of the corpora quadrigemina — Experiments of Hensen and Voelkers — Unilateral destruction of the corpora quadrigemina — Adamiik on stimulution of the nates — Expression of the emo- tions — Muscular coordination — Epileptic moans and cries — Functions of the crura cerebri and pons Varolii — Automatic movements — Functions of the cerebellum — Vertigo — Priapism — Diabetes, 30 10 CONTENTS. CHAPTER III. Functions of the Bulb. Receives and transmits both sensory impressions and motor impulses — Crossed paralysis — Reflex coordination — The respiratory centre — The cardio-inhibi- tory centre — The vaso-motor centre — The emotional centre — The centre for deglutition — The cesophagal and gastric centre — The salivary centre — The centre for articulate speech — The diabetic centre — General centre for the coordination of muscular movements, ...... 38 SECTION II. Regional Diagnosis in Brain Diseases. CHAPTER I. Cerebral Lesions. What lesions are of special value in establishing the theory of cortical localization — No known systemic lesions in the brain — Predominant influence of vascular lesions — No known anatomical centres of mental affections — Differentiation by elevation of temperature and by motor phenomena— Latent disease of the cortex — Convulsions — Sensory disturbances — Aphasic symptoms — Word- deafness — Paralysis — Monoplegias — Associated symptoms — Transient pa- ralysis — Destructive lesions — Secondary degeneration, ... 41 CHAPTEK II. Lesions of the Basal Ganglia. Cerebral hemiplegia accompanied with cerebral hemianesthesia — Central cere- bral hemiplegia — Temporary and persistent hemiplegia — Cerebral hemi- anesthesia — Destructive lesions of the internal capsule — Vaso-motor disturb- ances — Hemichorea — Thalamic lesions — Homonyomous hemiopia — Athetosis and unilateral tremor — Disorders of psycho-motor reflex actions — Lesions of the nates — Lesions of the testes, . 47 CHAPTER III. Lesions of the Cerebellum. General character of cerebellar symptoms — Cerebellar paralysis — Vomiting — Amaurosis — Incoordination of movement — Lesions of the middle lobe — Excitation of the genital functions — Lesions of the middle peduncle — Vertigo — Anarthia, headache, etc. — Diagnostic lesions, .... 53 CHAPTER IV. Lesions of the Cerebro-spinal Isthmus. Systemic lesions — Alternate paralysis — Lesions of the pons Varolii — Apoplectic symptoms and rise of temperature — General paralysis — Epileptiform convul- CONTENTS. 11 sions — Diabetes mellitus and insipidus — Albuminuria — Muscular rigidity — Emotional weakness — Lesions of the medulla oblongata— Implication of special nerves — Disturbances of respiration, circulation, etc. — Value of nega- tive symptoms, 57 PART II. Intracranial Diseases. SECTION I. Cerebral Affections. CHAPTER I. Anemia of the Brain. The intracranial circulation — The cerebro-spinal fluid — The three principal forms of cerebral anaemia, namely, the irritative, apoplectic, and syncopal— Symp- toms — Symptoms in the aged — Syncope — Vaso-motor anaemia — Paresis and paralysis — Causes — Diagnosis — Prognosis — Morbid anatomy — Pathology — Treatment — General and special indications, 62 CHAPTER II. Cerebral, Hyperemia. Active and passive hyperaemia — Symptoms of excitation— Symptoms of depres- sion — Headache — Hyperesthesia of the special senses — General anaesthesia — Irritability of the vascular system — Krishaber's investigations — The delir- ious, convulsive, and apoplectic forms — Causes — Diagnosis — Prognosis — Morbid anatomy — Pathology — Treatment— General indications— Special in- dications, 73 CHAPTER III. Cerebral Apoplexy. Definition— Symptoms — Hemiplegia — Causes — Cerebral haemorrhage — Haemor- rhage into the cerebral membranes — Embolism of cerebral arteries — Cere- bral hyperaemia — Sunstroke — Uraemic and alcoholic intoxication, . 91 CHAPTER IV. Cerebral Hemorrhage. Definition — Comparative frequency in different parts of the brain — Symptoms — Apoplectic and paralytic forms — Variations in the animal temperature — Conjugated deviations of the eyes and head — Symptoms of the second stage 12 CONTENTS. Acute bed-sores — Hemiplegia— "-Facial paralysis — Paralysis of the extremities — Secondary contraction — Causes — Diagnosis — Prognosis — Morbid anatomy — Pathology — Treatment — General and special indications, . . 93 CHAPTER V. Cerebral Thrombosis. Definition — Symptoms — Marantic thrombosis — Venous thrombosis in the adult — Causes — Diagnosis — Prognosis — Morbid anatomy and pathology — Athero- matous degeneration of the cerebral arteries — Illustrative case — Heubner's case — Eed and yellow softening — Treatment, . . . . . . Ill CHAPTER VI. Cerebral Embolism. Definition — Symptoms — Causes — Multiple emboli — Brown hospital case — Diag- nosis — Prognosis— Cerebral softening — Morbid anatomy and pathology — Virchow, Cohnheim and Schiitzenberger's observations — Partial cerebral anaemia and softening — Treatment, . • 116 CHAPTER VII. Cerebral Softening. Definition — Symptoms — Anaemia and red softening — Yellow and white softening — Variations of temperature — Mental debility — Paralysis — Headache 1 — Apha- sia — Chronic softening — Causes — Diagnosis— Prognosis — Morbid anatomy and pathology — Treatment — General and special indications, . 121 CHAPTER VIII. Encephalitis. Definition — Symptoms — Symptoms in the aged — When complicated with menin- gitis — Cerebral abscess — Causes — Diagnosis — Prognosis — Morbid anatomy and pathology — Treatment, 130 CHAPTER IX. Cerebral Hypertrophy. Definition — Symptoms — Causes — Diagnosis — Prognosis — Morbid anatomy and pathology — Treatment, 137 CHAPTER X. Cerebral Atrophy. Definition — Symptoms — Partial atrophy — General atrophy — Causes — Diagnosis — Prognosis — Morbid anatomy and pathology — Treatment — Electricity, 139 CONTENTS. 13 CHAPTER XL Primary Multiple Sclerosis. Definition — Charcot's researches — Symptoms — Sclerosis limited to the hemi- spheres — Muscular incoordination — Causes — Diagnosis — Paralysis agitans and chorea — Prognosis — Morbid anatomy — Pathology — Secondary multiple scle- rosis — Treatment, 143 CHAPTER XII. Athetosis. Definition — Symptoms —Causes — Diagnosis — Post-hemiplegic chorea — Prognosis — Morbid anatomy and pathology — Dr. Ringer's case — Treatment, 148 CHAPTER XIII. Progressive Facial Atrophy. Progressive laminar aplasia — Symptoms — Facial atrophy — Causes — Diagnosis — Morbid anatomy and pathology — Vulpian's views — Treatment, . 151 CHAPTER XIV. Myxcedema. Definition — Symptoms — Diagnosis — Tricuspid regurgitation — Scleroderma — Prognosis — Morbid anatomy and pathology — Treatment, . . 154 CHAPTER XV. Cerebral Tumors. Varieties— Glioma — Psammoma— Cholesteatoma — Xeuroma— Cancer of the brain — Tuberculous and syphilitic tumors — Mucous, lipomatous, cystic, and mel- anoid tumors — Symptoms — Causes — Diagnosis — Prognosis — Morbid anatomy and pathology — Aneurismal tumors — Treatment— General indications, 157 CHAPTER XVI. Cerebral Syphilis. Xature — Varieties — Symptoms — Congestive, vascular, and syphilomatous forms — Causes — Diagnosis — Syphilitic thrombosis — Prognosis — Morbid anatomy and pathology — Treatment, 164 SECTION II. Meningeal Affections. CHAPTER I. Simple Acute Meningitis. Lepto-meningitis cerebralis — Symptoms — Morbid anatomy — Pathology — Causes — Diagnosis — Prognosis — Treatment — General indications — Special indications, 171 14 CONTENTS. CHAPTER II. Tubercular Meningitis. Definition — Leptomeningitis — Symptoms — Prodromic stage — Symptoms of ex- citement — Symptoms of depression — Closing stage — Morbid anatomy — Pa- thology — Etiology — Diagnosis — Tache cerebrale — Prognosis — Treatment — General and special indications, 179 CHAPTER III. Traumatic Meningitis. Forms — 1. Pachymeningitis — Symptoms — Treatment — 2. Arachnitis — Morbid anatomy — Symptoms — Etiology — Diagnosis — Prognosis — Treatment — 3. Lep- tomeningitis — Symptoms — Morbid anatomy - — Pathology — Complication — Prognosis — Treatment, . • . . 189 CHAPTER IV. Chronic Meningitis. 1. Chronic convexital meningitis — Symptoms — Morbid anatomy and pathology — Causes — Diagnosis — Prognosis — Treatment — 2. Chronic basilar meningitis — Symptoms — Morbid anatomy — Pathology — Causes — Diagnosis— Prognosis — Treatment— General and special indications, 195 CHAPTER V. Epidemic Meningitis. Cerebro-spinal meningitis — Symptoms — Complications and sequalse — Morbid anatomy — Pathology — Causes — Diagnosis — Prognosis — Treatment — Special indications, . 203 CHAPTER VI. HEMORRHAGIC PACHYMENINGITIS. Hsematoma durse matris — Symptoms — Morbid anatomy and pathology — Views of Virchow and Huguenin — Causes — Diagnosis — Prognosis— Treatment, 214 CHAPTER VII. Chronic Hydrocephalus. Dropsy of the brain— Symptoms — Morbid anatomy and pathology — Enlargement of the head — Facies hydrocephalica — Causes — Diagnosis — Prognosis — Treat- ment — Special indications, 218 CHAPTER VIII. Foreign Products. Serum — External hydrocephalus — Serous apoplexy — Thrombi — Thrombosis of the longitudinal sinus — Thrombosis of the lateral sinuses — Parasites — Cys- ticerci — Hydatids— Prognosis — Treatment, . . . . • . 225 CONTENTS. 15 SECTION III. Symptomatic Affections. CHAPTER I. Cephalalgia. Headache — Varieties — 1. Congestive headache — Symptoms — Causes — Special in- dications — 2. Nervous headache — Symptoms — Causes— Special indications — 3. Sympathetic headache — Varieties — General and special indications, 230 CHAPTER II. Vertigo. Definition — Muscular coordination — Etiology and pathology — Varieties — 1. Laby- rinthine or auditory vertigo — Symptoms — Diagnosis — Prognosis — 2. Ocular vertigo — Symptoms — 3. Gastric vertigo — Symptoms — Diagnosis — 4. Nervous vertigo — Symptoms —5. Intracranial vertigo — Diagnosis — Treatment — General and special indications, 269 CHAPTER III. Insomnia. Sleep — Sopor — Partial insomnia — Complete insomnia — Causes — Treatment — General indications — Special indications, ..... 282 CHAPTER IV. Coma. Definition — Degrees of insensibility — Carus — Diagnosis — Causes — Prognosis — Treatment — Special indications, 286 s, CHAPTER V. Sunstroke. Varieties — 1. Syncop a/— Symptoms — 2. Asphyxial — Symptoms — 3. Hyperpyrexial — Symptoms — Vaso-motor paralysis and rise in temperature — Morbid anatomy — Causes — Prognosis — Treatment — General and special indications, 290 CHAPTER VI. Concussion of the Brain. Definition — Symptoms — Morbid anatomy — Pathology — Prognosis — Treatment — General and special indications, 297 CHAPTER VII. Hydrocephaloid. Definition — Symptoms — Symptoms common to other diseases — Diagnosis — Treat- ment — Special indications, 302 A TREATISE INTRACRANIAL DISEASES PART I. MATTERS PERTAINING TO REGIONAL DIAGNOSIS. SECTION I. PHYSIOLOGICAL CONSIDERATIONS. CHAPTER I. FUNCTIONS OF THE CEREBRUM. Although numerous experimental researches had been pre- viously made with a view to determine the special functions of different parts of the brain, it was not until the year 1870 that the cortical portion was found to be endowed with either sensibility or motor excitability; previous observations tend- ing to show that neither pain nor convulsive action could be produced by stimulation or lesion of any portion of either the grey or white matter of the hemispheres. In that year, how- ever, two German physiologists, Fritsch and Hitzig, by sub- jecting certain parts of the cerebral cortex of a dog to a weak galvanic current, discovered certain centres of motion in the grey matter of the hemispheres, which, when thus stimulated, could be made to produce certain well-defined muscular move- ments. These physiologists, by applying electricity to differ- ent portions of the cerebral surface, showed (1) that the grey matter of the hemispheres can be directly stimulated ; (2) that 18 INTRACRANIAL DISEASES. there are true motor centres in the cerebral cortex; (3) that the action on the muscular system is a cross-action, that is, that it acts only on the side opposite the seat of irritation; (4) that there are special centres or areas governing the move- ments of the extremities, the jaws, and the tongue; (5) that the special function of each area is limited to its particular centre, except so far as it may be affected by vicarious action ; and (6) that severe hemorrhage destroys the excitability of the grey matter of the cortex; thus accounting, perhaps, for the nega- tive results reached by previous investigators. According to the same authorities, the motor centres, even when contiguous to each other, or occupying the same convolution, may be connected with w y ide]y different sets of muscles. Thus, the centre governing the supinator and flexor muscles of the fore- arm is found to be in close relation with the centre controlling the zygomatic muscles of the face, w T hilst adjoining the latter is a centre affecting the movements of the eyes and head. These results were afterwards confirmed by Ferrier, who re- peated the experiments on the brain of a monkey, an ani- mal whose cerebral convolutions most nearly resemble those of man. The following is a brief summary of the results obtained by these observers, so far as they bear upon the theory of cerebral localization: 1. Notwithstanding the fact that, as shown by previous in- vestigators, the hemispheres fail to respond to any form of mechanical, chemical or thermal lesion or stimulation, this is found not to be the case with electrical stimulation, the direct ap- plication of which to the surface of the hemispheres, in certain regions, causing definite movements in certain remote parts of the body; and, what is still more important, these movements are found to be associated with irritation of certain circum- scribed areas. 2. While considerable differences exist between Hitzig and Ferrier in regard to the extent of cerebral localization, as well as in respect to the character and significance of the phe- nomena elicited by their experiments, the discrepancies be- tween them may be satisfactorily accounted for, partly by the FUNCTIONS OF THE CEREBRUM. 19 manner in which they interpret them, and partly by the difference in their methods of investigation. 3. The method employed by Hitzig consisted chiefly in applying directly to the surface of the hemispheres, by means of blunted electrodes, a galvanic current of sufficient intensity to cause a distinct sensation when applied to the tip of the tongue. Ferrier's method was by means of a similar applica- tion of the electrodes of an induced or secondary current, of a strength sufficient to cause a pungent, but quite bearable sen- sation when applied to the tongue, affording a greater degree of stimulation without danger of producing disorganization. 4. An electrical current that will cause intense and indefi- nite action in an animal non-narcotized, w T ill, according to Ferrier, excite only moderate and definite action in an animal merely rendered insensible to pain, and no effect whatever on one fully anaesthetized. The state of the cerebral circulation also greatly modifies its excitability, haemorrhage lowering it in a marked degree. Great differences also exist in different animals, with respect to the degree and duration of the exci- tability of the hemispheres. Again, various regions of the brain differ in respect to their excitability. Thus, a current sufficient to cause a decided contraction of the orbicularis oculi, will, according to this authority, fail to produce any movement of the limbs. By observing this principle, using the faradic current, and applying a current of sufficient strength to produce a uniformly definite effect, Ferrier obtained positive results in regions of the brain in which Fritsch and Hitzig, with the weaker galvanic current, failed to elicit symptoms, and which they therefore termed inexcitable. 5. The situation of the motor centres in man, according to the physiological experiments of Ferrier on the monkey, an animal whose brain, as already stated, most nearly resembles that of man, is as follows: (See Cut, page 20.) a. The centres for the movements of the eyes are situated on the posterior half of the superior and middle frontal convolu- tions (12), and the anterior and posterior branches of the angular gyrus (13, 13'). Electrical stimulation of the former (12) causes elevation of ilie eyelids, dilatation of the pupils, conju- gate deviation of the eyes, and turning of the head toward the op- 20 INTRACRANIAL DISEASES. posite side. Stimulation of the posterior centres (13, 13') causes the eyes to move toward the opposite side, with an upward or downward deviation, according as the electrodes are on one or the other branches of the angular gyrus. The connection of this region (the angular gyrus) with the organ of vision, has been noticed by Hitzig, Goltz, McKendrick and others, the first two of whom experimented upon dogs, and the latter upon pigeons. Ferrier objects to Goltz's method of research — which consisted in washing away a portion of the brain after trephining over the spot selected for investiga- tion — as not fulfilling the conditions required in investigations Diagram representing side view of the human brain. — (After Ferrier.) of this nature. Ferrier's method of localized destruction of special areas, was chiefly by means of the actual cautery, varied occasionally with excision of the part. The result of his experiments upon this part was, that while electrical irrita- tion of the angular gyrus, in which one of these motor centres for the eyes is situated (13, 13'), produces the movements of the eyes, pupils, and head above stated, its destruction causes no paralysis in the muscles of either the eye, its lids, or the pupils. Unilateral destruction of this centre, however, produces tem- porary blindness in the opposite eye; whilst bilateral destruction FUNCTIONS OF THE CEREBRUM. 21 of this centre causes 'permanent blindness in both eyes. It is plain from this that the centre of each hemisphere has a pecu- liar effect upon both eyes, which is explained by the peculiar decussation of the optic nerves in the optic chiasm. It is also plain that, as stated by Ferrier, the movements consequent on electrical stimulation of this centre are merely reflex indica- tions of sensory stimulation. Whether, as he says, these move- ments are ue to the associated action of lower centres, cannot be experimentally determined. We shall recur to this subject again, under the head of sensory centres (q. v.). b. The centres for the movements of the jaws and tongue, are situated at the inferior extremity of the ascending frontal (Broca's) convolution, on a level with the posterior termination of the third frontal convolution (9 and 10). Electrical stimu- lation of this region is attended with opening of the mouth, and with protrusion (9) and retraction (10) of the tongue; action bilateral. These movements frequently continue after the electrodes are withdrawn. Ferrier found, in experimenting upon the dog, that the stimulation of this region also occasionally caused vocalization, or feeble attempts at barking or growling. In one experiment this was exhibited in a very striking manner. Each time the electrodes were applied to this region, the animal uttered a loud and distinct bark. To exclude the possibility of mere coincidence, Ferrier says he then stimu- lated in succession various parts of the exposed hemisphere, producing the characteristic reaction of each centre, but no barking. We shall see hereafter that Broca's convolution is, in man, the seat of intelligent language, and this experiment seems to confirm the truth of Broca's discovery, so far as ex- periments on the lower animals could be expected to do it. c. The centres for the mouth and lips are situated on the ascending frontal convolution, above the centres for the jaws and tongue (7 and 8). Electrical irritation of the upper por- tion of this region (7), by its connection with the zygomatic muscles, retracts and elevates the angle of the mouth; whilst stimu- lation of the lower portion (8) elevates the ala of the nose and upper lip and depresses the lower lip, so as to expose the canine teeth on the opposite side. .d The movements of the upper extremity are so numerous 99 INTRACRANIAL DISEASES. and complicated, as to require many individual centres. That for supination and flexion of the forearm, is situated on the upper part of the ascending frontal convolution (6); that for extension and forward movement of the arm and hand, is situated at the posterior extremity of the superior frontal convolution (5); and the centre for backward movement of the arm with abduction, the palm of the hand being directed backward, as in swing- ing, occupies adjacent margins of the ascending frontal and ascending parietal convolutions (4). Centres for the extensors and flexors of the individual digits could not be differentiated, but the prehensile movements of the opposite hand are central- ized in the ascending parietal convolution (a, b, c, d), the stim- ulation of which causes individual and combined movements of the fingers and wrists, ending in clenching of the fist. Paralysis caused by destruction of these centres, when the injury is limited to the cortical grey matter of the region included in them, is confined strictly to the voluntary movements pro- duced by electrical stimulation of these particular centres, and without affecting the sensibility of the parts over whose move- ments they preside. e. The centres for the movements of the lower extremity are situated on the posterior parietal lobule (1), and on the upper part of the ascending parietal and adjoining part of the as- cending frontal convolution (2). The first of these centres (1) when electrically excited, advances the lower or opposite hind limb, as in walking. Occasionally this movement is confined to the foot and ankle, the foot being flexed on the ankle and the toes widely separated. Stimulation of the other centre (2) produces complex movements of the thigh, leg, and foot, with adapted move- ments of the trunk, by which the foot is brought to the median line of the body, as in scratching the chest or abdomen. De- struction of these centres, as in the case of those governing the movements of the upper extremity, causes paralysis of volun- tary motion, without affecting the sensibility, the paralysis being confined to the movements resulting from electrical stimulation of these centres. 6. Whilst the great majority of physiologists, including Fritsch, Hitzig, Ferrier and other distinguished investigators, regard the above-described centres as directly motor, other FUNCTIONS OF THE CEREBRUM. 23 noted observers, as Eckhard, Schiff, Hermann, and Brown- S'-quard, attribute the movements excited by electrical stimu- lation of the cerebral surface to a reflex, indirect, or vicarious action; and that, too, notwithstanding the fact that the results obtained by Hitzig and Ferrier are found to agree in most instances with clinical and pathological observation, as we shall see when we come to treat of the localization of cerebral diseases. Some contend that the movements observed are not due to the excitation of the cerebral cortex, but to the trans- mission of irritation to the motor ganglia below; in proof of which they point to the fact that Eckhard has succeeded in tracing one of the excitable fibres for the front leg from the cineritious substance down to the corpus striatum. MM. Lus- sana and Lemoigne, who also deny that the so-called cortical centres are true motor centres, found their objection upon the fact that. mechanical stimulation does not excite them, and that galvanism and faradism are also generally insufficient when the animal is fully anaesthetised, as well as immediately after death. They also point to the discovery of Goltz, who, in his experiments upon the dog, found that the motor paralysis observed after destruction of the cortical centres, is neither complete nor permanent, like that which follows the destruc- tion of the lower motor centres. Hence we find Dr. Brown- Sequard, the most noted skeptic on this subject, using the following language: "Take, for instance, the sense of volition; we find it destroyed or altered in diseases of the brain, yet cases are not wanting in which certain parts of the brain have been destroyed while volition was not lost; and this is true of all the functions referred to the brain. At times alteration or destruction of these functions attend lesions of the brain, at times again these lesions are present while the symptoms are absent, and at times an entirely different class of symptoms ma)' appear. Each alleged function of the brain may remain after the destruction of what is considered its centre"* Brown-Sequard also denies the doctrine of cross-paralysis, basing his opinion on the histories of less than three hundred cases in which paralysis occurred on the same side as the cerebral lesion. But as he had to ransack the entire literature of medicine to * Lecture delivered at the Cincinnati Hospital, March 13th, 1872. 24 INTRACRANIAL DISEASES. find these exceptions to the general rule, that the paralysis is on the side opposite to the injury, and as many of these cases were very old, and therefore probably incorrectly reported, his opinion on this point, as on that of the cortical motor centres generally, is diametrically opposed to that of most of his col- leagues. Moreover, from what Ave now know regarding the variations in the course of the pyramidal fibres, such excep- tional cases are perfectly consistent with the received rule on this subject. 7. The advocates of the cortical theory of localization rely for the support of their doctrine chiefly on the fact, that paralysis of voluntary motion generally follows destruction of the correspond- ing cortical centres, and that any apparent exception to this result is capable of explanation in a way consistent with their view. They allege, also, that the theory derives marked sup- port, not only from clinical observations, but from anatomical and pathological considerations. They refer with emphasis to the researches of Betz, who found in the region anterior to the fissure of Rolando, corresponding to Hitzig's motor centres, giant-pyramidal cells, while in the region posterior to that fis- sure, which is not excitable, layers of nuclei predominate. Xow these "giant-pyramids," which occur only in Hitzig's excitable zone, are not fully developed until after birth. Here, then, it is claimed, we have a striking analogy, so far as the nervous elements are concerned, to the motor elements in the grey matter of the spinal cord. As for the transient character of the paralysis observed after destruction of cortical motor centres, it should be remembered that it applies only to quadrupeds ; in man and the monkey the paralysis is permanent. In view of this fact, Ferrier perti- nently asks : " If we were to say, with Hermann, that the re- covery in dogs disproves the view of the motor functions of the cortex, how shall we account for the paralysis observed in man and monkeys?" The explanation usually given of the phenomena, as met with in quadrupeds, is, that a process of compensation is effected by another portion of the cortex tak- ing on the function of that which has been lost. In the case of bilateral movements, it is only necessary to assume a vica- rious action of the corresponding centre of the opposite hemi- FUNCTIONS OF THE CEREBRUM. 25 sphere. That such compensatory or vicarious action does take place where muscles of the opposite sides are usually associated in action, as in the movements of the eyes, chest, abdomen, etc., is evident, and seems to be satisfactorily explained by the theory of Dr. Broadbent, whose explanation is as follows : "Where the muscles of the corresponding parts on the oppo- site sides of the body constantly act in concert, and act inde- pendently, either not at all or with difficulty, the nerve-nuclei of these muscles are so connected by commissural fibres, as to be pro tanto a single nucleus. This combined nucleus will have a set of fibres from each corpus striatum, and will usually be called into action by both, but it will be capable of being ex- cited by either singly, more or less completely according as the commissural connection between the two halves is more or less perfect. According to this hypothesis, then, if the centre of volitional action of one side is destroyed, or one channel of motor power cut across, the other will transmit an impulse to the common centre, and this will be communicated to the nerves of the two sides equally, if the fusion of the two nuclei is complete, and there will be no paralysis — more or less imperfectly to the nerve of the affected side if the trans- verse communication between it and its fellow is not so per- fect, in which case there will be a corresponding degree of paralysis." The above theory, which is in complete harmony with the facts of clinical experience, not only accounts for the compara- tive escape of bilaterally associated movements in case of corpus striatum haemorrhage, which the theory was formed to explain, but serves also to clear up the transient nature of the paralysis resulting from destruction of the cortical centres in quadrupeds, the movements of which are more generally auto- matic than are those of man and the monkey. This explana- tion, however, is not quite satisfactory, since, after recovering from paralysis caused by the extirpation of one cortical motor centre, the destruction of the corresponding centre of the oppo- site hemisphere does not reinduce the paralysis from which the animal had previously recovered. Besides, even after the destruction of both cortical centres, the power of voluntary movement of the parts to which their influence seems to be 2G INTRACRANIAL DISEASES. distributed is not entirely abolished. To account for these phenomena, Carville and Duret adopt the hypothesis of Flou- rens, Longet, and others, namely, that other portions of the hemispheres gradually assume the functions of the parts which have been destroyed. This law of functional substitution, however, is in direct conflict, not only with the doctrine of cortical localization of function, but with the results of the experiments on which that doctrine is founded. The law of substitution, in order to be consistent with the theory of cortical localization, requires to be limited to those centres of action already established — the lower ganglia — which, with- out resuming new functions, may in an indirect manner com- pensate for the loss of the upper centres. THE SENSORY CENTRES. 7. We are indebted to Ferrier for most of our knowledge of the sensory centres of the cerebrum. We have already given the result of his experimental researches into that portion of the temporo-sphenoidal lobe known as the angular gyrus, in which is situated one of the motor centres controlling the movements of the eyes, pupils, and head, but w T hose destruction, while it produces no motor paralysis in the muscles of either the eye, the eyelids or the pupil (showing it to be not a direct but only a reflex motor centre), causes loss of vision in the opposite eye (which, however, is not permanent if the opposite gyrus remains sound), and when both angular gyri are de- stroyed, causes blindness of both eyes, which is complete and per- manent, thus proving it to be a true sensory centre. b. Pursuing his investigations, Ferrier found in the superior temporo-sphenoidal convolution a centre (14) which, under fara- dic irritation, caused the monkey operated upon to suddenly retract or prick up the opposite car, widely open the eyes, dilate the pupils, and turn the head and eyes to the opposite side — phenomena which a loud sound made in the ear opposite the irritated hemisphere would be likely to produce. This inference, as to the nature of the effect produced by electrical stimulation of this centre, was confirmed by destruction of the convolution, which, as in the case of the visual centre, caused apparent deafness on the opposite side, and, when both sides were de- SENSORY CENTRES. 27 strayed, the animal became totally deaf, no motor paralysis being discoverable in either case. c. In the lower part of the temporo-sphenoidal lobe, called the subiculum cornu ammonis, a centre was found which caused a peculiar torsion of the lip and partial closure of the nostril on the same side. This effect is similar to that produced by the direct application to the nostril of a powerful odor, rendering it highly probable that this is the special centre for the sense of smell. As in the preceding sensory centres, the conclusion drawn from the result of electrical stimulation of this centre, was confirmed by its destruction, which, when effected on both .sides, caused the loss of smell and taste, showing that this region contains the centres of both these senses. Unilateral destruc- tion of these centres produced the most marked effects upon the opposite side ; bilateral destruction abolished the sensory function altogether. d. Ferrier also succeeded in locating, with considerable certainty, the centre of tactile sensation, which he places in the region of the hypocampus major and uncinate convolution. This region is so difficult of access with the electrodes, as to render it impossible to reach it safely for electrical experimentation, and hence destruction of this region, which is found to abolish tactile sensation on the opposite side of the body, is the only reli- able test. Ferrier finds confirmation of this being the special centre of tactile sensibility, in (1) indirect or mediate electrical excitation; (2) in clinical and pathological evidence in man, as given by Charcot, Raymond, Veyssiere and others, which, though not due to disorganization of the centres of sensation, interrupt the path of transmission from the organs of sense to the sensory centres in the cortex, i. e., the centripetal fibres which proceed to the hippocampal region; and (3) the impair- ment, or abolition of vision on the same side as the cutaneous anses- thesia, in which respect Ferrier's experiments on the monkey coincide with clinical observation, the function being abolished or greatly impaired on the side opposite to the lesion, as is the case likewise with the senses of taste and hearing, but not with the sense of smell, as the olfactory centre is in the hemisphere of the same side. Hence, as stated by Ferrier, " with the ex- ception of the paths of olfactory sensation, section of the pos- 28 INTRACRANIAL DISEASES. terior division of the internal capsule is practically, at one blow, interruption of all the sensory tracts, and is equivalent to extirpation or disorganization of the sensory centres of the cortex. The differentiation of these into regions of special sense is simply a terminal specialization of the centripetal paths which radiate from the internal capsule or foot of the corona radiata into'the cortex." e. The occipital, as well as the temporo-sphenoidal lobes are now generally regarded as containing sensory centres, although partial or complete removal of them fails to show any effect upon the motor or sensory functions. Ferrier, how T ever, re- gards these lobes as specially related to the visceral sensibilities- He found that while their removal is without effect on any of the faculties of special sense, on the powers of voluntary mo- tion, or on the functions of respiration and circulation; and while their removal is a less severe operation than the re- moval of the frontal lobes, in which the animals retain their appetite and eat and drink with apparently their usual relish, the removal or disorganization of the occipital lobes is attended with a complete loss of appetite for food, although the appetite for drink still remains. 8. The experiments we have described seem clearly to es- tablish the following facts : (1) That there is a motor zone in the centre of the cerebral hemispheres, embracing the central and posterior portions of the frontal lobes; also, that there is a sensory zone, embracing the temporo-sphenoidal lobe, which is situated between the motor area, in front, and the occipital lobe, behind. (2) That these zones include distinct centres, each of which is endowed with its special and well-defined function. (3) That electrical stimulation of the motor centres produces contraction of certain sets of muscles with which they stand connected, while destruction of these centres pro- duces paralysis of said muscles. And, (4; that electrical irri- tation of the sensory centres exalts their functions, while bi- lateral destruction of said centres abolishes their function?. This is as far, perhaps, as experimental physiology will enable us, in the, present state of our knowledge, to go in the inter- pretation of cortical cerebral phenomena, for, as we have seen, some of the phenomena are inexplicable except upon the SENSORY CENTRES. 29 theory of substitution — a theory which is still a subject of much controversy. We shall see hereafter, however, that the doctrine of special and exclusive primary centres in the cere- bral cortex, derives very great support from anatomical, patho- logical and clinical considerations, which together furnish an amount of evidence in favor of the theory of localization that falls but little short of full demonstration. But motion and sensation are by no means the exclusive functions of the cerebral convolutions. Experimental and clinical evidences have established the fact that the anterior portion of the cerebral cortex is eminently psychical in its nature, being the special seat of volition and intelligent con- sciousness. The removal of the cerebrum in animals does not destroy the perceptive faculties of sight, hearing and taste, as asserted by Flourens,* nor, if the basal ganglia are left undis- turbed, does it permanently destroy the mechanism of coordina- tion of muscular movements, but the animals simply appear stupid, as though deprived of intelligence. Both Hitzig and Landoisf assert that when those portions of the cerebral cortex which govern the movements of the extremities, is excised, there is a rise in the temperature of the corresponding limbs, and that the elevation of temperature continues several months. A connection has also been observed between the cerebral cortex and the cardiac pulsations, a change in arterial pressure, dilatation of the pupils, salivation, and contraction of the spleen, bladder and uterus; but the true centres of some of these are not well determined, and there is reason to believe that they are really located in some other portion of the ner- vous system. The most important discovery, however, is that of Broca,| who, in the year 1861, succeeded in locating' the seat of intelligent language in the third convolution of the left anterior lobe of the brain. This discovery has since been re- peatedly confirmed, the most recent investigations tending, as I have elsewhere shown, § to prove that the special centre for articulate language is in, or very near, the island of Reil. * u Recherches experimentales sur les proprieties et les fonctions du systeme nerveux," Paris, 1842. f Virchow's " Archiv.," 1876. % Broca, Bui de la Soc. Anal, 1861. \ Nervous Diseases, p. 206. 30 INTRACRANIAL DISEASES. CHAPTER II. FUNCTIONS OF THE CEREBRAL GANGLIA. Meynert* divides the cerebral ganglia into two principal parts, the ganglia of the tegmentum pedunculi, and the ganglia of the pes pedunculi, the former comprising the corpora quadri- gemina and thalamus opticus, and the latter, the corpus striatum and cortex of the brain. These two great parts are again con- nected by commissural fibres, so as to form a special gangli- onic system. We shall consider the two principal members of this system under the head of 1. — The Basal Ganglia. Electrical stimulation of the corpora striata causes general tonic contractions of the muscles of the face, neck, trunk, and ex- tremities. When the irritation is confined to one of these ganglia, the spasms are unilateral, the flexors predominate over the extensor muscles, and the body is bent to the oppo- site side. According to Ferrier, Carville and Duret, muscular movements are not capable of being differentiated by the direct stimulation of these ganglia, as in the case of the corti- cal centres, although in Dr. Sanderson's experiments separate movements were produced after the cortical substance was re- moved ; but this result is referred by Ferrier to the stimulation of the medullary fibres connecting the cortical centres with corresponding centres in the corpus striatum, although these centres are not capable of individual excitation when the electrodes are applied directly to the ganglion itself. Hence he infers there is in the corpus striatum a combination or in- tegration of the various centres which are differentiated in the cortex. * Strieker's Handbook. FUNCTIONS OF THE CEREBRAL GANGLIA. 31 Although Ferrier generally found the optic thalami insensi- ble to faradization, there was marked impairment of sensory function when disorganized or destroyed by the actual cautery. On chloroforming a monkey, he inserted a wire cautery in such a manner as to traverse the optic thalamus completely. Before the animal recovered consciousness, the left eye ap- peared to be permanently closed, and when, after recovery, it opened its right eye, the right pupil was found to be dilated. The right side was completely paralyzed, cutaneous sensibility on that side was destroyed, and the animal was apparently blind ; but as the medullary substance just external to the ganglion had been previously broken up, in an unsuccessful attempt to destroy the optic thalmus, it is not certain that the blindness in this case was not due, to some extent, to the lesion of the medullary fibres and cortical substance. The experi- ment proves, however, that both vision and cutaneous sensi- bility may be destroyed by an injury in and around the optic thalamus. Now, Veyssiere, the result of whose experiments has been confirmed by Carville and Duret, has established, both by clinical evidence and by carefully conducted experiments on the lower animals, the fact that section of the posterior part of the peduncular expansion causes hemianesthesia. Moreover, Tiirck, Demeaux, Bourneville, Charcot, and others, report cases showing that in man hemianesthesia occurs when- ever the corresponding regions of the internal capsule are de- stroyed by disease ; while Ferrier's experiments show that, as a rule, vision is seriously impaired, if not quite abolished, on the same side as the cutaneous anaesthesia, i. e., the side oppo- site the cerebral lesion. AVe see, also, that there is a differen- tiation of the paths and centres of sensation from those of motor impulses ; and as the motor paths are limited to the corpus striatum and the anterior part of the internal capsule, the only path remaining for the transmission of sensory im- pressions from the periphery to the hemispheres, as pointed out by Ferrier, is through the tegmentum cruris cerebri, tit e optic thalamus and its medullary connections with the cortex. "To assert," says Ferrier, " in the face of these facts, that sensation can still continue, notwithstanding the total destruction of the 32 INTRACRANIAL DISEASES. optic thalamus, both cells and medullary fibres, is to assert nothing less than a physical impossibility."* It thus appears that the optic thalami bear the same relation to the sensory regions of the cortex, that the corpora striata do to the motor regions. The medullary fibres which converge to, and diverge from, the optic thalamus, are mostly distributed to the posterior and temporo-sphenoidal regions of the cortex, which, as we have seen, are special centres of sensation. Luysf says the body of this ganglion is made up of four sepa- rate ganglionic masses, (1) centre anterieur, (2) centre moyen, (3) centre median, and (4) centre posterieur, which are connected with the olfactory, optic, auditory and tactile tracts respec- tively, and with corresponding regions in the cortex. As the researches of Meynert,J however, led him to somewhat differ- ent conclusions, Ferrier is not disposed to give full credit to these results. Moreover, the theory that the optic thalamus is called into action in the upward transmission of sensory impres- sions, and that the corpus striatum is the centre through and by which the motor impulses are transmitted downward to the opposite side of the body, though in harmony with the evidence just adduced, is yet far from being fully demon- strated. For, although haemorrhage into the corpus striatum causes paralysis of the opposite side, instances are not want- ing where both ganglia have been removed without the loss of either sensation or motion. Moreover, while MM. Lussana and Lemoigne§ state that destruction of the optic thalamus resulted in blindness of the opposite eye, Longet,|| who suc- ceeded in destroying the ganglion on both sides, was unable to detect any impairment of vision, or any influence upon the movements of the pupil. At the same time, it must be ad- mitted that the distribution of the fibres of the crus cerebri are such as to point strongly to the corpora striata as motor centres, and to the optic thalami as presiding over sensory im- pressions. * " Functions of the Brain," p. 266. f " Recherches sur le Systeme Nerveux," 1865. % Vide, ante. I " Fistologia die Centri Nervosi Encefalici," 1871. || " Traite de Physiologic" functions of the cerebral ganglia. 33 2. The Corpora Quadrigemina. It is generally conceded that the corpora quadrigemina are the true optic ganglia, for when they are destroyed, vision is completely abolished, and the pupils no longer contract under the stimulus of light; but the experiments of Hen sen* and Voelkersf appear to indicate that the exact seat of the centre or centres controlling the function of vision, contraction of the pupil, and the movements of the eyeball, is situated in the aqueduct of Sylvius, immediately beneath the tubercula quadri- gemina; stimulation of the deeper portions of the nates, after removal of the upper, yielding more uniform results than before the section was made. This inference is sustained by the anatomical fact, that the deep origin of the third, or motor oculi nerve, can be traced to a grey nucleus in the floor of the aqueduct of Sylvius. Unilateral destruction of these ganglia causes blindness of the opposite eye; but vision remains even after the hemi- spheres have been removed, provided the optic ganglia are uninjured. This fact appears inconsistent with the results of Ferrier's experiments upon the angular gyrus,* in which vision was abolished when both gyri were destroyed; but the probability is that these ganglia sustain a similar relation to that portion of the cerebral cortex, that the basal ganglia do to the other cortical ceutres. Stimulation of the right side of the nates, according to Adamuk,§ causes both eyes to move to the left, and stimulation of the left side, to the right; in front it causes an upward, and behind, a downward movement of both eyes, accompanied with divergence or convergence of the optic axes and corre- sponding changes of the pupil. We thus see that the centres governing the movements of the eyeball and pupil are, like the movements themselves, closely connected with each other. The corpora quadrigemina have a marked influence on the expression of the. emotions, such as fear, terror, joy, etc. They also appear to be connected in some way with the function of * " Centbl. Med. Wiss.," 187C. J Vide ante, op. cit. . f " Archiv. f. Ophthalmol./' 1878. | " Ctntbl. Med. Wiss.," 1870. 3 34 INTRACRANIAL DISEASES. coordination of muscular movements, faradization of these bodies producing complex movements of all the voluntary muscles, especially of those concerned in progression and the mainten- ance of the normal attitude. This is in harmony with the dis- covery of Flourens,* that the removal of the corpora quadri- gemina impaired the power of muscular coordination, and sustains the belief that the mechanism of coordination is of a complex character, involving not only the cerebellum, but the tubercula quadrigemina, pons Varolii, and other ganglia. Faradization of the corpora quadrigemina, in animals, causes them to moan and utter peculiar cries; a fact that has led some to infer that the protracted moaning which is sometimes heard during attacks of epilepsy, is owing to irritation of these ganglia, just as the shrill cry that frequently ushers in the convulsive stage of that disease, points to irritation of the medulla oblongata. 3. The Crura Cerebri and Pons Varolii. The crura cerebri and pons Varolii, which form the greater portion of the meso-cephalon, are abundantly supplied with grey matter, showing that they are endowed with important ganglionic functions. The crura, as they diverge from each other in their upward course, are traversed by the third, or motor oculi nerves, the deep origin of which is just below the corpora quadrigemina. That some of the nerve fibres decus- sate between these points, is evident from the fact that de- struction of one crus cerebri causes paralysis of motion and sen- sation on the opposite side of the body, and paralysis of the motor oculi nerve on the same side. Again, some of the roots of the facial nerve, which makes its exit from the side of the medulla oblongata, can be traced as far as the floor of the fourth ven- tricle, while others spring from the upper border of the pons Varolii. As the latter are below the point of decussation, we find that injury of the pons causes complete facial paralysis on the same side, and paralysis of the extremities on the opposite side. Moreover, the fibres of the pons decussate in such a manner, * Op. cit., 1845. FUNCTIONS OF THE CEREBRAL GANGLIA. 35 owing to the separate origins of the roots above mentioned, that both sides of the face may be paralyzed and only one side of the body. It appears from various experiments made upon the pons Varolii, that automatic movements, especially those governing station and progression, are regulated by it, independent of the action of the hemispheres. A somewhat similar function of the pons applies to the sensation of pain, which appears from the experiments of Longet* to be perceived by it even after the removal of both the hemispheres and the basal ganglia. We are justified, therefore, in regarding the pons Varolii as the ganglionic centre by w T hich peripheral impressions are first converted into conscious sensations, and in which the volun- tary impulses which stimulate the muscles to contraction, originate. This ganglion has also an important influence on articulation, for although intelligent speech does not seem to suffer from disease seated in this centre, yet, owing to paresis and incoordination of the muscles concerned in the formation of sounds, the pronunciation of words is rendered more or less clumsy and unintelligible. 4. The Cerebellum. Although the most opposite opinions have at times been en- tertained regarding the functions of this organ, and although its physiological action cannot even yet be considered as fully settled, no fact perhaps is better established, than that the cerebellum forms an essential part of the central mechanism by which coordination of muscular movements is effected. The fact is likewise well established, that this ganglion is capable of exercising no truly mental function, either of sensation, volition, emotion, or intellect. The experiments of Flourensf on pigeons, the results of which have been repeatedly confirmed, prove conclusively that the removal of the cerebellum, while not impairing the functions of sensation, volition and intelligence, causes in all cases loss of the powers of coordination. Au- * Op. cit. f "Kecherches Experimental es sur les Proprietes et les Fonctious du Systeme Nerveux " 2d ed., 1842. 36 INTRACRANIAL DISEASES. thorities differ somewhat, however, as to the duration of these effects, Flourens asserting that the removal of the cerebellum causes permanent disorders of equilibrium, while the experi- ments of Dalton, Wagner, Mitchell and others, appear to show that recovery may take place after the removal or destruction of the greater portion of the organ. The intimate connections of the cerebellum w T ith the other portions of the encephalic mass, will serve to explain, to some extent, the complex movements and other phenomena pro- duced by stimulation or lesion of different parts of the organ. Thus, destruction of the anterior part of the middle lobe causes a tendency to fa 11 forward, while irritation of the same part, either by faradization or by disease, excites such muscular move- ments as would tend to counteract that effect. Again, destruc- tion of the posterior part of the middle lobe induces a tendency to fall backwards, and of the lateral lobes to fall sideways, while stimulation of these parts provokes those movements which are calculated to counteract such tendency, such as movements of the eyes in different directions, contraction of the pupil, and the peculiar movements of the head and limbs. These forms of vertigo are so similar to those which occur in " Meniere's disease," or auditory vertigo, as to lead some physiologists to infer that there is some sort of connection between the semi- circular canals of the ear and the cerebellum.* Few, however, are willing to accept such symptoms as positive evidence of the irritation of this centre, owing to the proximity of other points the irritation of which would be liable to excite similar symptoms, such as the corpora quadrigemina, the points of origin of the third, fourth and sixth nerves, and the different nuclei of the fourth ventricle. Moreover, as we have seen, the functions of cerebellar coordination cannot be completely sep- arated from those of the optic lobes and pons Varolii, these parts, according to Ferrier, forming a combined mechanism incapable of being separated without producing a general de- rangement of function. The influence of the cerebellum over peristaltic movements * See Vertigo, Part II. FUNCTIONS OF THE CEREBRAL GANGLIA. 37 in the oesophagus and stomach, has been pointed out by Budge; and Schiff mentions a very acute form of intestinal inflamma- tion, accompanied with haemorrhage, which resulted from in- juries to the peduncles. Priapism has occasionally been observed in haemorrhage of the middle lobe of the cerebellum, which has led some to re- gard this organ as the centre of the sexual appetite, but the effect mentioned was probably due to pressure of the clot upon the posterior surface of the medulla oblongata and pons Varolii. In fact, the centre of the sexual appetite appears from the most recent experiments to be located, not in the cerebellum, but in the lumbar region of the spinal cord. The relation of the kidneys, however, to the cerebellum, has been shown by Eckhard,* who found that galvanism 'of this organ produced diabetes. * << Beitrage," 1878. 38 INTRACRANIAL DISEASES. CHAPTER III. FUNCTIONS OF THE BULB. Owing to the fact that the medulla oblongata connects the spinal cord with the cerebrum, its functions are extremely varied and complicated. Thus : 1. As the centre from which are distributed most of the fibres which pass to the other intracranial ganglia, it receives and transmits both the sensory impressions and the motor im- pulses that pass to and from the cerebrum. 2. Its motor fibres decussate in the anterior pyramids, in such a manner as to connect each half of the brain with the opposite half of the body, producing in cases of injury and disease of the cerebrum the phenomena of crossed paralysis. 3. It gives origin to numerous important nerves, through which, in connection with their sympathetic relations, are manifested phenomena of reflex coordination originating in the following centres : a. The respiratory centre, the exact seat of which is in the apex of the fourth ventricle, at the point of the calamus scrip- torius. This centre has been termed by Flourens the nosud vital, or vital knot, because any considerable injury at this point causes immediate death. Faradization or morbid stimu- lation of this centre produces sudden tonic contraction of the respiratory muscles of the neck, chest, and diaphragm. Epi- leptic and other convulsions generally arise from irritation of the medulla oblongata, as well as the sharp cry which ushers in the convulsive seizure. b. The cardio-inhibitory centre, by which the heart is held under control, in obedience to sensory impressions transmitted to the medulla oblongata by means of sensory nerves. This FUNCTIONS OF THE BULB. 39 centre does not cause the regular pulsations of the heart, which are under the influence of the motor ganglia in the cardiac sub- stance itself; but its movements are inhibited, or arrested in diastole, by impressions carried to the medulla oblongata. If the mesentery of the frog be exposed and slightly tapped, the heart will immediately cease to beat, but will soon resume its rythmical action. This shows the responsive action of the medulla to afferent sensory impulses, and also its inhibitory influence upon the heart. The rythmical action of the heart is under a two-fold nervous influence. One, the inhibitory or restraining influence, is exercised through the pneumogastric nerve, section of which accelerates the pulsations until they be- come too rapid to be counted ; on the contrary, if the inhibi- tory action is called into full play by means of faradization, the heart will stand still during diastole. The accelerating action takes place through the sympathetic fibres proceeding from the medulla, and which reach the heart through the lower cervical and first dorsal ganglia of the sympathetic nerve. c. The vaso-motor centre, which regulates the size of the blood- vessels. Dittmer* locates this centre in the lateral columns, after the fibres have been given off to the anterior pyramids ; Clark places it near to the origin of the facial nerve ; whilst others limit it to the floor of the fourth ventricle. Stimulation of this centre causes contraction of the blood-vessels, whilst section of it paralyzes them. d. The emotional centre, which, acting through the facial nerve, gives expression to the countenance. Stimulation of this centre in the medulla oblongata produces spasm of the facial muscles, such as are often observed in convulsions arising from irritation of this portion of the nervous system. e. The centre for deglutition, which harmonizes the action of the muscles of the lips, tongue, palate, and pharynx in the act of swallowing, more particularly in the last two stages of that act, or from the time the food passes the isthmus of the fauces. /. The cesophagal and gastric centre, for regulating the move- ments of the oesophagus and stomach, and controlling the mechanism of the act of vomiting. *Lud wig's " Arbeiten," 1873. 40 INTRACRANIAL DISEASES. g. The salivary centre, which regulates the secretion of saliva, and possibly, also, that of the pancreatic fluid. The increased flow of saliva consequent upon the use of aromatic substances, such as ginger, cloves, etc., is due to afferent impulses sent through the gustatory branch of the fifth cranial nerve to the medulla oblongata, whence the efferent impulse is transmitted through the chorda tympani branch of the facial nerve. h. The centre for articulate speech, which coordinates the move- ments of the lips, tongue, and palate in the act of speak- ing. This act is a complex one, requiring two sets of nervous influences, one acting through the pneumogastric and spinal ac- cessory nerves for respiration and phonation, and the other for lingual and labial movements through the hypoglossus and portio dura, which act upon the muscles controlling the movements of the tongue, lips and palate. The nuclei of these nerves are not only situated close together, in pairs, but are so connected by commissural fibres extending from one side to the other, as to insure a simultaneous action of the muscles of articulation, even w T hen the motor impulse is unilateral. i. Finally, the medulla oblongata contains a diabetic centre, which, when irritated, produces a saccharine state of the urine. Experiments upon rabbits show that, when the animals are in good condition, a considerable amount of sugar is thus secreted, within an hour or two after the experiment is performed.* j. The existence of distinct centres of reflex coordination in the medulla oblongata, which have not only been clearly de- monstrated upon animals, but which, from pathological and anatomical considerations, are known also to exist in man, render it highly probable that the medulla is a general centre for the coordination of muscular movements, some of the special forms of which we have found to be possessed by the upper gan- glia of the cerebellum, corpora quadrigemina, and pons Varolii. *Ranney's Applied Anat.ofthe Nerv. Sys., 1881. CEREBRAL LESIONS. . 41 SECTION II. REGIONAL DIAGNOSIS IN BRAIN DISEASES. CHAPTER I. CEREBKAL LESIONS. We have seen that the investigations of modern physiolo- gists prove most conclusively that the various groups of mus- cles are under the direct control of different portions of the grey substance of the cerebral cortex, as well as of the related ganglia below ; for although lesions apparently contradictory of these results have from time to time been brought forward, Ferrier* has shown that in most cases the seeming contradic- tions are capable, not only of being reconciled with the theory of cortical localization, but oftentimes of confirming it in the most remarkable manner. This is especially true of lesions the effects of which are limited to particular areas, instead of being diffused, by pressure or otherwise, as in the case of tumors, where the effects are liable to be felt at a distance from the seat of lesion, and thus render the results more or less com- plex. Ferrierf enumerates the following lesions as being of special value in establishing the theory of localization of brain diseases, viz., "cases of wounds, laceration, or loss of substance, with various forms of chronic degeneration, such as atrophy, necrosis, etc., and the results of haemorrhage, inflammation, and the like, which, though at first complex, subside into local '■- ''Localization of Cerelral Diseases," J 879. f Op. cit. 42 INTRACRANIAL DISEASES. lesions, such as softenings, cysts, and abscesses; or, in general, all lesions which exclude meningo-encephalitis, mechanical compression, or general cerebral disturbance." This distinction is all that is necessary, so far as regional diagnosis is concerned, whilst the diagnosis of the nature of the lesion will depend on other characters, such as the general symptoms, the mode of onset, and the various special features by which we are enabled to individualize the disease. At the same time, however, it should be borne in mind that, so far as our present knowledge extends, there are no known systemic lesions in the brain.* The term systemic was applied by Vulpian to those lesions which are systemically circumscribed, that is, such as do not extend beyond the limits of certain clearly defined regions ; as in the spinal cord, where there are lesions limited to the anterior cornua of the grey substance, to the lateral fasciculi, and to the posterior columns. But there are no such systemic lesions known to occur in the brain ; no lesions invariably limited, for example, to the various portions of the cortex, to the thalami optici, or to the different ganglia of the corpora striata.f Not th^t anatomical demarcations of disease do not exist in the encephalon, but that they are rela- tively rare, and, to all appearances, wholly accidental. The explanation, according to Charcot, lies in the fact that the brain, unlike the other portions of the cerebro-spinal axis, is under the control of the vascular system ; or, in other words, the arteries, veins, and capillaries " command the situation." For example, the most constant anatomical lesion of the brain at present known is that of Broca, confined chiefly to the third left frontal convolution, or the island of Reil ; yet this is no ex- ception to the rule, since aphasia, as we have elsewhere shown,J is found to depend upon obstruction of the middle cerebral artery or its branches. Hence, Charcot calls especial attention to the importance of vascular ruptures and the consequent haemorrhage in the cerebral centres, and to the predominant * Charcot, " Localization in Diseases of the Brain," 1878. f I. e., the lenticular and cordated nuclei or ganglia, into which the corpora striata are now divided. X See Nervous Diseases, p. 218. CEREBRAL LESIONS. 43 influence of vascular obliteration by thrombosis and embolism, which result in extravasation, followed by partial softening of the brain. Another fact that should be carefully borne in mind is, that although the brain is undoubtedly the organ of the mind, it may be greatly diseased without producing any very obvious mental disorder. On the other hand, well-marked mental de- rangement may occur without any characteristic morbid ap- pearances showing themselves after death ; and even in those cases where morbid conditions are revealed by post-mortem examination, such as the various forms of degeneration in the vessels, nerve-cells, neuroglia, etc., there has not yet been dis- covered any definite relation between the locality of the lesion and the symptoms observed. Hence, so far as certain faculties of the mind are concerned — the affections, desires, emotions, etc. — there is at present no well-marked localization of function — one sound hemisphere being sufficient for the performance of every mental function. It by no means follows, however, that there are no special centres of mental action, and therefore that there can be no differentiation or localization of mental diseases. Indeed, so far as the general seat of the intellect is concerned, it may be said to be already well established. Vo- lition, also, when expressed in action, is differentiated both by elevation of temperature* of the cerebral centre and by the motor phenomena. Mental symptoms, however, are not only fre- quently difficult of appreciation, but we are not yet in posses- sion of the requisite criteria for determining with certainty whether the mind has, or has not, altogether escaped damage in every case attended with cerebral lesions. Moreover, the cases of bilateral cerebral lesions are comparatively few, and it is only in such, so far as diagnosis is concerned, that the men- tal symptoms or deficiencies can be said to have any weight. These considerations, however, only show the difficulties in the way of determining the localization of mental diseases and functions, and not the absolute non-existence of special centres of mental action. Strict research, therefore, may yet determine anatomical localizations of mental affections, but at present we * Prize Essay of 1880, Archiv. % of Med., New York, April, 1880. 44 INTRACRANIAL DISEASES. have no definite knowledge on which to base a regional diag- nosis in diseases of this charactor. The following general statements, based chiefly upon the observations of Ferrier, Charcot and Nothnagel, embrace re- sults which have received clinical verification, and can gener- ally be relied upon in the regional diagnosis of cortical lesions: 1. Although no exact localization of mental disturbances can yet be made, such derangements indicate, in general, disease of the surface of the brain, that is, of the grey substance of which the cerebral convolutions are chiefly composed. 2. Disease of the cortex may exist in a latent form, that is, without giving rise to decided symptoms ; hence, the absence of symptoms is no proof that the grey substance of the convo- lutions is not affected by disease. 3. Diseases within the motor area, however, generally give rise to symptoms, either of a positive or negative character. 4. Lesions of the cortex outside of the motor area will pro- duce no symptoms unless the cerebral membranes are in- volved, in which case there may be convulsions, and possibly, headache; these symptoms being the result of irritation of the motor and sensory areas of the cortex. 5. At present, sensory disturbances have but little value in the diagnosis of cortical lesions of the brain. Unilateral disturb- ances of vision sometimes occur, but so far they have only been observed in connection with diffused cortical lesions, such as progressive paralysis, cysticercus, etc., and are of no importance in regional diagnosis. As for hemiopia, it is only in cases where the symptom is developed suddenly, and is purely of a subjective character, that the existence of a cortical lesion can be suspected. If such a lesion exist, it will probably be located in the occipital lobe. 6. Aphasic or dysphasic symptoms indicate that the lesion involves one of the following localities, which are given in the order of their frequency : (a) the third left frontal convolution ; (b) the island of Reil ; (c) the white substance between the third left frontal convolution and the base of the cerebrum. 7. Lesions of the left parietal lobe, and more particularly of the first temporal convolution, are liable to produce word-deafness. CEEEBRAL LESIONS. 45 8. Cortical lesions generally give rise to motor derange- ments, the character of which is sometimes sufficiently diag- nostic to indicate the seat of the disease. 9. The possible implication of the corpus striatum will often render the diagnosis of cortical lesions more or less doubtful, especially when they take the form of a simple hemiplegia, such as generally results from a lesion of that ganglion. In such cases no positive diagnosis can be made. Other associ- ated symptoms, such as aphasia, may render the diagnosis more probable, but even then the aphasic or other cortical symptoms may be connected with a corpus striatum lesion. 10. Lesions of the cortex resulting in actual destruction of the grey matter of the motor area, are generally followed by pa- ralysis ; whilst irritative lesions of the cortex usually give rise to either partial or general convulsions. 11. Paralyses arising from lesions of the cortex generally in- dicate monoplegias, partial hemiplegias, paralyses of the hypo- glossal, facial and brachial nerves, or of the nerves of the face and arm, or arm and leg ; the leg alone is rarely involved. 12. Paralysis of motion, when confined entirely, or even chiefly, to the upper extremity, indicates not only that the lesion is located on the opposite side of the brain, but that it is probably confined to, or involves, the ascending convolutions of the parietal or frontal lobes. 13. When the paralysis is confined chiefly or exclusively to the muscles of the lower extremity, and is of intracranial origin, the lesion probably involves the convolutions at the upper extremity of the fissure of Rolando. 14. Monoplegias, even when of intracranial origin, do not indicate with absolute certainty, but only with great proba- bility, the existence of a cortical lesion. 15. The associated symptoms are often of very great import- ance in determining the diagnosis. Thus, if with paralysis of the extremities, there is also paralysis of the facial and hypoglossal nerves, and especially if ptosis is also present, the paralysis is probably due to a cortical lesion. On the other hand, if the motor hemiplegia is associated with marked dis- turbances of sensibility, it indicates either that the lesion does 46 INTRACRANIAL DISEASES. not involve the cortex, or if it does, that the lesion is extensive, and extends deeply into the white substance below. 16. Motor irritative symptoms arising from lesions of the cortex indicate that the seat of lesion is probably in the ascend- ing frontal or postero-parietal convolutions, or in the paracentral lobule. 17. Irritative symptoms take the form of partial or general con- vulsions, which may either precede or follow paralysis of the affected muscles. If partial, they may occur either as the re- sult of haemorrhage or softening, or the development of a tumor. If general, they will be of an epileptiform character, the initial spasms always recurring in the same group or groups of mus- cles in the face or extremity, and always subsequent to an existing paralysis. 18. The paralysis which follows motor disturbances resulting from cortical irritation, is generally of the transient variety, but it may be permanent. 19. Motor paralysis, due to destructive lesions of the grey matter of the cortex, occurs on the side of the body opposite the seat of the disease, and is generally permanent. 20. It is probable that only those destructive lesions of the cortex w T hich implicate the subjacent white substance, are capable of producing motor paralysis of the opposite side of the body; for no symptom of importance results from lesions of the centrum ovale, except such as occurs in the anterior and posterior central regions, namely, motor paralysis of the oppo- site side, similar to what is caused by lesions of the cortex and corpus striatum. 21. When, after an attack of hemiplegia from destructive lesions of the cortex, the paralyzed muscles become rigid, it indicates that a secondary degeneration of the nerve-fibres has set in, and is progressing downward along the spinal cord. This is most marked in cases where the lesion is seated in the paracentral lobule, but applies to some extent to the entire motor area of the cortex. LESIONS OF THE BASAL GANGLIA. 47 CHAPTER II. LESIONS OF THE BASAL GANGLIA. Charcot and Nothnagel have recently made the basal gan- glia the subject of special investigation, with the view of affording a satisfactory explanation of the clinical phenomena exhibited by the various lesions of these important organs; and as the results which they have reached are of great prac- tical interest and value, we shall present a synopsis of them nearly in their own words. As before stated, Charcot bases his views of cerebral local- ization chiefly upon the anatomy of the cerebral circulation. The following are his principal conclusions : 1. The symptoms which arise from softening of the entire region occupied by the basal ganglia, are those of cerebral hemi- plegia accompanied with cerebral hemianesthesia. We are not able to recognize the special symptoms which belong to de- struction of the thalami optici, the caudated or the lenticu- lar ganglia,* and still less, the various segments. It is possible, however, in some cases, to make a regional diag- nosis, based upon the arterial distribution ; as, for example, when the lesion affects all, or nearly all, of the territory of the lenticulo-striated arteries, or that of the lenticulo-optic arteries. In the latter case the symptoms of herniansesthesia are present, whilst in the former they are absent. 2. In lesions confined to either one of these ganglia, and where the internal capsule is not involved, it is impossible to distinguish, during life, a lesion limited to the lenticular ganglion from one confined to the caudated ganglion; and * The ventricular and extraventricular portions of the corpus striatum are now known as the caudated nucleus or ganglion, and the lenticular nucleus or ganglion. 48 INTRACRANIAL DISEASES. lesions of the thalamus opticus generally confound themselves clinically with those produced in the two compartments of the corpus striatum. 3. The symptoms which accompany lesions of these ganglia are those of common cerebral hemiplegia. This form of cerebral hemiplegia may be called central to distinguish it from cortical central hemiplegia. 4. Paralysis dependent upon lesions of these ganglia is gener- ally of motion only ; to which, however, disturbances of sensa- tion such as belong to central hemiansesthesia are sometimes added. 5. Hemiplegia arising from lesions confined strictly to these ganglia, is generally transitory, passing, lightly marked, and, in any case, is at first comparatively benign. This arises, doubtless, from the fact that these ganglia are scarcely ever affected in their totality. 6. If the internal capsule be involved, whether the grey sub- stance of the ganglia be implicated or not, the hemiplegia is of a very marked and persistent character. Thus, even w T hen very circumscribed, and especially when seated low down by the side of the peduncle, these lesions produce a motor pa- ralysis almost necessarily accompanied by late contractions ; a symptom of bad augury in these cases, because as a rule it in- dicates that the paralysis will be permanent. 7. If the lesion occupies any part of the anterior two-thirds of the capsule, that is, the region where the white tract separates the anterior extremity of the lenticular ganglion from the head of the caudated ganglion, and which belongs to the field of the lenticulo- striated artery, the paralysis will be exclusively that of motion; there will be no durable trouble of sensation. 8. But, on the contrary, if the lesion should extend to the posterior third of the capsule, in that region where it passes be- tween the posterior extremity of the lenticular ganglion and the thalamus opticus, the presence of cerebral hemianesthesia would be almost certain. 9. Most frequently the lesion extends to several parts, and paralysis of sensation will be accompanied with a more or less marked motor hemiplegia. LESIONS OF THE BASAL GANGLIA. 49 10. But it may happen that cerebral hemianesthesia will occur alone, at least as a permanent phenomenon ; as, for example, in those cases where the most distant parts, the most posterior portion of the internal capsule, would alone be definitely altered. 11. The above observations are based upon truly destructive lesions of the internal capsule, such as lacerations or necrosis, producing irreparable loss of substance. But the internal cap- sule may be only indirectly involved, as where one of the grey ganglia, in case of interstitial haemorrhage, may be so distended as to compress the nerve-fibres that compose the internal cap- sule, and so suspend their functions. In this case the paralysis would always be temporary, unless the compression was the result of a tumor. 12. The distinction just made should be carefully borne in mind, as the error has often been committed of attributing cer- tain symptoms to destruction of some one of the grey ganglia, as the thalmus opticus, or the corpus striatum, which were only the result of a neighboring accident, and the incidental compression of the internal capsule. 13. The thalami optici are not, as commonly supposed, the seat of common sensation, as is shown by the fact that where a hsemorrhagic lesion of the posterior tract of the thalamus opti- cus produced, in the first instance — that is, when conditions of pressure existed — sensitive and sensorial disturbances, which disturbances cease in the later stage, that is, from the date when re-absorption removes the pressure from the posterior or lenticulo-optic region of the internal capsule. 14. As concerns the region of the basal ganglia, it is the par- ticipation or non-participation of the anterior or posterior re- gions of the internal capsule which determines the situation and gives significancy to the symptoms. Nothnagel,* whose observations on the basal ganglia corre- spond with those of Charcot, adds also the following : 15. The motor hemiplegia resulting from stationary destruc- tive lesions of the corpora striata, affects constantly both ex- * " Topi^clie Diagnostik der Gehirnkrankheiten; eine klinische Studie," Ber- lin, 1879. 50 INTRACRANIAL DISEASES. tremities of one side, and the inferior branch of the facial nerve. Usually, also, the muscles of the trunk are rendered paretic. The hypoglossal nerve is either not at all, or only in the beginning affected, and seldom permanently. It is rarely the case that the extremities or the facial nerve are separately involved. 16. When hemianesthesia is an accompaniment of corpus striatum hemiplegia, it is sometimes characterized by the fact that, along with the cutaneous anaesthesia the nerves of special sense — sight, hearing, taste, and smell — on the corresponding side are affected ; but this is not the general rule, as the con- dition is usually confined to the skin. 17. The existence of hemianesthesia indicates the implica- tion of the most posterior part of the internal capsule, with the contiguous part of the corona radiata; nevertheless, lesions may exist in the posterior part of the internal capsule, between the lenticular nucleus and the optic thalamus, without giving rise to anaesthesia. 18. In most cases, the hemiplegia and the hemianesthesia exist together ; it is only occasionally that the hemiplegia dis- appears and the anaesthesia remains. 19. When the posterior portion of the internal capsule is in- volved, disturbances of a vaso-motor character occasionally occur in the paralyzed parts, such as increased temperature, redness, etc. 20. Although hemichorea frequently occurs in conjunction with hemianesthesia, its relations to the corpus striatum can- not at present be accurately determined. 21. Thalamic lesions cannot give rise to motor paralysis. On the contrary, when paralysis exists we must suppose other parts to be involved, even if the optic thalamus should be the principal seat of the lesion. 22. The same is also true of sensory paralysis. We are not warranted in diagnosticating the existence of a lesion of the optic thalamus, even though the relations which exist between injuries of the part of the internal capsule near the thalamus and sensibility, are such as to lead us to conclude that the lesion is situated near the thalamus, or in it, in such a manner LESIONS OF THE BASAL GANGLIA. . 51 that the internal capsule is also implicated. This is true, also, of the vaso-motor tracts. 23. Crossed amhlyopia or homonyomous hemiopia may occur through lesion of the posterior third of the optic thalamus, but which of the two conditions exist in these cases cannot, at present, be determined with certainty. Such visual disturb- ances, however, do not indicate the existence of thalamic lesions with any degree of positiveness, as they may occur with other localized lesions of the brain, such as those of the occipi- tal lobes, the optic tracts, and the corpora quadrigemina. 24. Such irritative motor disturbances as hemichorea, athe- tosis, and unilateral tremor, may possibly be due to lesions of the optic thalamus ; but even if the fact were definitely estab- lished, they would be of very little diagnostic value, as they may also occur in lesions of other parts. 25. It is also possible that disturbances of the muscular sense, and disorders of psycho-motor reflex actions, are indica- tions of thalamic lesions ; but further observations and investi- gations are necessary to settle these points. 26. A lesion of the optic thalamus may, perhaps, under the most favorable combination of circumstances, be diagnosticated, provided the conditions mentioned under the last three sec- tions be present, but even then there would be more or less un- certainty about it. 27. The symptoms resulting from lesions of the tubercula quadrigemina are sometimes hardly noticeable, and at others exceedingly ambiguous ; so much so, in fact, as to render the diagnosis of diseases of these organs very difficult and uncertain. 28. Lesions of the nates are generally, but not always, accom- panied with diminution of the sense of sight, or even blind- ness. This symptom, however, is too ambiguous to be neces- sarily referred to lesion of the corpora quadrigemina, unless it is of sudden development, and associated with engorged pa- pilla, optic neuritis, and optic atrophy. 29. Lesions of the testes are usually accompanied with para- lysis or paresis of the oculo-motor nerve, but neither the pres- ence or the absence of this symptom is an unfailing guide for diagnosis. 52 INTRACRANIAL DISEASES. 30. When a unilateral paralysis of the oculo-motorius arises from a bilateral lesion, and is unaccompanied with alternate paralysis of the extremities, the corpora quadrigemina are prob- ably the organs involved. 31. Conversely, bilateral implication of the motores oculorum appears to be sometimes due to a unilateral lesion of the cor- pora quadrigemina 32. Lesions of the nates appear to arrest the reactions of the pupil ; though nothing exact is known on this subject. 33. It appears that disturbances of equilibrium and coordi- nation may result from lesions of the testes, similar to those arising from disease of the cerebellum. LESIONS OF THE CEREBELLUM. 53 CHAPTER III. LESIONS OF THE CEREBELLUM. Owing to the great diversity and variableness of the symp- toms, the diagnosis of cerebellar diseases is extremely difficult and uncertain. Moreover, they may exist in a latent form, and therefore be incapable of being diagnosticated. This is particularly the case where the lesions are of a destructive character, and are confined to one hemisphere; whereas, if only a single lobe is involved, or the lesions are of slight ex- tent, the symptoms, though generally more characteristic, are at the same time more variable and more complicated. This will appear if we pass in review the symptoms belonging to the different regions of the organ. Paralysis of the opposite arm and leg is frequently met with in lesions of the lateral hemispheres of the cerebellum, but is generally more marked in the leg than in the arm, and is also less pronounced than in the more ordinan T forms of hemi- plegia, being usually absent from the face, and not accom- panied by much diminution of sensibility. Paralysis caused by superficial cerebral lesions may also be absent from the face, but it differs from cerebellar paralysis in being more marked in the arm than in the leg. Consciousness is seldom lost in lesions of this part, unless the injur}?" is sudden and the lesion extensive. Vomiting is perhaps more frequently met with in cerebellar than in cerebral lesions; and intense par- oxysms of pain are frequently complained of, especially in the occipital region. Slight tonic contractions of the facial and ocular muscles may occur, accompanied with more or less ri- gidity of the neck and of the paralyzed limbs ; but the move- ments of the tongue are not generally interfered with, nor is there usually any difficulty in articulation or deglutition. 54 INTRACRANIAL DISEASES. If the superior peduncles, which are in close anatomical re- lation with the corpora quadrigemina, are affected by the lesion, amaurosis may set in; but there is generally no mental disturbance or impairment, though there may be slight intel- lectual torpor or dulness, and perhaps some drowsiness. But the symptoms resulting from lesions in one lateral hemisphere of the cerebellum are often much less pronounced, there being perhaps no paralysis, but simply a paretic con- dition, characterized by an unsteadiness or incoordination of movement, or what is called a titubating gait. This muscular weakness, which is generally more marked in the legs than in the arms, is sometimes so great as to render the patient quite unable to walk or even to stand. Lesions of the middle lobe of the cerebellum are less fre- quently attended w T ith manifest symptoms than are those of the lateral hemispheres. Bastion* says "that in almost all the cases of disease of the cerebellum in which excitation of the genital functions has been noted, the lesion has been situated in the middle lobe. Symptoms of this type have, indeed, been observed in about one-third of the recorded cases of disease of the median lobe of the cerebellum. In both sexes there has appeared to be an increase in sexual desires, and in male patients there have been frequent erections, with or without seminal emissions. Such symptoms in connection with lesions of this part have all the more significance because they do not present themselves where only the lateral lobes of the cere- bellum are involved. With the limitation thus indicated, therefore, there would appear to be some foundation for the old phrenulogical doctrine as to the function of the cerebellum." If the lesion of the middle lobe be a large one, vision may be more or less impaired, in consequence of the irritation or pressure exerted by it upon the corpora quadrigemina through the superior cerebellar peduncles. Lesions of the middle peduncle of the cerebellum give rise to symptoms similar to those produced in animals by section of its fibres, namely, rotation in one uniform direction — i. e., * "Paralysis from Brain Disease," 1875. LESIONS OF THE CEREBELLUM. 55 from the sound towards the injured side — about the longitu- dinal axis of the body, with a deviation downwards and in- wards of the eye on the injured side, whilst that of the sound side is directed upwards and outwards. Vulpian explains these phenomena by supposing that there is in these cases an interruption of motor power from the muscles of the side of the body corresponding with the lesion, thus unbalancing the action of those of the opposite side. In order to understand the effect of lesions existing either here, or where the root of the peduncle is implicated in the substance of the lateral hemisphere of the cerebellum, it should be remembered that the fibres of the middle cerebellar pedun- cles decussate in the pons Varolii. Hence, if any paralysis is produced, it should be sought for on the same, and not on the opposite side of the body. The following summary and estimate of cerebellar symp- toms is based chiefly upon the observations of Nothnagel.* 1. The most characteristic symptoms of cerebellar affections are incoordination, a titubating gait, and intense vertigo. These symptoms are, however, met with in other brain dis- eases, and are therefore not pathognomonic. The diagnosis of cerebellar disease can only be made by taking into considera- tion all the phenomena, positive and negative. 2. Incoordination and vertigo, when dependent on cere- bellar disease, always denote implication of the middle lobe, either by its being the primary seat of the lesion, or by its functions being disturbed through pressure. 3. These symptoms are so important, that whatever other grounds we may have for suspecting a lesion of the cerebellum, we cannot, in their absence, diagnosticate cerebellar disease with any degree of certainty. 4. As vomiting is frequently an accompaniment of other intracranial affections, is lacking in all cases of distinctive lesions of the cerebellum, and is not always present in those due to pressure from contiguous organs, it is not of itself con- clusive evidence of cerebellar disease, though when constant * Op. cit. 56 INTRACRANIAL DISEASES. and severe it may assist in the diagnosis. The same is also true of loss or impairment of sight, and other interocular symptoms. 5. Anarthia, headache, and other, even the most diverse, derangements of the motor and sensory cerebral and spinal nerves may exist in conjunction with cerebellar disease, but as they are for the most part due only to pressure, they are of no diagnostic importance, and may even lead to errors of diagnosis. Occasionally, however, a symptom of this kind may be of some importance, as where paralysis of the whole of the right facial nerve points to the existence of a tumor on the corresponding side, and decided hemiplegia as having its seat on the basilar surface. 6. The only lesions of the crus cerebelli which are of diag- nostic value, are those of an irritative character, and then only when the connection of the crus with the cerebellum is not in- terfered with. The symptoms referred to, consist in forced po- sitions of the trunk, head, and eyes, rotations about the long axis of the body, and vertigo, with the inclination to fall to one side. 7. Of these symptoms, the turning of the body (which may take place in either direction) and the movement of the head and eyes, are the only ones which are characteristic of crus- cerebellar disease, and are wholly confined to lesions of the middle peduncle. LESIONS OF THE CEREBROSPINAL ISTHMUS. 57 CHAPTER IV. LESIONS OF THE CEREBKO-SPINAL ISTHMUS. We have already stated that the most marked pathological distinction between diseases of the cerebrum and those of the spinal cord, is, that while the cord is distinguished by the ex- tensive existence in it of those lesions denominated systemic, the cerebrum is characterized by no such mode of pathologi- cal alteration. On the contrary, no systemic lesion is at pres- ent known to exist in the brain. The contrast will be still greater, if we take into consideration the fact pointed out by Charcot,* that the most common anatomical cause of disease in the encephalon, haemorrhage by vascular rupture, whether resulting from the alteration known under the name of miliary aneurism, from softening consecutive to arterial narrowing, or from thrombosis or embolism, is something which in the spinal cord is almost unknown. Now, the various regions of the isthmus, by which is meant the crura cerebri, the pons Varolii, and the medulla oblongata, constitute, so to speak, the transition between the cerebrum and the spinal cord; for in the former, and more particularly in the medulla oblongata, are found systemic lesions similar to those seen in the cord, and on the other hand, a considerable number of haemorrhages and softenings are found resulting from vascular lesions, more especially in the pons, the pathol- ogy of which approaches more nearly that of the cerebrum. Bastion says that some lesions of the crus cerebri can be diagnosed with the greatest certainty. Nothnagel, on the contrar3 r , asserts that it cannot be affirmed with absolute cer- tainty that lesions of these parts give rise to well-marked * Op. cit. 58 INTRACRANIAL DISEASES. symptoms. The truth appears to be, however, that when the lesion involves only the upper and outer part of the crus, that is, the part next to the cerebral hemispheres, the symptoms so closely resemble those met with in lesions of the optic thala- mus, that no sufficient distinction can be made between them ; but if the lesion should implicate the inner and inferior part of the crus, that is, the part near the pons, or if there should be a larger lesion, involving both the pons and the contiguous parts of the crus, so that the motor-oculi nerve on the same side becomes paralyzed simultaneously with the occurrence of crossed hemiplegia, the diagnosis would be neither difficult nor uncertain. The symptoms produced by lesions in the lower and inner part of the crus cerebri, are those caused by a peculiar form of what is known as alternate paralysis. The motor-oculi nerve is paralyzed on the side of the lesion, and as a consequence, all the muscles of the eyeball are paralyzed, except the exter- nal rectus and the superior oblique, so that it is impossible to move the eye, except slightly in an outward and upward di- rection. The paralysis of this nerve also causes a partial clos- ure of the eye on the same side from dropping of the upper lid, dilatation and sluggishness of the pupil, external strabis- mus, and double vision. At the same time there is a hemi- plegic condition of the opposite side of the face and body, in consequence of wmich the tongue deviates towards the para- lyzed side; articulation becomes generally more or less im- paired; and sensibility on the paralyzed side is usually greatly diminished, especially in the limbs, the temperature of which is sometimes considerably elevated. Similar symptoms to the above are produced by a lesion in one lateral half of the pons Varolii, especially in the lower part of it, where the paralysis of the face exists on the side of the brain lesion, and a more or less complete motor and sensory paralysis of the trunk and limbs on the opposite side. A lesion in the upper part of one lateral half of the pons produces the same general effect as in the lower part, except that the facial paralysis exists on the same side of the body as that of the paralyzed limbs. In both cases the paralysis is generally well- LESIONS OP THE CEREBRO-SPINAL ISTHMUS. 59 marked, involving not only the superficial muscles of the face, but those concerned in articulation and deglutition. Sensi- bility is generally impaired in proportion as the lesion ap- proaches or involves the side of the pons. Occasionally we have unilateral hyperesthesia instead of anaesthesia; and either condition may exist with or without painful or other abnormal sensations in the paralyzed limbs. If the lesion involve the lateral part of the pons, similar symptoms may also present themselves in the face, in consequence of the im- plication of the trigeminus, together with paresis of the muscles of mastication, provided the motor division is also injured. When the central parts of the pons are involved, if the lesions be extensive, the most profound apoplectic symptoms may appear, and if suddenly produced, death may speedily ensue. Under these circumstances, if life be prolonged for several hours or days, the temperature gradually rises on both sides of the body, until at the time of death it often reaches a maximum of 109° or 110° F. Less extensive lesions of the central parts of the pons may also cause insensibility and coma, which, however, may after- wards gradually disappear. We then find a condition of general paralysis existing, both sides of the body being pretty equally affected. In these cases, if there is diminished or per- verted insensibility, and at the same time well-marked facial paralysis, together with difficulty in swallowing and impaired articulation, the latter not aphasic, we may safely conclude that the symptoms are caused by a central lesion of the pons Varolii. Slight or irritative lesions of the pons, instead of producing apoplectic symptoms, may in the beginning give rise to epi- leptiform convulsions, especially if the injury occurs suddenly. In other cases, however, such lesions neither produce convul- sions nor loss of consciousness. If they irritate the fourth ventricle we may have diabetes mellitus, and if the lower part of the ventricle be implicated, as may happen if the medulla oblongata instead of the pons should be the seat of the in- jury, it may either take the form of diabetes insipidus, or of albuminuria. 60 INTRACRANIAL DISEASES. Other symptoms also occur in lesions of the pons, such as early rigidity of the paralyzed limbs, trismus, or rigidity of some of the cervical muscles, conjugated deviation of the eyes, and a peculiar mental condition, known as emotional weakness, apparently of a hysterical character. Perhaps, as suggested by Althaus,* the polyuria, so frequently associated with hys- teria, and which, as we have just seen, may arise from irrita- tion of the lower part of the fourth ventricle, is a concomitant symptom of the same condition. Lesions of the medulla oblongata, in addition to the usual symptoms of paralysis, give rise to the phenomena due to im- plication of nerve-roots, such as respiratory and circulatory disturbances, aphonia, dysphagia, anaesthesia, dysesthesia, etc. Their diagnostic value, according to the estimate placed upon them by Nothnagel and other leading authorities, is given in the following summary: 1. Lesions of the crura cerebri may produce motor, sensory, and vaso-motor symptoms, but the phenomena are not usually sufficiently distinctive to serve as diagnostic marks of disease of the crura cerebri, as they may also occur in lesions of the upper part of the pons, or of the corpus striatum. 2. The paralysis resulting from lesions of the crura cerebri generally involves, not only the nerve-tracts of the extremities of the opposite side, but also of the facial, hypoglossal, and tri- geminus of the opposite side. 3. A lesion of the crus can. only be diagnosticated with certainty, when a paralysis of the oculo-motor nerve of the same side occurs suddenly, and simultaneously with paralysis of the nerves of the upper and lower extremities, or the facial nerve of the opposite side. 4. Motor and sensory disturbances of single nerve-tracts, and abnormalities in the excretion of urine, are of no diag- nostic value in lesions of the crus cerebri. 5. Stationary destructive lesions of the pons Varolii derange the functions of the motor, sensor} T , and vaso-motor nerves of the extremities, and the fifth, sixth, seventh, twelfth, and pos- sibly the eighth and eleventh cranial nerves, the number of * " Diseases of the Nervous System," 1878. LESIONS OF THE CEREBRO-SPINAL ISTHMUS. 61 nerves involved varying according to the extent and exact situation of the lesion. 6. The same group of symptoms are often met with in lesions of the pons that occur in those of the cerebrum, and cannot be distinguished from them unless they occur in con- junction with difficulties of articulation, and even inability to speak, when they may indicate with some degree of probability a lesion of the pons. 7. The only very certain indication of the existence of an intrapontine lesion, is the sudden onset of a well-marked form of cross-paralysis, which involves the motor and sensory nerves of the extremities on the side opposite to that of the lesion, and the trigeminus, abducens, facial, and hypoglossus, on the side corresponding to that of the lesion. 8. So far as relates to the implication of special nerves, it may be said that, if the abducens be paralyzed, and the other symptoms indicate at the same time the existence of an intra- cranial lesion, the latter will almost certainly be located in the pons Varolii. 9. Disturbances of respiration and of the circulation, diffi- culty of deglutition, and spasm of individual muscles, are only of importance, as aids to diagnosis in diseases of the pons, when accompanied by more characteristic symptoms. 10. Lesions of the medulla oblongata frequently produce no other symptoms than those due to paralysis of the extremities, and hence cannot be diagnosticated with any degree of cer- tainty ; but when the paralysis is associated with aphonia, and with respiratory and circulatory disturbances, they may gener- ally be safely referred to injury of the medulla, since these symptoms are not observed among those of destroying lesions of other parts of the brain. 11. If any one of the symptoms which may arise from im- plication of the nerve-roots of the medulla be wanting, it not only aids us in more exactly locating the seat of the lesion, but also helps us to distinguish the lesion from that which produces progressive bulbar paralysis.* * See Nervous Diseases, p. 168. G2 INTRACRANIAL DISEASES. PART II. INTRACRANIAL DISEASES. SECTION I. CEREBRAL AFFECTIONS. CHAPTER I. ANEMIA OF THE BEAIN. That the quantity of blood within the cranial cavity is al- ways the same, as was formerly taught by the Edinburgh pro- fessors, is no longer an open question, having been fully settled in the negative by recent physiological experiments, as well as by abundant clinical and necroscopical evidence. Even were the brain entirely incompressible, which is not the case, varia- tions in the quantity of blood circulating in it is rendered possible, not only by the vessels which pass between the two surfaces of the skull, but especially by the changes which take place in the quantity of the cerebro-spinal fluid, which is in an inverse ratio to the amount of blood contained in the cerebro- spinal blood-vessels. For example, in cerebral hyperemia, where the vessels of the brain are found loaded with blood, the cerebro-spinal fluid is almost entirely absent; while, on the other hand, it is greatly increased in hydrocephalus, where the brain presents an anaemic or exsanguine appearance. More- over, Donders, who watched the cerebral circulation through a AN.EMIA OF THE BRAIN. 63 glass crystal inserted in an opening made in the skull of ani- mals, saw marked variations in the size of the blood-vessels of the pia mater, which became dilated at every expiration. There are three distinct forms of cerebral anaemia, namely, (1) hypsemia, which consists in a diminished supply of blood circulating in the vessels of the brain ; (2) hydremia, in which the circulatory fluid is deficient in haeinatin, the blood being too watery ; and (3) hypsemia et hydremia, in w T hich both con- ditions exist. The first may be referred to whatever cause im- pedes the flow of blood to the brain, to contraction of the cere- bral vessels by spasm or otherwise, or to any other condition whereby the intracranial space is lessened ; the second, to the various causes which produce impoverishment of the blood, and give rise to general anaemia ; and the third, to sanguine- ous losses, which, when excessive, always produce both paucity and poverty of the circulating fluid. Symptoms. — The symptoms vary considerably, according as the anaemia is gradually or suddenly produced. When it occurs gradually, the symptoms at first are similar to those of the opposite condition of hyperaemia, namely, great excitement of the cerebral functions, headache, flashes of light before the eyes, confusion of sight, humming in the ears, vertigo, loss of memory, and sometimes convulsions. At a later period, if the disease goes on. unchecked, symptoms of paralysis may super- vene. This is particular^ the case with infants and children, in whom a protracted diarrhoea is apt to produce a state of general and cerebral anaemia. The symptoms in these cases so closely resemble those of acute hydrocephalus, as to have had the name of " hydrocephaloid " applied to them. In ad- dition to the symptoms above mentioned, the stage of excite- ment is marked by a flushed face, hot skin, frequent pulse, and a contracted pupil. This stage is soon succeeded by that of prostration and stupor. The face is pale, the pupils are dilated and fixed, and the special senses are lost ; complete in- sensibility supervenes, the respiration becomes embarrassed, the pulse vanishes, and, unless the condition is quickly re- lieved, the case soon ends in death. In the aged, however, the symptoms are somewhat different. 64 INTRACRANIAL DISEASES. Iii these cases there is generally a narrowing of the cerebral arteries, in consequence of atheromatous degeneration of the inner coat ; and the circulation is still further impeded by the rigidity of the vascular walls ; for liquids are propelled more easily through elastic than through inelastic tubes. Another impediment in these cases is cardiac weakness, which is usu- ally a marked symptom in advanced life. As a consequence, such subjects suffer greatly from vertigo, the slightest emotion or muscular effort being sufficient, in many cases, to bring it on. In fact, it is no uncommon thing for attacks of vertigo to appear and disappear several times a clay without any appar- ent cause. If standing, the patient suddenly becomes blind, staggers, and, if not supported, falls to the ground. The hori- zontal position soon restores the brain to its normal condition, but, owing to the debility of the heart, the least exertion again disturbs the circulation, and the attack is liable at any time to be renewed. During the stage of excitement, which is not wholly wanting even in the aged, the temper is more or less irritable, the special senses are perverted, and there is more or less intolerance of light and noise. This stage, which is generally short and variable, is followed by great depres- sion. The speech becomes slow, the mind apathetic, and, in many instances, the patient gradually sinks into a state of se- nile dementia. Generally the most marked symptom in these cases is drowsiness — a drowsiness, however, from which the patient may be easily aroused, but only to relapse again into sleep, sometimes alternating with a low delirium. As before stated, the muscular system is greatly enfeebled, and the heart's action is weak, irregular, and easily disturbed. When cerebral anaemia sets in suddenly, as in flooding, traumatic haemorrhages, and other rapid losses of blood, the symptoms presented are those of syncope, namely : rapid loss of consciousness, of the senses, and of voluntary motion, accom- panied with a retarded pulse and respiration, and frequently with slight convulsions. At first everything turns black; vertigo, tinnitus aurium, faintness, sickness of the stomach, and vomiting, rapidly supervene; the surface becomes cold and pale, the pulse small and scarcely perceptible, and the ANJEMIA OF THE BRAIN. Q5 respiration slow and irregular ; insensibility, trembling, and convulsions frequently follow ; and these are succeeded in some cases by delirium and death. Acute attacks of cerebral anaemia do not, however, always depend upon sudden loss of blood, but may arise from shock or fright. This is called vaso-motor ansemia, and is of different degrees of intensity. When slight, it simply causes pallor, more particularly of the face, with perhaps some chilliness of the skin. Severe attacks excite such an intense spasm of the cerebral vessels as to entirely empty the arterioles of blood, inducing vertigo, fainting, insensibility, and, in some cases, sudden death. In most cases, however, relaxation of the cere- bral vessels quickly follows, and is succeeded by the opposite condition of hyperemia, attended by excitement, and in some instances by delirium — symptoms which gradually disappear as the cerebral circulation becomes equalized. Owing to the close vaso-motor connection of the blood-vessels of the posterior lobes with those of the abdominal viscera, anaemia of these lobes are sometimes accompanied with dis- turbances of the abdominal circulation sufficient to give rise to congestion of the liver, dyspepsia, constipation, disease of the uterus and of other abdominal organs; hence the frequent association of this form of anaemia with melancholy and hypo- chondria, which often appear to be of abdominal, rather than of cerebral origin. Instead of simple paresis, there may be actual paralysis, and this may be either partial or general. Several cases are on record where hemiplegia was caused by venesection, the anaemia having been mistaken for cerebral congestion. This mistake is especially liable to be made in the case of young children suffering from exhausting diarrhoea, on account of the similarity of the symptoms to those of tubercular menin- gitis, as before mentioned. Causes. — Of the various causes which give rise to cerebral anaemia, none is more common, or more potent, than the copi- ous and protracted bleeding frequently met with in cases of flooding after childbirth, or in connection with miscarriages and abortions, and in the various forms of uterine haemor- 5 GG INTRACRANIAL DISEASES. rhage. Excessive menstruation, also, as well as venesection, hemorrhoidal fluxes, and even nose-bleed, occasionally produce it. Injury of large blood-vessels, the rupture of aneurisms, and the ligature of the carotid artery, have all caused it; and in a few cases in which both carotids have been tied, death has resulted from the cerebral anaemia thus induced. Other debilitating discharges, such as chronic diarrhoea and dysentery, overlactation, long-continued suppuration, and all diseases which impoverish the blood, such as cancer, tubercu- losis, chronic nephritis, lead and mercurial poisoning, etc., are capable of producing it. Insufficient nutrition may likewise so impair the quality of the blood as to have a similar effect. Cerebral anaemia may also result from any impediment to the circulation which prevents the cerebral vessels from receiv- ing an adequate supply of blood, as in cases where there is aortic obstruction or mitral regurgitation; or in fatty degener- ation of the heart and myocarditis, where the organ is too feeble to carry sufficient blood to the brain ; also in those cases where the intracranial space is much encroached upon by tumors, extravasations of blood, or the effusion of serum. The sudden diversion of large quantities of blood from the arterial to the venous system, as in tapping for ascites, or to remote organs or parts, as in the applications of Jounod's cup- ping boot, will sometimes be followed by this condition ; at least syncope is not an uncommon result of such operations. Cerebral anaemia is sometimes induced by the injudicious use of certain medicines, such as arsenic, calomel, tobacco, tar- tar emetic, oxide of zinc, and the various bromides. Allopath- ists frequently take advantage of this property of the bromides to produce artificial sleep, especially in cases where the in- somnia is caused by cerebral hyperemia. The same property, of course, renders these remedies homoeopathic to cerebral anem ia. Anemia of the brain may be produced by certain mental emotions, especially fright, the shock of which is sometimes sufficient to cause syncope, and even death. How often people faint from the most trifling surgical operations, such as vacci- nation. I once witnessed a case of this kind in a strong, AN.EMIA OF THE BRAIN. 67 robust farmer, who fainted entirely away before a particle of blood was drawn. The passage of even a weak galvanic current through the brain often causes cardiac depression and syncope, and may so paralyze the action of the heart as to prove fatal. Hammond* says that excessive mental exertion may pro- duce cerebral anaemia. We know that this is a very common cause of cerebral congestion, but anaemia of the brain can only arise from it as a secondary effect of nervous exhaustion. I have myself witnessed it in this class of cases, but onty in con- nection with general anaemia and neurasthenia. Diagnosis. — Great care is necessary in some cases, espe- cially with children, to distinguish cerebral ansemia from cerebral congestion. When caused by debilitating losses, and especially when associated with general ansemia, or with an impaired state of the assimilative functions, the history of the case, together with the fact that the symptoms of cerebal anae- mia diminish or disappear when the patient is in the recum- bent position, will generally serve to distinguish it from hyperaemia of the brain, with which alone it is liable to be confounded. In other cases it may be necessary to atten- tively consider all the characteristic symptoms of the disease. Thus, not only are the pain and vertigo increased by assum- ing the erect position, but the former, instead of being general, is usually limited to a particular part of the head; the face is pale, the skin cold, the pulse weak and rapid, and the pupils dilated; the ophthalmoscope exhibits retinal anaemia, and the patient, instead of being wakeful, is often overcome by drowsi- ness. Moreover, exertion and lowering treatment always in- crease, whilst the contrary influences mitigate, the disorder. Prognosis. — However induced, cerebral anaemia is always attended with great danger to life, especially in the case of children, though when recognized and taken in hand early the disease, even in its acute form, will generally yield to ap- propriate treatment. But when there is such a sudden and profuse loss of blood as to render the patient pulseless, or * " Diseases of the Brain," Seventh ed., 1881. 68 INTRACRANIAL DISEASES. cause convulsions, recovery is always a matter of considerable doubt. Morbid Anatomy. — The veins of the pia mater are found on post-mortem examination to be nearly empty, and the small quantity of blood contained in them, and in the sinuses of the dura mater, is thin and watery/ The grey matter of the brain is so pale as to be nearly white, and the white substance has an abnormally white, or milky appearance, owing to the absence of the ordinary blood-points seen on section. The meshes of the pia mater contain an unusual quantity of serum, but the ventricles of the brain are generally empty. Pathology. — That the symptoms of cerebral anaemia are caused in most cases by an insufficient supply of blood to the brain, and in others by an altered or impoverished state of that fluid, has been proven by the independent investigations of many observers. Jacobi, Fleming, and Hammond, by com- pressing the carotid arteries, and thereby cutting off the usual supply of blood to the brain, produced all the characteristic symptoms of the disease, including convulsions. Nothnagel, by irritating the peripheral nerves, produced similar phe- nomena in animals by reflex action. Kussmaul and Tenner proved that, while hyperemia of the brain does not excite con- vulsions, faradization of the cervical sympathetic may cause not only dilatation of the pupil, but anaemia of the retina and convulsions, and that, too, notwithstanding the fact that only a portion of the vaso-motor nerves of the brain pass through the cervical sympathetic. They showed, also, that both cere- bral anaemia and convulsions may be produced by simply suppressing the breathing, and thereby depriving the blood of oxygen. We have seen that many cases of cerebral anaemia are due to an impoverished condition of the blood. In these cases there is a deficiency of the red corpuscles; and as these are the carriers of oxygen, the effect on the nutrition of the brain is the same as though the quantity of blood sent to that organ was below the normal standard; the only difference being, that the symptoms of cerebral anaemia are developed in a gradual instead of a sudden manner. ANEMIA OF THE BRAIN. ij\) Treatment. — In simple syncope, all that is generally re- quisite in the way of treatment is, to place the patient, as quickly as possible, in a horizontal or recumbent position, so as to favor a return of blood to the brain. If, however, the fainting is of frequent occurrence, it will be found to depend upon general anaemia, or some other affection, against which the treatment will need to be specially directed. Thus, an ex- hausting diarrhoea, dysentery, or other acute or chronic dis- charge, will not only require to be promptly arrested, but the quality of the blood should be improved by the use of such articles of diet as are best calculated to restore the lost elements, more particularly the various forms of animal food, such as beef- tea, milk, eggs, and the different kinds of meat. Even in these cases the recumbent position should be enjoined, especially if the heart's impulse is much weakened; nor should the patient be allowed to assume the erect position, even for the evacua- tion of the bladder and bowels, so long as any considerable liability to syncope exists. We have the testimony of Hammond, that a weak galvanic current is decidedly beneficial in these cases. This result is somewhat puzzling to this author, as the primary galvanic current applied to the brain or sympathetic nerve contracts the cerebral blood-vessels, instead of dilating them; just what it should do if it acts homoeopathicall} 7 , and hence, although he does not comprehend its action, he very properly advises that the tension should be quite low, and that the current should only be passed for a few seconds at a time. The Nitrite of Amyl is a good palliative remedy in the treat- ment of cerebral anaemia, especially in acute cases, but as it causes dilatation, instead of contraction, of the cerebral vessels, it will need to be used low. A few drops, inhaled from a handkerchief, will, as a general rule, quickly dissipate the most alarming attack of syncope, especially if it be the result of a feeble action of the heart. This remedy is to be preferred, in most cases, to any other form of stimulant, not only on ac- count of its promptness of action, but because it may be re- peated as often as may be necessary without any deleterious result. 70 INTRACRANIAL DISEASES. General Indications. — 1, Calc., Carb. veg., China, Ferr., Helon., Hydras.; 2, Arn., Ars., Camph., Puis., Scilla, Staph., Sulph.; 3, Bell., Bry., Cin., Con., Graph., Ign., Lach., Lycop., Merc, Natr., Natr. mur., Nux v., Phos., Phos. ac, Rhus,' Sep., Sil., Verat. Vital Fluids. — When caused by loss of: 1, Calc., Chin., Ferr., Nux v.; 2, Carb. veg., Cin., Helon., Hydras., Phos. ac, Staph., Sulph. Convulsions. — Ars., Bell., Calc. c, Camph., Cina, Con., Igna., Lycop., Nux v., Puis., Sulph., Verat. Delirium. — Ars., Bell., Bry., Igna., Lach., Lycop., Phos. ac, Scilla, Sepia, Sulph., Verat. Vertigo. — Ars., Baryta c, Bell., Carb. veg., Graph., Lycop., Nux v., Phos. ac, Puis., Sepia, Sil., Sulph., Verat. Special Indications. — Arsenicum. — Great prostration, with rapid sinking of the vital forces; pale, chlorotic colored face; violent headache, noises in the ears, dimness of vision, vanishing of the senses, impaired memory; great anguish, restlessness and fear of death; vertigo, syncope, delirium, chilliness. Espe- cially suited to cases aggravated by the injudicious use of Ferrum. Camphor. — Violent throbbing headache ; pale, cold skin ; vanishing of the senses; great embarrassment of the respiration and circulation; spasms and convulsions. Hahnemann says of this remedy : " Vertigo, loss of consciousness, and coldness of the body, appear to be primary symptoms of a dose of Cam- phor, and point to a diminished afflux of the blood to those parts which are distant from the heart." Camphor is best adapted to those cases of cerebral anaemia which take the form of syncope, especially when caused by haemorrhage, diarrhoea, cholera, etc. China. — Cerebral anaemia, caused by the excessive loss of animal fluids, as in haemorrhage, spermatorrhoea, diarrhoea, leucorrhoea, overlactation, etc. ; headache, especially in the morning; ringing in the ears; obscuration of sight ; pale, cold face; coldness of the extremities; great debility, with tingling and trembling, or twitching of the muscles and limbs ; faint- ness, which is relieved by lying down ; vertigo, especially on raising the head ; insomnia. AN.EMIA OF THE BRAIN. 71 Cina. — Paleness of the face, especially around the nose and mouth ; transient dizziness, with obscuration of sight ; faint- ness, relieved by lying down ; spasms and convulsions ; para- lytic lameness. In children, especially when complicated by verminous irritation. Ferrum. — Hydrsemia, with great paleness of the face, lips, and mucous membrane of the mouth ; noises in the head ; bellows-sound of the heart ; muscles flabby and weak ; easily exhausted from slight exertion ; oedema of the face and limbs ; hammering headache; shortness of breath. This remedy is more particularly adapted to chlorotic females, and to cases resulting from passive haemorrhages. Ipecacuanha. — Pale face, with blue margins around the e} T es; cold hands and feet ; nausea, with or without vomiting ; vio- lent headache, excited and aggravated by stooping ; vertigo, with temporary loss of consciousness ; convulsive movements of the limbs ; heaviness of the head, with great drowsiness ; restlessness and sleeplessness at night. This remedy is best adapted to children, and to cases resulting from the loss of ani- mal fluids. Katrum mur. — Pale, sallow complexion; great depression of spirits ; circulation excited by every movement of the body ; pressure and swelling of the stomach ; excessive weakness and prostration ; hard, irregular and insufficient stools ; great drowsiness, especially during the daytime. Cerebral anaemia, resulting from the loss of animal fluids, or from onanism. Natrum sulph. — Great drowsiness, languor and prostration ; watery condition of the blood ; constant chilliness, especially in the evening ; trembling of the body, with jerking in the limbs. More particularly adapted to what is called the hydro- genoid constitution. JSfux vom. — Nausea and vomiting, with frequent eructations of sour-smelling fluids or food; anorexia, with loathing of food ; anaemia, with coldness of the whole body ; drowsiness, vertigo, mental weakness, constipation, syncope, sleeplessness at night, spasms and convulsions. Especially suited to cases complicated with gastric irritation, indigestion, and consti- pation. 72 INTRACRANIAL DISEASES. Secale cor. — Cerebral ansomia, complicated with diarrhoea, metrorrhagia, spasms, and convulsions. Sulphur. — Chronic cases, occurring in scrofulous, or cold, phlegmatic constitutions, especially when other indicated reme- dies fail to produce any lasting benefit ; also, when preceded or accompanied by eruptions, or when caused by their sup- pression. Veratrum alb. — Acute cases caused by violent purging, attended with fainting fits, spasms, and convulsions, and fol- lowed or accompanied by paralytic weakness. This remedy is suited to conditions similar to those for which Secale is indi- cated, but with this difference, that while the latter is better adapted to cases arising from flooding, Veratrum is better suited to such cases as depend on losses occasioned by exces- sive alvine discharges. CEREBRAL HYPEREMIA. 73 CHAPTER II. CEREBRAL HYPEREMIA. Cerebral hyperemia, or congestion of the brain, is of two kinds, active or arterial, and passive or venous. In the former, a larger quantity of blood than usual is sent to the brain, constituting what is termed rush of blood to the head. In the latter, there is no actual increase in the amount of blood sent to the brain, but, owing to obstruction, it does not return freely through the cerebral veins, which therefore become over- charged w T ith blood, constituting what is sometimes called stag- nation of blood in the brain, or hyperemia by stasis. Symptoms. — There are two distinct classes of symptoms met with in this disease, namely, those of excitation and those of depression. The former embraces such symptoms as wake- fulness, or morbid vigilance ; pain in the head ; intolerance of light, noise and pressure ; singing or ringing in the ears ; sparks or dark specks before the eyes ; contraction of the pu- pils ; redness and heat of the face ; full and strong pulse ; throbbing of the carotids ; grating of the teeth ; restlessness at night ; vivid dreams ; jerking of the limbs ; vertigo ; convul- sions. The symptoms of depression are for the most part the reverse of these. Thus, the head feels dull and heavy; the limbs go to sleep, and have a heavy, paralytic feeling; there is great dulness of the senses; the pupils are dilated, the pulse small and frequent, and the respiration slow, irregular, or ster- torous; nausea, vomiting, and constipation are of frequent occurrence, and there is generally more or less anaesthesia and paralysis. The symptoms, however, vary greatly in different cases, both as to number and intensity. In some instances, the only 74 INTRACRANIAL DISEASES. symptom complained of is sleeplessness. This condition is per- haps the most constant of any, as sound sleep is impossible while the brain is in a state of active hyperemia, and conse- quently in an excited condition. Hence, although the patient may be greatly exhausted, and may even have lost much sleep, it is generally not until after midnight, and frequently not until near morning, that the cerebral circulation becomes suffi- ciently tranquil for the brain to sleep, and when it does, it is apt to be more or less disturbed by unpleasant dreams, so that when the patient awakes, he generally feels as tired and unre- freshed by it as though slumber had never visited his eyelids. But it is not often that the only evidence of cerebral hyper- emia is wakefulness. In most cases some other of the symptoms of excitability are superadded. Headache, especially, is almost always present, and sometimes it constitutes the most striking feature of the disease. When severe, the suffering may be so great as to unfit the patient for every kind of mental or physi- cal labor ; but in most cases it consists of a dull, aching pain, such as we w r ould expect from overdistension of an organ in- closed, as is the brain, within rigid walls. Even when no actual pain exists, there is always present a more or less un- comfortable feeling in the head, generally a sensation of ful- ness or tightness, which changes to pain whenever the patient's head assumes a dependent position, or when he en- gages in any protracted mental or physical employment. Next in frequency, generally, are derangements of the special senses. Various noises in the ears, such as singing, ringing of bells, and the different forms of tinnitus aurium, are experienced in these cases, and sometimes the sound, which is wholly sub- jective, appears to come from the occipital region. Occasion- ally, the sound appears to be of the nature of an explosion, like the report of a pistol, which so startles and deceives the patient that he sometimes imagines himself to be the object of a murderous assault. In other cases the sensation is that of something suddenly giving way within the head, and is usu- ally accompanied with a sharp, snapping sound. These cases are generally preceded or accompanied by intense vertigo and pain in the head, followed in some instances by unconscious- CEREBRAL HYPEREMIA. 75 ness, and appear to belong to what Dr. Searle styles " a new form of nervous disease." Owing to a hypersesthetic condition of the auditory nerve, the sense of hearing is often morbidly acute, so that sounds that would not attract the attention of others, not only annoy, but frequently become intolerable to the patient. Even the ticking of a clock, or the barking of a dog, may, in the excited condition of the patient's brain, render him almost frantic. This is especially apt to be the case at night, when the still- ness of the hour, the wakefulness of the patient, and the de- pendent position of the head, combine both to exalt and to pervert the already exaggerated sense of hearing, thus giving rise to a great variety of illusions and hallucinations, which the mental condition is ill fitted to bear or to correct. Of the other senses, none is more frequently disturbed than that of vision. The hypersemia of the retina and optic nerve, which are readily distinguishable by the ophthalmoscope, generally gives rise to more or less photophobia and lachry- mation, together with a variety of subjective symptoms, such as flashes of light, muscse volitantes, moving vapors, etc. These symptoms, like all others pertaining to the head, are aggravated by the general congestion of the cerebrum, as well as by any cause which increases it, such as mental and physi- cal exertion, dependent positions, etc. Hallucinations of sight are also common, but, owing to their frequent dependence on diseases of the eye, they are more apt to be referred to disturbances in that organ than to congestion of the brain, which is not infrequently the true cause. Even diplopia does not always arise from strabismus, astigmatism, or other form of ocular disease, being sometimes due to simple hypersemia of the brain; but in these cases it is generally transient, and limited to bright objects. It is no uncommon thing for the senses of smell and taste to be exaggerated or perverted, and even lost. I have a patient now under treatment who has a natural dislike of the odor of musk, and whose life has long been rendered miserable by the constant perception she has of that "intolerable smell." At first I was inclined to attribute the defect to the 76 INTRACRANIAL DISEASES. congested state of the Schneiderian membrane, but on careful investigation I found that the origin of the trouble corre- sponded with the setting in of unequivocal signs of cerebral hyperemia, and, although decidedly chronic, it has already been considerably benefited by treatment based upon this view of its pathology. General sensibility and the poicer of motion usually suffer to a greater or less extent, anaesthesia of the skin being generally associated with muscular paresis, and cutaneous hyperesthesia with involuntary muscular movements of the limbs or of in- dividual muscles. Thus, the patient sometimes experiences crawling sensations about the face, scalp, and limbs, as though covered with live ants, while the limbs themselves feel heavy, cold, or numb; or the reverse state may occur, attended with neuralgic pains, partial convulsions, etc. But the most important phenomena known to arise from cerebral hyperemia are those pertaining to the general circula- tion. Dr. Hammond,* but more particularly M. Krishaber,f has drawn attention to a class of cases in which the heart and general circulation are especially involved. These cases are characterized by an extreme "irritability of the vascular sys- tem, so that the least movement, such as rising erect from the sitting posture, or to the sitting from the recumbent, leads to the acceleration of the pulse of from 20 to 30 or even 40 beats a minute. Besides this, there are frequent and violent palpi- tations, either spontaneous, or provoked by the most insignifi- cant causes, either mental or physical.'' As this presents a perfect picture of some cases of narcotine poisoning, and also of the cardiac disturbances sometimes caused by dyspeptic troubles, it will be well to consider in this connection the results of Krishaber's more recent investiga- tions on this subject. The following is a summary of the lead- ing symptoms, as given by Hammond :J The disease is sometimes developed with great suddenness, but ordinarily it advances little by little to completeness. * Op. cit. t "De la Neuropatliie Cerebro-cardiaque," Paris, 1873. t Op. cit. CEREBRAL HYPEREMIA. 77 When the former is the case, the patient experiences, under the influence of great mental excitement, pain in the head, vertigo, an inability to speak, or, at least, imperfection of ar- ticulation. There are noises in the ears, flashes of light before the eyes, and occasionally, for a short time, double vision. The heart beats with increased force and rapidity, and is more or less irregular in its action; the face is flushed, and a feeling of suffocation is experienced. If he attempts to walk, his gait is uncertain or staggering, not only in consequence of the ver- tigo present, but from actual loss of power in the limbs. Numbness is commonly felt in some part of the bod}^, and clonic spasms of the muscles, notably of those of the face, are generally present. With all these physical symptoms, there are others indicting mental disturbance. Chief among these are hallucinations or illusions of the senses, particularly of sight and hearing. Insomnia is an almost invariable attend- ant, and what little sleep the patient obtains is interrupted by unpleasant or even frightful dreams. Gradually the dis- order becomes established, and the other functions, especially those connected with digestion, are deranged. From the first the urine is loaded with urates and phosphates. No one can mistake this assemblage of symptoms for those of any other disease, as it exhibits a fair representation of cerebral hyperemia. Such cases, however, are not always sudden in their onset; at least, I have known the phenomena to recur at regular intervals for long periods of time, the attacks assuming in some instances a regular tertian or quar- tan form, suggestive of malarial influence. Two years ago I had a case of this kind under treatment The subject, a man set. about 45 years, enjoyed good health up to about the age of 40, when he had an attack of typhoid fever. Since that period he suffered from regular tertian attacks of cerebral hyperemia of the character above described. On his "well days," as he called them, his head was easy, his mind clear, the heart's action regular and normal, the digestive powers good, and the patient could walk about freely, and even attend to business. But on the alternate, or " sick days," he was obliged to remain quiet in bed, abstain from eating, and even from conversation, 78 INTRACRANIAL DISEASES. as any attempt to assume the erect position, any emotional excitement, or even a light meal, would at once disturb the action of the heart, excite vertigo, noises in the ears, and all the other symptoms of cerebral hyperemia. He had been treated by several eminent physicians of the old school, most of whom, regarding the disease as one of malarial origin, pre- scribed quinine in large doses, and thus greatly aggravated his disorder. Others, regarding it as a case of cerebral anaemia, also gave tonics with a like result. To cap the climax, others treated him for heart disease and dyspepsia, ringing the changes again upon tonics and stimulants, until the poor man well nigh despaired of recovery. The consequence was, that although I at once recognized the case as one of cerebral hy- peremia, and treated it accordingly, it required more than eighteen months' appropriate treatment to effect a cure. Various other types of cerebral hyperemia are met with in practice, some of which belong to the active, and some to the passive form. They are known as the delirious or maniacal, the convulsive or epileptiform, and the apoplectic. Other minor types are also occasionally seen, such as the soporific, the paralytic, and the aphasic. 1. The Delirious Form. — This form is generally the result of a high degree of active hyperemia. There is vertigo, throbbing in the head, flushing and heat of the face, suffusion of the eyes, excessive restlessness and mobility, often combined with weakness, or an inability to maintain the erect position, and delirium, generally of an active, but sometimes of a low, typhoid, or passive character. In some cases the patient is irritable, extremely nervous and peevish, and apparently labor- ing under an attack of hysteria, or of delirium tremens. The delirium is often characterized by an inclination to laugh or cry, to talk foolishly, to escape from some loathsome or fright- ful object, while the whole expression is one of terror and feverish excitement. In other cases the patient is attacked with paroxysms of acute mania, during which he is disposed to injure himself or others, to fight, tear off his clothing, or destroy the objects within his reach. In either case, after a variable period of excitement, the patient becomes exhausted CEREBRAL HYPEREMIA. 79 and falls into a heavy stupor, accompanied by relaxation of the limbs, and, in some cases, by involuntary evacuations from the bladder and bowels. On awaking, there is more or less prostration, heaviness or numbness of the limbs, weakness and confusion of the mind, and an imbecile expression of the coun- tenance, from which the patient only slowly recovers. Some- times the injury is still more profound, paralysis being super- added to the above phenomena. 2. The Convulsive Form. — The spasmodic phenomena which characterize this form of cerebral hyperemia resemble those of an ordinary epileptic seizure, being attended with a loss of consciousness, but without any premonitory cry or aura. Neither do the convulsions of cerebral hyperemia ever occur during sleep, since, as we have seen, true sleep is incompatible with a hyperaemic condition of the brain. Those convulsions which do occur during sleep are, so to speak, ansemic convul- sions, as, indeed, are probably all convulsions arising from irritation of the brain, whether the latter be in a state of general hyperemia or anaemia. In the former case the hyper- emia, if active, may be so severe as to lead to oedema; this will necessarily produce more or less anaemia of certain parts of the brain, which in turn may give rise to convulsions. On the other hand, passive or venous congestion of the brain can only occur by depriving that organ of its usual amount of arterial blood, thus causing an arterial anaemia, which may also excite convulsions. So that, although convulsions depend upon an anaemic condition of the convulsive centre in the brain, it is possible for them to take place, not only during a state of general cerebral hyperemia, but even in consequence of it. 3. The Apoplectic Form. — This form is the result of the highest degree of cerebral hyperemia. In most cases the attack is preceded by the usual promonitory symptoms of apo- plexy, such as headache, dizziness, weight or fulness in the head, drowsiness, confusion of mind, hyperesthesia of the special senses, flushings of the face, epistaxis, and other symp- toms of cerebral hyperemia. Suddenly there is an increased determination of blood to the head, and the patient falls to 80 INTRACRANIAL DISEASES. the ground in a state of insensibility. This condition, which is accompanied with more or less anaesthesia and paralysis, may last only for a few minutes, or it may continue for several hours. The paralysis is never complete, though it may affect one or all of the limbs. The muscles of the face are rarely im- plicated, though the patient, when spoken to loudly, answers in a slow, indistinct, and difficult manner. The respiration and circulation are more or less embarrassed, but there is seldom any stertor, flapping of the cheeks, or profound impli- cation of the respiratory centre. The pulse may be slow and intermittent, or quick and scarcely perceptible. There is generally more or less difficulty of swallowing; and although the patient may be temporally roused by shouting to him, the perception of things in general is lost. Reflex excitability, however, usually persists, and may even be increased. Thus, a loud noise or a bright light will generally attract the patient's attention, and will sometimes cause discomfort. In most cases the attack gradually passes off, leaving both mind and body more or less enfeebled, but without any decided loss of either sensation or motion. Occasionally, it is true, a certain degree of paresis, or even hemiplegia, may remain for a few days, but it disappears much more quickly than in true apoplexy. Some- times, however, the termination of the attack is much less favorable; the symptoms gradually grow worse and worse, in- voluntary discharges take place from the bladder and bowels, the patient sinks into a state of profound coma, and eventually dies. Causes. — The causes of cerebral hyperemia are very numer- ous. It is evident that whatever is capable of increasing the force of the general circulation, of augmenting the amount of arterial blood in the brain, or of giving it a peculiar direction to that organ ; and also whatever obstructs or impedes the re- turn of blood from the head, thus producing congestion of its sinuses and veins, may all act as the immediate causes of cere- bral hyperemia. No doubt such cases alone, without any peculiar predisposition, may produce the disease in most in- stances, but with many there is a marked liability to determi- nation of blood to the brain — a liability which appears to be CEREBRAL HYPEREMIA. 81 hereditary ; at least it seems to run in certain families, espe- cially those of a sanguinous temperament. Overrichness of the blood, or a plethoric condition of the system, the cessation of growth, and the change of life, are all predisposing causes ; and hence the aged and those in middle life are more subject to it than the young, and men more than women. Hence, also, it is often found to be associated with free living. But the most powerful predisposing causes, doubtless, are diseases of the heart, especially pericarditis, endocarditis, and hyper- trophy of the left ventricle, in active hyperaemia; and dilatation of the right ventricle, fatty degeneration, and valvular diseases, in passive hyperemia. Among the more common exciting causes are : exposure to extremes of heat and cold, and especially to the direct rays of the sun; violent emotions; excessive mental labor; excite- ment of the passions, particularly the sexual ; excesses in eat- ing and drinking; the sudden suppression of habitual dis- charges, especially the haemorrhagic, such as the catamenia, piles, etc.; sudden and violent physicial exertion, more espe- cially when the head is in a dependent position, as in stooping ; the use of certain drugs, such as quinine, belladonna, opium, glonoin, nitrite of amyl, etc., and inflammatory conditions in the vicinity of the brain, such as quinsy, mumps, facial ery- sipelas, etc. Passive or venous hyperemia may be brought about by such causes as prevent a sufficiently rapid emptying of the jugular veins, such as a goitre or other tumor pressing upon them, or upon the descending vena cava; violent and prolonged strain- ing, as in childbirth or at stool ; playing upon wind instru- ments; violent fits of coughing, as in croup, whooping-cough, etc. ; dilatation of the right ventricle, producing tricuspid in- sufficiency and pulmonary congestion ; pleuritic effusions ; emphysema; working in compressed air; intracranial tumors; and cerebral embolism, thrombosis, and extravasations. Diagnosis. — There are some points of resemblance between cerebral hyperemia and intracranial haemorrhage, embolism, thrombosis^ vertigo, epilepsy, softening, and uraemia ; but as all of these affections are characterized by well-marked differ- 6 82 INTRACRANIAL DISEASES. ences, they are not liable to be mistaken for this disease, pro- vided proper attention is paid to the symptoms. The case is different, however, as regards cerebral anaemia, the first stage of which closely resembles that of cerebral hyperemia. Thus, headache, vertigo, numbness, sense of constriction, tinnitus aurium, dulness and confusion of mind, lassitude, impaired memory, and even loss of consciousness, are common to both diseases. But in cerebral anaemia the face, instead of being flushed, is pale and cold; the pupils are dilated, not con- tracted; there is drowsiness instead of wakefulness; the vertigo is increased by the erect, and diminished by the recumbent posit on ; the pulse, instead of being strong and slow, is weak, frequent, and irregular ; there is no throbbing of the carotid and temporal arteries, but bellows-murmurs are heard at the base of the heart and in the veins of the neck. Moreover, the opthalmoscope shows anaemia of the retina, instead of the large and tortuous arteries and checked disk belonging to cerebral hypersemia. Prognosis.— The prognosis in cerebral hypersemia depends greatly upon the form and stage of the disease. Active cere- bral hypersemia is a much more rapid, but less fatal form, than the passive. Recovery from it generally takes place under homoeopathic treatment, especially if it has not passed beyond the first stage. The passive form, though generally a more serious, is not a very fatal affection ; but complete re- coverjr from it cannot be expected -to take place unless the causes which produce it are removable. Pulmonary conges- tion appears to be one of the most frequent complications in fatal cases, since, according to Althaus, six out of nine cases of sudden death from cerebral hypersemia exhibited congestion of the lungs. The subjects of this disease are also liable to a number of other secondary lesions, such as encephalitis, soften- ing of the brain, cerebral haemorrhage, and general paralysis ; lesions especially apt to occur in the convulsive form. As might be expected, the danger in these cases is generally in proportion to the frequency of the attacks. Old school authors give a mortality for this disease varying from ten to twenty per cent. T find upon looking over my Case-Books for the CEREBRAL HYPEREMIA. 83 past twenty years, during which time I have treated all such cases homceopathically, that of one hundred and forty-two well-developed cases, all but four, or at most five, recovered. Of the fatal cases, two (one a painter and the other a printer) died of softening of the brain ; one (an excessive smoker) from paralysis of the heart; and one (a confirmed drunkard) from general paralysis. Besides these, there is one case, marked doubtful, of a lady about forty-five years of age, who was sud- denly seized with delirium, and died comatose within thirty hours of the beginning of the attack. The diagnosis was acute congestion with effusion, but no post-mortem examination was allowed. Morbid Anatomy. — Although the post-mortem lesions in this disease are sufficiently characteristic, they are not always present after death — a circumstance which some have endeav- ored to explain by assuming that, where the hyperemia was of an active character, the distended arteries have emptied themselves just before death, either by discharging their con- tents into the veins, or by effusion of serum through the coats of the capillary vessels. In the great majority of cases, however, we find after death the cerebral vessels loaded with blood, the convolutions of the brain more or less obliterated, and the pia mater detached so as to be easily lifted from the cerebral surface. The blood- vessels, both of the pia mater and the substance of the brain, are increased in size; the latter exhibiting, on section, larger and more numerous blood-points than usual, and the former having a red or rose-colored appearance. The white matter, besides being increased in density and consistence, has a slight pinkish appearance, and the grey matter appears dark red, or of a violet hue. The ventricles and subarachnoid spaces are often filled with serum, and the veins of the pia mater are more or less enlarged and tortuous. Repeated and long-continued attacks of cerebral hyperaemia exhibit, on microscopical examination after death, minute granules of haematin in contact with the blood-vessels, and also, in the case of the smaller capillaries minute aneurismal 84 INTRACRANIAL DISEASES. swellings. Two French observers, Durand-Fardel* and Cal- meil.f were the first to point out a cribriform appearance (Vetat crible) which is seen on making a transverse section of the hemispheres in these cases. This appearance, which is sup- posed to be due to the distension and subsequent shrinkage of the capillary vessels, is caused b} 7 the presence of numerous fine holes, which are plainly visible to the naked eye. In some cases the cerebral capillaries are ruptured, blood being extravasated into the medullary substance, and forming rose- colored patches; more commonly, however, the vascular dis- tension is relieved by effusion of serum through the coats of the capillaries into the brain and subarachnoid spaces. Sub- sequently the brain becomes atrophied, and its ventricles filled with serum. Pathology. — We have already pointed out the fact, under the head of cerebral anaemia (q. v.), not only that a free vas- cular connection exists between the outer and inner surfaces of the skull, but that variations in the quantity of blood within the cranium may easily take place by means of the equalizing effect of the cerebro-spinal fluid, the quantity of which appears to be regulated by the amount of blood present in the cerebro- spinal blood-vessels. Moreover, these vessels, according to Robin* and His,§ are surrounded throughout their entire length by perivascular canals, or ring-like spaces, which in cases of chronic hypersemia become permanently enlarged. Finally, by observations made through a watch crystal fixed in the hole of an animal's skull, the cerebral vessels themselves have been seen to increase and diminish in diameter accord- ing to the amount of pressure exerted upon their contents during the act of respiration. That such changes may take place without causing undue pressure upon the cerebral tissue, is shown by the experiments of Pagenstecher on dogs, w T ho found that about twenty-three fluid ounces could be injected into the cavity of the cranium * Traite pratique des Maladies des vieillards, deuxieme ed., Paris, 1873. f Be la paralysie considerie chez les alienes, etc., Paris, 1826. X Jour, de la Phys. de I' Horn, et des Anim., 1859. I Zeitseh.f. Wisnenchaft. ZooL, 1865. CEREBRAL HYPEREMIA. 85 before producing symptoms of compression. It is believed, therefore, that in many cases of active cerebral hyperemia the quality of the blood favors the congestion, by giving rise to an undue activity of the serous membranes surrounding the brain, and thus exerting more or less of a suction action in their direction. Treatment. — Nearly every case of cerebral hyperemia will be benefited, and many will be cured, by the removal of the cause. Hence, the first thing to be done is, to remove or lessen, as far as possible, the exciting causes. Thus, the passive form requires rest, both physical and mental, and the avoidance of everything calculated to disturb the circulation or affect the mind, such as excesses in eating and drinking, the excitement; of the animal passions, and every form of mental and bodily ex- ertion. Active cerebral hyperemia generally requires similar restrictions, except that the injunction as to rest need not, in the majority of cases, be insisted upon to so great an extent. The patient, however, should abstain from all severe muscular ex- ertions, especially while in a stooping posture. Care should also be taken to keep the feet warm, the head elevated and cool, and the clothing about the neck and chest loose and com- fortable. Cold to the head is an important adjuvant in the treatment; of the active form of cerebral hyperemia. Even ice and ice- water may be safely and advantageously applied to the head and neck in these cases, provided the feet and legs are im- mersed in hot water at the same time. If this precaution be not observed, it will be safer to apply warm water to the head, the evaporation from which produces a comfortable sense of coolness, and rapidly reduces the temperature of the parts to which it is applied. Various agents are known to possess the power of contract- ing the cerebral blood-vessels, the most efficient of which are, the constant galvanic current, ergot, and the bromides of po- tassium, sodium, and calcium. The galvanic current should be applied by placing one pole of the battery over the sympathetic nerve in the neck, and the other opposite the seventh cervical vertebra ; using not to ex- 86 INTRACRANIAL DISEASES. ceed ten Smee's cells, nor allowing the current to act for more than two or three minutes. Ergot and the bromides are allopathic remedies, and there- fore require to be used in material doses. Hammond recom- mends the former in drachm doses of the fluid extract, and the latter in twenty-grain doses, in solution, three times a day. I have myself obtained excellent results, in several cases, by giv- ing the bromides in tw T o-grain doses, every hour, but have sel- dom had occasion to resort to them in active cerebral hyper- emia, the homceopathically indicated remedies having gener- ally given speedy and permanent relief. General Indications. — When caused by mental emotions : Aeon., Cham., Coff., Igna., Nux v., Opi., Ver. v. Brain-fag: Arn., Aur., Calc. carb. and hypophos., Erythrox. c, Igna., Nux v., Pic. ac, Phos., Phos. ac, Puis., Rhus t., Sec. c, Sulph., Zinc, phosphide. Alcoholic drinks: Arsen., Calc. c, Gels., Ip., Lach., Nux. v., Puis., Opi., Ver. v., Sulph. Dentition : Aeon., Bell., Calc. c, Cham., CofF., Gels., Ver. v. Straining or injury : Aeon., Arn., Bry., Calc. c, Cic, Merc, Rhus t. Amenorrhcea: Aeon., Apis, Apoc, Bell., Bry., Calc. c, Carb. v., Chin., Cimicif., Coca, Cycl., Cupr., Dig., Graph., Kali c, Lycop., Merc, Nat. m., Phos., Puis., Rhus, t, Senec. g., Sep., Sulph., Xanth. Hemorrhoidal suppression: Aeon., Cham., Calc. c, Carb. v., Nux v., Puis., Sulph. Constipation: Bry., Igna., Nux. v., Opi., Merc, Puis., Sulph. Visceral congestion, or chill: Aeon., Arn., Ars., Bell., Bry., Calc. c, Cham., Dig., Ipec, Lycop., Merc, Rhus t., Stram., Sulph., Ver. Hypertrophy of left ventricle: Aeon., Aur., Cact. gr., Glon., Iod., Kalm., Spig., Spong. Tricuspid regurgitation: Bell., Hysoc, Kali c, Puis., Tart, emet. Vertigo, When there is much : Aeon., Arn., Bell., Calc, Causi, Cic, Coca, Lach., Lycop., Nit. ac, Nux v., Phos., Puis., Rhus t , Sep., Stram., Sil., Sulph., Ver. CEREBRAL HYPEREMIA. 87 Loss of consciousness, When there is: Arm, Bell., Baryt., Camph., Cic.j Cupr., Hyos., Kal., Nux v., Opi., Phos. ac, Plat., Puis., Rhus, Stram., Ver. Special Indications. — Aconite. — Great restlessness and anxiety, with dry, burning skin; throbbing pains in the head, with fulness and heaviness; piercing pains in the forehead and temples; vertigo, especially when stooping; flashes of light before the eyes; photophobia; buzzing in the ears; temporary blindness; disposition to faint; palpitations of the heart; ag- gravated by movement; more or less relief in the open air. Especially indicated in the active form, or when caused by violent emotions, such as anger or fright. Amyl nitr. — Throbbing, with sense of heat and fulness, in the head; buzzing and throbbing in the ears; protrusion of the eyes ; flushing of the face ; beating of the carotids ; violent palpitations. Arnica. — Heat and burning in the head, with coldness of the remainder of the body; throbbing in the forehead and temples, increased by stooping or exercise; burning, buzzing and beating in the ears; vertigo, attended with nausea or vomiting; delirium, obscuration of sight, or loss of conscious- ness. This remedy is more particularly indicated after a blow or fall, or when the congestion is the result of mechanical violence. Auriun. — Heat and roaring in the head, with scintillations before the eyes ; desire for death, with suicidal tendency; ag- gravated by mental exertion. Belladonna. — Redness of the face and eyes; roaring and humming in the ears; great sensitiveness to light and noise; painful stitches in the head; delirium, spasms and convul- sions; morbid vigilance, or its opposite, stupidity; contraction or dilatation of the pupils ; double vision ; loss of conscious- ness; stiffness of the tongue and neck; aggravation of the symptoms by stooping, exercise, light or noise. Bryonia. — Painful outward pressure in the forehead and temples; bleeding of the nose; intolerance of light and noise; buzzing in the ears; startings in sleep, with twitchings of 88 INTRACRANIAL DISEASES. the facial muscles; red, bloated face; great impatience and irritability; nausea and vomiting; constipation. Cactus. — Throbbing pain in the head, with red and bloated face; heavy, pulsating pain in the top and right side of the head, ameliorated by pressure, but aggravated by light and noise; vertigo; anxiety. Cimicifuga. — Severe pain in the head, especially over the right eye; heat and fulness of the head, with throbbing and pressure; pain in the temple and vertex, with a sensation as though it would burst; heaviness and dulness of the head; the brain feels too large for the skull. Coffea. — Great nervousness, wakefulness, and exaltation of the senses; heat in the head and face; epistaxis; buzzing in the ears ; flushing of the face, with cold feet ; red and glisten- ing eyes ; symptoms aggravated by talking. Well adapted to infantile cases, especially when caused by teething or diarrhoea. Gelsemium. — Dull, pressive, and stupefying headache, ex- tending from the occiput to the os frontis ; vertigo, with dim- ness of vision ; diplopia ; buzzing in the ears ; morbid vigi- lance, or its opposite, drowsiness; mirthfulness, alternating with depression of spirits ; mental confusion ; pain in the nape of the neck, with disposition to throw the head backward. This is generally one of our most reliable remedies in cerebral hypersemia, whether caused by teething, mental emotions, sup- pression of the menses, or exposure to the rays of the sun. Glonoin. — Determination of blood to the head ; throbbing headache, with very rapid pulse ; flashes of light before the eyes ; singing and buzzing in the ears ; fulness in the forehead and vertex, with dulness of mind ; fainting, with black spots before the eyes; vertigo; strong beating of the carotid and temporal arteries; great restlessness and impatience; when caused by extremes of heat or cold. Hyoscyamus. — Dark red face, with sparkling eyes ; delirious, drowsy, or unconscious ; great nervousness, with twitching of the tendons ; grating of the teeth ; sudden startings during sleep ; throbbing of the carotids ; double vision ; jerking of the limbs. Mercurius. — Feeling of great fulness and pressure in the CEREBRAL HYPEREMIA. 89 head ; sensation as if the brain was rigidly compressed ; great restlessness and anguish, especially at night ; burning of the eyes, with lachrymation ; buzzing in the ears, with dulness of hearing ; headache of a tearing, boring character ; vertigo ; fre- quent sweating without relief. Nux vom. — Headache, with or without nausea or vomiting ; dulness and confusion of the head; drowsiness, with a tendency to coma, or the opposite condition of wakefulness, with burn- ing of the eyes, and intolerance of light and noise ; ringing in the ears; vertiginous intoxication and cloudiness; symptoms aggravated by eating, by exercise in the open air, and by coffee. This remedy is particularly adapted to cases caused by exces- sive mental labor, by the habitual use of intoxicating liquors, and by sedentary modes of life. Opium. — Comatose sleep, with apoplectic symptoms, such as stertorous breathing, sighing and moaning, slow pulse, dark red and bloated face; or drowsiness, with confusion of the mind, and sense of heaviness and pressure within the head ; or else the opposite condition of wakefulness, with delirium } flushing of the face, scintillations before the eyes, humming in the ears, throbbing of the temporal arteries, spasms and con- vulsions. This remedy is especially indicated in those cases of cerebral hypersemia characterized by symptoms of depres- sion, and also in such as are caused by fright or debauchery. Phosphorus. — Heat and throbbing in the head, with vertigo ; buzzing in the ears ; swelling under the eyes ; emphysema ; palpitation of the heart; burning and stinging pains in the brain ; sense of weight in the forehead, increased by stooping ; heat in the vertex. Especially suited to chronic cases, with tendency to softening of the brain. Pulsatilla. — Oppressive, beating headache, with confusion of the mind ; red and bloated, or pale face ; scintillations before the eyes ; buzzing in the ears ; double vision ; vertigo ; drow- siness in the daytime and sleeplessness at night ; bitter, bilious taste in the mouth ; nausea or vomiting ; scanty or suppressed menses ; worse in a warm room, better in the open air. Rhus tox. — Heavy, reeling headache; shaking or wavering sensation in the brain, especially when walking ; burning, 90 INTRACRANIAL DISEASES. throbbing pains in the head, with sense of fulness; vertigo when lying down ; red and burning, or pale and puffy face ; great restlessness, especially at night; pains aggravated by eating. Especially adapted to cases caused by cold, or when aggravated by damp weather. Veratrum vir. — Heat, fulness and sense of weight in the head, with violent throbbing of the carotid and temporal arte- ries ; flushed face ; ringing in the ears ; sensitiveness to light and sound ; double vision ; derangement of the stomach ; op- pressed respiration ; palpitation of the heart ; tingling and numbness in the limbs ; vertigo ; confusion of mind ; loss of memory; spasms and convulsions; congestions caused by teething, or by alcoholic stimulants. CEREBRAL APOPLEXY. 91 CHAPTER III. CEREBRAL APOPLEXY. The term apoplexy, which is derived from a Greek word signifying "to strike," was originally used by the Greek writers to denote a sudden loss of consciousness and volition, with more or less disturbance of the circulation and respiration. Since the beginning of the present century it has been mainly confined to cerebral haemorrhage, for although the symptoms may be induced in other ways, haemorrhage into the brain is the most common cause of the apoplectic seizure. The term, however, is objectionable, when used to denote a particular disease or condition, partly because the group of symptoms to which it is applied is common to a variety of cerebral lesions, and partly because it has been used to denote haemorrhage into other organs, as the lungs, the kidneys, etc. As a consequence, the term is now seldom used to designate a definite lesion or disease, but any condition of the brain characterized by the following group or train of Symptoms. — In most cases the attack is preceded by certain premonitory symptoms, such as pain in the head, ringing in the ears, altered vision, vertigo, drowsiness, loss of memory, and other evidences of cerebral hyperemia, to which are sometimes added, more or less numbness and pricking in the extremities. In other cases no premonitory symptoms are present, but the patient, previously in apparent health, falls down insensible, with a total abolition of all the sensorial functions, or manifests a momentary apprehension of impend- ing danger, by raising his hands to his head and making some alarming sign or exclamation, at the very instant of falling. The degree to which the several functions are affected varies greatly in different cases. When very severe, sensation, con- sciousness, and voluntary motion, are all lost. In other cases, 92 INTRACRANIAL DISEASES. there is a greater or less degree of senso-inotory impairment, the patient being in a state of semi-consciousness, sensible to outward impressions, and capable, to some extent, of voluntary movements. The pupils are at first generally contracted, frequently in an unequal degree, but in some cases they are largely dilated, and insensible to the stimulus of light. More or less paralysis is generally associated with the attack, however light the stroke. Usually, one side of the body is motionless, constituting hemiplegia. When paralysis exists, the tongue is turned towards the paralyzed side, the function of deglutition is lost or greatly impaired, the respiration is slow and heaving, and the breathing loud and stertorous ; there is also retention, or involuntary discharge, of urine and faeces. Though the power of voluntary motion in these cases is lost, there is sometimes more or less rigidity or spasmodic contrac- tion of the muscles, the symptoms being, as it were, of a mixed character, partly paralytic and partly spasmodic. The pulse is sometimes slow, full, and bounding ; at other times it is weak, small, and intermitting. In the former case, there is more or less heat and flushing of the face, with warmth of the extremities ; in the latter, on the contrary, the face is pale and sunken, and the extremities cold. "We have aimed to give, in the above description, only so much of the symptomatology of this affection as may serve for the easy recognition of what is known as the apoplectic state; but it should be remembered that the assemblage of symptoms to which the name is applied may be produced in various ways, and may or may not be complicated with paralysis. In order, therefore, to avoid unnecessary repetitions, and at the same time enable the reader to obtain a comprehensive view of the whole subject, we shall treat at length, in separate chap- ters (q. v.i. of each of the pathological conditions enumerated in the following list of Causes. — a. Cerebral Haemorrhage. b. Haemorrhage into the Cerebral Membranes. c. Embolism of Cerebral Arteries. d. Cerebral Hyperemia. e. Coup de Soleil. /. Ursemic and Alcoholic Intoxication. CEREBRAL HAEMORRHAGE. 93 CHAPTER IV. CEREBRAL HEMORRHAGE. Syn. — Apoplexia Savguinia. By cerebral hemorrhage is meant the extravasation of blood from the cerebral vessels into the substance of the brain, or into its ventricles. The haemorrhage may take place from either the large cerebral arteries, such as the middle cerebral and basilar, or from the capillary vessels of the brain. It may spring from a single vessel or from several, and may be more or less in quantity, producing clots of various dimensions, from the size of a pea to that of an orange, and even larger. It may set in gradually or suddenly, and continue until it meets with sufficient resistance from the surrounding tissues to check the further effusion of blood, or it may take place by fits and starts, according to the varying degrees of pressure exerted at different times upon the cerebral vessels. There is no portion of the brain which may not be the seat of haemorrhage. As might be expected, however, cerebral haemorrhage occurs much more frequently in some situations than in others. Thus, in 579 cases reported by Gintrac, the cortical substance of the hemispheres was affected in 45; the anterior lobes of the brain in 17 ; the middle lobes in 127 ; the posterior lobes in 33 ; the corpora striata in 72 ; the optic thalami in 38 ; the crura cerebri and pons in 76 ; the cerebel- lum in 55, and the medulla oblongata in 2. Symptoms. — Occurring as it does under such a great variety of circumstances, the symptoms by which an attack of cerebral haemorrhage manifests itself, differ very much in different cases. They may, however, be divided into two classes, apo- plectic and paralytic. 94 INTRACRANIAL DISEASES. In the majority of cases, the attack is preceded by premoni- tory symptoms of various kinds, such as severe paroxysms of pain in the head ; giddiness, especially when stooping or sud- denly turning the head ; flushings of the face, accompanied with coldness of the hands and feet ; frequent bleedings at the nose, particularly in elderly people; flashes of light before the e} 7 es ; paralysis of the external rectus muscle of the eye ; mydriasis; amblyopia from extravasations in the retinse; drowsiness; disinclination to work; neuralgic pains, involving, more particularly, the terminal branches of the ulnar nerve; twitchings of the muscles of the face, or some portion of the extremities, especially the fingers and toes ; numbness of one side of the body ; and sudden difficulty in speaking, in conse- quence of slight paralysis of the tongue, and other muscles con- cerned in articulation. A greater or less number of the above signs may exist for days and even weeks before the actual onset of the attack, but none of them affords any positive indication of the gravity of the haemorrhage. On the contrary, it often happens that in the apoplectic form of the disease they are wholly wanting. Whether present or absent, however, the attack is always more or less sudden in its onset. In a small number of cases, indeed, it may be absolutely sudden; but it much more frequently happens that the attack is immediately preceded by slighter symptoms, such as dizziness, noises in the head, dark specks before the eyes, tingling in the limbs, and thickness of speech. In well-marked cases, the patient, if standing, suddenly staggers, falls, and at once becomes unconscious. Examining the patient, we now find that, although the functions of circu- lation and respiration continue to be performed, he is insen- sible to stimulation, and is paralyzed on one side of the body. His senses are so far extinguished that neither loud sounds, bright lights, nor substances having a strong and disagreeable smell or taste, make any impression on the brain. The face is livid, swollen and distorted, or pale and corpse-like. The breathing is slow and stertorous ; the cheeks are flabby, and protrude during expiration ; the mouth is more or less open, and is drawn towards the non-paralyzed side ; the eyelids are CEREBRAL HAEMORRHAGE. 95 closed; the conjunctiva injected and insensible; the eyeballs fixed ; the pupils sluggish, but variable as to size, being gener- ally dilated, but sometimes contracted or unequal, according as the nerves of the iris are irritated or paralyzed. If the haemorrhage be great, or the attack very severe, the lower sphincters are more or less paralyzed, and all control over the urine and faeces is lost. The reflex excitability of the spinal cord is generally increased, owing to the fact that the inhibitory influence usually exerted by the brain is removed. Thus, if the sole of the foot be tickled, the leg will be drawn up, or jerked to one side. Such is the general condition of the patient when the extra- vasation takes place into the corpus striatum and optic thala- mus; when it opens into the meninges or the lateral ventricles, the limbs of one side are spasmodically affected, being either contracted or convulsed. An apoplectic attack of this character may result in death within a few days, a few hours, or even a few minutes, accord- ing as the lesion is more or less severe. When slight, the apo- plectic condition may last not more than half an hour or so. In other cases it may disappear more gradually, accompanied with symptoms denoting the return of consciousness. In fact, as there is every degree of injury and of shock in these cases, so there is every sort of gradation between the deepest coma and mere mental confusion — conditions which manifest them- selves by various degrees of stupor, delirium, and mental inco- herence. For example, when consciousness begins to return, if spoken to loudly, the patient may open his eyes, turn over in bed, or attempt to speak; or be may simply raise his eye- lids for a moment without taking any further notice ; or he may answer "yes " or " no," and again lapse into stupor. Other symptoms also manifest themselves in different cases, or in different stages of the same case, according to the gravity of the attack. The movements of respiration and circulation, instead of being slow and regular, as at first, frequently become irritated and irregular. Thus, the breathing becomes short and superficial ; or, having been accelerated, it becomes re- tarded and intermitting. Under these circumstances the air- 96 INTRACRANIAL DISEASES. passages become more or less obstructed with mucus; and a mixture of mucus and saliva escapes from the half-open mouth. But one of the most important and peculiar symptoms is the variation in the animal temperature. At first it undergoes a marked reduction, the thermometer in the rectum indicating, in most cases, a temperature of 96° or 97°F. This reduction appears to correspond to the continuance of the haemorrhage. After the latter has ceased, the thermometer generally rises to about the normal standard (99.4°-101°), at which point, if the patient is to recover, it remains nearly stationary. But when the haemorrhage is very extensive, or there is an unusual fall of temperature at the commencement, the mercury again rises, and this time may reach an elevation of 103°, 105°, and even 107°F., indicating a fatal termination. Another peculiar symptom sometimes observed in these cases is, the conjugated or conjoint lateral deviations of the eyes and head towards the sound side. This deviation is sometimes seen during the period of unconsciousness, but it may continue afterwards, the patient after his return to consciousness having no power to correct it. By great effort he may succeed in turning the head in the opposite direction, but not the eyes. This symptom is not due to paralysis, but to spasm, excited partly by irritation of the third cerebral nerve, which produces internal deviation on the side opposite the lesion ; partly by irritation of the sixth nerve, which causes external deviation on the same side ; and partly by irritation of the eleventh, or spinal accessory nerve, which, by producing contraction of the sterno-mastoid muscle, causes the deviation of the head. Alt- haus says that this symptom always denotes a sudden and extensive injury to the brain, which, mostly proves fatal; but Hammond declares that he has met with the deviations in about one-third of his cases of cerebral haemorrhage, having been present from the beginning, and that they disappeared in a few days. Should the patient live to reach the second stage of the dis- ease, a different set of symptoms, characteristic of the period of inflammation, generally supervenes. This period usually sets in about the eighth or ninth day after the occurrence of the CEREBRAL HEMORRHAGE. 97 extravasation, with symptoms of cerebral fever, such as restless- ness, pain in the head, delirium, convulsions, nausea and vom- iting. This stage may last from three or four days to a week, and then terminate, either in death, or, by a gradual abate- ment of the symptoms, in resolution. In the latter case, the mind becomes every day more and more clear, articulation more distinct, and movement of the paralyzed limbs more free and easy. For some reason, the leg usually recovers its power much sooner than the arm, so that the patient is often able to walk about long before he can make any use of the upper ex- tremity. When, as sometimes happens, the arm regains its power before the leg, the termination is usually fatal. An acute bed-sore sometimes forms over the gluteal region of the paralyzed side, and occasionally, but very rarely, over that of the sound side. This acute sloughing process, which occurs quite independently of pressure, or of any external irritating influence, may begin to manifest itself within three or four days after the apoplectic seizure. It commences in the form of an erythematous spot, or macula, which is soon succeeded by the appearance of bullae filled with colorless serum, which afterwards becomes sanguinolent. The raised cuticle soon gives way, and is followed by a gangrenous condition of the part, which spreads so rapidly that the patient seldom lives long enough for the slough to separate ; indeed, according to Charcot,* the lesion is one that almost invariably indicates a fatal termination of the case. After the acute symptoms have subsided, that is to say, in about ten or twelve days after the occurrence of the haemor- rhage, there remains either complete hemiplegia, or a degree of paralysis corresponding to the locality and extent of the central lesion. When the entire corpus striatum is involved, there is complete paralysis of the opposite side of the body. In most cases, however, the paralysis is incomplete, the mus- cles which escape being those of the eye, neck, back, and chest. This incomplete form of facial paralysis readily distinguishes cerebral palsy from facial paralysis, properly so called. In the * Arckiv. de phys., 1868. 7 98 INTRACRANIAL DISEASES. latter affection it is utterly impossible for the patient to close his eye on the paralyzed side, whereas in the cerebral form he can shut it with apparent ease. He cannot, it is true, close the lids as firmly as he can those of the opposite eye, nor can he close the eye of the affected side without shutting that of the sound eye at the same time; at least he can only do so with great difficulty. Moreover, the muscles which chiefly suffer in these cases are those of mastication, so that when the patient attempts to close the jaw, the temporal and masseter of the sound side contract more energetically and promptly than those of the affected side. Other facial muscles are like- wise implicated, rendering the cheek flabby, the nostril con- tracted, and the lip depressed and drawn towards the healthy side. Owing to the peculiar action of the genio-glossus muscle, the tongue, in most cases of cerebral paralysis, deviates towards the paralyzed side. In a few cases, however, the tip of the tongue is turned towards the sound side, the lesion being in the medulla oblongata, below the point w T here its fibres decussate. The diaphragm and muscles of the back are not affected in cerebral haemorrhage, but the straight muscles of the abdomen appear to be weakened on the paralyzed side, as is seen when the patient attempts to assume the sitting posture by the aid of these muscles. As before stated, the upper extremity is more profoundly paralyzed than any other part. The movements of abduction and adduction, flexion and extension, pronation and supi- nation, are all rendered impossible. Unless improvement speedily sets in, contractions of the paralyzed muscles soon take place, the flexor muscles being generally more affected than the extensors. Not only the muscles of the arm, but those of the wrist and fingers suffer from contraction or paralysis. The flexors of the fingers are sometimes so forcibly contracted as to irritate the palm. The lower extremity is at first as much affected as the upper, but it generally recovers more quickly from the paralysis. The flexor muscles of the paralyzed leg are apt, however, to CEREBRAL HEMORRHAGE. 99 remain somewhat contracted in these cases, causing the patient to limp more or less in his walk. As might be expected, most voluntary movements are more or less imperfectly executed for a considerable period after the attack. At times, indeed, especially when under the influence of strong excitement, the patient may be able to perform or- dinary movements with facility; but until the muscular power has fully returned, they are made in a more or less awkward and difficult manner. In some cases the paralyzed limbs become permanently contracted. This was formerly thought to be due to secondary encephalitis, but Charcot, Tiirck, and Vulpian have shown it to be the result of certain secondary changes in the nervous centres, especially sclerosis of the lateral columns of the spinal cord. This late rigidity of the paralyzed muscles differs from the early rigidity, not only by the lateness of its appearance, but by being both progressive and permanent. Causes. — The chief predisposing causes of cerebral haemor- rhage are inheritance and old age. Statistics show that it occurs in the descendants of apoplectic parents much more frequently than in others, owing either to a similarity of physical con- formation, or, which is more probable, to some inherited weak- ness of the system, the existence of which in the parents con- stitutes the original predisposition to the complaint. Thus, Piorry mentions the case of a woman, three of whose children had died of convulsions, while she herself was a paralytic, and her mother, uncle, brothers and sisters, to the number of twelve, had all died, either of cerebral haemorrhage or of con- vulsions. Old age, however, is the principal predisposing cause, and is doubtless the most powerful, as the great majority of cases occur after the age of forty. The greatest number of deaths from cerebral haemorrhage occurs at about the age of seventy years, after which the number diminishes, but not the ratio. Hence, people advanced in life, especially if they are, or have been, very hard thinkers, or addicted to excesses of any kind, are very apt to be cut off in this manner. For these reasons, probably, women, whose habits of life are generally more regular than those of men, are less liable to the disease. 100 INTRACRANIAL DISEASES. Cardiac affections were formerly supposed to favor the dis- ease by causing more or less congestion of the brain, and when other circumstances concur to produce this condition, such as granular degeneration of the kidney, which leads to increased tension in the cerebral vessels, no doubt they contribute to the result. But ordinary hypertrophy of the left ventricle from disease of the aortic valves, instead of causing cerebral haemor- rhage, can at most merely compensate for the imperfect closure of the valves, without increasing the force of the cerebral circulation, and consequently without endangering the rupture of cerebral blood-vessels. Very cold weather undoubtedly favors the production of the disease, as cerebral haemorrhage is much more common in midwinter than in summer.. The same is also true of sudden variations of temperature, especially from mild to cold weather. The exciting causes Of cerebral haemorrhage are quite numer- ous, but they may be reduced to a very few classes, viz., to what- ever tends to produce congestion of the brain ; such as violent mental emotions, long exposure to the direct rays of the sun, heavy lifting or straining, hard coughing or vomiting, sexual intercourse, playing upon wind instruments, childbirth, the free use of alcoholic stimulants, compression of the vessels of the neck, dependent position of the head in stooping, etc. To these may be added, repelled eruptions, an overloaded state of the stomach, the sudden suppression of habitual discharges, long exposure to extreme cold, and an unhealthy state of the blood, such as exists in chlorosis, scurvy, typhus, syphilis, etc. Diagnosis. — Cerebral haemorrhage is liable to be confounded with both syncope and coma. In syncope, however, the sur- face is pale and cold, the features are contracted, the pulse is lost at the wrist, and the respiration is temporarily suspended — symptoms the very reverse of those usually met with in cerebral hemorrhage. Coma is a frequent accompaniment of various diseased conditions, and can only be differentiated by the cause, which, in cases of cerebral haemorrhage, generally depends upon sudden pressure on the brain, while in other cases it is symptomatic of asphyxia, narcotic or uraemic poison- ing, inebriation, cerebral concussion or inflammation, hysteria, CEREBRAL HEMORRHAGE. 101 etc. Coma may also result from embolism, thrombosis, men- ingeal haemorrhage, tumor, or abscess; but in these cases the diagnosis is generally more or less uncertain and difficult. In case, however, a young person suffering from disease of the left side of the heart suddenly becomes unconscious, the probability is that the attack is due to cerebral embolism. The probability is considerably increased if the resulting hemiplegia occurs on the right side, as embolism in the brain is most frequently met with in the left middle cerebral artery or in some of its branches. Cerebral haemorrhage and thrombosis bear a close resem- blance to each other, since they have a great tendency to occur in elderly people, and each is liable to be preceded by pre- monitory signs; but the development of the symptoms in thrombosis is generally much slower than in haemorrhage, or in embolism; so that when the attack occurs in an elderly person, and is preceded by long-continued and well-marked prodromata, and especially if the arteries are rigid and the cardiac pulsations weak, we are justified in referring the attack to thrombosis. As for cerebral tumors or abscesses, the symptoms, like those in thrombosis, are not only gradual in their development, but are frequently of an epileptic character. A fixed pain in the head is generally one of the most prominent symptoms; and the paralysis, although unilateral, is frequently limited to one or more of the cerebral nerves. Moreover, the symptoms, in- stead of gradually diminishing, as in cerebral haemorrhage, become, as a general rule, more and more pronounced. Cerebral haemorrhage may be distinguished from asphyxia by the fact that in the latter the respiration is suspended. Moreover, the cause which suspends the respiratory move- ments, whether it be mechanical injury, strangulation, drown- ing, or the inhalation of noxious gases, is generally plainly manifest. The comatose state of an epileptic paroxysm closely resem- bles that of an apoplectic seizure due to cerebral haemorrhage, but the stupor of epilepsy is not usually accompanied by ster- torous breathing, nor is it often of long duration. Moreover, 102 INTRACRANIAL DISEASES. if the comatose condition is the result of an epileptic paroxysm, more or less froth, often colored with blood from a bitten tongue, may be found upon the lips, and not unfrequently small spots of extravasated blood may be seen under the skin of the forehead, e} r elids, and cheeks. Concussion is liable to be mistaken for cerebral haemorrhage, unless the patient has received mechanical injuries of such a nature as to show that the symptoms are the result of a fall or blow, such as bruises, fractures, bleeding from the nose or ears, etc. It is possible, however, that the fall may have been the consequence of a haemorrhage within the brain, in which case he may appear to be suffering from simple concussion when the chief injury is one of compression, perhaps complicated with fracture of the cranium. Hysterical coma sometimes bears a very close resemblance to that of cerebral haemorrhage, and may even be accompanied by well-marked hemiplegia; but in these cases there are gen- erally other evidences of the hysterical condition present, such as the hysterical constitution, an unembarrassed state of the circulation, freedom from stertor, etc. Uraemic coma is distinguished from the coma of cerebral haemorrhage, by the history of the case, the absence of hemi- plegia, the altered state of the urine, and the general presence of anasarca. Alcoholic intoxication is frequently confounded with cerebral haemorrhage, much to the discredit of the profession; though it must be confessed that the resemblance between the two conditions is sometimes so great as to render it extremely dif- ficult to make a satisfactory diagnosis. When, with the usual signs of inebriety, there is neither hemiplegia nor stertor, it will generally be safe to attribute the symptoms to drunken- ness, especially if the habits of the patient are of a character to warrant such a conclusion. Prognosis. — Cerebral haemorrhage is always a very danger- ous disease; so much so, that it is generally impossible, soon after the attack, to determine the result with any degree of accuracy. As a general rule, however, it may be stated that the danger to life is in proportion to the severity of the seizure; CEREBRAL HEMORRHAGE. 103 and in the severe apoplectic form the disease is almost always fatal within a few hours. If, however, life be prolonged three or four days, there is some degree of hope. Among the more important signs threatening a fatal issue, are: protracted coma, convulsions, general paralysis, dilated pupils, obstructed res- piration, foaming at the mouth, frequent vomiting, coldness and clamminess of the surface, and involuntary evacuations. Still, if the vital powers are husbanded, the patient may pos- sibly survive even these formidable symptoms, though it must be confessed, that if the patient escape for the time, he is very liable to sink sooner or later, either from a recurrence of the attack, or by a general failure of the vital powers resulting from the injury done to the brain. If, however, the patient survive the first onset of the disease without any subsequent aggravation of the symptoms, there will always be room for hope, even when the extravasation of blood is extensive. But it should always be remembered that about the eighth or ninth day of the seizure is a critical period, for then inflammation sets in about the clot and may destroy the patient. Not more than one in three of the cases attended with coma and hemiplegia survives the attack; whilst few if any can be said to fully regain their health. Each succeeding attack leaves the system less capable of enduring a renewal of the haemorrhage, so that finally the mental faculties, the power of speech, and the coordination of movements, are more or less defective. Besides, relapses are common, the disease being, as a rule, progressive in its nature. Consequently, although the patient may survive the second, third, and even fourth attacks, both the mental and physical powers suffer a gradual decay from secondary atrophy, which, as before stated, sooner or later terminates in death. Mild forms of the disease, however, especially such as are not attended with loss of consciousness, are not generally fatal, though the risk of inflammation excited by the clot is so great, that the patient cannot be considered out of danger, even in these cases, until after the eighth or ninth day of the seizure. Morbid Anatomy. — When the blood escapes into the sub- stance of the brain, it forms one or more cavities by the sepa- 104 INTRACRANIAL DISEASES. ration or laceration of the cerebral fibres, the haemorrhage con- tinuing until the resistance of the tissues becomes so great as to overcome the tension of the effused blood, when it ceases. The resulting cavities, and consequently the clots, differ greatly in size and shape, being round, oval, or irregular in form, and varying in diameter from that of a hazelnut or cherry to that of an orange. There is generally only one cavity and clot, though there may be several. In the former case, the clot is usually large, and occupies some portions of the grey matter. Most cases of cerebral haemorrhage result from rupture of the small branches of the middle cerebral artery. The blood penetrates the substantia perforata lateralis, and, pushing aside the optic thalamus, ruptures the corpus striatum, and finally invades the lateral, and sometimes the third and fourth ventricles. Next in order of frequency comes the optic thalamus. In more than half of the cases collected by Andral, the haemor- rhage took place into either the corpus striatum or the optic thalamus, or else into both. In about fifteen per cent, of the cases it occurred in the corpus striatum alone ; and in about seven per cent, of them in the thalamus opticus alone. We have already given Gintrac's statistics, in which it will be seen the corpus striata and optic thalami were found to be simulta- neously involved in nearly nine per cent, of the whole number of cases. Owing to pressure of the clot, the convolutions are often found flattened, the blood-vessels empty, and the cerebral tis- sue pale and anaemic. In most cases, the clot is mixed with debris of the cerebral matter, and the brain-tissue surrounding it is more or less softened. If the patient survive the stroke, the blood corpuscles and nerve-fibres undergo fatty degenera- tion, the effused serum is absorbed, and the fibrinous debris contracts and becomes hard, changing gradually from a black to an ochre color. Examined with the microscpe, the altered matter is found to contain granulations of haematosin and crystals of haematin and haematoidin. In some few instances, however, absorption fails to take place, and the cavity remains distended with blood until a new haemorrhage occurs, CEREBRAL HEMORRHAGE. 105 or an abscess results. The condition of the blood-vessels will be given under the head of Pathology. — The investigations of MM. Charcot and Bouchard leave little room for doubt, that cerebral hsemor- rhage is generally due to what they term miliary aneurisms. These minute aneurisms form upon the smaller branches of the cerebral arteries, in consequence of an inflammatory con- dition which results in atrophy of their middle coat, on which their power of resistance chiefly depends. These dilatations vary in size from a millet seed to that of a large pin-head. They adhere to the perivascular sheath ; and when ruptured they sometimes heal spontaneously by the formation of a clot in them, which afterwards undergoes degeneration. They are usually very numerous, and have been found in all parts of the brain ; in the fissures between the convolutions, in the white substance of the hemispheres, in the basal ganglia, in the cerebellum, and in the pons Varolii. They are not, how- ever, confined to the brain, but have been discovered in the central artery of the retina, in the oesophagus, on the visceral layer of the pericardium, and in the branches of the splenic artery. Nothing is positively known as to their origin, but it is reasonable to suppose that they owe their formation either to hereditary influences, or to debilitating causes, such as in- temperance, malnutrition, and old age. But although miliary aneurisms may, in the great majority of cases, be said to constitute an important factor in the pro- duction of cerebral haemorrhage, they are not the only form of vascular disease existing in these cases; for not only is athe- romatous degeneration of the cerebral blood-vessels a common pathological condition in the aged, but cases of cerebral haemor- rhage have been observed in which this condition affected all the arteries of the brain, while at the same time no miliary aneurisms were anywhere present. Other conditions doubtless favor the rupture of cerebral blood-vessels, such as an increased tension of the blood in the vessels; an unhealthy state of the blood, such as exists in typhus, scurvy, etc., rendering it unfit for the nourishment of the blood-vessels; atrophy or softening of the brain substance; 106 INTRACRANIAL DISEASES. and the various deteriorating influences mentioned under the head of causes. Treatment. — The treatment of cerebral haemorrhage is three-fold, preventive, palliative, and curative. 1. Preventive Treatment. — The preventive treatment consists in the avoidance, as far as practicable, of the ordinary causes of cerebral hsemorrhage, and the administration, when re- quired, of the remedies recommended for cerebral hypersemia (q. v.). 2. Palliative Treatment— -The palliative treatment of cerebral haemorrhage consists in the application of such auxiliary measures, and the observance of such hygienic regulations, as are calculated to lessen the effects of the injury and promote the welfare of the patient, especially at the time of the stroke and during the period of unconsciousness. Thus, the patient should be kept in such a position as will favor the return of blood from the head. The head and shoulders should be raised by pillows, the clothing loosened about the neck, and free ventilation of the patient's chamber constantly secured. The lower extremities, and especially the paralyzed limbs, should be kept warm by means of flannel wrappings, frictions, etc.; and the bowels should be emptied from time to time with lavements of tepid water, to which may be added, if necessary, a tablespoonful or two of castor oil. Attention should be paid to the bladder, and the urine drawn off regularly with the catheter, until the patient becomes able to void it voluntarily. The diet is also an important matter. In the early stages of the attack, nothing but gum-water, barley or rice-waier, toast-water, and similar farinaceous drinks, should be allowed; but as the case advances, and improvement sets in, more nu- tritious substances may be cautiously administered, such as milk, beef-tea, soft-boiled eggs, etc., provided no ill effects are thereby produced; but if, on strengthening the diet, the face becomes flushed and headache ensues, all stimulating and highly nutritious articles of food should be immediately with- drawn. If symptoms of inflammation set in, the treatment recommended for meningitis and encephalitis should be ob- served. CEREBRAL HAEMORRHAGE. 107 3. Curative Treatment. — The curative treatment consists, first, in the administration, as required, of the remedies specially indicated by the symptoms; and, secondly, in the removal, as far as possible, of the secondary effects of the injury, especially the paralysis and anaesthesia. No attempt, however, should be made to overcome the pa- ralysis until the brain symptoms have entirely disappeared, nor until the period of inflammation has fully past. It will then be proper, in most cases, to take measures for the relief of the paralysis, and for the prevention of muscular contrac- tions. For these purposes, in addition to the indicated reme- dies, we may make use of massage and electricity. The former is accomplished by kneeding the affected muscles with the fingers, and by flexing and extending the joints every day for ten, fifteen, or twenty minutes at a time. But the most successful treatment for hemiplegia, aside from medicine, is electricity. At first, or in recent cases, the induced current will usually be found to afford sufficient stim- ulation for the purpose. The current, which should be strong enough to produce contraction, or to cause slight pain, should be applied by means of wet sponges to the skin covering the muscles, or, if necessary, to the nerves. Old cases, and such as will not yield to the induced current, should be treated with the primary current, applied in such a manner as to be interrupted, as the constant current will not produce contrac- tions. Electricity is also a potent agent in promoting the restoration of sensibility, in cases in which the anaesthesia does not disappear spontaneously. Dr. Hammond extols the use of strong magnets in the treat- ment of the hemiplegia resulting from cerebral haemorrhage. In one of two cases in which he employed this agent, the paralysis and hemianaesthesia disappeared within half an hour; and in the other the hemianesthesia was overcome in less than five minutes. He made use in these cases of a mag- net capable of sustaining ten pounds of iron, simply laying it against the paralyzed side of the body. General Indications. — Premonitory symptoms. — Aeon., Amyl nit,, Bell., Cham., Gels., Glon., Hyos., Phos., Sepia, Strain., Yerat. vir. 10 S NIAL DISEASES. « During the attack. — Aeon.. Arn.. Bell.. C ecul., B Lach., Lauroc. Xux v., Opium, Merc Sanguin. Sub» changes. — Anacard.. Caust.. Cupr., Kali, Plumb., Rhus, Strain., Zineum. Special Indication — A — Inflammatory stage, or when the head is hot. the carotids throbbing, the pulse full, hard and strong, or weak, but not intermittent, the skin hot or warm, but not cold, and especially when caused by suppre- ha?niorrh: iges i after fright or vexation. — Drowsiness :th moaning and insensibility: eyes staring or dim; pupils dilated or contracted: pulse irregular, intermittent, or full and strong; respiration labored and snor- ing; involuntary evacuations of fseees and urine; paralysis, especially of the left side. This remedy is particularly suited to stout, middle-aged, plethoric people, with strong hemor- rhagic tendencies. Baryta. — Drowsiness, with semi-consciousness, in old people: dimness of sight : breathing short and suffocative : pulse small and irregular: anxiety, fear, and loss of memory: great rest- lessness and moaning ; paralysis of the tongue : general paralysis, especially of the right side; frequent discharges of urine and faeee- Especially suited to old people, particularly those ad- dicted to the excessive use of alcoholic drinks. Belladonna. — During the first, or con^ : t stage, during the period of stupefaction, and also during the inflamma: i period; drowsiness or loss of consciousness, with dilated pu: ils slow and full pulse, labored, irregular, and stertorous breath- ing: or, red and staring eyes, with redness of the face and icy coldness of the extremities : convulsive movements: paral; psis of the tongue, limbs, etc.; involuntary discharges of faeces and urine; dysphagia; wandering s of the mincL Cocculus. — Strong determination of blood to the head, fol- lowed by drowsiness, vertigo, and loss of consciousness: dim- ness of vision; pupils greatly dilated or contracted, -vith spasmodic rolling of the eyeballs: pulse small and hard; breathing tight and oppressed, with or witho ; stertor; con- vulsions and paralysis, esj e daily of the lower extremities CEREBRAL HAEMORRHAGE. 109 Lachesis. — Congestion to the head, with blueness of the face; absence of mind when conscious; drowsiness, or sopor and in- sensibility; dim and distorted eyes; pulse small, weak and irregular, or full and hard; slow, heavy, wheezing respiration; trembling of the muscles, or paralysis, especially on the left side; when caused by mental emotions or the abuse of liquors. Laurocerasus. — Patient speechless when conscious, or insensi- ble, with complete loss of consciousness and sensation; bloated face; eyes distorted and staring; vision completely lost; pupils dilated or contracted, and immovable; pulse very small, slow and irregular; convulsions, with subsequent paralysis, includ- ing paralysis of the sphincters ; great coldness, with clammi- ness of the surface, and deficient susceptibility to the action of remedial agents. Mercurius. — Constipation, followed by vertigo and loss of consciousness; dilatation of the pupils, with vanishing of sight; dyspnoea; feeble, slow, and trembling pulse; urine suppressed, or dark and turbid; great sinking and prostration; spasmodic movements of the limbs; paralysis, preceded by formication and followed by contractions. Nux vom. — Attacks preceded by constipation and high living, or by premonitory symptoms, such as vertigo, headache, roar- ing in the ears, etc.; sopor, with snoring; eyes dull and blurred; pulse full and hard, or small and weak; suffocative fits, or anxious dyspnoea; retention of urine; paralysis, especially of the lower limbs and lower jaw; cold extremities. Opium. — Coma, preceded by headache, vertigo, and other evidences of cerebral congestion ; pupils dilated, and insensible to light ; pulse slow, full or weak, and intermittent ; retention, or involuntary evacuation of urine; red and bloated face; trembling of the muscles; convulsive movements; dropping of the lower jaw; tetanic rigidity of the whole body ; head hot, with cold sweat; foam at the mouth; respiration slow, heavy and snoring. Pulsatilla. — Loss of consciousness, preceded by drowsiness, and occurring at the climacteric period, or preceded by an arrest or disturbance of the menstrual function ; eyes dull and bleared ; pulse almost imperceptible ; respiration impeded and 110 INTRACRANIAL DISEASES. rattling ; retention or incontinence of urine ; red and bloated face; violent palpitation of the heart; great weakness and trembling, followed by loss of motion. Sanguinaria. — Attacks caused by venous congestion ; burn- ing heat and redness of the face ; distension of the temporal veins ; sharp pain in the back of the head ; dizziness on quickly turning the head ; burning of the ears ; paralysis of the right side. , Sepia. — Attacks preceded by venous congestion, or by deter- mination of blood to the head ; headache coming on with flashing pains; vertigo when walking; intermitting pulse; cold feet ; absence of mind ; palpitation of the heart ; jerking of the limbs ; sudden stoppage of the menses. Especially adapted to women at the climacteric period, and to men ad- dicted to drinking and venery. Stramonium. — Vertigo, followed by stupor and insensibility; pupils dilated and insensible; pulse small, irregular, and almost extinct; deep, stertorous breathing; involuntary emis- sions of urine ; spasmodic rigidity and trembling ; stupefaction alternating with delirium ; convulsive movements ; paralysis, especially of the organs of speech. Zincum met. — Attacks preceded by stupefying headache, with great drowsiness, cold hands and feet, and livid face ; stupor, with vanishing of sight ; quick and irregular, or slow and weak pulse; weakness, heaviness, and trembling of the limbs; anxious dyspnoea; palpitation of the heart; jerking and twitching of the muscles ; senses remain disturbed after the attack ; symptoms aggravated by wine. THROMBOSIS OF CEREBRAL VESSELS. Ill CHAPTER V. « THROMBOSIS OF CEREBRAL VESSELS. By Cerebral Thrombosis is meant the gradual closure of a blood-vessel in the brain, by the deposition of fibrine upon its internal surface. It differs from embolism (1) in the clot origi- nating in the blood-vessel itself, instead of being carried into it from a distance ; (2) in being either venous or arterial ; and (3) in being gradual instead of sudden in its development, Symptoms. — The gradual occlusien of a cerebral vessel by a thrombus, gives rise to a large number of initiatory symp- toms, such as headache, vertigo, impaired memory, difficulties of speech, ocular troubles, diminished sensibility on one side of the body, tottering gait, and other evidences of approaching paralysis. These symptoms, however, are often interrupted by periods of apparent improvement; and even after paralysis sets in, the loss of power in the muscles of the face, arm, or leg, is not only gradual in its advance, but is interrupted by stages of remission, until at last the vessel is completely blocked up, when hemiplegia supervenes. Even then, unless speedily fol- lowed by death, improvement is likely to occur, and may con- tinue for a considerable period ; but as the disease is progres- sive, the attack is almost certain, sooner or later, to be repeated. The symptoms vary in different cases, according to the seat and extent of the lesion. When considerable, as where a large vessel or a number of small ones are closed, the paralysis is progressive, and is accompanied with muscular contractions and mental torpor. As in embolism, when the left middle cerebral artery is plugged, right hemiplegia with aphasia is produced ; whereas, if the same artery on the right side is oc- cluded, there will be left hemiplegia, but no aphasia. 112 INTRACRANIAL DISEASES. "What is called marantic thrombosis, or that form which occurs in the condition known as marasmus, is most frequently seen in weakly infants, especially after exhaustive attacks of diar- rhoea. In these cases, there is generally more or less rigidit} r of the muscles of the neck, back, and extremities ; and in some instances ocular troubles are present, such as ptosis, strabis- mus, and nystagmus. There is also, as in hydrocephaloid, cerebral ^seinia, followed by somnolence and coma; but these are not generally preceded, as in acute hydrocephalus, by marked excitement and convulsibility. Here the superior lon- gitudinal sinus is the seat of the thrombus. In adults, the symptoms of venous thrombosis are not usu- ally so well marked. There is generally, however, more or less headache, and mental and physical depression ; changes in the size of the pupils are also not uncommon ; and in some cases there is nausea and vomiting, swelling of the veins which communicate with the affected sinuses, more or less oedema, trembling of the limbs, and even convulsions. Thus, when the superior longitudinal sinus is involved, we have swelling of the veins of the auricular and temporal regions, together with epistaxis from congestion of the veins of the nose. Thus, also, thrombus of the transverse sinus leads to oedema behind the ear ; and thrombus of the cavernous sinus, which commu- nicates with the ophthalmic veins, frequently causes a bulging of the eye between the lids, which are oedematous, and also hyperasmia of the fundus oculi. Causes. — Whatever impedes the flow of blood in the cere- bral vessels may lead to the formation of thrombi, not only in the cerebral veins and sinuses, but in the arteries. Hence, we find that coagulation of blood in the vessels of the brain is most apt to occur in debilitated states of the system, as in the advanced stages of tuberculosis and cancer; after typhus and other low fevers; exhausting diarrhoeas, especially in young children; chronic inflammation of the joints; diffuse suppu- rations; caries; syphilis; atheromatous degeneration in the aged and decrepid ; cardiac debility ; pressure from tumors and effusions, and other like causes. It has also been attrib- uted to other agencies, such as exposure to intense heat, THROMBOSIS OF CEREBRAL VESSELS. 113 severe mental strain or shock, and suppression of the menses ; and there can be no doubt that blows on the head produce it, by exciting phlebitis in the sinuses of the dura mater. The disease is much more common in males than in females, probably because the former, in consequence of exposure, are more subject to rheumatism, which seems to favor the disease by increasing the amount of fibrine in the blood, and also by impairing the action of the heart. Diagnosis. — Cerebral thrombosis may be distinguished from cerebral haemorrhage by the gradual development of the symp- toms; from encephalitis by the absence of fever; and from both, by the previous history of the case. It may be distinguished from embolism by (1) its slow development; (2) the advanced age of the patient; (3) the evidences of atheroma, fatty degen- eration of the heart, slight attacks of paresis or paralysis, and other characteristic symptoms; and (4) the absence, in most cases, of any previous history of rheumatism. Prognosis. — The prognosis in cerebral thrombosis is un- favorable, not only because the conditions which lead to it are of an unfavorable character, but because the disease is pro- gressive, and the danger of complete obliteration very great; in which case the probability that the collateral circulation will become sufficiently established to prevent softening is very remote. Moreover, the inefficiency of medical treatment in controlling the progress of the disease, is also an unfavorable omen. Morbid Anatomy and Pathology.— Although a number of the older medical authors have recorded undoubted cases of thrombosis, Virchow,* in 1816, was the first to give a full and satisfactory explanation of its nature. Since then, many cases of cerebral thrombosis, both arterial and venous, have been met with, fully confirming Virchow's observations, and leaving no room for doubt as to the pathology of the affection. Many of these cases are due to atheromatous degeneration of the cerebral arteries, of which the following, which recently occurred in my practice, is a good illustration. The patient * Neue Notizen, Heft xsxvii. 114 INTRACRANIAL DISEASES. was a man seventy-two years of age. For years he had ex- hibited symptoms of atheroma, and of fatty degeneration of the heart. The radial and temporal arteries were rigid from atheromatous degeneration; and when he came under my care, about four months previous to his death, there was evi- dent disease of the aortic valves. The patient had already had two attacks of right-sided paresis, accompanied with aphasia; and shortly after I saw him he had another, which came on suddenly, and left him unconscious for a period of nearly three hours. He, however, slowly rallied again, but never fully recovered his speech, nor the use of his right extremities. About six weeks after this he had a fourth attack which proved fatal, dying in a comatose condition some forty-eight hours after the stroke. TJie post-mortem examination showed centres of softening in the cortex of the left middle lobe of the brain, which were clearly traceable to thrombi blocking several of the branches of the left middle cerebral artery, the walls of which were all affected with atheromatous degeneration. The other cerebral arteries, as well as the aorta and the aortic valves, were atheromatous, while the chord se tendinese and muscular structure of the heart had undergone fatty and calca- reous degeneration. A still more remarkable case of arterial cerebral thrombosis has been described by Heubner,* in which syphilitic thrombi were found closing the right anterior and left middle cerebral, the left vertebral, and the basilar arteries. In consequence of the diseased condition of the blood-vessel, the internal coat becomes roughened — a circumstance which favors the deposition of fibrine at that point. The primary layer of the thrombus, thus formed, becomes gradually thick- ened by fresh accretions, until finally it fills the whole calibre of the vessel and completely obstructs it. The clot which closes the vessel is, in the beginning, nothing but coagulated blood; but as the elements of which it is com- posed are deposited gradually, the red corpuscles are washed away by the current of blood which continues to flow through * Die Luetische Erkrankung der Hirnarterein, 1874. THROMBOSIS OF CEREBRAL VESSELS. 115 the vessel during the process of formation, so that the thrombus may be of every shade of color, from a white to a brown. For the same reason, the lower layers of the clot are usually of greater consistency than those nearer the centre of the vessel. and consist almost entirely of fibrine. TVnile the artery is undergoing occlusion, the part of the brain to which it is distributed is more or less anaemic; but as soon as it becomes entirely closed, the anaemic parts change to a pink or reddish color, which is known as red softening. This state is probably one of passive hyperaemia, combined with (edematous swelling and haemorrhage; and unless the collateral circulation is speedily and adequately established, neero-biotic or yellow softening quickly supervenes. Treatment. — The treatment of this affection resolves itself chiefly into (1) the removal, as far as possible, of all debilita- ting causes and conditions; (2) aiding the general circulation, when defective, by both local and constitutional means: and (3 1 the administration of such medicines as the symptoms may, from time to time, indicate — remedies which have already been given under the heads of cerebral anaemia, apoplexy and haemorrhage (q. v.). After the collateral circulation has become established, electricity will often be found to be a useful aux- iliary in restoring the strength of the patient, and especially in overcoming the muscular paresis or paralysis still existing. 116 INTRACRANIAL DISEASES. CHAPTER VI. EMBOLISM OF CEREBRAL ARTERIES. By cerebral embolism is meant the sudden obliteration of one or more cerebral arteries or arterial capillaries, by small clots carried into them from distant parts of the body. Symptoms. — Cerebral embolism, unlike cerebral thrombo- sis, has no precursory symptoms, but the patient is seized with- out premonition with symptoms of apoplexy, such as sudden loss of consciousness and paralysis. These s} T mptoms, how- ever, are generally less pronounced than in cerebral haemor- rhage, there being in many cases no coma, but merely confu- sion of mind, with sudden paralysis of one or more sets of muscles on the side opposite the lesion. There are generally no symptoms of compression, though there may be epiliptiform convulsions. The pulse is usually small and weak, and the temperature is somewhat depressed. The symptoms, however, vary in different cases. Thus, there may be no paralysis whatever, or it may be limited to a single part, as the arm, the leg, the face, or the tongue. The faculty of language is generally either lost or greatly impaired ; and sometimes there are ocular troubles, such as amaurosis, ptosis, or strabismus. There may or may not be headache, vertigo, vomiting, dilated or con- tracted pupils, and the other signs usually met with in cere- bral haemorrhage, the presence or absence of these symptoms depending upon the artery affected. Thus, if the embolus blocks the left middle cerebral artery, which is its usual site, we may have all the signs of corpus striatum haemorrhage, or simply hemiplegia with aphasia. Similar effects will be pro- duced by blocking of the right middle cerebral artery, except that there will be no aphasia. Obliteration of the basilar ar- EMBOLISM OF CEREBRAL ARTERIES. 117 tery by an embolus causes vomiting ; whilst plugging of the ophthalmic artery produces sudden amaurosis. The ophthal- mic artery and its branches may be gorged with blood from embolism of the middle cerebral artery, and then the optic papilla will appear red, and the vessels of the retina, enlarged and congested. Causes. — Acute and chronic endocarditis are the most common causes of cerebral embolism. The emboli, which con- sist of clots of blood, fibrine, atheromatous debris, or prolife- rated connective tissue, are detached from their several seats on the valves of the heart and other parts of the endocardium, the lining membrane of the aorta, or from a thrombus formed in the pulmonary vein, and, entering the circulation, are swept onward through the carotid or vertebral arteries into a cere- bral artery — generally the left middle cerebral — where they become impacted. Other large arteries are sometimes ob- structed in this manner, as the internal carotid, the vertebral, the anterior cerebral, and the basilar. Instead of a stoppage of one of the main cerebral arteries by a comparatively large mass, numerous small emboli may form from a quantity of fibrinous debris entering the circulation from an aneurismal sac, a pulmonary abscess, or a heart-clot. An interesting case of this kind occurred under my care, in Brown General Hospital, in 1864. Oscar M. Root, of Co. B, 107th N. Y. Vol., entered the hospital for gun-shot wound of the hand. After convalescence, he continued weak and unfit for duty, and so was allowed to remain in the hospital. One pleasant day in September I gave him a pass to go outside the hospital grounds, where he remained three or four hours, quietly walking about. On returning, about 5 p.m., he sud- denly became unconscious, and was found to be paralyzed on the right side of the body. The next day consciousness re- turned, but he was unable to speak intelligently. Two days afterwards, at midnight, he suddenly died. A post-mortem examination showed a large, white heart-clot filling the left ventricle, and no less than six small emboli blocking the branches of the left middle cerebral artery. There was no organic disease of the heart, though the ventricular walls ap- peared somewhat thin and flabby. 118 INTRACRANIAL DISEASES. Diagnosis. — When the symptoms of apoplexy are present, it may not be possible to distinguish the disease with certainty from cerebral haemorrhage; but in many cases there is only sudden paralysis without loss of consciousness. Eight hemi- plegia with aphasia indicates, as we have seen, occlusion of the left middle cerebral artery; whilst embolism of the right middle cerebral produces left hemiplegia without aphasia. We have also seen that plugging of the ophthalmic artery gives rise to sudden amaurosis; whilst the sudden blocking of the basilar artery causes vomiting. These are diagnostic points of great value when other symptoms are found to correspond. When the symptoms of paralysis vanish suddenly, we may be sure the stroke was not caused by cerebral haemorrhage; and if recovery takes place within two or three days after the attack, it can only be referred to an embolus. Moreover, the disease occurs without reference to age; there are no premon- itory symptoms; the paralysis, in the great majority of cases, is on the right side, and is usually combined with aphasia; finally, the disease is almost always associated with organic disease of the heart. Prognosis. — The tendency to softening of the brain is so great in every case of cerebral embolism, as to render the prognosis exceedingly grave. There can, of course, be no safety for the patient until the collateral circulation is fully established; still, if three or four days pass without any ag- gravation of the symptoms, and especially if they become gradually ameliorated, there will be some hope of a favorable issue. The degree of paralysis depends upon the extent of the lesion, and when this is considerable, death may take place within a few hours, but it is not always sudden, and is often preceded by pneumonia. In cases where the collateral circulation is quickly, but not perfectly restored, there is a corresponding improvement in the paralytic symptoms. Thus, the limbs may regain a certain degree of voluntary power, while the faculty of speech and the mental functions may re- main more or less impaired. Morbid Anatomy and Pathology. — Since the year 1847, EMBOLISM OF CEREBRAL ARTERIES. 119 when Virchow* first described the manner in which the so- called " vegetations," or fibrinous deposits, are detached from the valves of the heart and transported to distant parts of the body, his observations and conclusions have been confirmed by many competent observers, especially by Cohnheim and Schutzenberger,f who have shown that the cerebral blood- vessels may be plugged by fibrinous concretions derived from the heart or large vessels; that this occlusion causes anaemia of those portions of the brain to which the affected artery is distributed; that in most cases partial or complete hemiplegia is the immediate consequence of the lesion; and that if the obstruction is not speedily overcome, softening of the brain is sure to result. The reason that the left middle cerebral artery is most fre- quently obstructed by emboli is, that the left carotid — arising as it does from the arch of the aorta more nearly in a line with the current of blood from the heart, than either the in- nominate or the left subclavian — receives the clot, which, after passing through the internal carotid, is swept with the more direct current into the middle cerebral artery. More than three-fourths of all the cases of cerebral embolism on record occurred in the left hemisphere, and a still larger proportion of these implicated the left middle cerebral artery. For obvious reasons, the portions of the brain behind the clot are more or less congested, while those to which the oc- cluded vessel is distributed are pale and anaemic. An im- portant fact in the pathology of embolism is, that the artery itself is not diseased. If examined during the first stage, or previous to the setting in of cerebral softening, those parts of the brain supplied by the obliterated vessel will be found bor- dered by a zone of congested tissue, with perhaps a number of small extravasations of blood. The changes which take place subsequently belong to cerebral softening (q. v.). Treatment. — The most that can be done in these cases, in the way of treatment, is, to favor the establishment of the * Archiv. fur Pathol. Anatomie, I, 272. f Gaz. des Hop., 80, 1857. 120 INTRACRANIAL DISEASES. collateral circulation by lowering or raising the head, accord- ing as the cerebral circulation is more or less embarrassed; by promoting the general circulation by friction, and wrapping the body and limbs in warm blankets, in case the patient is somnolent and the bodily temperature much reduced ; and by the administration of such remedies as are best calculated to equalize the circulation and sustain the powers of the system; all of which have been fully considered under the heads of apoplexy and cerebral haemorrhage (q. v.). CEREBRAL SOFTENING. 121 CHAPTER VII. CEREBRAL SOFTENING. Softening of the brain usually depends upon embolism or thrombosis of certain cerebral blood-vessels, especially of the middle cerebral artery. The disease was formerly re- garded as an inflammatory affection, whereas it is now known to result, in most cases, from disturbances in the nutrition of the parts supplied by certain cerebral arteries, the plugging of which, by depriving them of nutritive material, eventually produces necro-biotic softening. Symptoms. — The symptoms vary according as they are produced by a thrombus or an embolus. When caused by a thrombus, the disease is never so sudden in its invasion as when produced by an embolus; neither is it attended by the shock to the brain which usually accompanies the sudden entry of a foreign body, such as is met with in cerebral haem- orrhage and embolism. In whichever way produced, however, the symptoms peculiar to those diseases are the ones which first present themselves. Thus, we may have the premonitory symptoms of thrombosis, such as headache, vertigo, loss of memory, difficulties of speech, numbness and creeping chills in one side of the body, various ocular troubles, staggering gait, incontinence of urine, and other symptoms indicating the approach of paralysis; and finally, perhaps, hemiplegia, which may occur gradually or suddenly, according as the affected vessel is large or small, or according as it affects the cortical or basal sphere of nutrition. When, as in many cases of embolism, the initial symptoms are those of apoplexy, they are similar to those produced by cerebral hsemorrhage, being attended in some instances by coma, dilated or contracted 122 INTRACRANIAL DISEASES. pupils, stertor, vomiting, convulsions, and paralysis, as de- scribed under that bead. These apoplectic symptoms may vanish more or less suddenly, or they may continue with little or no remission until the death of the patient, which may occur within a few hours after the stroke. The first stage in the process of softening is that of simple anaemia, and probably lasts only one or two days. If the collateral circulation is not fully established, we next have one of two conditions, namely, the appearance known as red softening, or the condition called yellow or white softening. The first is due to hypersemia, with cedematous swelling and haem- orrhage, and the latter to the subsequent changes in the af- fected tissues, or else to simple necro-biosis of the parts, or what is called primary yellow softening, in which the character- istic degeneration occurs without any previous hypersemia and haemorrhage. In cerebral softening, the variations of temperature are more frequent, but much less marked, than in cerebral haemorrhage. Thus, in many cases, but not in all, the temperature suddenly rises soon after the attack to 102°-104° F., and then falls again to about the normal average. Sometimes it remains stationary at this point for a day or two, or undergoes morning or even- ing fluctuations, oscillating back and forth with marked irreg- ularity ; but as the softening process advances, the tempera- ture gradually begins to rise, and finally reaches a maximum of 103° or 104°F., which is much less than that of cerebral haemorrhage. The next stage, or that of yellow softening, does not usually set in until about the tenth day, though it may occur earlier, some cases being much more rapid in their progress than others. The mental symptoms now become more prominent. Delusions and hallucinations occasionally take possession of the patient's mind, and sometimes he is delirious, but these symptoms are generally of short duration. He is particularly apt to be what is called "notional," indicating weakness of mind. The mental debility also shows itself in other ways. Thus, although unable to execute any complicated intellectual operation, or even to concentrate his attention upon any partic- CEREBRAL SOFTENING. 123 ular matter, he ma} 7 nevertheless deem himself fully capable of managing his business affairs, and that, too, notwithstanding the continuance of motor paralysis and the loss of sensibility on one side of the body. As a general rule, however, the mem- ory is so much impaired, that if the patient attempts anything of the kind, he will make frequent, and often ludicrous mis- takes, such as charging himself with articles he has sold, or imagines he has sold, to others, and vice versa. It is no un- common thing for such patients to forget the names of the places where they reside, and even to forget their own names. At the same time, it is equally true that softening may occur without the patient exhibiting any signs of imbecility; or, what is more common, there may be a general loss of intelli- gence, and yet some of the mental faculties, such as the will, may be greatly increased in power. Headache is a very common and persistent symptom of soft- ening of the brain ; is usually seated in the forehead ; and is generally of a dull, gnawing character. Other troublesome head symptoms, such as a sense of constriction, vertigo, weight and fulness, are generally present. Drowsiness, also, is a prominent feature in these cases, especially in the later stages of the disease. But the most marked phenomena are those connected with the functions of speech and motion. The former is almost always more or less affected, either in the form of aphasia, or from paralysis of the muscles concerned in articulation. AVhen caused by cerebral embolism or haemorrhage, the defect is apt to be of an amnesic character, words being either mis- placed, or used in a wrong sense ; but when thrombosis or capillary obstruction is the cause, the trouble is generally of a paralytic nature. Owing to paresis of the muscles of articula- tion, many patients omit the last letter or syllable of all but the shortest words, both in reading and speaking. Thus, a patient of mine called a " Manual of Materia Medica," " Manu of Mater Medic." The same patient when asked his name, replied, " Samu Wils." This clipping of words is sometimes one of the earliest manifestations of the disease. As a general rule, however, the first evidence of paresis, in 124 INTRACRANIAL DISEASES. softening of the brain, is manifested in the lower extremity. Sometimes the patient stumbles, or the leg suddenly gives way at the knee. In other cases, the muscles of the hand and arm are first affected. The patient's grasp is weakened, so that he frequently drops what he is holding, and if tested by the dynamometer, it will be found to be considerably less than normal. In these cases of chronic softening, the paralysis generally goes on from bad to worse, with perhaps occasional intervals of improvement, until complete hemiplegia is produced, and all muscular power is lost. In cases attended with apparent amendment, the patient's friends are very liable to be de- ceived with the vain hope that he is recovering, especially if the mental condition is also ameliorated ; but the physician should not allow himself to be deceived, as these cases are almost certain, sooner or later, to terminate fatally. So that, whether acute or chronic, the disease eventually is generally marked by the symptoms of aphasia, paralysis, coma, convul- sions, and death. The duration of the disease varies from a few days to several years. If, with Hammond and others, we limit the necro- biotic process to the stage of yellow or white softening, then the range is from ten or twelve days to about three years. Some cases, however, terminate by apoplexy in the course of three or four days, while others are protracted to as many years. The former are generally due to embolism, and the latter to thrombosis, of cerebral vessels. The symptoms above described are those which belong to softening of the cortical substance, the optic thalamus, or the corpus striatum. But when the necro-biosis is seated in the pons Varolii, and limited to it, there is little or no intellectual derangement, but the symptoms are such as we would natu- rally refer to that ganglion, such as dyspnoea, cardiac disturb- ances, nausea, vomiting, difficulty of swallowing, glosso-labio- laryngeal paralysis,* etc., according as the lesion involves one or more of the nerves springing from that part of the brain. * See Nervous Diseases, p. 168. CEREBRAL SOFTENING. 125 Softening of the cerebellum cannot be distinguished clinically from other structural lesions, such as haemorrhage, tumor, or abscess, though the symptoms peculiar to diseases of this part, taken in connection with the history of the case, may furnish sufficient data on which to base a probable opinion. Causes. — We have already considered the chief points in the etiology of cerebral softening, under the heads of cerebral em- bolism and thrombosis (q. v.). Other agencies, however, are re- garded as influencing its occurrence, especially age; for al- though the disease has been met with at every period of life, it is chiefly a disease of old age. Hammond, who claims to have seen forty-five cases of cerebral softening which were not the result either of haemorrhage, embolism, or thrombosis, says that eleven of them were clearly the result of intense and long- continued intellectual exertion. Kostan mentions, among other causes, blows upon the head, the excessive use of alcoholic liquors, and exposure to the action of severe cold, to the rays of the sun, or to intense heat. It is probable, indeed, that any cause capable of exciting cerebral inflammation, may occasion- ally act either as an exciting or a predisposing cause of the disease. Diagnosis. — Softening of the brain, unless preceded by the symptoms of haemorrhage, embolism, or thrombosis, is liable to be mistaken for chronic meningitis, meningeal haemorrhage, and cerebral tumors. In chronic meningitis, the headache is usually more circumscribed, the paralysis more limited, and the spasms of the limbs more frequent; while there is an ab- sence, in most cases, not only of well-marked febrile symptoms, but of that progessive intellectual impairment which charac- terizes most cases of necro-biosis. Hsematoma of the dura mater may generally be distinguished by the early occurrence of coma. Cerebral tumors are characterized by intense pain and convulsions, the intellect and speech remaining, as a general rule, unaffected. In most cases, also, the history of the case will aid in the diagnosis. Prognosis. — The prognosis is exceedingly grave, though not altogether hopeless. If, as stated by Hammond, the pa- tient be young, of good constitution, and of temperate habits; 126 INTRACRANIAL DISEASES. if the centre of softening be small, and not involving the more important parts of the brain, there is some encouragement to expect a favorable termination. There is no doubt that partial cerebral anaemia may occur from embolism of cerebral vessels, and yet, owing to the prompt establishment of the collateral circulation, never advance to the stage of yellow softening; and, on the other hand, the affected tissue may degenerate into what is called white softening, the history of which is decidedly chronic. But that the necro-biotic process, when once set up, can be effectually arrested, or that the paralysis and other consequences resulting from it can be permanently overcome, is not only highly improbable in itself, but is unsupported by any clinical evidence. Morbid Anatomy and Pathology. — We are chiefly in- debted to the investigations of Virchow, Heubner, Soulier and Cohnheim for our present knowledge of the necro-biotic pro- cess known as softening of the brain. When the obstruction in the cerebral vessels takes place on the far side of the circle of Willis, necro-biosis is quickly established, because there is no free vascular connection by which a collateral circulation can be speedily effected. Hence, the parts supplied by the vessel at once become anaemic, and, nutrition being cut off, soon undergo one or the other of the following changes: In the first place, hyperemia, with ©edematous swelling and haemorrhage, may be the speedy result. This is the condition known as red softening — a condition long held, both by the French and English schools, as being of inflammatory origin. In this state, the cerebral mass appears increased, whilst its consistency is diminished. The capillary haemorrhage is so great as to change the color of the parts to a bright pink, and even to a deep red ; but the color gradually fades, until within a few weeks it presents the appearance of yellow softening. In red softening the color, as shown by the microscope, is due entirely to the extravasation of red corpuscles. At a later period the nervous elements undergo degeneration. The nu- clei of the neuroglia and of the connective tissue of the perivas- cular lymphatic spaces, as well as of the muscular coat of the blood-vessels, and also the cells of both the cerebral substance CEREBRAL SOFTENING. 127 and the capillary vessels, are all metamorphosed into granular globules ; and finally nothing remains but fatty detritus mixed with crystals of haematin. Now, the explanation of this process is as follows : When an isolated terminal artery is obstructed, the blood flows backward from the proximal portion of the artery, which is still pervious, into the corresponding vein, producing hyperaemia and haemor- rhage by transudation of the red corpuscles from the entire vascular sphere of the obstructed vessel. In case the patient survives a sufficient length of time, white softening is produced, the cerebral matter changing into a milk- like emulsion, part of which eventually becomes absorbed, leaving in some cases a cyst partially filled with liquid, re- sembling the cysts found after ordinary attacks of cerebral haemorrhage. But if no hyperaemia and haemorrhage occur, then we have what is called primary yellow softening or simple necro-biosis, the parts immediately undergoing fatty degeneration, without the previous changes above mentioned. This result occurs, according to Cohnheim, in those cases where the blood coagu- lates so quickly in the sphere of the obliterated vessel, as to prevent any reflux of blood through the corresponding vein — an event which is found to occur chiefly where the propulsive power of the heart is perceptibly diminished. Treatment. — It is evident from what has just been said, that the only chance for the patient lies in the early adoption and steady use of supporting measures, and that any treatment cal- culated to lower the tone of the system, no matter what it may be, must have a prejudicial effect. At the same time, it is equally evident that, as the symptoms vary according to the special cause that produces them, so the treatment must in an especial manner be directed against the latter, as affording the only chance of curing, or even of ameliorating, the condition of the patient. As embolism and thrombosis are the two principal causes of the disease, the reader is referred to those heads for such treat- ment as relates especially thereto. We may also add, that all intellectual exertion, and every form of mental and bodily ex- citement, should be avoided. If the general circulation is 128 INTRACRANIAL DISEASES. much embarrassed, the patient should be kept in a quiet, re- cumbent position, while the body and extremities should be kept warm by artificial heat or by additional clothing. General Indications. — When caused by arterial obstruction, Abro- tanum, Anacard., Arsen., Digit., Xux yom., Phos., Phos. ac, Pier, ac, Zinc phosphide, Zincum. When recent, or due to inflammatory action, Bell., Gels., Glon., Merc, Xux vom., Plumb. When there is active hypersemia, Aeon., Bell., Bry., Glon., Xux vom. Where there is passive congestion, Gels., Opium. For headache, Aeon., Bell., Bryon., China, Gels., Glon., Igna., Xux vom., Phos. ac, Sulph. For vertigo, Arm, Bell., Chin., Con., Digt., Iod., Lack., Xux vom., Puis., Sulph. For insomnia, Cact., Cham., CofT., Gels., Hyosc, Xux vom. For drowsiness, Bell., Digt., Opium, Phosp. ac, Zincum. For loss of memory, Alum., Amm. c, Anac, Bell., Bovis., Cocc, Hyosc, Xat. m., Olean., Phosp. ac, Sulph. For aphasia, Bell., Canst., Colch., Conium, Glonoin, Kali brom., Lycop., Oleand., Stram. For imbecility, Ambra., Arm, Selen., Sepia. For convulsions, Bell., Calc c, Cupr., Xux vom., Strych. For local paralysis, Aeon., Bell., Caust., Gels., Igna. For general paralysis, Cocc, Conium, Phosp., Phus. For hemiplegia, Arnica, Baryta c, Cocc, Xux vom., Strych. Special Indications. — Aconite. — Headache, especially when caused by active cerebral hypersemia; also for well-marked febrile symptoms, or when the bodily temperature is too high, especially at the beginning of the disease; local paralysis. Belladonna. — When recent, or due to inflammatory action, especially if there is a fixed headache, vertigo, drowsiness, or loss of memory; absent-minded or forgetful; local paralysis; convulsions. Digitalis. — Softening of the brain arising from arterial ob- struction, and attended with vertigo, or cardiac weakness. Gelsemium. — Recent inflammatory cases, or when there is headache from passive congestion ; ocular troubles. CEREBRAL SOFTENING. 129 Nux vomica. — Softening of the brain arising from active con- gestion, cerebral inflammation, or arterial obstruction; head- ache; vertigo; sleeplessness; convulsions; hemiplegia. Natrum mur. — Aphasic symptoms; making mistakes in writing; talking awkwardly, or in an absent-minded and dis- tracted manner, saying things not intended. Lycopodium. — Forgetful; omits letters and words in writing; uses wrong words to express his meaning; confusion of mind, especially about common things. Phosphoric acid. — Cerebral softening attended with severe headache or drowsiness, with loss of memory; general paralysis. Phosphide of Zinc. — Softening of the brain from vascular obstruction, especially when accompanied with severe head- ache, dizziness, insomnia, loss of memory, or drowsiness; car- diac weakness, with palpitation. Strychnia. — Cerebral softening from arterial obstruction, es- pecially when accompanied by general paralysis, or hemi- plegia, or when Nux vomica is inefficient. 130 INTRACRANIAL DISEASES. CHAPTER VIII. ENCEPHALITIS. Encephalitis, or, as it is sometimes called, cerehritis, is a partial inflammation of the substance of the brain ; the dis- ease being confined to certain foci, or centres. General inflam- mation of the brain seldom or never occurs without involving the cerebral membranes, and it is therefore described under the head of meningitis (q. v.). Encephalitis is not only limited to comparatively small por- tions of the cerebral tissue, but is usually of a subacute or chronic character. It is, however, sometimes acute, especially if the inflammation involves a considerable portion of the cere- bral substance, in which case the inflammation passes rapidly through its several stages, and may soon terminate in death. Even when the disease is limited to a very small portion of the brain, it may prove speedily fatal, owing to the particular part affected ; as, for example, the corpora pyramidalia of the medulla oblongata, or the parts contiguous to the cerebral membranes. Symptoms. — Although encephalitis is generally marked at different stages of its progress with more or less irregularity of function, delirium, and spasmodic action, the symptoms vary greatly in different cases, and are rarely sufficiently character- istic to entitle them to be regarded as pathognomonic. Thus, the disease sometimes runs its entire course without giving rise to any well-marked cerebral symptoms. In other cases, it be- gins in a very slow and insidious manner, and it is not, per- haps, until after the disease has made considerable progress that the diagnosis becomes at all clear. Again, it may set in suddenly, with s}^mptoms of apoplexy, and afterwards run a very protracted course ; or, as occasionally happens, the initial ENCEPHALITIS. 131 symptoms may be of a high inflammatory character, in which case the cerebral membranes are apt to be more or less involved. In most cases the patient is attacked with a dull, but some- times severe, deep-seated pain in the head, commonly of a con- tinuous, but occasionally of a paroxysmal character, which frequently precedes all other s}^mptoms. Afterwards, and sometimes from the very commencement, other premonitory symptoms are experienced, such as vertigo, dimness of vision, buzzing in the ears, disposition to faint, nausea, loss of appe- tite, hesitancy of speech, wandering pains in the limbs, sensa- tion of numbuess or tingling in various parts of the body, with heaviness and cramps in the extremities, and an unsteadiness of gait, betokening the approach of paralysis. These symptoms, however, are all common to other cerebral diseases, and although the general health is now more or less impaired, the ordinary absence of fever, and of any derange- ment of the intellect, prevents, as a general rule, all apprehen- sions of impending danger, until at last the patient is suddenly seized with stupor, insensibility, and paralysis. From this condition he may so far recover as to exhibit some signs of in- telligence ; but some degree of drowsiness, apathy, and mental weakness, as well as loss or impairment of the special senses, remains. As the disease advances, the flexor muscles of the paralyzed limbs become rigidly contracted. This condition of rigidity, or tonic spasm, is supposed to indicate the process of softening of the affected tissues. If the patient survives this stage of the disease, the rigidity of the paralyzed muscles gradually gives way, and is suc- ceeded by complete paralysis. Exacerbations and remissions frequently occur, but sooner or later the patient sinks into a state of profound coma, from which the system never rallies, and death at last closes the scene. This is a brief outline of the most common form of the disease; but, as before stated, there is no fixed type to the malady, nor any regular order of succession in the symptoms. In almost every case the mental faculties are more or less impaired. As a general rule, symptoms of depression show themselves from the very beginning. The patient is drowsy, 132 INTRACRANIAL DISEASES. indifferent, forgetful, thinks slowly, hesitates in his speech, and is easily confused. He is seldom attacked by mania, but is apt to be somewhat delirious at times. At the close he gen- erally sinks into a state of dementia, followed by coma. The nerves of special sensibility are generally affected, es- pecially those of sight and hearing. Hyperesthesia of the retina is not uncommon ; and there is generally more or less ciliary neuralgia, accompanied with suffusion of the conjunc- tiva, and a contracted state of the pupils. The hearing in most cases is very acute at first, and accompanied by tinnitus aurium. As the disease advances, however, these two senses generally become more and more impaired, and are finally lost. Common sensibility suffers in like manner; at first from hyperesthesia, and afterwards from anaesthesia. Thus, we have pains in various parts of the body and limbs, often ac- companied by cramps, or we may have formication and numb- ness. Headache, though generally present from the begin- ning, is not usually very severe, and when it is, it shows that the cerebral membranes are more or less affected. Fever is seldom a prominent symptom unless the mem- branes are implicated, or the disease is complicated by pyaemia, otitis, or some other disturbing cause. The temperature rises but little above the natural standard, rarely exceeding 102° F. The pulse, which at first is generally somewhat accelerated, rising in some instances even as high as 120, becomes retarded as the disease advances, falling occasionally as low as 40 beats in the minute. The respiration is not usually much affected in the earlier stages, but towards the close it becomes irregular and ster- torous, and ends frequently in asphyxia. The digestive organs are more or less deranged, the appetite being deficient, the tongue coated, and the bowels constipated. Nausea and vomiting are apt to prove troublesome, especially when the cerebellum is implicated. The motor function is almost always impaired, there being at first increased excitability, followed sooner or later by pa- ralysis. Thus, there is tremor of the flexor muscles, twitch- ing of the muscles of the face, and clonic or tonic spasms. ENCEPHALITIS. 133 General convulsions may also occur, especially towards the close, with or without loss of consciousness. Paralysis may take the form of hemiplegia, or it may be confined to a single limb. In most cases, however, it takes the form of paresis, causing an unsteadiness in the use of the hands, or a tottering gait. The ocular muscles are frequently involved; and we may have facial palsy, from implication of the portio dura. The action of the tongue and other muscles concerned in ar- ticulation are always more or less impaired, rendering the speech thick, hesitating and indistinct. In the aged the disease generally pursues a very chronic course. There is headache, dizziness, general weakness, men- tal hebetude, disinclination to work, irritability of temper, de- pression of spirits, and restlessness, the latter more especially at night. The mental faculties are more or less impaired ; and the patient suffers from tremor, epileptiform attacks, and in- complete paralysis with contraction. At last the system be- comes completely broken down, and convulsions, paralysis, delirium, coma, and death, make up the subsequent history. AVhen encephalitis is complicated with inflammation of the meninges, as in cases arising from otitis, or from injury, the symptoms are mixed with those of meningitis. The onset in these cases may be gradual or sudden, according to the extent of the lesion and the particular parts affected. When the mor- bid phenomena are rapidly developed, the cerebral disturbance is usually very great, being attended with headache, vomiting, fever, convulsions, somnolence, and coma. In other cases, the disease is often protracted through many months, remis- sions or intermissions alternating from time to time with exacerbations. If the patient survive long enough, the disease generally ter- minates in the formation of cerebral abscess, the chief symptoms of which are circumscribed and persistent headaches, usually accompanied with rigors, and, in many cases, with convulsions. Causes. — Encephalitis is generally the result of traumatic injuries, such as blows, falls, etc. Hence it is found to occur chiefly in adult males, who are more exposed than females to this class of accidents. Erysipelas, ozcena, caries, syphilis, scarlet fever, glanders, variola, pyaemia, septicaemia, and 134 INTRACRANIAL DISEASES. typhoid fever, may give rise to it by transmitting the morbid process to the cerebral tissues. It may also be caused by the development of foreign bodies in the brain, such as tumors and aneurisms. Among other causes are long-continued and severe intellectual exertion, mental anxiety, venereal excesses, expos- ure to extreme heat, and especially the inordinate use of alco- holic liquors. Diagnosis. — Encephalitis is liable to be mistaken in some cases for acute meningitis, and in others for cerebral haemor- rhage, tumors, or the disease called general paralysis. In acute cerebral meningitis, the fever is always much greater than in encephalitis; the convulsive movements are also more general, the headache is more severe, and the delirium is more constant and marked. In cerebral haemorrhage the symptoms, instead of becoming more and more pronounced as the disease pro- gresses, as in encephalitis, generally become progressively ameliorated. The symptoms attending the formation of cere- bral abscesses closely resemble those which accompany the growth of tumors in the brain ; and the same is true of those which characterize the disease known as general paralysis.* Encephalitis is generally of shorter duration than general pa- ralysis, and is not marked by the "mania de grandeur" peculiar to the latter affection ; but our chief reliance in the diagnosis must be the history of the case. Prognosis. — Idiopathic encephalitis is almost always fatal ; the same is also true when the inflammation spreads from neighboring parts. When the disease results from injury there is some hope of recovery, but not after it has passed the stage of red softening. Occasionally, after the brain tissue has broken doAvn and an abscess has formed, the pus escapes from the cranium through the nose or ear, or through some artificial opening; but however promising the first effect of the discharge may appear, the amelioration of the symptoms is found to result simply from the diminution of pressure, and to be of but temporary benefit; the patient gradually passes into a state of deep coma, which is soon followed by death. Morbid Anatomy and Pathology.— The first change that * See Nervous Diseases, p. 173. ENCEPHALITIS. 135 occurs in the affected tissues is that of red softening, there being hyperemia and capillary haemorrhage, which renders the cerebral matter moister and softer than usual, and gives it a reddish appearance. The microscope shows an abundance of white corpuscles, disintegrated red corpuscles, and nerve- fibres, masses of nuclei, amyloid corpuscles, and pus. The arterial capillaries are dilated, and their thickened coats in a state of fatty degeneration. After a time the blood corpuscles become entirely dissolved, forming with the disintegrated cerebral matter a jelly-like substance; or else a dirty yellowish matter is left, which becomes enclosed in a membranous capsule or cyst. Yellow bands of sclerosed connective tissue are found in the grey matter of the brain, closely connected with the pia mater, which is thickened and opaque. The most frequent seat of the inflammatory process is the grey matter of the cortex, the corpora striata, the optic thalami, and the cerebellum. Although' there may be several centres, the inflammation is never widely diffused. The cineritious matter is generally first attacked, and afterwards the inflam- mation spreads to the white substance. As a consequence, cerebral abscesses occur chiefly in the medullary matter. When multiple they are generally small, being sometimes not larger than a hazel-nut; in general, however, they vary in size from that of a cherry to that of a small orange. In acute cases the abscess is irregular in shape, and being surrounded by no membranous capsule, encroaches more and more upon the adjacent cerebral substance, which is in the condition of red and grey softening. In this way the pus may ultimately reach the surface of the brain, or break through into the lateral ventricles; and if, as is generally the case in these instances, the disease is due to injury or caries of the cranial bones, the pus may eventually escape through the nose or ear. But when the inflammatory process is more chronic, the abscess is generally of an oval form, and contained in a mem- branous capsule composed of connective tissue. If large the abscess will give rise to symptoms of compression, and if rup- tured will prove speedily fatal. 136 INTRACRANIAL DISEASES. Treatment. — The treatment of this disease is similar to that recommended for cerebral hyperemia, meningitis, and soft- ening (q. v.). The only curative stage, if such there be, is the first or congestive period. So long as there is neither heem- orrhage nor softening, we may reasonably hope, not only to relieve the symptoms, but to cure the inflammation. But when suppuration and abscess have occurred, we can only hope to palliate the symptoms, prolong life, and render the patient's condition more comfortable. Kafka claims to have used Glonoin 1st to 2d, successfully, for a number of years, in this disease — even when the disorgan- izing process was progressing — so long as the symptoms of cerebral hyperemia predominated. No doubt Glonoin will prove a valuable remedy in the initial and purely hypersemic stage of the malady; but it is not likely to prove anything more than palliative after the suppurative process has set in. Kafka also relates a case in which Arsenicum was used, appar- ently with success, even when cerebral softening, with progres- sive increase of the morbid phenomena, coexisted side by side w r ith the symptoms of cerebral hyperemia ; the remedy having been employed after the hypersemic condition had been re- lieved by the administration of Glonoin and Belladonna. If, as I have elsewhere stated, it be possible for complete recovery to take place in encephalitis after disorganization of the cere- bral tissues has occurred, I have no doubt Arsenicum will prove an efficient remedy, not only because it is capable of producing decomposition of organic tissues, but because its pathogenesis, as exhibited in the cephalalgia, vertigo, wandering pains, im- paired sensibility of the limbs, delirium, coma, lassitude, de- bility, trembling, tetanic spasms, and paralysis, presents a per- fect picture of cerebritis, and is therefore truly homoeopathic to that condition. Other remedies, such as Iodine and Plumbum, have been recommended in this disease, but chiefly on theoretical grounds, there being but little clinical experience in their favor. Cannabis indica and Kali bromalum have proved highly useful in some cases by lessening the irritability of the nervous system. CEREBRAL HYPERTROPHY. 137 CHAPTER IX. CEREBRAL HYPERTROPHY. By hypertrophy of the brain is meant, not an excessive devel- opment of the cerebral substance itself, but an excessive growth of the neuroglia, or interstitial connective tissue, whereby the bulk of the organ is abnormally increased. The hypertrophy is mostly confined to the hemispheres, the pons Varolii, and the medulla oblongata; the cerebellum is scarcely ever affected. Symptoms. — So long as the skull is yielding — i. e., during infancy and childhood — there may be no observable symp- toms; no disturbance of motion and sensation, nor even of the mental faculties, except such as arises from an undue enlarge- ment of the head. At a later period, however, symptoms of pressure are likely to manifest themselves, giving rise at first to general muscular weakness, especially in the lower extremity. As a consequence, the patient's grasp is weak, and he is apt to stagger and stumble in his walk. Paralysis and convulsions are of rare occurrence, even in a mild form ; but ow T ing to the anaemic state of the brain, the convulsions, which, if present, are at first partial and of short duration, sometimes develop into well-marked epilepsy and eclampsia. Sensibility is likewise impaired, though rarely to the extent of actual anaesthesia. Headache and vertigo are not uncom- mon, and we may also have tinnitus aurium, photophobia, and dilated pupils. The mind is generally more or less depressed, exhibiting, in some cases, a marked degree of mental torpor and vacuity, or even idiocy. Mental excitement, on the other hand, is rare ; but owing to incidental circumstances, a con- dition of cerebral hypersemia sometimes exists, attended with delirium, and occasionally with mania. 1-1 S DTTRACRAOTAT. DM C uses. — Hypertrophy of the brain is sometimes congenital. The strumous constitution appears to form a predisposition to the disease, as it is frequently developed during infancy and early childhood, in connection with rachitis and enlarged lym- phatic glands. In adults it is chiefly confined to males, espe- cially those addicted to the re use of alcoholic liquors, me. -- timmes rem .:;.". ::nmm :n. Diagnosis. — In infancy, owing to the enlargement of the head, the disease is liable to be mistaken for hydrocephalus. The chief difference between them is, that children affected with cerebral hypertrophy are mentally brighter and more precocious than usual, while in hydrocephalus it is the reverse. Prognosis, — In :-::-: rases me iisease r- t::::t^t/' m~ m irs ::^-:r:5. I:: mrimen .".:-. m rim - - rakes mare fmm pressure caused by cerebral congestion, the result of incidental diseases which, under other circumstances, might have a dif- remm issue Ir: ;_ :lul:^ trie amentia ami mm-trie rives s to apoplectic attacks which often prove speedily fatal. Morbid Anatomy and Pathology. — On removing the mmmmr m i : renins tie intra mater rm main immediately e.m ands to snch a site as to overlap the bones. The convolu- tions are flattened, and the fissures hardly discernible. The ventricles are also narrowed by compression, and contain scarcely any serum. The cerebral tissue is pale, dry and anaemic ; the membranes thin and bloodless; and even the skmimmes ire trim ami art: rmie i mm messme. A rareim examination shows, that while there is no undue amount of cerebral matter present, there is an excessive development of me nemmm rmlermr :ne main i:.mr.m. ani mm elastic than the normal organ. Treatment. — The treatment, which is necessarily wholly palliative, consists chiefly in improving the general health, guarding against exposure to all injurious influences, relt - ing cerebral hyperemia when present, and abstaining alto- gether from the use of alcoholic liquors. Remedies specially mmir: me~~.rm.rs nmirrrm. mm:: emmi imrrm the course of the malady, are those usually employed in cere- bral anaemia and hyperssmia, convulsions, epilepsy, and paralysis, ami metmte met" n;r :e temtrei iiere. CEREBRAL ATROPHY. 139 CHAPTER X. CEREBEAL ATROPHY. Atrophy op the brain is, properly speaking, a simple wasting of the brain tissue, without its undergoing any de- generative changes; but, as commonly used, it also includes that form of atrophy which is sometimes associated with what is known as diffuse cerebral sclerosis. Symptoms. — The disease when congenital constitutes the various grades of idiocy. Children subject to it are more or less idiotic, and suffer from epilepsy and paralysis. The symptoms are generally more severe in early life than they are at a later period. The mind is weak, and generally more or less depraved and revengeful. The special senses, if not entirely wanting, as in the deaf, dumb and blind, are usually very deficient. There is hemiplegia, generally incomplete, with anaesthesia and atrophy of the paralyzed parts, including both the muscles and the bones. Hence the limbs are thin, short, and often disproportioned to the size of the body; there is also a wasting of one side of the face. The deformity is often rendered still greater by an hypertrophy of the adij)Ose tissue. Cerebral atrophy also occurs during adult life; and may be either partial or general, stationary or progressive. Partial atrophy of the brain is generally due to local lesions, such as haemorrhage, softening, and encephalitis. In these cases the initial symptoms are usually those of apoplexy, en- cephalitis, etc., the motor paralysis being unilateral and more or less stationary. In the course of time, however, the atrophy, though partial, becomes sufficiently great to cause a gradual deterioration, not only of the mental faculties, but of all the functions of the nervous system. TEACRAXIAL DISEASES. ors mostly _ The A and progress ith _ radual Loss The mind zolarly g no mental er. _ - ient lan_ _ _ 5. In most cases i - is i and an cranial ne: - ;.nd a sJ llse rhc last stage resem- bles thai : the - _ ral paralysis : the in- san _ a victim to lecnhitus liarrhces pul- monary liseasc : Ire sy Causes. — Partial atrophy ss _ ital, is ; result of sti^o lo:-a" disease such as n agf - : ; encephalitis tumors, etc In the: is confined tc me hemis and may Beet any tissue or par: sf it When genera] it is rften associ nic alcoholism Bright 1 * liseasc : the kidney shi m ::■ blood poi- : ....:._ r some other fc rm of cachexia. Diagnosis. — Ihc liagnosis : cerebral atrc iple ii complicated with linuse cerebral sclerosis mnsl ays be very ancertahi since "It symptoms arc doI : :l ... m tc both foi ins but alsc tc >thei iiseases rae- ti as are m : i - : mm l scleras havT jccorrec ition to the other sn .ere t . i kedm contractions and yet no sclerosis c mid be detected m post-mortem Examination. The symptoms : mbosis and softening : : ben bear a striking resemblance tc those :: serebral especj Id the sclerosed form bat in the latter disease the c o generally met with at an earliei period and they are also ! const: Prognosis. — Pui - complicated the brain, whro. a congenital >i isnnd ibtedly incnrable bnt when the atrophy is progi sssive there ms y be - m 3 | rospect of ameliorating the : ... :: the patient causing an absorption . : blood-dots iiminishing pressure from conges- arresting ret rding progress : the liseaseby im- CEREBRAL ATROPHY. 141 proving the nutrition of the atrophied cells, and by mitigating the severity of the symptoms, especially convulsions and mus- cular contractions. At the same time it must be admitted that, as a general rule, very little permanent good can be effected in these directions in this class of cases. Morbid Anatomy and Pathology. — In congenital cases, the atrophy is generally limited to one hemisphere, usually the left, which is sometimes less than half the size of the right. The atrophy involves not only the cerebral ganglia, but ex- tends to the corresponding crus, pyramid, and antero-lateral column of the cord. The ventricles are widely dilated, and contain a considerable amount of serum. The brain substance varies greatly in consistence, being sometimes soft, at others hard and elastic. In partial atrophy, the aplasia is confined more particularly to the nerve-cells, though it may affect any of the cerebral tis- sues. In these cases the atrophy extends, until it reaches, as in the former case, the lateral column of the spinal cord. The degenerated tissues are found to contain numerous amylaceous and colloid corpuscles and granular cells. General cerebral atrophy is symmetrical, and is primarily seated in the neuroglia, the nerve-cells becoming affected sec- ondarily. The convolutions are shrunken, and in some places widely separated. The ventricles, subarachnoid space, and meshes of the pia mater, contain a large amount of serum ; the blood vessels are abnormally twisted and enlarged ; the mem- branes are thickened and hazy; and the cerebral tissues, though occasionally soft and moist, are generally hard and elastic. Treatment. — The only remedies that I have found to be of any very great value in this disease, are Baryta carb., Baryta % mur., and Baryta iod. Not only does the symptomatology of Baryta correspond closely with that of cerebral atrophy, but the clinical evidence in its favor is by no means inconsiderable. It has been found to be especially adapted to the physical, men- tal and nervous weakness experienced in these cases, and to be equally suited to the atrophy of children, the strumous dys- crasia associated with it, and the paralysis of old people, espe- cially when produced by apoplexy. Other remedies which 142 INTRACRANIAL DISEASES. may sometimes prove useful, are those usually employed in cerebral hxmorrhage, encephalitis, hemiplegia, convulsions, and epilepsy. Electricity, in the form of galvanism, may also be employed in these cases with occasional benefit. Both the induced and primary currents may be required, the interrupted current being the best for the paralysis, and the constant current for the relaxation of contractions. Ten ordinary cells will gener- ally furnish a current of sufficient intensity, the sponges being applied over the mastoid processes every second or third day, for a period not exceeding three or four minutes at a time. That these measures iD crease the nutrition of the atrophied cells, in some cases, there is good reason to believe, since we have more than once seen the paralysis lessened, the contrac- tions relaxed, the mind improved, the epileptic paroxysms ar- rested, and the wasted limbs considerably enlarged and strengthened, by their influence. PRIMARY MULTIPLE SCLEROSIS. 143 CHAPTEK XI. PRIMAKY MULTIPLE SCLEEOSIS. I make use of the term " primary " to distinguish this form of cerebral sclerosis, because multiple sclerosis may be limited to either the brain or spinal cord, or it may involve both. Charcot has shown* that cerebral lesions, locally considered, do not all equally tend to produce secondary sclerosis, some being almost always followed by descending sclerosis, while others never are. To the latter belong, more particularly, those lesions which are confined to the substance of the central grey masses, namely, the lenticulated and caudated ganglia and the optic thalami. The same is true of the grey cortical substance of the hemispheres, when very superficial, and, in certain cases, even when extensive and profound. We shall see hereafter, that in primary multiple sclerosis of the brain, the lesion consists of plates or nodules of sclerosed tissue scattered throughout the entire substance of the cerebrum. Symptoms. — One of the first and most marked symptoms of this disease is pain in the head; not a constant, but a sharp, electric-like pain or shock. In other cases, the first symptom observed is an epileptic paroxysm. Shooting pains, of a simi- lar nature to those in the head, are also experienced at times in other parts of the body. But the most common disorder of sensibility is a peculiar numbness of the extremities of the fingers or toes. The sensation, which is generally limited at first to one upper or lower extremity, is that of cushions, and is only experienced when objects are touched. Disorders of motility are next experienced, but as the prog- * Localization in Diseases of the Brain, 1878. 144 INTRACRANIAL DISEASES. ress of the disease is generally slow, it is often many months before they make their appearance. Of these, the first and most characteristic is tremor. This symptom is generally gradual in its development, being sometimes confined for months to a single muscle of the hand or foot, and afterwards involving the extensors and flexors of the entire member or limb. The trembling generally begins in one of the limbs, and gradually extends to the other limb on the same side, and lastly to the head; but sometimes it commences in the head and afterwards invades the limbs, unilaterally, one after the other. At first, and for a considerable period after the begin- ning of the disease, the tremor is to some extent under control of the patient's will. Thus, he will sometimes stamp his foot upon the ground and arrest the trembling for a few seconds, but the respite grows shorter and shorter, and finally ceases altogether. The same is true of sleep, which usually has a quieting effect at first, but eventually it ceases to afford any relief whatever. The tremor is always increased by emo- tional excitement, and not unfrequently by the voluntary efforts of the patient to arrest it. The trembling is not con- fined to the muscles which move the head and limbs, but sooner or later involves those of the face. The eyeballs, the upper lid, the lips, the lower jaw and the tongue, are the parts principally affected. Paralysis is the next symptom of importance, and, accord- ing to Hammond,* when the sclerosis is limited to the hemi- spheres, or begins in them, it always follows the tremor. This is doubtless true in the primary form of the affection, which we are now considering, and is an important point in the differential diagnosis. The same authority also claims, not only that the paralysis always succeeds the general appearance of tremor in these cases, but that it also follows the course of the trembling, no limb ever being paralyzed till it has for some time been affected with tremor. This, however, does not apply to the muscles of the face, the paralysis of which appears to be independent of the tremor. Op. cit. PRIMARY MULTIPLE SCLEROSIS. 145 But while paralysis appears to follow the appearance of tremor in the limbs, the same does not always seem to be true of paresis, which may exist prior to the occurrence of the trembling. This is best shown by the dynamograph, the pa- tient being unable to maintain continuously an equally strong grasp, even for a short period. Incoordination of muscular movements is closely connected with paresis. It is only by concentrating the volitional power' upon the object by means of sight, that the muscles can be made to act in harmony, so as to successfully carry out the in- tended movement. Thus, I once had a patient affected with this disease, who was not able to carry food to his mouth with- out steadily looking at it during the performance of the act. Dr. Hammond mentions the case of a lady affected with this disease, who undertook to help her invalid husband to rise from his chair, and as she turned to look at a band of music which happened at that instant to pass the door, she involun- tarily relaxed her hold, and let him fall to the floor. Patients affected with this disease often manifest a great degree of haste in their movements, especially in walking. Sometimes the gait almost amounts to a trot. This peculiar walk doubtless arises from the greater ease with which such patients are able in this manner to carry out their intended movements and maintain their equilibrium. Sensibility is variously affected in these cases. Thus, there may be, not only anaesthesia, but more or less hyperesthesia, deafness, amblyopia, and, in some cases, complete amaurosis. The disease, which is always progressive, may last from a few months to eight or ten years, or even longer. Slow as it may be in its progress, however, the patient sooner or later becomes bedfast, and finally dies, either of decubitus, coma, or convulsions. Causes. — Age appears to act as a predisposing cause of pri- mary multiple sclerosis, as the disease seldom affects } T oung people, or those under fifty- years of age. There is some doubt whether heredity has anything to do with its origin, though Hammond says, that of thirteen cases which have occurred in his practice, five had immediate ancestors who suffered from 10 146 INTRACRANIAL DISEASES. some form of tremor and paralysis. The disease is much more common in males than females. Among the exciting causes may be mentioned, syphilis, rheumatism, scarlatina, typhoid fever, and inordinate mental and physical exercise. Diagnosis. — The disease is most liable to be mistaken for paralysis agitans ; indeed, it has heretofore been generally in- cluded under that head. But functional paralysis agitans, which is a very different affection, is more apt to occur before than after fifty years of age. Moreover, in the latter disease there are no head symptoms, no muscular incoordination, no inability to trace a straight line with the dynamograph, no muscular anaesthesia, and no abnormal states of sensibility. As to the secondary form of multiple sclerosis, it may gener- ally be distinguished by the fact that the tremor precedes the paralysis, and also by the fact that the trembling is associated with voluntary as well as with involuntary muscular move- ments. Chorea also bears considerable resemblance to this disease, but may be distinguished from it, not only by the history of the case, but by the facts that it generally occurs in youug people, has no head symptoms, nor any actual tremor, but simply a more marked degree of incoordination, the disorderly movements being more irregular and extensive. Prognosis. — The prognosis in this malady is bad, very bad; but if seen early and subjected to proper treatment, the dis- ease, if not entirely arrested, may often be rendered lighter, and the patient's life prolonged and rendered more com- fortable. Morbid Anatomy. — The general condition of the brain is similar to that described under the head of cerebral hyper- trophy, though less pronounced. Thus, the convolutions are somewhat flattened by pressure, the grey substance is atrophied and anaemic, while the membranes are more or less opaque, and contain an unusual quantity of serum. But the chief morbid condition observable in these cases, consists in plates or nodules of indurated matter, found scat- tered throughout the tissue of the cerebral hemispheres. These masses of hardened tissue vary in size from that of a hazel- PRIMARY MULTIPLE SCLEROSIS. 147 nut to that of a small walnut. Their color is white, or nearly so, and their density varies from that of fresh cheese to that of cartilage. The microscope shows them to consist mainly of the neu- roglia, which has undergone hypertrophy at the expense of the nervous tissue, the debris of which are also present in the form of fibres, free nuclei, and nucleated cells. Amyloid cor- puscles are sometimes present, but not always. The patches vary greatly in number, being sometimes pres- ent in large numbers, while occasionally they are solitary. They are not confined to the hemispheres, though that is their usual seat; but they are occasionally found at the same time in the medulla, the pons, and the cerebellum. When the spinal cord is likewise involved, it is no longer a case of pri- mary, but of secondary multiple sclerosis. Pathology. — That numerous cases of multiple sclerosis have been observed in which the lesion was confined to the brain, cannot be questioned. Bat whether these cases are really different in their nature from those in which the spinal cord is also implicated, is not so certain. We know that multiple sclerosis is progressive, and we also know that in many cases the spinal form is secondary to that of the brain. But it does not follow, by any means, that it is always so; nor that the primary disease is not, in many cases at least, an independent affection. Certain it is, that when confined to the encephalon, it gives rise to symptoms sufficiently characteristic to entitle it to be regarded as a distinct affection. Treatment. — The treatment of this disease does not differ essentially from that already given under the head of cerebral atrophy (q. v.). In addition, however, to the measures there recommended, I would suggest a trial of the following reme- dies, some of which I can recommend as useful from actual experience: Argentum nitr., Belladonna, Helleborus, Hyoscyamus, Stramonium^ Tarantula, and Zincum. 148 INTRACRANIAL DISEASES. CHAPTER XII. ATHETOSIS. The term athetosis, from atferoc, without fixed position, was first used by Dr. Hammond, to designate a comparatively new and peculiar nervous disease, the chief characteristics of which are, an inability to retain the fingers and toes in any fixed position, and by their constant motion. Symptoms. — The disease usually sets in with one or more epileptic paroxysms, followed in some instances by loss of motion, sensation, and speech. As a general rule, however, there is no paralysis, but there is always more or less numb- ness on the affected side, which is generally the right. The intellect is always impaired, the memory enfeebled, and in most cases there is cephalalgia and vertigo. There may or may not be aphasia; but there is generally more or less tremu- lousness of the tongue, even when there is no paralysis. The characteristic symptoms, however, are the athetoid movements of the fingers and toes, with pains in the spasmodically affected muscles, and a tendency to distortion. The movements of the affected member, though complex and involuntary, are to some extent under the control of the patient. Thus, one patient, when told to close his hand, seized the wrist with the other hand, and then, by exerting all his power, succeeded at last in closing his fingers, but they immediately opened again and renewed their movements. The movements are not those of simple flexion and extension, but complicated and grotesque. They occur both when awake and when asleep, and are only temporarily restrained by certain positions and by powerful exertions of the will, as when held in a vertical position, or when firmly grasped. During the continuance of the movements, the muscles of the affected limbs are in a state of tonic spasm, causing them to appear hard and rigid. The movements, which take place ATHETOSIS. 149 slowly and with great force, are somewhat paroxysmal, being worse at one time than at another, but never cease altogether. When, by an extreme exertion of the will, the patient succeeds for a moment in quieting the movements of the fingers, they at once become strongly abducted, and remain so until the movements are resumed. The contractions increase in severity as the disease pro- gresses, and the numbness and pain in proportion to the in- crease in the contractions. For half an hour or so after sleep there is usually a period of comparative repose, the move- ments then being somewhat less severe; but sometimes the patient has great difficulty in getting to sleep, in consequence of the severity of the pain caused by the tonic contractions. The affected limbs become developed to a greater degree than the others, owing to the almost continuous action of their muscles. Causes. — Nothing is positively known as to the cause of this singular malady. Dr. Ringer thinks that it is sometimes due to embolism of the left middle cerebral artery, as the symptoms in some cases appear to correspond with those pro- duced by such a lesion. In other cases they resemble those of general cerbral atrophy. Diagnosis. — The disease is liable to be confounded with post-hemiplegic chorea, as has actually been done by Charcot and others. In the latter disease, however, the movements are quick, irregular, jerky, and variable; while in athetosis they are slow, uniform, and systematic. Moreover, athetosis is not always preceded by hemiplegia; neither is it always confined to one side of the body, MM. Oulmont* and Broussef having described cases of double athetosis without liemiplegia. Prognosis. — There is little or no hope of ultimate recovery in these cases. The prognosis in any particular case will largely depend, of course, upon the nature of the cause; and as athetosis is in all probability the result of degenerative changes in the central ganglia of the brain, the final outcome must be bad. Morbid Anatomy and Pathology. — The disease appears * Etudes Cliniques sur VAthetose, Paris, 1878. f Montpellier Medical, t. xxxiv, 1877. 150 INTRACRANIAL DISEASES. to be seated chiefly in, and just external to, the central cerebral ganglia — the corpus striatum and optic thalamus. In Dr. Rin- ger's case, the whole of the corpus striatum was much damaged, involving both the caudated and lenticular nuclei. There was not only much atrophy and slight degeneration of the intra- ventricular portion, but about one-fifth of the lenticular gan- glion was destroyed, as well as a few of the fibres of the inner capsule, passing between the nuclei of the corpus striatum. The optic thalamus was also atrophied, and a small portion of the lower and outer part of this body was completely de- stroyed, while a considerable portion of the white matter ex- ternal to the thalamus, embracing sensory fibres of the external capsule, was also destroyed. In the case reported by M. Lan- douzy,* there was found an old centre of softening occupying exclusively the lenticular portion of the corpus striatum. In a case reported by Dr. Sturges,f the whole of the anterior por- tion of the corpus striatum was destroyed. Dr. Ringer sums up the pathology of his case — a patient who had mitral obstruction with regurgitation — as follows: "Dazzling before the eyes, dimness of sight, giddiness preced- ing loss of consciousness, and followed by loss of speech and sensation, and motion of the right side, point conclusively to the left hemisphere of the cerebrum as the seat of the disease. The giddiness indicates the mesencephale; the loss of speech, the posterior part of the third frontal convolution ; the loss of sensation, the thalamus opticus ; and the loss of motion, the corpus striatum, as the parts probably affected. As speech returned before sensation, and sensation before voluntary mo- tion, the main stress of the disease must have fallen on the corpus striatum, and in a less degree on the thalamus opticus. It is probable, I think, that the cause of the disease in this case is an embolon set free from the diseased mitral valves blocking the middle cerebral artery." Treatment. — The treatment, which should be based upon the symptoms, is similar to that given under the heads of embolism, softening, epilepsy, hemiplegia, and cerebral atrophy (q- 4 ,. * Progres Medicate, 1878. f Lancet, March, 1879. PROGRESSIVE FACIAL ATROPHY. 151 CHAPTER XIII. PROGRESSIVE FACIAL ATROPHY. This disease was first described by Parry as early as 1825, but did not attract much attention until Lande, who collected a considerable number of cases, described the affection under the name of progressive laminar aplasia. Symptoms. — The first symptom usually noticed in these cases is a white or pale spot on one of the cheeks. This spot is more or less irregular in outline, and exhibits a tendency to spread in one or several directions. At the same time, or shortly afterwards, a slight depression is observed in the same place, owing to atrophy of the skin and cellular tissue. Sub- sequently, the muscles themselves undergo atrophy, thereby causing a still greater depression in the cheek. As the disease progresses, other points of atrophy make their appearance in the vicinity, the wasting process continuing until, in some cases, the muscles of the face, the lips, and, in some rare instances, even those of the neck, become involved. In many cases the tongue is atrophied on the side correspond- ing to the facial disease, and when protruded it points towards the affected side. The disease sometimes involves the veil and pillars of the palate, the uvula, and even the muscles of the larynx; nevertheless, the function of deglutition is not im- paired, nor is that of phonation often interfered with. The affected muscles, which, though weakened, are never completely paralyzed, retain their electro-excitability, but are sometimes affected by fibrillary contractions. Sensibility is not generally disturbed, but neuralgic pains are sometimes felt in the vicinity of the parts, especially in the fronto-temporal region, and spasmodic movements occasionally occur in the muscles of the face or jaws. 152 INTRACRANIAL DISEASES. The nutrition of the skin begins to suffer at an early period of the disease, as shown not only by the white spot in the trophic centre, but by the discoloration and falling out of the hair, the cilia, the supercilia, and the beard, as well as by the diminution of the sebaceous secretion on the affected side. Causes. — The etiology of progressive facial atrophy is ob- scure. Although the disease is generally met with in early or adult life, and is more common in females than in males, Vulpian attributes its origin in a certain number of cases to traumatic violence inflicted on the head and face. In one case it is said to have followed an attack of scarlatina. Diagnosis. — In its early stages, the disease might, in some cases, be mistaken for facial paralysis. The latter, how r ever, comes on suddenly, while this is developed very gradually; moreover, the electro-excitability of the muscles is always di- minished in facial paralysis, which is not the case in this disease. Progressive muscular atrophy, when seated in the face, is not confined to that part, nor to one side, as in facial atrophy. Morbid Anatomy and Pathology. — No post-mortem ex- amination has yet been made in this disease of the nerves or nerve-centres. A microscopical examination of the affected muscles made by Dr. Hammond, shows no evidence of degen- erative changes of any kind. The nbrillse have been found reduced in diameter to about one-third of the natural size, and also diminished in length. The internal perimysium, or connective tissue of the muscles, is also considerably dimin- ished in thickness. So far as the muscles are concerned, therefore, there is simply atrophy without degeneration — a condition essentially different from what exists in other amy- otrophic diseases, such as infantile and adult spinal paraly- sis, pseudo-hypertrophic paralysis, and progressive muscular atrophy. Vulpian refers the trophic disorder of the face to some intra- cranial lesion. He says: "This affection is produced in a certain number of cases as a consequence of traumatic violence inflicted on the head or face. Its development is accompanied, in the great majority of cases for several years, with pains of PROGRESSIVE FACIAL ATROPHY. 153 greater or less violence seated in the head, ordinarily toward the fronto-temporal region. Sometimes there are spasmodic movements of the muscles of the face or of the jaws. In some rare cases there has been numbness in the superior extremity of the opposite side. These are the circumstances which seem to point to a cerebral lesion. But we cannot affirm that such lesions exist, while we have no post-mortem examination to enlighten us on this point, and while we are embarrassed to designate a seat for the lesion, which can reasonably explain all the phenomena of the disease."* Treatment. — Faradization of the affected parts appears to have slightly benefited a few cases, but in the great majority of cases neither this nor any other measure has appeared to do the least good. The remedies which we think would be most likely to prove beneficial, are : Argent, nitr., Arsen., Plumbum, Sulphur. * Legons sur VAppareil Vaso-moteur, ii, 1875. 154 INTRACRANIAL DISEASES. CHAPTER XIV. MYXCEDEMA. The term myxedema was first applied by Dr. Ord* to a dis- ease characterized by a peculiar form of oedema, or puffiness of the skin, over the entire surface of the body. The disease closely resembles anasarca, the chief difference being that the tissues, instead of pitting on pressure, as in oedema, return with prompt and firm resiliency after the pressure is removed. Symptoms. — The surface of the body presents an appear- ance resembling that of anasarca. When pressed upon, how- ever, the tissue is found to be resilient, leaving no indentation as in ordinary oedema. The cheeks are red from capillary congestion, and the eye- lids, nostrils, and lips are swollen and prominent. The swell- ing or puffiness may involve, not only the face, but the whole surface of the body, and is especially marked in the hands and fingers, giving to them a blunted or clubbed appearance ; at the same time there is no distortion of the nails. There is also well-marked anaesthesia of both the general and special senses. The sense of touch is greatly impaired, there being not only a feeling of numbness, but a cushioned or padded feeling, both of the fingers and feet. The numbness is also present in the face, the tip of the tongue, and the upper and lower extremities. Sight and hearing, as well as taste and smell, are all greatly diminished in acuteness, vision generally more or less deranged, and smell sometimes almost abolished. The temperature of the body is always below normal; and the muscular and coordinating power decidedly weakened. * Medico-Chirurg. Trans., vol. lxi, p. 57. MYXCEDEMA. 155 Articulation is slow and indistinct, the grasp feeble, and the gait tottering. The patient, although able to stand with the eyes closed, requires the aid of sight to coordinate the move- ments, and even then they are performed in an awkward and uncertain manner. The electro-excitability of the muscles is greatly diminished in all parts of the body ; the response to both the galvanic and faradic currents becoming less and less as the disease pro- gresses. A characteristic feature of the disease is the mental con- dition, which bears a considerable resemblance to acute de- mentia, and is accompanied by hallucinations, illusions, and delusions. The organic functions are all more or less imperfectly per- formed. The pulse is irregular, or slow and feeble, the temper- ature depressed, the appetite impaired, the bowels constipated, the urine loaded with urates, and the sleep disturbed, short, and unrefreshing. Diagnosis. — The disease may be easily distinguished from ordinary oedema, by its never pitting upon pressure. Tricus- pid regurgitation, and other cardiac affections interfering with the return of blood from the right side of the heart, are at- tended with a similar clubbing of the fingers, but the other symptoms will prevent any error in diagnosis. The same is true of scleroderma, which is liable to be confounded with this disease, unless we bear in mind that in the former the surface is hard, that there is a sense of constriction about the parts, that there are no mental symptoms, nor any permanent reduc- tion of temperature, such as is met with in this disease. More- over, myxoedema belongs to a much more advanced period of life. Prognosis. — The prognosis could not be worse than what it is, as treatment has hitherto proved utterly unavailing, and several cases have terminated fatally. Morbid Anatomy and Pathology. — The swelling is caused by a mucoid substance deposited throughout the body, but more particularly the skin. This mucoid deposit closely sur- rounds all the terminal nerves, blunting their sensibility and 156 INTRACRANIAL DISEASES. interfering with their conducting power. Similar deposits are also found in the brain and other nerve-centres, and as these envelope the nerve-cells, they will serve to explain the im- pairment of the mental functions, which occurred in one case before there was any appearance of external swelling. Treatment. — I am not aware that this disease has ever been subjected to homoeopathic treatment. The old school, into w T hose hands nearly every case has heretofore fallen, has brought to bear upon it its most powerful remedies, such as electricity, phosphorus, strychnia, and arsenous acid, but with- out improving in the least the nutrition of the parts, or amelio- rating the condition of the patient. As such treatment, how- ever, is wholly empirical, it does not follow that the homoeo- pathic administration of such remedies as Arsenicum, Baryta, Carbo an., Iodine, Lachesis, and Silicea, would prove equally un- availing. At the same time, it must be confessed that, con- sidering what we know of its pathology, it would be highly presumptuous to count upon any marked success in the treat- ment of this disease, even under the most favorable circum- stances. CEREBRAL TUMORS. 157 CHAPTER XV. CEREBKAL TUMORS. Tumors of the brain differ greatly in size and character, some being peculiar to the organ, while others resemble tu- mors found in other parts of the body. Varieties. — Glioma is the name given by Virchow to a tu- mor of the brain due to proliferation of the cerebral connec- tive tissue, the neuroglia. These growths, which are found in the white substance of the hemispheres, and especially in the posterior lobes, sometimes grow to the size of an apple. They are of a white or pinkish color, translucent, and either hard or soft. The hard, which contain but few cells, resemble fibroma; the soft contain numerous cells and nuclei, and have nearly the consistence of the brain substance. They are of slow growth, and never contain any of the nervous elements. Another tumor peculiar to the brain is called psammoma, or sand-tumor, so named from the resemblance of its constituents to grains of sand. This tumor, which is seldom larger than a small cherry, consists of isolated grains of chalky matter embedded in the neuroglia. It springs from the dura mater, and is mostly found at or near the base of the brain. Cholesteatoma, so called because it contains, besides its other constituents, cholesterine and stearin e, is also seated at the base of the brain. This tumor sometimes reaches the size of a walnut, but is generally much smaller. It is made up chiefly of epidermoid cells, concentrically arranged, which have un- dergone degeneration. It is entirely devoid of blood-vessels, has a pearly appearance, and arises sometimes from the brain itself, and at others from the cerebral membranes. Neuroma, is a small tumor due to hyperplasia of the grey substance of the brain. It varies in size from that of a millet- 158 INTRACRANIAL DISEASES. seed to that of a pea. It is found in all parts of the hemi- spheres — in the white substance, in the ventricles, and on the surface of the convolutions. Mucous, lipomatous, cystic, melanoid, and other forms of cere- bral tumors, are sometimes met with, but they are not of suffi- cient importance to merit a special description in this place. The most important forms are those which owe their exist- ence to a peculiar constitutional dyscrasia, namely, the cancer- ous, the tuberculous, and the syphilitic. Cancer of the brain may be of an encephaloid, scirrhous, or colloid character, but it generally belongs to the encephaloid variety. It usually springs from the dura mater, though it may begin in any part or tissue of the cerebrum. "When it arises from the external surface of the dura mater, it gradu- ally destroys the skull-bones, and eventually bursts forth in the well-known form of fungus heematodes, or fungus durse matris. When, on the other hand, it springs from the internal surface of the membrane, it invades the various structures of the brain, following especially the course of the olfactory and optic nerves. Finding a ready passage for itself through the bony foramina provided for the exit of these nerves, it is very apt to appear eventually in the orbit, or in the spheno-maxillary fossa. Primary cancer is generally single, and secondary, multiple. It is of rapid growth, and is frequently accompa- nied with similar deposits in other organs. Histologically, these tumors do not differ from cancerous growths in other parts of the body. In some cases the cerebral substance near- est the cancer undergoes softening, and in others, it remains unaltered. Tuberculous tumors are mostly confined to children, and are generally seated in the hemispheres or cerebellum. When single, they often attain the size of a grape or cherry. They are generally associated with tuberculous deposits in other organs, and undergo similar changes. Syphilitic tumors will be described in the next chapter (q. v.). Symptoms. — The symptoms common to all cerebral tumors, are : headache, vomiting, and optic neuritis ; though it is pos- sible for a large tumor to exist in the brain without giving CEREBRAL TUMORS. 159 rise to any symptoms. On the other hand, most cerebral tu- mors produce a variety of local and general disturbances, the character of which depends upon their nature, size, and seat. The first symptom that generally attracts attention is head- ache. The pain is usually limited to a particular spot or re- gion of the head, corresponding to the situation of the tumor. It varies greatly in different cases, being sometimes dull and continuous, at others, sharp, lancinating, and paroxysmal. As the disease progresses the pain generally becomes more and more severe, until in some cases the patient is unable to restrain his cries. In other cases the patient suffers but little from pain, but is drowsy, low-spirited, and irritable. The memory is more or less impaired, and there is a general lack of both mental and bodily energy. These symptoms become more marked as the tremor develops, the mind either gradually sinking into a state of melancholy, and finally of complete imbecility, or else they give rise to delusions and hallucinations, accompanied with attacks of mania ; the patient at last dying comatose. Almost every patient suffers more or less from vertigo, and also from nausea and vomiting. The special senses suffer to a greater or less degree, especially the sense of sight. Indeed, several eminent pathologists* assert that optic neuritis is an invariable accompaniment of cerebral tumors. Both optic nerves are implicated, though one may be less affected than the other. The ophthalmoscope also ex- hibits atrophy of the optic nerve, which may result primarily from the intracranial pressure, or secondarily from the neuritis. Hemiopia, diplopia, strabismus, and other ocular troubles, are also of frequent occurrence in these cases. Paralysis, which is seldom entirely absent, generally takes a hemiplegic form, but is sometimes paraplegic. It is frequently limited to the muscles supplied by a particular nerve, as the third or sixth. It is generally slow in its progress, correspond- ing with the growth of the tumor. * Annuske, Graefes Archiv., vol. xix, pt. 2, 165. 1G0 INTRACRANIAL DISEASES. Epileptic attacks are common, and may occur either with or without loss of consciousness. In the latter case, the convul- sive movements are usually confined to one side of the body, and occasionally to a single set of muscles, such as those of the eye or face. But spasms which commence locally, and ulti- mately become bilateral, are generally attended by loss of con- sciousness. In these cases, post-epileptic paralysis is generally observed. Tonic spasms are much less frequently met with in cases of cerebral tumor than the clonic form. Their distribution is similar to that of clonic spasms. In some they are limited to the muscles of the head and neck ; in others the muscles of the face and limbs are involved. Various other symptoms are sometimes present in these cases, such as hyperesthesia, anaesthesia, paresis, tremor, dis- turbances of equilibrium, disorders of digestion, assimilation, secretion, respiration, and circulation, most of which are plainly the result of the cerebral lesion. Causes. — Age is one of the predisposing causes in some kinds of tumors. Thus, tuberculous tumors are most frequently met with in young children ; while aneurismal tumors are most common in persons of advanced life. Sex also appears to have some influence in this respect, as males are more fre- quently affected than females, probably because they are more exposed to injury. Heredity is another cause, as shown by the various forms of diathetic tumors, which owe their existence to constitutional dyscrasise. The chief exciting causes are trau- matic injuries, such as blows on the head, falls, etc. Other ex- citing causes are: various parasites, such as the cysticercus and echinococcus, great mental and physical exertion, cardiac hypertrophy, cerebral embolism, and calcareous degeneration. Diagnosis. — When, in addition to headache, vomiting, and double optic neuritis, a case is attended with frequent epileptic attacks, some of which are slight, we are justified, in the ab- sence of any symptoms or history pointing to some other form of cerebral lesion, in referring the morbid phenomena to intra- cranial tumor. Epileptic convulsions occurring late in life should always excite suspicion of such a cause, especially if CEREBRAL TUMORS. 161 unilateral, or unattended with loss of consciousness. Very limited paralysis,, also, points to this cause, especially if the other symptoms correspond. The situation of the tumor may often be determined by the peculiar character of the symptoms. Thus, when seated in the convexity, there is severe headache and epileptic spasms, but no anaesthesia or paralysis. When the anterior lobes are affected, there is frontal headache, mental excitement, and anosmia. When the parietal lobe is involved, there is anaesthesia, with slight unilateral paralysis. When the occipital lobes are im- plicated, we have intense headache, vertigo, and melancholy, but no paralysis. Tumors of the corpus striatum produce hemiplegia; of the corpora quadrigemina, ocular paralysis, blindness, and hemiplegia ; of the area near the optic chiasm, headache, hemiopia, anosmia, paralysis of the ocular muscles, and anaesthesia of the parts supplied by the fifth nerve. When the cerebellum is affected, the symptoms are occipital head- ache, vertigo, and tottering gait. Tumors of the pons Vorolii produce paralysis of the muscles supplied by the third, fifth, and sixth nerves, difficulty of swallowing, and crossed paraly- sis of the limbs. Tumors of the medulla oblongata produce convulsions, anaesthesia, defective articulation, difficulty of swallowing, paralysis of the bladder, and diabetes mellitus. Prognosis. — There is perhaps no class of brain lesions more uniformly fatal than that of cerebral tumors. The only excep- tion is the syphilitic, which is generally amenable to proper constitutional treatment. Morbid Anatomy and Pathology. — We have already sufficiently described the morbid anatomy of all the principal kinds of cerebral tumors, except the aneurismal, which we will now consider. Aneurismal dilatation of the large cerebral arteries is not a very uncommon occurrence, since more than one hundred and fifty cases have already been reported, and many more would no doubt have been recorded had they not been con- founded with apoplexy, or some other form of brain lesion. The arteries most liable to be affected are the sylvian and the basilar. These aneurismal tumors do not differ in struct- 11 162 INTRACRANIAL DISEASES. ure from those found in other parts of the system. They vary in size from that of a cherry to that of a large plum, or even a walnut. They are more common on the left than on the right side, probably for the same reasons that embolism occurs more frequently on that side of the brain. The symptoms of cerebral aneurisms are for the most part similar to those of other cerebral tumors producing pressure or irritation in the same localities, except that rupture and subsequent haemorrhage, which has been observed in about one-half of the cases reported, gives rise to symptoms of apo- plexy, and proves speedily fatal. The pressure produced by cerebral tumors generally, on the brain substance, not only causes local symptoms, but in many cases leads to fatty degeneration and atrophy of distant parts. It also causes displacement of the parts in the immediate vicinity of the tumor, renders the cerebral tissue dry and anaemic, and causes more or less wasting of the nervous structure. Treatment. — We have seen that several varieties of cerebral neoplasmata consist of hypertrophied connective tissue, pro- ducing a condition similar to that known as cerebral sclerosis. Now, as Baryta carb., Baryta mur., Baryta iod., are of undoubted value in the treatment of the latter affection, it is highly prob- able that the same medicines will render good service in the former. These remedies may very properly be given in all cases in which we have reason to suspect the presence of a solid tumor in the brain, as being most likely to meet the pa- thological indications. At the same time, we may, by admin- istering such remedies as cover the totality of the symptoms, best relieve the various functional disturbances produced by the adventitious growths, and thus contribute materially to the comfort and welfare of the patient. In this way the epileptic seizures may be rendered lighter, the pains less intense, and even the paralytic symptoms may be measurably modified and relieved. Whilst, therefore, there is but little room for encour- agement in these cases, so far as ultimate recovery is con- cerned, they should not be looked upon in all cases as utterly hopeless, as some of our remedies have proven successful under CEREBRAL TUMORS. 163 circumstances apparently no more favorable than these. Take Silicea, for example, which has not only removed diabetic symp- toms in a number of instances, but relieved the pains of cancer, and caused the shrinkage of fibroid tumors. In addition, therefore, to the treatment recommended under hemiplegia, epi- lepsy, convulsions* and cerebral atrophy (q. v.), a careful study should be made of the following General Indications. — Atheromata. — Bell., Calc, Graph., Sil., Sulph., Thuja. Cysts. — Apis., Arsen., Apocyn., Sil. Hxmatomata. — Arm, Con., Iod., Sulph. Lipomata. — Bar., Calc, Croc, Graph., Lapis alb., Phos., Phyt. Fibrous. — Bar., Bell., Calc, Con., Sil. Fibro-Scirrhous. — Ars., Ars. iod., Aur., Carb. an., Con., Cal., Lapis alb., Nit. ac, Sil. Melanoid. — Phos., Sang., Sil., Thuja. Colloid. — Carbol. ac, Hydr., Phos. Fungoid. — Ars., Carb. an., Nit. ac, Phos., Sil., Staph., Sep., Thuja. * See Nervous Diseases, p. 27. 164 INTRACRANIAL DISEASES. CHAPTER XVI. CEREBRAL SYPHILIS. When we consider the prompt effect which appropriate med- ical treatment has upon syphilitic diseases of the brain, we are not surprised to find that the characteristic lesions are not of an inflammatory character, as was formerly supposed, but are generally localized, the membranes and substance of the brain not being, as a rule, profoundly affected. Not only have nu- merous cases occurred in which no lesions could be discovered after death, but Heubner asserts that there is no case on record in which the existence of ordinary meningeal inflammation could be established by microscopical evidence; while Dr. Dowse,* one of the latest investigators of this subject, says that the share taken by the proper nervous elements in the patho- logical changes which affect the nervous system in these cases is extremely limited. Varieties. — There are three principal forms or varieties of syphilitic lesions of the brain, namely, the congestive, the vascu- lar, and the syphilomatous. 1. The congestive form of cerebral syphilis exhibits scarcely any anatomical changes, unless the disease has lasted for a considerable period, and even then they are not very marked, the membranes having simply lost their transparency, and the cerebral convolutions appearing to be slightly atrophied. 2. The vascular form affects the cerebral arteries, especially the carotids, and the arteries at the base of the brain. The vessel changes from a translucent, pinkish color, to a greyish- white ; is reduced in diameter by a greyish deposit between * Syphilis of the Brain and Spinal Cord, 1879. CEREBRAL SYPHILIS. 165 the endothelium and the elastic coat of the vessel; and finally becomes completely occluded by the syphilitic thrombus, con- sisting of endothelial cells developed by proliferation into con- nective tissue. 3. The syphiloma, or syphilitic tumor, commonly called gumma, consists of two varieties, the soft and the hard. The soft gumma has the appearance of greyish-red gelatin, and consists of round cells and nuclei, mixed with branched, stellate, and spindle-shaped cells, and enlarged capillary vessels. The hard gumma, wmich is probably only an advanced stage of the soft, is of a cheesy consistency and well-defined outline. It is devoid of cells or of blood-vessels, being dry, yellow, and homogeneous, except near the border, where there are occa- sional oil-globules, interspersed with pigmentary granules and crystals. This tumor varies in size from that of a filbert to that of a walnut, or even larger ; and not unfrequently appears to be moulded by the shape of the parts where it is located, as though originally in a soft condition. Symptoms. — The symptoms of the hyperxmic form of cere- bral syphilis are at first of a fleeting and somewhat indefinite character. The mind is either unduly excited or depressed ; and although there is at first no marked mental unsoundness, there is more or less eccentricity of manner, confusion of thought, and delusion. The general health also suffers, pass- ing gradually from a state of simple debility to one of paresis and nervous prostration, accompanied with trembling of the tongue when protruded, embarrassment of speech, unequal pupils, tottering gait, formication, and numbness. Fresh syphilitic outbreaks are apt to occur from time to time; and these are usually attended by an aggravation of all the symp- toms, mental as well as physical. Paralytic attacks of aphasia, hemiplegia, and paraplegia, become more and more frequent and permanent ; the general debility increases ; and, unless the disease is speedily arrested by treatment, the patient dies within a few days, from the effects of cystitis, decubitus, and nervous exhaustion. The symptoms of the vascular form differ according as the disease affects the cortical or the basal sphere of nutrition. In 1G6 INTRACRANIAL DISEASES. the former case, there is generally a gradual narrowing of the affected arteries, giving rise to debility, impairment of the mental faculties, and, in many cases, to somnolency, which may deepen into the apoplectic seizure. But in the basal form, the symptoms are usually much more rapidly developed. Sometimes there is multiple thrombosis of one or more of the basal arteries, in which case the patient generally dies suddenly, with all the symptoms of cerebral apoplexy. In other cases, there are premonitory symptoms, especially ocular troubles, such as ptosis, diplopia, and amblyopia ; or the irritation may involve other cranial nerves, producing spasm of the sixth and seventh nerves, or hyperesthesia and anaesthesia in certain branches of the fifth nerve. Hemiplegia may afterwards gradually set in, attended or not with aphasia, but without loss of consciousness. The patient gradually grows worse, be- comes somnolent, suffers from headache, confusion of mind, and other head symptoms, and, unless relieved by treatment, will finally die, notwithstanding temporary intervals of im- provement. The symptoms attending the development of cerebral syphi- loma are somewhat peculiar. One of the most characteristic is an intolerable headache, which occurs in paroxysms, and is most intense at night. The paroxysms last for several weeks, when they remit for a while, and are again succeeded by a fresh attack ; and thus it may continue, unless relieved by treatment, for several years. After a time epileptic seizures occur; or there may be unilateral attacks of convulsions, with- out loss of consciousness. In this case, the spasms are probably due to irritation of the surface of the opposite hemisphere. The patient now becomes more or less irritable, and either mentally excited or depressed. The mind gradually becomes impaired, the speech slow and embarrassed, and sometimes aphasic symp- toms make their appearance. Unless relieved by treatment, symptoms of muscular paresis and incoordination set in; the grasp becomes weak and uncertain, and the gait irregular and tottering. Frequent epileptic attacks occur, which, becoming more and more severe, are at last followed by coma, exhaus- tion, and death. CEREBRAL SYPHILIS. 167 Causes. — Cerebral syphilis, like every other form of the affection, is due to a specific poison affecting the constitution ; and belongs for the most part to the tertiary stage, or to the latter part of the second stage. It is invariably preceded by a hard infecting chancre, the cerebral symptoms not manifest- ing themselves in many cases until after the lapse of several months or years. In some instances, however, they show themselves as early as the beginning of the second stage, or soon after the appearance of the rash or angina. All ages are subject to it, but it is most common between the ages of twenty and forty years. Males are more liable to it than females, constitutional syphilis being more common in men than in women. The chief predisposing causes appear to be, an incomplete or unsuccessful medical treatment, and what is known as the neuropathic constitution. The latter may be either heredi- tary or acquired. In these cases, the ancestors or immediate relatives are found to have suffered more or less from epi- lepsy, chorea, neuralgia, and other nervous diseases. What- ever weakens the nervous system, such as severe mental labor, sexual excesses, or too free indulgence in the use of alcholic liquors, will also act as an exciting cause. Dr. Dowse says, "I have clearly traced a cerebral syphilis when the exciting cause has been venereal excesses, over-study, mental anxiety, worry, and even fright."* Mechanical injuries of the brain, such as are produced by blows or falls upon the head, will also favor the development of cerebral syphilis. Diagnosis. — The previous history of the patient constitutes one of the most important factors in the diagnosis. Age is also of great diagnostic importance, as paralysis occurring in youth- ful persons is, in the great majority of cases, of syphilitic origin. Violent proxysmal headache is another characteristic symptom of the disease. There is no form of headache so intense as that which results from syphiloma of the dura mater. The pain is not only very intense, but is localized, remittent, and in- creased by pressure. The reverse of this, however, is the case * Op, cit. } p. 17. 168 INTRACRANIAL DISEASES. when the pia mater is involved; the pain is never intense and is never localized, but is diffused over the forehead, and of a dull, aching, congestive sort. The temperature, on the con- trary, is higher in these cases, and there is greater constitu- tional disturbance. In case the patient has no clear syphilitic history, the differ- ence between the real and apparent age, the facial expression, and especially opthalmoscopic symptoms, are generally suffi- cient to clear up the case. These symptoms consist in swelling, hyperemia and oedema of the papilla, varicosity of the veins, and a peculiar form of neuro-retinitis and choroiditis. There may also be optic atrophy, but this is the least certain of all the ocular changes which occur in syphilis, and should there- fore not be relied upon as a diagnostic symptom. Syphilitic thrombrosis is perhaps the most difficult form of cerebral syphilis to diagnose. Dr. Dowse says : " It is peculiar to syphilis that the subsidence of the symptoms is rapid, whilst their invasion is comparatively slow. A man free from syph- ilis goes to bed, and overnight has felt quite well, but finds in the morning that he cannot move his arm or leg. This mode of attack is rarely the case where the lesion is due to syphilis. A syphilised patient, without premonitory warning of any es- pecial kind, may have an epileptic fit, but he will not without warning fall in an apoplectic fit. This does not imply that he will not have a fit of apoplexy ; but for some days, or it may be weeks, previous to this calamity, he will be heavy and leth- argic, although he is not able to sleep; he is restless, and all his doings and movements are without any definite purpose ; he may not eat unless requested to do so, or if he sits down to partake of a meal, he rises before he has finished, and his knife, fork or glass may suddenly fall from his hand, or his hand may shake so that he is unable to carry a glass to his mouth, or if he does so, it rattles against his teeth, and the fluid escapes at the corners of his mouth, of which he is, in a measure, un- mindful ; and, finally, he may neglect and appear to be regard- less of, the calls of nature. It is after symptoms such as these that the man with syphilitic arterial changes is usually found breathing stertorously and in a comatose, apoplectic state. CEREBRAL SYPHILIS. 169 There may be subsequent convulsions, or there may not, and the comatose state may be slight, or it may be profound ; the comatose condition is the more usual, and it resembles a deep stupor, out of which the patient may be roused by pinching or pricking, to a state of apparent subjective consciousness, which is only a grade, however, beyond the mere automatic. He may continue in this state for one or two weeks, or, as I have seen cases, for three weeks ; and then, with returning con- sciousness, the paralysis disappears, the intellect brightens, and he may even, for a time, so far recover as to be able to attend to his business or professional pursuits, but after this there is rarely a return of the evanescent forms of paralysis previously noted. After an attack of this nature, when paralysis super- venes (and it is very rarely that it does not, sooner or later), it is usually persistent and permanent, and death may take place during an attack similar to that just noticed, or it may be preceded by a series of epileptiform seizures, ending in profound coma."* Prognosis. — Syphilis generally yields more readily and rap- idly to appropriate medical treatment than any other form of brain disease. Not that every case of cerebral disease that has syphilis for its origin may be rapidly and thoroughly cured, for there is many a cerebral paralysis due to syphilis, which will not readily yield to specific measures; but as a rule, syphilitic lesions of the brain, like those of other organs, are quite amenable to treatment. Much, however, depends upon the situation and degree of the disease, as well as upon the means adopted. Morbid Anatomy and Pathology. — The morbid anatomy of syphilitic cerebral lesions has to some extent already been given. The anatomical features of syphiloma are thus given by Rindfleisch : " Its specific anatomical character does not reside in any marked deviation of the gummatous tissue from the familiar types of inflammatory growth, but rather in the circumscription of a more or less spheroidal nodule in the midst of a larger deposit of newly-formed embryonic tissue, a * Op. tit, p. 38. 170 INTRACRANIAL DISEASES. nodule which differs from the embryonic tissues round it in the farther course of its metamorphoses. For while the-latter undergo conversion into fibroid tissue, forming a cicatrix char- acterized by a tendency to extreme contraction, the former, retaining the circular form of its cells, and occasionally pro- ducing an anastomotic network of corpuscles, materially un- dergo a necroid transformation of its intercellular substance. The cells grow fatty, their place is taken by round or stellate aggregations of fat granules, which appear to be capable of lasting as such for long periods of time. The final result is a yellowish-white rounded nodule, of a soft and elastic consist- ency, embedded in a deposit of newly-formed connective tis- sue. This is the specific tumor of syphilis, the " Tophus or Gumma Syphiliticum." Dr. Dowse * sums up the essential, gross pathological feat- ures of these lesions as follows : " They include (a) the inflam- matory thickening of the membranes. This thickening may originate in the lining membrane of the osseous system with which the nervous structures come into contact, (b) The invasions of the neuroglia, or connective tissue, by a diffuse form of gummatous infiltration, which might be the result, primarily, of disease of the circulatory system, or alterations of the fluids circulating within the vascular channels of the nervous tissue. The lacter condition gives rise to albumino- fibroid changes, more especially in the white nerve substance, and is often associated with a low form of inflammation of the membranes, (c) The appearance of syphilomatous masses, which often occur singly, but may be numerous. Their seat may be over the surface of the hemispheres, and I have usually found them in the upper convolutions of the anterior lobes, or they may occur at the base. At any rate, they are to be seen almost invariably at the cortex, and closely united with the membranes. They extend into the surrounding tissue, which is generally found to be softened, hypervascular, and of a faint yellow color. When examined, they present the appearances which have been previously noted, the nerve-cells and vessels * Op. cit., p. 95. CEREBRAL SYPHILIS. 171 giving evidence,, under the microscope, of the usual degenera- tions consequent upon vascular occlusion."' The same author,. who caused a microscopic examination to be made of a longi- tudinal section through a capillary vessel of the second left frontal convolution, found the coats separated, and in some parts almost obliterated,, by an aggregation of small cells or nucleor growths. This invasion involved the inner rather than the outer tunics of the vessel, a point upon which Heub- ner lays great stress as being especially diagnostic of their syphilitic origin. Treatment. — The treatment of syphilitic affections of the brain is of two kinds, namely, symptomatic and specific. The symptomatic treatment does not differ essentially from that given under the heads of cerebral hyperemia, thrombosis, and tumors (q. v.). The specific treatment consists mainly in the prompt and judicious administration of anti-syphilitic remedies, such as Kali iodatum, Mercurius corrosivus, Arsenicum iod., Aururu, Corydalis, Mezereum, Phytolacca, Stillingia. 172 INTRACRANIAL DISEASES. SECTION II. MENINGEAL AFFECTIONS. CHAPTER I. SIMPLE ACUTE MENINGITIS. This disease is a lepto-meningitis cerebralis, or simple acute inflammation of the pia mater of the brain. It may be par- tial, general, or limited to either the convexity or base of the brain. Symptoms. — Owing to the fact that the inflammation, instead of seizing at once upon the entire membrane, generally advances gradually from one point to another, different stages of the inflammatory process are apt to exist at the same time in different parts of the diseased membrane. Consequently, the two stages of irritation and depression are not, as a rule, so sharply defined as to serve as a reliable basis for descrip- tion. Neither is it practicable to give all the groupings of symptoms met with in the various forms of the disease. The symptoms are found to vary considerably in different cases, according as the disease is of primary or secondary origin ; they are also greatly influenced by the seat, extent, and intensity of the inflammatory process, as well as by the age of the patient. When primary, the disease is generally ushered in by severe chills, intense headache, and high fever; and is attended by more or less delirium, convulsions, or maniacal excitement. In other cases it assumes a somewhat latent form, being accompanied with only slight symptoms, or at most with depression and paralysis. SIMPLE ACUTE MENINGITIS. 173 In infancy the attack usually sets in after a period of rest- lessness, with convulsions, high temperature, and very quick pulse. The large fontanelle pulsates and is tense. The convul- sive seizures follow each other with greater or less frequency, the child remaining weak and somnolent between them. At last the patient sinks into a state of coma, followed by paraly- sis. Older children often remain excited to the end, scream- ing, vomiting, and complaining of cephalalgia, intolerance of light, and other evidences of cerebral disturbance. In adults, severe headache is one of the most constant symptoms, especially when the disease is confined strictly to the pia mater. The patient moans, screams, grasps the head with his hands, complains of stitches and lancinating pains through the head, and exhibits an expression of intense suf- fering. There is photophobia, tinnitus aurium, hyperesthesia, and increased reflex excitability. If the skin be ever so lightly irritated, it is apt to break out into patches of erethematous redness. In other cases the symptoms are simply those of maniacal excitement, without any marked increase of tem- perature, or other evidence of fever. This is most likely to occur if the disease is complicated to any considerable extent with inflammation of the brain substance {meningo-cerebritis), in which case the patient is apt to be simply restless, sleepless, and subject to mental hallucinations, which may pass into muttering delirium. In either case, however, the patient sooner or later sinks into a state of stupor and indifference, accompanied or followed by muscular tremors, convulsions, paralysis, coma, and death. Tonic contractions of certain muscles, especially those of the head and neck, occur in these cases, by which the parts are drawn backwards or to one side; the arms also are sometimes similarly affected ; and there may be a condition of trismus. The limbs are always greatly weakened, but although they may become paralyzed, there is seldom hemiplegia or paralysis of the sphincters. Towards the last, however, it is not uncom- mon to have incontinence of urine and faeces. At this time, also, other typhoid symptoms predominate. The tongue is thickly coated, or brown and dry ; deglutition is difficult, the 174 INTRACRANIAL DISEASES. pulse is slow, or quick and irregular; the respiration is dis- turbed, sighing, and more or less uneven ; the temperature is high and variable ; and the skin is hot and dry, or else bathed in a copious perspiration. The pupils vary greatly at different stages of the complaint, being sometimes contracted, at others dilated, and occasionally of unequal size. As a general rule they are either contracted or of a medium size during the stage of excitement, and dilated or unequal towards the close, or during the stage of depres- sion. They may, however, be either dilated or contracted during the whole course of the disease. The pulse and temperature also vary considerably, the former being at first large, hard, and frequent, reaching as high as 140 or 150 per minute, afterwards falling to 60 or less, but towards the close becoming frequent again, though small and irregular. The temperature, which at first is increased, afterwards becomes lowered, the mercury indicating a range of from 94° to 104° F. Thirst, anorexia, and vomiting, which are nearly always present at the beginning, sometimes continue throughout the disease, or reappear from time to time during its course. Morbid Anatomy. — At first, the only morbid appearance that presents itself is the redness of hyperemia, resulting from a more or less uniform injection of the capillary vessels of the pia mater. At a later period, there is congestion of the larger vessels, together with an effusion of fibrine, white blood-cor- puscles, and serum into the subarachnoidal space, which soon becomes turbid or yellowish, and finally changes into pus. The effusion is greatest in the vicinity of the larger blood-ves- sels, lines of pus being especially conspicuous along the course of the parietal veins, or spread out in the form of thin mem- branous patches beneath the arachroid. The inflammatory products may be limited to the convexity and lateral portions of the hemispheres ; or they may be confined to the base of the brain ; or they may involve the entire surface of both regions. When the inflammation is general, and also when limited to the basal region, the ventricles usually contain more or less fluid, and the central parts of the brain are generally softened ; SIMPLE ACUTE MENINGITIS. 175 but when the convexity alone is affected, the ventricles are apt to be dry and empty, even though the cerebral cortex should be involved in the inflammatory process. Pathology. — It is generally conceded that the symptoms of irritation, or those that belong to the initiatory stage, are due to congestion; and that those of depression, met with in the later stages of the complaint, are caused mainly by effusion and the resulting pressure. As to the starting point of the disease, it doubtless lies in the vascular system, but whether excited by the presence of minute emboli, thromboses, or capillary ruptures, is an un- settled question. When we consider the prevalence of the disease among cachetic subjects, and its frequency in cases of rheumatism, endocarditis, and erysipelas of the head and face, we cannot doubt that it often originates in one or the other of these modes, even though the primary histological changes have as yet escaped detection. Causes. — As a primary affection, the disease is most fre- quently due to cold and dampness, or to prolonged exposure to furnace-fires, or to the heat of the sun. The disease is most apt, however, to occur in connection w T ith, or immediately after, some other acute affection, such as the various exanthe- matic fevers, small-pox, rheumatism, pleurisy, pneumonia, etc. It is frequently associated with erysipelas of the head and face, especially in its later stages. It is also sometimes met with in Bright's disease of the kidney, in typhoid fever, and in broken-down states of the system, whether arising from dyscrasia, or from the decreptitude of old age. Sex appears to exercise considerable influence in its pro- duction, as it occurs much more frequently in males than in females, probably in consequence of the former being more exposed to the influence of syphilis and other exciting causes. While not confined to the period of infancy and childhood, it is much more rarely met with after the age of twenty than before. Diagnosis. — Simple meningitis is most liable to be con- founded with the tubercular variety of the disease. The pres- ence or absence of a tubercular constitution, the general 176 INTRACRANIAL DISEASES. history of the case, and the conditions under which the disease is developed, will often throw much light upon the case. The temperature frequently rises higher in simple meningitis than it does in the tubercular form, which latter seldom exceeds 100° or 101° F. Other symptoms, also, are usually less prom- inent in the tubercular form, such as delirium, retraction of the head, etc. On the other hand, tubercular meningitis is of much greater frequency than the simple form, though the proportion of males to females is considerably greater in the latter. Prognosis. — The prognosis is always unfavorable, at least nine out of every ten cases proving fatal within the first three weeks, and the great majority succumbing within the first ten days of the disease. Patients, however, sometimes make good recoveries from it, as shown by the subsequent post-mortem appearances of persons dying from other diseases. Treatment. — The treatment required in the initial stage of simple cerebral meningitis is identical with that of hyper semia of the brain (q. v.). After this brief period has passed, and the period of depression has set in, the chances of recovery are indeed small, but the treatment, if strictly homoeopathic, may yet be crowned with success. General Indications. — Aeon., iEsc. gl., Apis, Bell., Bry., Camph., Canth., Cimicif, Cin., Coca, Cup., Dig., Gels., Glon., Hell., Hyos., Lach., Merc, Op., Stram., Sulph., Tart, em., Verat. vir. In Infants. — Aeon., Apis, Bell., Cin., Glon., Hell., Lach., Merc. In Erysipelas Cases. — Apis, Bell., Lach., Merc, Phos., Rhus, Verat. vir. Heat or Sunstroke. — Arm, Bell., Camph., Gels., Glon., Lach., Scutel., Therid. Exposure to Cold. — Aeon., Bell., Bry., Dulc, Gels., Rhus. Exanthematic Fevers. — Aeon., Apis, Bell., Lach., Merc, Rhus, Sulph., Verat. vir. Special Indications. — Aconite. — Inflammatory fever, with dry, burning heat of the skin ; red and inflamed eyes ; burning, throbbing, or lancinating pains through the whole head ; pulse SIMPLE ACUTE MENINGITIS. 177 full and hard ; anxiety and fear of death, or delirium with great anguish ; vomiting of bile ; convulsions, or tonic con- tractions, with tendency to paralysis ; pupils contracted or dilated. Especially indicated at the commencement of the disease, and also in erysipelas cases. jEthusa cyn. — Stinging, lancinating pains through the head ; obstinate vomiting ; tetanic convulsions; staring eyes ; pupils dilated and insensible ; drawing in the nape of the neck ; face pale and collapsed ; coma ; pulse small and frequent, with cold skin. Apis met. — Infantile cases, with delirium, loss of conscious- ness, and occasional shrill screams; bending back and rolling of the head ; squinting of the eyes ; dilated pupils ; child puts its hand to its head while it screams, even when unconscious ; face pale, or marked with red streaks and spots ; scanty or sup- pressed urine ; stool thin and scanty, or suppressed ; very frequent and weak pulse, or else slow and irregular ; convul- sions, trembling of the limbs, and paralysis. Apis is not only suitable to infantile cases, but also to those preceded by, or com- plicated with erysipelas. Arsenicum. — Stinging and lacerating pains in the head ; staring eyes, with dimness of vision and altered pupils ; burn- ing and swollen skin, with or without moisture ; rapid, feeble, and intermitting pulse ; vertigo, delirium and insensibility ; tonic spasms, Allowed by paralysis. Especially suited to the last stage. Belladonna. — Burning, stinging, or lancinating headache ; red and sparkling eyes, with distorted orbs ; face and skin red, burning, and swollen ; violent delirium ; frequent vomiting ; small and quick, or intermitting pulse ; loss of consciousness, spasms, paralysis, and relaxation of sphincters. Especially suited to children, and to cases complicated with erysipelas. Bryonia. — During the first stage, with sharp and violent pains in the head, red and inflamed eyes, quick and hard pulse, hot and burning skin, vertigo, delirium, cramps, and convulsions; or else at a later period, with sopor, dim and glossy eyes, slow and irregular pulse, cold, pale, moist skin, dry lips, and dry and brownish tongue; other symptoms are, 12 178 INTRACRANIAL DISEASES. bending of the head backward, constant motion of the jaws, and constipation. Cantharides. — Sharp, lancinating pains in the head; great heat of skin, with fiery, sparkling and distorted eyes, and full and hard pulse; vertigo, delirium, or insensibility; tonic spasms and convulsions. This remedy is especially indicated in cases following the retrocession of erysipelas of the head and face. Cina. — Violent headache in the forehead and occiput; burn- ing heat, especially in the face, or with red cheeks contrasting strongly with pallor about the nose and mouth ; child cross and peevish; quick and irritable pulse; screams and startings in sleep; vertigo; vomiting; white, milky-looking urine; de- lirium, cramps, and convulsive movements. Suited to either real or pseudo-meningitis when attended with worm symptoms. Cuprum. — Head hot, with sharp, lancinating pains shooting through it; consciousness with vertigo, or delirium with stupor; tonic spasms and convulsions; red and inflamed eyes with rolling orbs; quick and strong pulse, together with more or less vomiting; but the remedy is better suited to the last stage, attended w 7 ith slow, small and weak pulse, blue, shrunken face, suffocative breathing, dimness of vision, moist hands, and paralysis. Digitalis. — Stupor, gradually deepening into coma; small and slow pulse; dilated pupils, with insensibility of vision; general or partial convulsions; labored breathing; irregular action of the heart, sometimes very weak, at others strong; particularly adapted to the last stage. Gelsemium. — Intense congestion of the brain, especially in teething children; severe pain in the occiput; head hot, with redness of the face; nausea, with blindness; child drowsy, and wants to be let alone; frequent startings in sleep; con- stant internal fever, though without thirst, and the feet and hands cool and moist. Glonoin. — Extreme cerebral congestion, attended by the most intense headache, flushed face, full and rapid pulse, red, hot and staring eyes, photophobia, ringing in the ears, beating of the temporal arteries, nausea and vomiting; stupor, with TUBERCULAR MENINGITIS. 179 sunken eyes, slow, irregular pulse, and cool and moist skin. This remedy is suited to every stage of the complaint, pro- vided it is used sufficiently high. Helleborus. — Violent headache, especially in the occiput; head drawn back, with stiffness of the cervical muscles; eyes staring and oblique; face pale and cedematous; forehead con- tracted, and covered with cold perspiration; frequent starting and screaming during sleep; working of the jaws, the lower one depressed; breathing irregular, sometimes quick, at others slow and deep, or sighing; jerking of the limbs, with convul- sive movement of individual muscles. Hyoscyamus. — Delirium, gradually passing into stupor and coma; sticking paius in the head, with red, burning face, red and sparkling eyes, contracted pupils, and full, strong, and quick pulse; or else loss of consciousness, cold and pale face, dilated pupils, weak and intermitting pulse, and paralysis. Mercurius.- — Drowsiness with great, restlessness; frequent vomiting; starting and screaming in sleep; pupils dilated or uneven; pale and shrunken countenance; skin covered with perspiration; respiration irregular and difficult; retention or inconstancy of stool and urine. Opium. — Stupor and insensibility; stertorous breathing; pulse small, weak, and irregular; frequent vomiting; pupils dilated ; eyes half open ; when aroused, patient immediately relapses into a state of insensibility; urine suppressed. Rhus tox. — Sticking pains in the head ; inflamed and swollen eyes ; red and burning face ; wild delirium, or slow and indis- tinct muttering ; cramps, numbness, and paralysis. Especially suited to cases complicated with erysipelas of the head and face. Stramonium. — Violent delirium accompanied by frightful screams ; head drawn backward ; convulsive movements of the limbs; conjunctiva injected; face red; great dryness of the mouth ; vomiting, constipation, and retention of urine; sleep almost natural, but on being aroused the patient does not recognize his friends. Sulphur. — Often indicated as an intercurrent remedy, es- pecially after Bryonia, Cuprum and Rhus. 180 INTRACRANIAL DISEASES. CHAPTER II. TUBERCULAE MENINGITIS. Syn. : Acute Hydrocephalus. Tubercular meningitis is a peculiar and very fatal form of lepto-meningitis, due to a deposit of tubercular granules in the pia mater at the base of the brain. For many years it was supposed to be peculiar to infancy and childhood, but it is now known to manifest itself occasionally as a complication of chronic phthisis in. adult life. Nevertheless, the affection occurs with such special frequency during infancy and child- hood, as to fully entitle it to be still regarded as a disease of early life. Symptoms — Although somewhat arbitrary, the symptoms of tubercular meningitis may be most usefully and conveni- ently arranged in four periods, or stages : 1. The prodromic or formative stage ; 2. The stage of irritation or excitement; 3. The stage of depression ; and 4. The stage of paralysis. 1. The Prodromic Stage. — The symptoms belonging to this stage may be very slight or altogether wanting, but generally they are sufficiently well marked to attract attention, and in some cases, especially in very young children, they are so pro- nounced as to exhibit the characteristic features of the full- formed disease at the very outset. As a general rule, during this stage the child appears listless and drooping; is more or less feverish and irritable ; suffers from occasional headache- looses flesh; is dizzy, sleepless, pale, and occasionally has a dry cough. The appetite is capricious and irregular, and there is occasional vomiting. Sometimes the abdomen is tumid, and the patient suffers from alternate attacks of diarrhoea and con- stipation. The alvine discharges are seldom of a perfectly TUBERCULAR MENINGITIS. 181 healthy character. The tongue is moderately furred and quite moist. The skin is almost always preternaturally dry; and although there is seldom any well-marked febrile move- ment, flashes of heat alternating with chills are apt to occur from time to time. The pulse sometimes slackens or inter- mits, and this is found to occur most frequently at the seventh, ninth, and sixteenth beats. This irregularity of the pulse is a highly characteristic symptom of the disease, and is met with in every stage. The face, which is generally of an unhealthy color, is sometimes red and sometimes pale. The eyes are more or less dim, and frequently look anxious and amazed, especially after waking. The gait is generally awkward and heavy; and the muscular system having lost its tone, the patient soon becomes exhausted. These symptoms are seldom all present in the same case, or at the same time, and those which are, often intermit, coming on at about the same hour every day, so as frequently to be mistaken for those of hydro- cephaloid, or of ordinary infantile fever. Very young children are apt to be exceedingly restless, sensitive to light and noise, frequently scream out suddenly, refuse the breast, bend the head and trunk backward, or grasp at the head as if in pain, exhibiting, as before stated, the symptoms of the second, or full- formed stage, at the very outset. This stage varies greatly in duration in different cases, sometimes lasting only a few days, but occasionally protracted over a period of several weeks, or even months. 2. The Stage of Excitement. — After a longer or shorter period, the stage of high irritation or excitement sets in. There is great restlessness and anxiety, with undue heat of the head ; and if the child is old enough, he complains of violent head- ache, and frequently cries out, "Oh, my head !" The carotids are now seen' to throb violently; the eyes, which are turned up, are painfully sensitive to the light; and the pupils, though generally contracted, are sometimes exceedingly variable. The tongue is usually covered with a dirty ish- white or brown coat ; the appetite is lost ; vomiting, generally of bile, occurs from time to time ; and there is unquenchable thirst. At the same time, there is marked emaciation, with pain in the limbs 182 INTRACRANIAL DISEASES. and abdomen, and the latter is retracted. The stools are gen- erally green or dark-colored, and constipated. The urine is greatly diminished in quantity, and either high-colored, or turbid, with whitish sediment. The skin is more or less re- laxed, especially about the forehead, and of a dingy-white color ; and the face, which is pale, is either sunken or swelled. The pulse is generally slow and intermitting, but occasionally regular. The breathing is frequently hurrier', irregular^and interrupted by moans. Patients usually have a wandering look during this stage, cry out from time to time, and occa- sionally grate their teeth. The decubitus is on the side, with hand to the head. Convulsions sometimes occur, and may be repeated several times in succession. The temperature is con- siderably elevated, ranging from 101° to 103° F. The symp- toms still continue to vary in violence at times, and are some- times greatly abated. This is especially apt to be the case just previous to passing into the third stage. The duration of this stage is from a few hours to a week or more. 3. The Stage of Depression. — As soon as this stage is fully entered upon, the senses become greatly blunted, and sopor sets in, which is followed by stupor and insensibility. The pulse is now feeble and irregular ; the eyes are turned in various directions, inward, outward, or downward ; the pupils are dilated, and the irides are more or less insensible to the stimulus of light. The eyelids are half closed, the cornea dim and blurred, and vision either double or otherwise perverted. The patient generally lies grasping and picking with the hands, moaning and groaning, with an irregular and feeble pulse, cool and somewhat moist skin, foul breath, and moist tongue. Paroxysmal flushes of the face sometimes occur, not- withstanding the great emaciation and debility. The alvine and urinary discharges are suppressed. The temperature is now almost always below the normal standard, especially in young subjects. Consciousness sometimes momentarily returns at the close of this period, but the patient soon relapses again into complete insensibility. The " hydrocephalic cry " is heard during this stage, but whether caused by pain or by reflex irri- tation is uncertain. Convulsions are such a marked feature as TUBERCULAR MENINGITIS. 183 not unfrequently to occupy the greater portion of the period. The decubitus is on the back; and the duration of the stage is from one to two weeks. 4. The Closing Stage. — This stage is characterized by paraly- sis, which is generally confined to the right side, and is usu- ally immediately preceded by convulsions. The head is drawn back, with great distortion of the face and limbs. The patient generally lies in a state of complete unconsciousness, but some- times raves. The face and head, on one side of the body, is usually drenched in sweat, while the other is cold and dry. The face is of a bluish or violaceous hue, the respiration hur- ried, and the breath cold. The pupils are almost always widely dilated, but occasionally they are contracted. The discharges are voided involuntarily, the urine being of a deep } 7 ellow color. The temperature generally sinks several degrees below the normal standard, but in some cases it gradually and steadily rises until it reaches 105° or 106° F. before the patient expires. The duration of this stage is from a few hours to one or two weeks, and that of the whole disease is from two to three weeks. Morbid Anatomy. — The characteristic anatomical feature of this disease is the presence in the pia mater of numerous miliary tubercles, or, as they are sometimes called, granules. These granulations are of a greyish or yellowish- white color, similar in appearance, and doubtless also in character, to those which occur in pulmonary miliary tuberculosis. They are located chiefly at the base of the brain, and it is only in a small proportion of cases that they occur to any considerable ex- tent elsewhere. They are generally very numerous along the course of the great vessels, especially in the fissure of Sylvius. There is also to be found in the subarachnoid space adjoining the blood-vessels, a jelly-like substance, similar to the exuda- tion which occurs in simple meningitis. The ventricles gen- erally contain from two to six ounces of turbid serum, and the fornix and adjacent tissues are often much softened, and are sometimes even diffluent. This softened tissue exhibits under the microscope the presence of numerous granulation corpus- cles. The substance of the brain is everywhere abnormally 184 INTRACRANIAL DISEASES. vascular. The pia mater is always more or less inflamed, thickened by infiltration of plastic matter, and unduly adhe- rent to the cerebral surface. Pathology. — As before stated, miliary tubercles and tuber- cular deposits are generally present in these cases in other portions of the body, particularly in the lungs, bronchial glands, and peritonaeum, proving conclusively, I think, that acute hydrocephalus is nothing more nor less than a true tubercular form of meningitis. The granulations appear first at the base of the brain, probably in consequence of the greater vascularity, of that part of the organ. These adventitious deposits excite a com- mon inflammation in the neighboring tissues, and thus give rise to the morbid phenomena characteristic of the affection. These facts not only throw a flood of light upon the pathology of the disease, but are of the greatest consequence so far as the prognosis and treatment are concerned. Etiology. — While there can be no doubt of the fact that tubercular meningitis, instead of being an independent affec- tion, is but an expression of that general state of the system known as acute tuberculosis, there are nevertheless a number of determining causes that are worthy of consideration. Thus, age appears to be an important factor, since the disease occurs w r ith special frequency in children between the ages of two and seven, is less common between eight and ten, still less between ten and twenty, and is rarely met with beyond these extremes, though it has been known to occur in very young infants, and also in advanced life. In children it is apparently often inherited, while in adults it occurs generally as a com- plication in the course of chronic phthisis. Males appear to be more subject to the disease than females, and this is said to be the case at all ages. As to other exciting causes, although they probably exert but little if any independent influence upon the disease, yet, owing to the strong predisposition existing in these cases, and the constant irritation caused by the presence of foreign matter within the cranium, there is a constant tendency to relapse upon exposure to extremes of cold and heat, blows, TUBERCULAR MENINGITIS. 185 falls, rapid jolting or exercise, the irritation produced by worms or teething, the repercussions of cutaneous eruptions, ordinary attacks of fever and inflammation, and in fact any- thing calculated to accelerate the circulation, or cause a deter- mination of blood to the brain. The same is true, also, of hygienic deficiencies, especially those which favor mal -nutri- tion, such as seclusion from air and sunlight, an insufficient quantity or a poor quality of food, or a diet that induces functional derangements of the digestive organs; to which may be added, neglect of cleanliness, improper or insufficient clothing, and, in the case of adults, unhealthy occupations. Diagnosis. — The importance of making an early and cor- rect diagnosis in these cases cannot be overestimated. Un- happily, this is often a very difficult thing to accomplish, especially in the earlier stages, as the symptoms of the first two stages of tubercular meningitis are frequently far from distinctive. It is true, the symptoms may be caused by the development of this disease, but, on the 'other hand, they may also represent simply some form of gastro-intestinal irri- tation, or at most the setting in of a specific fever. Under these circumstances, it is but natural to infer, that a careful examination of the general condition of the patient will materially assist in clearing up the diagnosis; but the fact is, this general condition sometimes only serves to still further complicate the case. For not only is it extremely difficult, at times, to recognize acute tuberclosis when it actually exists, but it not unfrequently happens that the state in question gives rise, not only to the same kind of constitutional symp- toms, but apparently to the same form of cerebral disturbance; and that, too, when, as the subsequent histor} 7 of the case may demonstrate, no tubercular meningitis is present. Such symp- toms, however, should always put us upon our guard ; and if the general condition of the patient and the history of the case are such as to establish the existence of acute tuberculosis, the cerebral symptoms may safely be regarded as an expres- sion of the meningeal affection. Trousseau insists upon the great importance of the so-called "tache cerebrale " as a diagnostic sign of tubercular menin- 186 INTRACRANIAL DISEASES. gitis. This is a peculiar form of vaso-motor irritability ex- hibited when the nail of the finger, for example, is drawn across the abdomen or other portion of the body; in which case, if tubercular meningitis is present, a red line is almost certain to be slowly developed, and to remain a longtime. But as this symptom is sometimes met with in other diseases, Trousseau justly regards the irregularity of the respiration as a still more important diagnostic sign of tubercular menin- gitis; as in no other disease, he says, do we meet with this singular anomaly. If, then, along with these characteristic symptoms, together with those of the premonitory and initial stages above enumerated, the patient becomes more and more drowsy ; if the pulse falls much below the natural standard and at the same time becomes irregular ; if there is also a feverish condition existing, with but little if any thirst ; and especially if there is retraction of the abdomen and obstinate constipation present, we may safely conclude that tubercular meningitis is the only intracranial disease with which we have to do. Prognosis. — Whether complete and permanent recoveries ever take place after the disease is fully developed, may well be doubted. Although apparent recoveries have occasionally been reported, most authors regard all such cases as instances of mistaken diagnosis, believing it to be irrational to expect radical cures in cases where the cause cannot be removed. There is reason to believe, however, that such cures have, in some rare instances, been affected, especially under homoeo- pathic treatment; unless, indeed, we choose to regard such apparent recoveries as nothing more than a long and com- plete remission in the intensity of the symptoms. While, however, death is almost certain within three or four weeks from the full development of the disease, I am strongly in- clined to think, in common with some others, that, if taken in hand early and judiciously treated, the farther development of the disease may be prevented. But, of course, such a result cannot, from the very nature of the case, be counted upon with any degree of certainty ; and therefore the practitioner should be prepared to find his efforts in this direction, if not wholly TUBERCULAR MENINGITIS. 187 thwarted, at least attended with but a very indifferent measure of success. Treatment. — It is evident from what has been said, that if any permanent good is to be accomplished in this disease by medical treatment, the case must be taken in hand at a com- paratively early period, before any well-marked organic changes have taken place in the diseased membrane. During the purely premonitory stage there is hope, as at that time the symptoms of irritation predominate ; and as the condition is one of simple hyperaemia, such remedies as Belladonna, Clna, Gelsemium, and Glonoin, are not only specially indicated, but are found to be highly serviceable in allaying the morbid action. Even at a later period, after the tubercular process has set in and the disorganizing metamorphosis is progress- ing, we have found good results to follow the administration of these and other indicated remedies, though of course the case will then need to be very closely watched and carefully treated. As regards hygienic measures, which should on no account be neglected, reference may be made to the therapeutic hints given under this head in the above section on etiology. General Indications. — Prodromic Stage. — Bell., Bry., Cham., Gels., Glon., Ign., Ipec, Puis., Yerat, vir. First Stage. — Aeon., Bell., Gels., Glon., Hyosc, Hell., Stram., Zinc. Second Stage. — Apis, Apoc, Artem., Bell., Cin., Dig., Hell., Hyosc, Merc, Stram. Third Stage. — Apis, Arg. nitr., Cupr., Ign., Indigo, Ipec, Mosch., Op., Plumb., Rhus tox., Sulph. General Condition. — Baryta carb., Calc carb., Calc phos., Lycop., Phos., Silic, Sulph. Special Indications. — In addition to the special indicaiions given under the heads of Simple Meningitis and Cerebral Hyper- emia (q. v.), the following closely-related remedies should receive particular attention : Baryta carb. — Glandular enlargements; stiffness of the neck; 188 INTRACRANIAL DISEASES. eruption upon or behind the ears ; wasting of the flesh ; ver- tigo ; drowsiness ; stitches in the head, commencing immedi- ately on entering a warm room. This remedy is called for in all cases where the above symptoms show themselves, and especially if there are suspicious hereditary proclivities. Calcarea carb. — Lively, precocious, large-headed children, with tender constitutions, a swollen abdomen, and irregular bowels, which are inclined to looseness ; profuse perspiration about the head and neck during sleep ; child screams out unexpectedly or without cause. Especially suited to children of scrofulous habit, and as an intercurrent remedy. Calc. phos. — Children with retarded dentition, scrofulous, and greatly emaciated ; stools loose, green, and occasionally slimy ; child always wanting to nurse ; muscles shrunken and flabby ; slow in learning to walk ; craves potatoes and other forms of starchy food. This remedy is also suited to the scrofulous dyscrasia, especially when it threatens to run into acute tuberculosis, or is complicated therewith. Kali iod — This is Kafka's specific for this affection. He advises the remedy to be used early, before the tubercular exu- dation has taken place as well as afterward, the remedy having acted favorably at both periods. The special indications are : stinging, darting pains in the head, preventing sleep ; pain and heat in the head, with burning and redness of the face ; haemorrhage from the nose ; drowsiness ; dry and hacking- cough ; spasmodic contraction of the muscles; chilliness al- ternating with flashes of heat ; paralysis, especially when hemiplegia Lycopodium. — Somnolency, gradually deepening into coma ; convulsions, either partial or general ; child throws its head from side to side, moans, and screams out in sleep ; child sleeps with its eyes only half closed ; face pale and cold ; neck stiff; body greatly emaciated; bowels costive. This is a highly important remedy in this disease, on account of its relationship to anaemia and tuberculosis. Silicea. — Children with enlarged heads and slowly-closing fontanelles ; great drowsiness, with determination of blood to the head, especially when the head is low ; heat and redness TUBERCULAR MENINGITIS. 189 of the face, with cold hands and feet ; disposition to sweat about the head and face ; sudden starting in sleep ; violent stitching headache ; sour eructations, frequently associated with nausea and vomiting ; obstinate constipation. Spongia. — This is Hering's great remedy for scrofulous and tuberculous subjects. The special indications are : Redness of face, with anxious expression of countenance ; determina- tion of blood to the head ; heat in the head ; bending of the head backwards ; face alternately red and pale ; eyes staring, lids wide open ; vision double. Child frequently wakes with a start ; muscular twitchings accompany the fever ; somno- lency and stupor. 190 INTRACRANIAL DISEASES. CHAPTER III. TRAUMATIC MENINGITIS. There are three distinct forms of traumatic cerebral menin- gitis, namely: 1. pachymeningitis, in which the inflammation is limited chiefly to the external surface of the dura mater; 2. arachnitis, in which the inflammatory process is confined to the arachnoid membrane; and 3. leptomeningitis, or, as it is sometimes called, subarachnoid meningitis, in which the pia mater and subarachnoidean areolar tissue are involved. 1. Pachymeningitis. Traumatic cerebral pachymeningitis, or inflammation of the outer surface of the dura mater of the brain, is always a sur- gical disease. It is secondary to all those forms of head injuries by which the skull-bones are fractured or penetrated, such as gun-shot wounds, bayonet-thrusts, sabre-cuts, etc. In most cases the bone itself is contused and more or less of the pericranium about the wound separated. Symptoms. — For several days after the accident the patient appears to do well, and the surgeon, if inexperienced, is apt to imagine that, notwithstanding the severity of the wound, the parts have escaped serious injur}\ In the course of a week or ten days, however, the patient begins to suffer from pains in his head, loses his appetite, feels chilly, and becomes more or less restless and anxious. As these symptoms increase, the patient becomes dull and drowsy, and may sink into a state of stupor or insensibility. Other symptoms, also, may present themselves, such as rigors, delirium, convulsions, vomiting, constipation, coma, metastatic inflammation of the TRAUMATIC MENINGITIS. 191 lungs and other organs; but most of these symptoms are due to the setting in of pyaemia, a condition which needs to be carefully distinguished from the meningitis itself. The py- aemia, which is a very common complication in these cases, is due, not to the pachymeningitis, but to inflammation of the bone, and this may be the cause of either, or of both, of the former diseases. If the diseased bone be examined, it will be found discolored, the diploe of a greenish color, and below it, probably, a small collection of pus. The pus itself is gener- ally discolored, and is surrounded by a layer of viscid lymph, which separates the membrane from the bone. In most cases, the inflammation extends to the arachnoid membrane, which is separated from the hemispheres by a layer of puro-lymph. This gives rise to other symptoms, the most important and characteristic of which is crossed hemiplegia. In interpreting the symptoms above given, we should re- member that rigors seldom occur in these cases except as a result of pyaemic infection, the decomposing material finding its way into the circulation through the veins of the diploe, which become inflamed in conjunction with the gangrenous osteitis. We may be quite certain that this is the case if the rigor be repeated. This complication is as common as it is fatal ; and even when pyaemia is not present, arachnitis general^ is, so that the surgeon has but little chance of saving his patient, whether he trephines him or not. Treatment. — As will be seen, these are purely surgical cases, and require surgical treatment. This, however, should be strictly homoeopathic, as well as preventive, in its character, for if either of the complications above mentioned should set in, recovery would be scarcely possible. Hence, after carefully cleaning the wound, if the surgeon finds that a depressed fracture is present, he should at once trephine, so as to prevent the supervention of meningitis, by elevating the depressed bone, removing the detached fragments, if any, and allowing a free escape of the secretions. He should then apply a dress- ing of charpie, or of borated cotton, saturated with Calendula lotion, and this should be kept diligently moistened. At the same time the indicated remedy should be given internally, 192 INTRACRANIAL DISEASES! which in most cases will be either Aconite or Belladonna. This is far better than what is called the Lister's plan of treatment, which furnishes little or no protection against con- tagion, and scarcely ever succeeds in preventing inflammation, with all its direful consequences. 2. Arachnitis. Although this form of traumatic meningitis is of common occurrence, Althaus denies the possibility of its existence as a distinct disease, on the grounds that Kolliker and other his- tologists have shown that the so-called parietal layer of the arachnoid does not exist, while inflammation of the visceral la} r er never occurs without simultaneous inflammation of the pia mater. But it is a sufficient answer to this reasoning to say, that the anatomical characters of arachnitis are unmis- takable, and that the distinction between this disease and in- flammation of the subarachnoidean areolar tissue and pia mater is easily made, especially upon post-mortem examination, as we shall presently show. Morbid Anatomy. — The leading anatomical peculiarity of arachnitis consists in this, that an even layer of purulent lymph covers the cerebral convolutions, but does not dip into the sulci, owing to the intervention of the arachnoid mem- brane; which stretches across instead of entering the cerebral depressions; but when, on the contrary, the subarachnoid spaces are involved, the sulci are filled with lymph, and the internal surface of the arachnoid remains free and unaffected. Symptoms. — The leading symptoms of acute diffuse arach- nitis are : more or less delirium, generally of a mild, wander- ing character, elevation of temperature, and hemiplegia; the latter attended by incontinence of fseces and urine, and occa- sionally by unilateral sweating. The hemiplegia, which is the most important and characteristic symptom, is seldom com- plete, its degree being proportionate to the extent of the arachnitis. In cases where the inflammation involves the membrane of both hemispheres, all the limbs are liable to be- come paretic, in which case the hemiplegia is not so easily distinguishable. TRAUMATIC MENINGITIS. 193 Etiology. — Many cases of arachnitis result from compound fracture of the skull, with laceration of the dura mater. In these cases the arachnitis is secondary to osteitis. Sometimes the brain substance is also punctured, and then the case is liable to become complicated with diffuse encephalitis. As to the accompanying hemiplegia, it can hardly be due to the ef- fused fluid, for this is generally inconsiderable in quantity. Most likely it results from some change in the cortical sub- stance of the brain, as the latter is generally found to be more or less discolored, and of a greenish-grey appearance. Diagnosis. — We have already hinted at the fact that diffuse encephalitis may complicate the case, and thus obscure the symptoms. But as encephalitis is not likely to follow in these cases unless there has been a direct injury of the brain, if the evidences of arachnitis are widely diffused over one of the hemispheres, and at the same time accompanied by hemi- plegia of the opposite limbs, we may safely conclude that the case is one of true arachnitis. This inference may not, it is true, always turn out to be correct, but the exceptions, if such there be, are probably more apparent than real ; since it is only when, in consequence of the extreme illness of the patient, the hemiplegia should happen to be overlooked, that there would be any liability of making a mistake. It should be remembered, also, that the hemiplegia involves both sensa- tion and motion; although, as the hemiplegia is incomplete, the defect in sensation is liable to escape detection. In all well-marked cases, however, no such ambiguity exists. Prognosis. — The prognosis is of the gravest possible char- acter, since it is even doubtful whether recovery has ever oc- curred after the disease has once become fully established. Treatment. — As in cases of traumatic pachymeningitis, the chances of success will depend much more upon the prevention of the inflammation, than they will upon curing it after it has once become established ; hence measures.similar to those rec- ommended under that head (q. v.) should be adopted. After the inflammation has once set in, however, the chief reliance will have to be upon such remedies as Aeon., Apis, Ars., Bry., Kali iod., Merc, and Sulph. 13 194 INTRACRANIAL DISEASES. 3. Leptomeningitis. Traumatic leptomeningitis is, as the name implies, a form of inflammation which involves primarily the areolar tissue of the subarachnoidean spaces, and, it may be, also the structure of the pia mater. It may follow any form of injury to the skull- bones which involves perforation or laceration of the visceral layer of the arachnoid ; but as its most common and interest- ing form is met with after fracture of the base of the skull, or through the petrous portion of the temporal bone, we shall confine our description of the disease to that class of cases. Symptoms. — The symptoms of basal subarachnoid inflam- mation are often very obscure, but the condition may be rea- sonably inferred to exist when, after an injury to the base of the skull, vague cerebral symptoms, such as complete insomnia, with mild delirium, but without paralysis, set in ; and especially so if these symptoms have been preceded by deafness, facial pa- ralysis, and bleeding from the ear — symptoms which denote fracture of the petrous portion of the temporal bone. Other important symptoms, such as optic neuritis, variations of tem- perature, etc., have not yet been clearly identified as belonging to this disease. Patients affected with traumatic leptomenin- gitis may die very quickly, but as a general rule they live sev- eral clays after the injury, and in some cases appear to make good recoveries. Morbid Anatomy. — The inflammatory process is generally principally confined to the subarachnoid spaces at the base of the brain and medulla oblongata. Serous lymph is found in- vesting these parts beneath the arachnoid membrane, and ad- hering closely to them, as well as to the nerve-roots springing from them. The lymph is closely bound down by the super- imposed layer of the arachnoid, which is itself perfectly trans- parent and unaffected. The lymph cannot be wiped away, or otherwise removed, unless the arachnoid membrane is either lacerated or cut, proving conclusively that it is situated be- neath it. Pathology. — It is probable that the inflammation gains ac- cess to the subarachnoid spaces, by traveling along the trunks TRAUMATIC MENINGITIS. 195 of the seventh nerve, affecting first the parts adjacent to the roots of this'nerve, and afterwards spreading upwards through the posterior fissures to the ventricles, or over the surface of the hemispheres, or else downwards on the medulla oblongata and its adnexa. One of the peculiarities of this form of meningitis is, that the fracture associated with it, instead of being a simple one, as it appears, is actually compound, air reaching the sub- arachnoidean spaces through the fracture, either by the way of the external meatus or the Eustachian tube. Whether the inflammation of the subarachnoidean areolar tissue ever results from this admission of air or not, is a question which we have no means of deciding. It is highly probable, how- ever, that such is the fact, as we know that the admission of atmospheric air into wounds, and especially into suppurating cavities, is not only highly prejudicial, but determines to a great extent the character of the inflammation. Prognosis. — The most that can be positively asserted under this head is, that while man} T of those that recover from frac- tured base are doubtless cases of simple though severe contu- sion, others, especially those attended by the above symptoms, and in which more or less serous fluid has escaped from the ear, are probably cases of basal meningitis. Such recoveries are, of course, very rare ; so rare, indeed, as to call for an un- favorable prognosis in all cases. Treatment. — There is nothing peculiar about the treat- ment of these cases, the symptoms in every instance clearly pointing out the appropriate remedies. Hence, in addition to the necessary surgical measures, should any be required, the practitioner will do well to study the special indications given under the head of Simple Cerebral Meningitis (q. v-). 196 INTRACRANIAL DISEASES. CHAPTER IV. CHRONIC MENINGITIS. Chronic cerebral meningitis may be most conveniently and profitably considered under two heads, according as it involves either the membranes of the convexity, constituting what we shall call Chronic Convexital Meningitis, or as it affects the membranes at the base of the brain, generally known as Chronic Basal Meningitis. 1. Chronic Convexital Meningitis. This is sometimes the sequela of the acute form of the dis- ease, but more frequently it comes on without a previous acute attack. Symptoms. — The symptoms of chronic convexital menin- gitis resemble for the most part those belonging to the disease commonly known as general paralysis of the insane ; * they also resemble to some extent those produced by softening of the convexity. When, however, the disease follows an acute attack of meningitis, the symptoms are similar to those of that affection, but are less violent, and pursue a much less rapid course. Generally the first symptom to attract the at- tention of the patient is headache. The pain, which though persistent is not very intense, is usually situated either in the forehead or at the top of the head. It is aggravated by heat, by mental exertion, and by bending the head forward. More or less vertigo and drowsiness are also generally present in these cases. But the leading feature of the disease is paralysis, which may show itself by impaired articulation, trembling of * See " Nervous Diseases," p. 173. CHRONIC MENINGITIS. 197 the muscles, weakness of the limbs, paralysis of the lower sphincters, defective memory, and a general impairment of mental vigor. Muscular spasms, involving both single muscles and groups, are not uncommon ; and occasionally there are epileptic and epileptiform convulsions. Hemiplegia, involving one whole side of the body, may set in, or the paralysis may affect only a single limb, or a partic- ular group of muscles. The ocular muscles generally escape altogether, and so do the special senses, with the exception of general sensibility, which is usually more or less elevated or depressed. Thus, there may be either local or general anaes- thesia ; or there may be hyperesthesia of the skin and of the sensory nerves generally, giving rise to neuralgic pains in various parts of the body. The mental faculties, though weakened, are not, as a rule, greatly disturbed, unless the cortical substance of the brain is also involved in the inflammation, and then we have the dis- ease known as general paralysis of the insane. In these cases, and also when the disease follows an acute attack, or when it is subacute, the symptoms are more vio- lent, being attended by more or less delirium, vomiting, scanty and high-colored urine, constipation, defective vision, convul- sions, paralysis, coma, and even death. Such cases, however, can scarcely be regarded as cases of simple chronic meningitis, although described as such by many of the older authors, but rather as a complication of the disease with cortical inflamma- tion of the brain, such as is met with in some cases of chronic mania, and also in general paralysis. Morbid Anatomy and Pathology. — Although the thick- ening and opacity of the arachnoid, so frequently met with in chronic cerebral diseases, and which was formerly regarded as due to chronic inflammation, is now looked upon by many as a mere result of degenerative overgrowth — the consequence, chiefly, of frequent and long-continued congestions — there can be but little doubt, I think, that, as a general rule, the condi- tion in question does result from chronic inflammation, rather than from simple irritation or congestion. For, in addition to the hyperemia and thickening, we have, in the majority of 198 INTRACRANIAL DISEASES. cases, adhesions of the membranes to each other and to the cerebrum, as well as deposits of exudation on the surface of the brain which are distinct from the alterations of the mem- branes. Thus we may have, not only injection, opacity, and thickening of the membranes, but serous and gelatiform ex- udatious beneath the arachnoid, discolored fluids and puriform matter in the same situation, and adherent and non-adherent false membranes. Syphilitic gummata and tubercular gran- ules are also sometimes found in the membranes of the con- vexity, but these neoplasmata are much more common in the membranes at the base. Causes. — There are numerous causes capable of exciting chronic convexital meningitis, though many cases occur in which the etiology is more or less obscure. It is generally admitted that the disease is sometimes the result of an acute attack of convexital meningitis. It may also originate in the same way as the acute affection, namely, by prolonged expos- ure to extreme heat, both natural and artificial, by blows and falls upon the head, and by the excessive use of alcoholic liquors. It may also be caused by any severe mental strain, especially when long continued. Cerebral syphilis and tuber- culosis are likewise occasional causes, but when produced by the last-named condition, it should not be confounded with acute hydrocephalus, which is an entirely different affection. Diagnosis. — The comparative mildness of the symptoms, as well as the chronicity of its course, will serve to distinguish the disease from the acute form of the affection ; and when originating in the latter, the previous history of the case will be sufficient to establish its true nature. The case is different, however, when we come to compare the symptoms of this dis- ease with those of inflammation and softening of the cortex, and particularly when the two diseases are combined, as the symptoms of the two conditions are almost identical. Here the intensity of the symptoms, and the nature of the cause producing them, are about the only means we have of differ- entiating between them. Thus, while the pain is less in soften- ing than it is in inflammation of the membranes, the mental symptoms are more severe, and vice versa. CHRONIC MENINGITIS. 199 Prognosis. — The prognosis, as in every other form of cere- bral inflammation, is unfavorable. The only exception is where the disease is of a syphilitic nature, in which case the chances of recovery are good, provided the case is taken in hand early and properly treated. Non-syphilitic cases, how- ever, are not always fatal, as is proved by the fact that post- mortem appearances have established the previous existence of the disease in individuals who have died of other affections. Treatment. — The treatment of chronic convexital menin- gitis differs in no essential respect from that of the acute form already given under the head of Simple Meningitis (q. v.). Should there be reason, however, to suspect the existence of a tubercular complication, or if there are evidences of any form of tuberculosis, the practitioner should not fail to consult the indications given under the head of Tubercular Meningitis. Syphilitic cases will, of course, demand anti-syphilitic treat- ment; and whenever the dyscrasia can be satisfactorily made out, the practitioner can pretty safely rely on Kaliiodatum and Mercurius corr. as being effective remedies in the case. 2. Chronic Basilar Meningitis. Those cases of chronic basilar meningitis which result from injuries, have already been considered under the head of Traumatic Leptomeningitis (q. v.). Symptoms. — Tonic and clonic spasms, affecting the muscles of the neck and limbs, are generally among the earliest symptoms of the disease. Sometimes the patient is seized at the outset with general convulsions of an epileptiform char- acter, but without losing consciousness. At others, the spas- modic action is confined to particular muscles or sets of muscles, especially those of the upper extremity. Pain is also a prominent symptom, and sometimes it is about the only one that attracts the attention of the patient. It is generally located in some part of the head or face, and is remarkable both for its intensity and its obstinacy. Vertigo is another marked symptom, and is so great in some cases as to compel the patient to constantly maintain the recumbent position. 200 INTRACRANIAL DISEASES. But the most important symptom belonging to these cases is paralysis. As the disease is seated at the base of the brain, the paralysis may implicate any of the parts supplied by the motor branches of either of the cranial nerves. This gives rise to a great variety of symptoms, according to the particular nerves affected. Thus, if the seventh cranial nerve be impli- cated, we shall not only have facial paralysis, but we are also liable to have more or less impairment of articulation and deglutition, in consequence of the paralysis involving some of its branches of communication with other nerves. If the third be involved, then there may be paralysis of the levator palpe- brse muscle, causing a dropping of the upper lid; or there may be external strabismus and double vision, owing to paralysis of the internal rectus muscle ; or, if the implication of the nerve is incomplete, there may be simple dilatation of the pupil, with or without deficient accommodative power. In this case, also, the vision is more or less injured, owing chiefly to paralysis of the ciliary muscle, and consequent weakness of the accommodation. Defective vision may also result from an extension of the morbid process from the affected membrane to the optic nerve, giving rise to hyperemia of the optic nerve and retina, and even to optic neuritis, in which case vision may be entirely lost. The sense of hearing may also be greatly impaired, or even lost, by the auditory nerve becoming implicated in the inflammation. Anaesthesia is common, and this symptom may exist either with or without paralysis. The anaesthesia may be limited to a small portion of the surface of the body, as the face, trunk, upper or lower extremities, or it may involve the whole of one side. The mind is not usually affected to any considerable extent, at least at the outset, nor, indeed, so long as the inflammation is strictly limited to the basilar membranes. It is only when the inflammatory process involves more or less of the mem- branes of the convexity that the mental faculties are apt to suffer any permanent weakness or derangement. Morbid Anatomy. — The anatomical changes met with in chronic basilar meningitis, do not differ in their nature from CHRONIC MENINGITIS. 201 those we have already described as belonging to the convexital form. The only peculiarity worthy of note, is the fact that here the morbid changes are generally much more limited in extent than they are in the former situation, the altered patches being sometimes less than half an inch in diameter. Syphi- litic and tubercular deposits are more common in this position than they are in the membranes of the convexity, probably for the same reason that the inflammatory process itself is more frequent in this portion of the cerebral membranes. Pathology. — It is only necessary to bear in mind the dis- tribution of the cranial nerves, in order to correctly interpret the symptoms arising from one or another of them becoming involved in the inflammatory process. The disturbances thus produced furnish us a ready means of determining, in most instances, the precise seat of the disease ; and this is still fur- ther facilitated by the circumscribed character of the inflam- mation. It is only, however, when the inflammatory process affects the substance of the brain itself, that the functions of motility and sensibility are disturbed in the trunk and limbs. Aphasia points to the third left frontal convolution of the brain, the morbid process reaching it through the fissure of Sylvius. Whenever, as not unfrequently happens, there is an alteration in the locality of the symptoms, the change indicates a transference or extension of the disease to a new region. Thus, the disease has been known to involve the third, fourth, fifth, sixth, and seventh nerves, in regular succession. Causes. — Hammond* regards syphilis as the most common cause of chronic basilar meningitis; next, the abuse of alco- holic liquors ; and next, excessive emotional disturbance. According to my experience, however, alcoholic beverages take the first rank in this disease as causative agents, though this may not be the case in our metropolitan cities, where syphilis is of comparatively greater prevalence. This disease has also been known to follow blows upon the head, atmos- pheric changes, and certain diseases, especially scarlet fever, diphtheria, suppurative otitis, and epidemic cerebro-spinal meningitis. * Loc. cit. 202 INTRACRANIAL DISEASES. Diagnosis. — This disease is not liable to be mistaken for any other affection of the brain, provided sufficient attention is given to the history of the case, and the extent and charac- ter of the symptoms. This is not the case, however, with thrombosis of the arteries at the base of the brain, the symp- toms of which are scarcely distinguishable from those of chronic basilar meningitis. Generally, the best clue in these cases is the exciting cause, which, in connection with the his- tory of the case, may be sufficient for all practicable purposes, since the treatment of thrombosis is not likely to be followed with any permanently good results. Prognosis. — The prognosis of simple chronic basilar men- ingitis is more or less favorable or otherwise, according to the nature of the cause. When produced by syphilis, the disease, if promptly and correctly treated, may almost always be sub- dued. The same is true when the disease is due to severe moral perturbations, anxiety, or too close confinement to busi- ness, provided the patient can* be induced to submit to the requisite hygienic treatment. On the other hand, those cases which result from the abuse of alcoholic stimulants, as well as those which supervene upon purulent otitis, diphtheria, and epidemic cerebro-spinal meningitis, are generally fatal. Treatment. — The therapeutic measures already laid down in previous articles for the treatment of various forms of men- ingitis (q. v.), furnish all the directions and indications neces- sary for the successful management of every curable case of this disease, and therefore need not be repeated here. As for the resulting paralysis, we have the following General and Special Indications. — For Paralysis of the Facial Muscles. — Bar., Bell., Cadm., Caust., Cocc, Gels., Kali chlo., Nux vom., Op., Strain. For Paralysis of the Tongue and Organs of Speech. — Bar., Bell., Cocc, Dulc, Gels. For Paralysis of the Muscles of the Eye. — Argentum nitricum.— Weakness or paralysis of the ciliary muscles. Causticum. — Paralysis of any or all of the ocular muscles, especially when resulting from exposure to cold. CHRONIC MENINGITIS. 203 Cuprum acet. — Paralysis of the nervus abducentis. Euphrasia. — Paralysis of the oculomotor nerve, especially when caused by cold, or a catarrhal condition of the eye exists at the same time. Gelsemium. — Paralysis of the oculo-motor and abducens nerves, or when it gives rise to double vision. Kali iod. — When the paralysis is of a syphilitic origin. Mercurius. — Same indication as for Kali iod. Nux vom. — When aggravated by the use of tobacco or stimulants. Opium. — Paralysis of the ciliary muscle. Paris quad. — Paralysis of the iris and ciliary muscle, espe- cially when there is pain in the eyes as if they were being pulled into the head. Phosphorus. — Paralysis associated with weakness of the sex- ual organs, and especially with spermatorrhoea, Rhus tox. — When resulting from exposure to cold and damp, or from changes in the weather. Senega. — Weakness of the superior rectus or superior oblique, in which the diplopia is relieved by bending the head forward. Spigelia. — When the paralysis is associated with sharp stab- bing pains through the head. Stramonium. — Paralysis from brain troubles, or when asso- ciated with facial paralysis. 204 INTRACRANIAL DISEASES. CHAPTER V. EPIDEMIC MENINGITIS. Syx. : Cerebrospinal Meningitis. This is an epidemic, acute, diffusive inflammation of the membranes of the brain and spinal cord, resulting in a de- posit of puro-lymph upon the surface of the arachnoid, and an effusion of serum into the ventricles and subarachnoid space. Symptoms. — The attack, which is usually very sudden, is generally ushered in by vomiting, faintness, and severe head- ache; the latter being especially marked in the back of the head and neck. In many cases there are distinct chills, fol- lowed speedily by fever; but as a general rule reaction does not occur until a later period, being preceded by cold extremi- ties, insensibility, and sometimes convulsions. These symp- toms are followed by tonic spasms of all the extensor muscles of the limbs. If the patient survive this state of collapse, which is not always the case, he complains of severe pains in the back of the head and neck and along the spine ; and as these symp- toms increase in severity, the tonic rigidity becomes more and more developed, until opisthotonos, and a general tetanic condition, is induced. Accompanying this muscular spasm is a hypereesthetic state of the skin ; and neuralgic pains also appear in different parts of the body. On or about the second day of the disease, and sometimes at an earlier period, there generally appear upon the surface, in severe cases, irregular purplish spots, varying in size from a pin's head to large patches. The eruption usually shows itself first upon the lower extremities, and feels like small, EPIDEMIC MENINGITIS. 205 hard pebbles under the skin. In some cases the eruption is entirely absent, or is confined to only a small area; in others, it becomes so general as to cover nearly the whole surface of the body. In addition to this characteristic eruption, which has conferred upon the disease the popular name of spotted fever, other skin eruptions frequently make their appearance, such as herpes, ecthyma, and pemphigus; the latter being confined, for the the most part, to the advanced stages of the malady. The vesicular eruptions, which are as common in mild as in severe cases, are most frequent on the face, neck, and shoulders. Both the temperature and the pulse are very irregular. The former generally rises from 100° F. to about 104° F., but is subject to very marked variations above and below these points; whilst not unfrequently it remains for a considerable period nearly at the normal standard, without any abatement of the other symptoms. On the other hand, as already stated, the temperature sometimes never rises, the patient dying in a state of collapse. The pulse, which does not always correspond to the temperature, generally rises to about 120, and has a peculiar jerking character. It is very irregular, sometimes varying twenty, thirty, and even forty beats within a few hours. The symptoms taken as a whole are decidedly typhoid from the beginning. The tongue, which at first is heavily coated and moist, generally becomes black, dry, and sometimes cracked, by the fourth or fifth day of the disease, especially in comatose cases. The stools are sometimes loose and offensive, and at others the reverse. In unfavorable cases, the stupor deepens into coma, faeces and urine pass off involuntarily, the vital powers become more and more depressed, and finally death closes the scene. In favorable cases, on the other hand, the sjunptoms are generally less severe, especially those of depres- sion, which are not only milder but less permanent, and in some cases do not appear at all ; the remaining symptoms gradually abate, and convalescence begins in from one to three weeks from the commencement of the disease. Complications and Sequelae. — Of those belonging to the 206 INTRACRANIAL DISEASES. nervous system, paralysis is the most frequent, and is gen- erally confined to one of the upper extremities. The eye is often irreparably injured by the setting in of a low form of purulent opthalmitis, attacking either a part or the whole of the organ, and generally resulting in its entire destruction. In other cases the inflammation is limited to the cornea or iris, which, though not destroying the organs, may neverthe- less permanently impair the sight. The sense of hearing is not often destroyed, but a few cases of permanent deafness have been met with, doubtless arising from injury to the audi- tory nerve, the external origin of which is frequently im- bedded, so to speak, in the fibroid deposit on the surface of the medulla. Haemorrhages are not uncommon, especially in malignant cases. These generally occur from the nose, bow- els, kidneys, and uterus ; sometimes, also, from the ears. Acute inflammation, terminating in purulent effusion, some- times attacks the larger joints, and is a frequent complication in some epidemics. Chronic meningitis, with its train of se- quelae, has also been observed in these cases. Morbid Anatomy. — The most marked and characteristic alteration met with in epidemic meninigitis, is the yellowish- white or greenish-yellow deposit of puro-lymph found at the base of the brain. This deposit, however, is not confined to the base, but in fatal cases is also met with on the convexity, along the sulci, in the fissure of Sylvius, between the chiasma and pons, on the pons and cerebellum, and on the posterior surface of the cord. Serum is found in the ventricles and subarachnoid space ; the cerebral membranes are all more or less injected ; and the arachnoid is not only extremely vascu- lar, but is rendered opaque by the puruloid deposits before mentioned, w 7 hich vary in consistence from a thin, milk-like lymph to thick and dense fibrino- purulent deposits. The brain substance itself is more or less injected, and sometimes small spots of secondary softening occur, but in other respects the organ generally exhibits a normal appearance. Pathology. — Epidemic meningitis is an infectious disease, but what the real nature of the infective element consists in, is unknown. It has, like all other so-called zymotic diseases, EPIDEMIC MENINGITIS. 207 been attributed to certain disease-germs introduced into the system from without, and more especially through the several mediums of the air, the water, and unwholesome food ; but as yet nothing definite has been discovered in these directions. Admitting that it is produced or propagated by a disease- germ, it appears to nourish best in damp, overcrowded, and badly ventilated habitations, in camps, jails, and other un- healthy situations ; yet it is not confined to such localities, nor to the lower walks of life. Besides, there is no known reason why it has such a special affinity for the central nervous sys- tem. The mystery doubtless belongs to the same category that determines the chief pathological changes of diphtheria to the mucous membrane of the fauces and neighboring parts, of variola and other allied diseases to the skin, and of syphilis to the periostial and other tissues. Causes. — Age appears to be an important factor in these cases, as the disease is most common during early life. It is especially frequent just before the period of adolescence, is not uncommon in early childhood, but is seldom met with after thirty-five or forty years of age. Sex also seems to have considerable influence, the disease being much more common in males than females. Whether occupation is a predisposing or exciting cause of the malady is not definitely known. The disease frequently appears among young army recruits, but this is probably due more to the sanitary surroundings than to the occupation itself. Physical exhaustion, however, in whatever way induced, is undoubtedly a predisposing cause. The disease appears more frequently in winter and spring than it does in hot weather; and in cold and temperate climates rather than in the tropical regions. Its epidemic and infectious nature has already been considered. Diagnosis. — The disease is liable to be confounded with typhus fever, purpura haemorrhagica, and malignant scarli- tina. It may be distinguished from ordinary typhus by the nervous symptoms, and by the sudden appearance of the characteristic rash, which is not preceded by petechise. Pur- pura haeniorrhagica is not attended by such high constitu- tional disturbances, nor by the peculiar nervous symptoms 208 INTRACRANIAL DISEASES. which characterize epidemic meningitis. Malignant scarlet fever may generally be distinguished by the rash, sore throat, and nervous symptoms, as well as by the prevailing character of the epidemic ; but when the two diseases prevail together, the diagnosis will often be extremely difficult. Prognosis. — The prognosis varies greatly in different cases, depending chiefly upon the grade or intensity of the s} 7 mp- toms. When very mild, the disease usually terminates in recovery within two or three weeks. On the other hand, very severe cases, occurring suddenly, and accompanied by great depression of the vital powers, the characteristic eruption, haemorrhage, and coma, generally terminate fatally within a few hours, or at farthest within two or three days. Cases of medium severity, however, though often protracted, usually recover under homoeopathic treatment, the duration of the disease being from two to six or eight weeks. Occasionally a case assumes the chronic form, but in these instances the patient generall} r sinks into a state of marasmus, and dies in the course of a few months. The disease is most fatal about the age of puberty, probably for the same reason that it is most frequently met with at this period of life. The mortality in different countries varies from about forty to eighty per cent., and averages about sixty per cent., being highest, it is said,* among the Irish constabulary. Treatment. — Ice to the head and spine often has the effect of allaying the pain, but there is no evidence of its having been of any permanent benefit to the patient. Other local applications are equally valueless ; and the practitioner will succeed best by confining himself strictly to the homoeopathic treatment, as given in the following Special Indications. — Aconite.— In cases where there is well- marked reactionary fever, attended by chilliness, thirst, rest- lessness, dryness of the skin, and anxiety of mind. Agaricus. — Drawing pains in the back of the head ; violent pains all along the spine; stiffness and soreness of the nape of * Dr. Grimshaw in Quain's Die. of Med., p. 228. EPIDEMIC MENINGITIS. 209 the neck and spine ; great weight in the forehead and temples, with delirium and coma. Apis mel. — Burning and throbbing in the head, with pain and stiffness in the back of the neck ; great prostration, both physical and mental ; brain feels tired ; stabbing pains in the occiput; swelling of the face, giving it an cedematous appear- ance ; hypersethesia of the skin, with stinging pains all over the surface; sense of suffocation, with great oppression of breathing; dulness of vision; urine scanty or suppressed; pulse variable and intermitting. Argentum nitr. — Intense headache ; vertigo ; photophobia ; ringing in the ears ; chilliness ; clouds before the eyes ; diplo- pia ; deafness ; cutting pains extending from occiput to fore- head, increasing and diminishing frequently ; face pale and emaciated; tongue coated white, or else black, hard, and dry; sordes upon the teeth ; lips and nails blue ; breathing greatly oppressed ; incontinence of faeces and urine ; jerking and trembling of the limbs ; epileptiform convulsions. Arnica. — Great general prostration, with a sore, bruised feel- ing everywhere ; back of the neck extremely sensitive to the touch ; diuresis ; formication and cramps in the extremities. Arsenicum. — Great restlessness and prostration ; the char- acteristic thirst for but little water frequently repeated ; tongue dry and trembling ; stiff, sore feeling in the back of the neck ; scalp sensitive and painful ; vertigo, with humming in the ears ; face pale and corpse-like ; dulness of vision ; diarrhoea; anxious respiration ; tetanic rigidity ; spasmodic grinding of the teeth ; comatose state. Baptisia. — Typhoid symptoms, accompanied by a bruised and painful feeling in the back of the head and neck ; wan- dering pains in all the limbs ; body feels universally stiff and sore ; great restlessness, especially of the head and limbs, which are in constant motion ; dark, livid spots on the skin ; consti- pation; stomach sore and sensitive to pressure; vertigo; weak- ness and trembling of the limbs. Belladonna. — Violent, stupefying headache, worse in the back of the head, and extending to the neck ; ameliorated by bend- ing the head backward ; convulsive movements, especially of the muscles of the face and neck ; grinding of the teeth ; 14 210 INTRACRANIAL DISEASES. hyperesthesia of the senses ; upper part of the body hot, extremities cold; retention or inconstancy of the urine; pupils dilated ; coma, either with or without delirium. Bryonia. — Intense headache, with stiffness of the neck, and great pain and soreness in all the limbs and joints; symptoms greatly aggravated by motion. Camphor. — Throbbing pain in the back of the head, w T hich is drawn backwards or to one side ; death-like paleness of the face ; tetanic spasms ; violent cramps in the stomach and limbs ; general surface of the body blue and cold ; cold, clammy perspiration ; great oppression of the chest, with diffi- cult breathing ; no reaction from the initiatory chills. Cannabis ind. — Vertigo on rising, with stunning pain in the back of the head ; pain across the shoulders and spine ; fixed, staring eyes, with dilated pupils ; hearing acute ; face cold, with drowsy and stupid expression of countenance ; great oppression of the chest ; convulsions ; emprosthotonos or opis- thotonos, with loss of consciousness ; collapse, with pale, clammy, and insensible skin ; pulse feeble and irregular. Cantharides. — Violent, lancinating pains in the occiput, extending deep into the head ; priapism, with amorous frenzy ; eyes staring, or dull and sunken ; face pale, with ter- ror-stricken expression of countenance ; spasmodic constric- tion of the throat; retention and suppression of urine; tetanic spasms ; fainting, trembling, and general coldness. Chininum. — Violent throbbing headache, with vertigo, heat in the face, and extreme weakness ; symptoms intermitting. Cicuta. — Head retracted; muscles of the neck sore and stiff; vertigo, with moaning delirium ; anxious expression of coun- tenance ; double vision ; dilated pupils ; spasmodic action of the muscles of the face and limbs ; tonic contraction of the cervical muscles ; opisthotonos ; convulsions, attended with cries, working of the jaws, distortion of the limbs, painful dis- tention of the abdomen, and spasm of the muscles of the chest, followed by insensibility and immobility; general paralysis; diarrhoea or constipation ; ashy hue of the skin ; pain in the stomach with vomiting. Cimicifuga. — General headache, but not very violent, except it may be in the vertex and occiput; pain in the neck, shoul- EPIDEMIC MENINGITIS. 211 ders, and spine ; low, restless, excitable delirium, like that of delirium tremens ; eyes painful and sensitive to pressure ; pupils dilated ; general prostration, accompanied by more or less nausea and vomiting ; profuse cold sweat all over the body, with very quick pulse ; tongue swollen and throat dry, causing a constant desire to swallow ; muscular twitchings in various parts of the body. Cocculus. — Severe headache, with vertigo, vomiting, and feeling as if the eyes would be torn out; face pale and bloated; painful' stiffness of the muscles of the neck ; convulsive trem- bling of the head ; epileptiform convulsions ; constriction of the chest, with heavy and laborious respiration ; fainting fits ; miliary eruptions. Orotalus. — Extremely violent headache ; pains in all the limbs ; staring eyes, with delirium ; burning, unquenchable thirst ; nausea and vomiting, preceded or accompanied by faintness ; anxious breathing ; purplish spots on the skin ; diarrhoea, with faintness ; pallid face ; painful heaviness of the limbs ; feeble pulse. Cuprum. — Convulsive symptoms predominate ; nausea and vomiting from cerebral congestion ; nervous trembling, with hyperesthesia of the senses ; sad, depressed features, with dim, lustreless, sunken eyes, surrounded with blue rings ; somno- lency or coma ; general paralysis. Digitalis. — Sharp stitches and severe cutting pains in the nape of the neck ; stiffness in the back and side of the neck ; violent, lancinating pains in the head, especially in the occiput; head tends to fall backward when sitting or walking; delirium resembling that of delirium tremens; heart's action slow, irreg- ular, and labored ; depression, accompanied by faintness and vomiting ; convulsions, with retraction of the head ; syncope, with coldness and tendency to collapse. Gelsemium. — Severe chill, followed by cerebral and spinal congestion ; great depression, with dilated pupils, livid cheeks, dulness of speech, icy coldness of hands and feet, extreme weakness, very weak pulse, and laborious respiration ; nausea and vomiting ; general muscular paresis, without any impair- ment of the mental power ; somnolency and coma ; sweating relieves. 212 INTRACRANIAL DISEASES. Glonoin. — Violent, throbbing headache, accompanied by a bursting sensation ; face pale, or else deeply congested ; blind- ness, with nausea and faintness ; pain throughout the central nervous system ; labored action of the heart. Hydrocyanic acid. — Malignant cases, attended with imme- diate collapse ; protruded, half-open eyes ; dilated and station- ary pupils ; blindness ; bloated and bluish face ; tongue pro- truded and paralyzed ; general coldness ; feeble, irregular pulse and respiration ; incontinency of faeces and urine. Hyoscyamus. — Violent headache, alternating with pains in the back of the neck ; throbbing sensation in the brain ; draw- ing in the nape when turning the head ; heaviness of the head, with dimness of vision, palsy of the tongue, and small, inter- mitting, and quick pulse; convulsions, with spasms of the chest, and temporary arrest of breathing ; stiffness of cervical muscles and trismus ; constant grinding of the teeth ; epilep- tiform convulsions ; jerking of the limbs ; brown spots and large pustules on the skin, also gangrenous vesicles ; involun- tary stool and urine. Lycopodium. — Congestive headache, with pain extending down the neck ; hyperesthesia of the special senses ; oppres- sion of the chest, with fan-like movement of the nostrils; sense of constriction in the chest and abdomen, as though bound with a hoop ; melancholy and irritable ; dreads solitude ; numbness and twitching of the limbs. Nux vom. — Hyperesthesia of the cerebro-spinal system of nerves ; shocks in the brain ; scalp sensitive to the touch ; loud, reverberating sounds in the ear; oversensitive to odors; stitches through the body ; conscious opisthotonos ; convul- sions renewed by the least touch ; numbness and paralytic drawing in the limbs ; bruised sensation in the head, limbs, and body, with feeling of heaviness. Opium. — Stupor, or tendency thereto, with or without de- lirium ; head and limbs feel cold, numb, and heavy ; eyes fixed and hall closed ; pupils dilated and immovable ; face bloated and muscles relaxed ; opisthotonos, with constrictive feeling in the chest, and dyspnoea ; vomiting and colic ; abdo- men hard and swollen ; bowels loose or constipated ; convul- EPIDEMIC MENINGITIS. 213 sions, with spasmodic jerkings of the limbs; painless paralysis ; anaesthesia ; hot or cold perspiration ; worse while sweating ; coma. Phosphorus. — Congestive headache, with burning and sting- ing pains in the occiput ; petechial and purpuric eruptions on the surface of the limbs or body; dulness of hearing; dysp- noea; frequent fainting; great prostration; tingling and tear- ing pains in the limbs ; laming pains in the spine. Plumbum. — Early paralytic symptoms ; heavy feeling in the back of the head ; retraction of the abdomen ; obstinate con- stipation ; somnolency; emaciation; contraction of the limbs; colic ; limbs feel too heavy to be moved. Rhus tox. — Vertigo, with heavy, bruised feeling in the brain, extending to the ears and back of the neck ; vesicular erup- tions on the face and upper part of the body ; great restless- ness, with aching pains in the limbs ; bruised feeling in the back and limbs ; somnolency ; bleeding at the nose ; dry cough, with perhaps bloody sputa. Veratrum alb. — Violent headache, with delirium ; vomiting, with convulsive shocks in the head as soon as the latter is raised ; stiffness of the neck, with bursting sensation in the head, and choking in the throat ; face pale, cold, and cadaver- ous looking; head thrown back, and rolling from side to side; convulsions, w T ith loss of sense and motion; coldness and numbness in the limbs; watery diarrhoea, attended with collapse. Veratrum vir. — Loss of consciousness, with coldness of the surface, slow, irregular and feeble pulse, and general prostra- tion of the vital power; vertigo, with dimness of vision, dilated pupils, and vomiting ; severe pain in the neck and shoulders ; sudden spasmodic action of the muscles of the face and limbs; convulsive twitchings, as from electric shocks; opisthotonos, with trismus ; trembling of the whole body ; pulse frequent and feeble. Zinc. — Retarded convalescence ; coldness of the body ; pros- tration of the vital power, with profuse and easy sweating ; trembling and twitching of the hands and feet ; priapism ; dysuria ; flatulent colic ; constipation ; weak, watery eyes ; flushes of heat in head and face ; weak memory. 214 INTRACRANIAL DISEASES. CHAPTER VI. HEMORRHAGIC PACHYMENINGITIS. Syx. : Hematoma of the Dura Mater. This is a peculiar form of chronic inflammation of the in- ternal layer of the cerebral dura mater, resulting in the forma- tion of false membranes from which originate repeated attacks of haemorrhage, the latter constituting what is called hsematoma durse matris. Symptoms. — There are two stages in the history of this disease. The first is characterized by an intense headache, generally most severe at one particular point, which is fre- quently the vertex. Other less distinctive symptoms belong- ing to this stage are : more or less vertigo, mental confusion, uncertainty of movement, restlessness at night, contraction of the pupils, and occasionally, fever and convulsions, the latter especially in the case of children, in whom the disease gen- erally pursues a far less chronic course than it does in adults. The second stage, which includes the whole period from the first effusion of blood until the termination of the case, is char- acterized at first by a more or less rapid increase of mental hebetude, which gradually, but in an intermitting manner, passes from a state of somnolency to that of coma ; the rapidity depending, of course, on the rapidit} T of the effusion. The headache continues permanently fixed, the pupils contracted, and, whilst the patient is conscious, the vertigo and other brain symptoms more marked and troublesome. Thus we may have facial palsy, stammering, loss of voice, aphasia, un- steady gait, a voracious appetite, and constipation. When the hsematoma is unilateral we may have hemiplegia, more or less complete. At last, when the sac gives way, and the HEMORRHAGIC PACHYMENINGITIS. 215 hemorrhage from the ruptured cyst spreads into the sur- rounding tissues, the symptoms of apoplexy, if not already fully developed by the previous pressure of the hematoma, now show themselves, producing complete loss of conscious- ness, hemiplegia or general paralysis, distortion of the face, difficulty of swallowing, great oppression of breathing, and finally death, which may or may not be preceded by delirium and convulsions. The duration of this stage, in the case of children, is usually only a few days ; whilst in adults it may continue for weeks and months. Morbid Anatomy and Pathology. — The first thing ob- served in these cases, according to Virchow, who made a special study of the disease, is hyperemia of the dura mater of the brain, especially of that portion of it which corresponds to the convexity. This leads to the formation of a false mem- brane on the internal surface of the dura, which at first is extremely thin, soft, and delicate, resembling somewhat the appearance of a spider's web. This membrane afterwards varies in consistence according to age, and is separable into two or more layers, sometimes even as many as twenty, each traversed by numerous fine blood-vessels. Owing to the great number and extreme delicacy of these newly-formed vessels, they are especially liable to become ruptured, and the effused blood, pressing upon the several layers of which the false membrane is composed, forms with it an organized sac, into which the subsequent effusions of blood are poured ; or the blood may be effused between the layers in one or more places, thus forming one or more simple or loculated cysts. The cysts adhere externally to the dura mater; internally they rest upon the arachnoid, covering the convolutions, which they compress and atrophy. They are generally situated near the middle line of the convexity, the general membrane of the hematoma often extending symmetrically on both sides. The contained blood is either in a liquid or a coagulated con- dition, and exhibits in different cases every stage of degenera- tion, according to the age of the hematoma. These views of Virchow, though generally received by pathologists, have been recently opposed by Huguenin and 216 INTRACRANIAL DISEASES. others, who contend that the older doctrine, namely, that the hemorrhage precedes the formation of the* false membrane, is the correct one, and that the dura mater is not primarily inflamed, as Virchow asserts. At present, therefore, the pa- thology of the disease cannot be considered as definitely settled ; one party regarding the disease as a chronic pachy- meningitis, and the other as a truly hemorrhagic affection. Causes. — Hematoma generally occurs after fifty years of age, and is much more common in men than in women. It is, however, met with at all ages, especially in early child- hood, when it is almost as frequent as in advanced life: The disease is seldom, if ever, met with in healthy indi- viduals, but chiefly in those whose constitutions have become impaired by intemperance or old age, or weakened by such debilitating diseases as scurvy, delirium tremens, Bright's disease of the kidneys, anemia, haemophilia, diseases of the chest, etc. It also occurs in the subjects of insanity, and in persons who have suffered from a previous injury to the head. Diagnosis. — The diagnosis of hemorrhagic pachymenin- gitis, or hematoma of the dura mater, is a matter of great difficulty, and can seldom amount to more than a mere probability, as the symptoms are common to the various forms of cerebral and meningeal haemorrhage, as well as to other varieties of head trouble. Moreover, the disease is frequently associated with other cerebral disorders, the symptoms of which, occurring as they do simultaneously with those of the hematoma, often so modify or overshadow the latter as greatly to obscure the secondary affection. Those cases, however, where, after a period of headache, the symptoms of coma slowly supervene, and where at the same time there are no symptoms of any other form of localized injury to the brain or its membranes, we may reasonably refer to this category, especially if they occur in the aged, and are associated with a broken-down state of the system. Infantile hematoma is liable to be mistaken for tubercular meningitis, but the history of the case, and a careful comparison of all the symptoms of the two diseases, will generally lead to a correct diagnosis. Prognosis. — The prognosis, though extremely unfavorable, HEMORRHAGIC PACHYMENINGITIS. 217 is not altogether hopeless, at least in the case of adults, as a number of cases are on record in which the symptoms of hematoma were present, and yet the patients recovered. Treatment. — Rest, cold to the head, and the homceopathi- cally indicated remedy, constitute the summum bonum in every case. AVe can therefore add nothing to the thera- peutic measures already given under the head of Cerebral Haemorrhage (q. v.). 218 INTRACRANIAL DISEASES. CHAPTER VII CHRONIC HYDROCEPHALUS. Syn. : Dropsy of the Brain. This disease may be defined to be, a gradual effusion of serous fluid into the ventricles of the brain in such quantity as to distend them, and thereby enlarge the head. This definition purposely excludes those cases where the fluid has been found within the so-called cavity of the arachnoid, and which have probably resulted from an accidental rupture of the ventricular walls ; and also those cases where serum has accumulated be- neath the arachnoid as a sequence of cerebral atrophy or wast- ing — secondary affections which will be considered in the next chapter. Symptoms. — The disease is both congenital and acquired. Extra-uterine cases generally begin to manifest themselves during infancy, or soon after birth, before the cranial bones have become permanently united. In certain rare instances, however, the head commences to enlarge after the sutures have united ; up to, and even beyond, the period of middle life. The earlier symptoms may precede the beginning of the en- largement, and vice versa. In the former case, symptoms more or less resembling those of acute hydrocephalus set in, and are soon followed by a perceptible enlargement of the head ; or, the irritative symptoms abate and become more or less chronic before the head commences to enlarge, so that for a time the practitioner may be in doubt as to the real nature of the dis- ease. Sooner or later, however, the enlargement begins to manifest itself; and as this continues gradually to increase — even though, as sometimes occurs, no other 'symptom may show itself for a considerable period — there can no longer be CHRONIC HYDROCEPHALUS. 219 any room for doubt. The disease is now not only quite mani- fest to the eye, but the patient has a somewhat uncertain and tottering gait, which is often characteristic of the affection, especially in the case of children. As the disease advances, the child becomes dull and peevish ; tremors of the limbs set in, so that he can no longer walk ; the senses gradually fail ; there is more or less insensibility of the skin ; taste becomes perverted and weak; the sense of smell is diminished; dim- ness of vision follows; and finally hearing itself fails. The digestive functions generally remain longer unimpaired, but they, too, at last become involved ; vomiting occurs, and ema- ciation, notwithstanding an increase in the amount of food, is likewise produced. Costiveness and scanty urine are also attendant symptoms. At last, symptoms of paralysis set in, the eyes are turned to one side, the pupils are dilated, and vision is either greatly impaired or becomes extinct. The rec- tum and bladder become implicated, so as to lose all control over their contents. Finally, after successive attacks of spasms and convulsions, the paralysis becomes complete; suffocative fits occur, during which the breathing becomes labored and stertorous ; insensibility follows ; the pulse becomes small, feeble, and intermitting; and death finally closes the scene. Such is the general history of most cases; but sometimes, owing to a fall or blow upon the head, or some other cause, convulsions occur at a much earlier period ; or it may be that apoplectic symptoms, such as coma and paralysis, take prece- dence of all other phenomena. This is especially apt to be the case in adults, owing to the unyielding condition of the cra- nium. Moreover, complications are liable to occur, resulting perhaps from the presence of a cerebral tumor, or some other primary intracranial affection, and then the symptoms will be correspondingly modified. Thus, if under these circumstances we make an ophthalmoscopic examination of the fundus of the eye, we may find, even at a comparatively early period of the disease, a well-developed optic neuritis ; a condition which in these cases will sooner or later terminate in amaurosis or true blindness. Morbid Anatomy and Pathology. — The bones of the era- 220 INTRACRANIAL DISEASES. nium are found in one of two conditions, either with the fon- tanelles open and the sutures widely separated, or else with the sutures, and perhaps the fontanelles also, completely closed. The latter may represent cases which have become stationary, or more than usually chronic ; but of this we have no certain evidence. The bones of the cranial vault are generally more or less thinned or atrophied from pressure, but this is not always the case ; on the contrary, they are sometimes thick- ened, and that, too, even in children. As the bones of the face usually remain firmly united, whilst those of the vault are w T idely separated from each other, the head generally presents a peculiar wedge-shaped appearance, especially when the en- largement is extreme. In these cases the forehead is so prom- inent as to overhang the face, whilst the eyeballs are deeply sunk in their sockets ; and as the face is either unchanged or more or less emaciated, the disproportion between them is so remarkable as to make the expression highly characteristic of the disease (fades hydrocephalica). The amount of fluid contained within the cranium is some- times enormous, amounting in one case, it is said, to twenty- seven pounds. In this case, although the child was only six- teen months old, the head measured fifty -two inches in circum- ference. Where the head is so large as to be greatly dispro- portioned to the size or age of the child, of course it cannot be maintained in an upright position without the aid of the hands or of some artificial support. Generally, this is not at- tempted, but the child is kept in a horizontal or recumbent position. As the ventricles become more and more distended by the gradually accumulating fluid, the hemispheres slowly expand, the convolutions unfold, and the whole cerebral mass becomes thinned and distended, until at last it resembles a mere bag of brain-matter filled by the expanded ventricular membranes and their fluid contents. At the same time, both the mem- branes and the brain substance, instead of becoming softer and less compact, are rendered tougher and more dense, the lining membrane of the ventricles thicker and more resisting, the brain-matter tougher than natural. Possibly this may be CHRONIC HYDROCEPHALUS. 221 due in some cases, in part at least, to previous inflammatory action, but numerous post-mortem examinations prove con- clusively that this cannot always, nor even generally, be the case ; for whilst the brain substance rarely shows signs of atrophy, there is apparently an overgrowth of the neuroglia — the result probably of the long-continued mechanical conges- tion of the tissues. That this explanation is the true one, ap- pears evident also from the fact that no other signs of inflam- mation are to be found in these cases, except in a few rare instances, where the presence of a tumor or some other intra- cranial affection affords a sufficient explanation of its existence. Causes. — We have just referred to one of the supposed causes of chronic hydrocephalus, namely, inflammation of the lining membrane of the ventricles. The disease may also be an occasional sequela of acute hydrocephalus {tubercular men- ingitis), but as there is no absolute proof of this, we can only regard it as a probable supposition. A third and doubtless much more frequent cause of the dropsy, is to be found in the mechanical congestion of the great veins of Galen by the press- ure of tumors and other morbid growths upon the straight sinus, as this would have a direct tendency to produce the con- gestion in question. The disease, though generally confined to children, is occasionally met with in adult, middle, and more advanced life. Congenital cases are comparatively rare ; and owing partly to mechanical violence, and, in some cases, to defective development of the cerebral mass, generally prove fatal at the time of birth. Diagnosis. — After the head begins to enlarge there can generally be no difficulty in recognizing the disease at once, but previous to this period it can only be a matter of conject- ure. When the enlargement is inconsiderable the practi- tioner, in forming a diagnosis, should take into consideration the shape of the head, as well as the general character of the symptoms, since the heads of healthy children often vary con- siderably in point of size, and what might justly be regarded as a large head in the offspring of some parents, would only be of natural, or even small dimensions in that of others. Prognosis. — Although chronic hydrocephalus is generally 222 INTRACRANIAL DISEASES. fatal, sooner or later, it is not always so. A considerable number of cases live a good many years after the setting in of the disease ; whilst a few even appear to have recovered. As a general rule, however, death takes place within one or two years. Sometimes the disease is stationary for a considerable period, and then perhaps it will make rapid progress again, so that it is difficult to say, in any instance, whether medicine has had any curative influence over it or not. Death com- monly occurs from exhaustion ; but sometimes the patient is carried off by convulsions, or by some intercurrent disease, as pneumonia or pleurisy. Treatment. — This may be either general or local. Local treatment has in the great majority of instances been produc- tive of more harm than good. Tapping is claimed to have permanently relieved a few cases, but the ordinary result of the measure, as might have heen anticipated, has been to hasten, and sometimes to cause a fatal termination, by excit- ing inflammation of the brain and its membranes. Compres- sion has also for the most part either proved entirely nugatory, or else has been attended with dangerous consequences from compression from both the brain and the pericranial vessels. Special Indications. — Arsenicum. — Swelling, particularly of the head and face ; vomiting on being raised up in bed ; impair- ment of the special senses; emaciation and muscular weak- ness ; constipation ; retention, or involuntary discharge of urine ; anxious and oppressed breathing at night, or when in bed ; thirst ; the child strikes its head, as though for tem- porary relief. Calcarea carb. — Scrofulous swellings ; old, pale, and haggard expression of countenance; face swollen or puffed; great weakness of the limbs ; spasms and convulsions ; small, feeble pulse ; suppression of urine ; paralysis ; anterior fontanelle wide open ; head very large ; copious perspiration on the head and shoulders, especially when sleeping. Calcarea phos. — Head greatly enlarged ; face pale, sallow, or yellowish ; look stupid ; eyes turned to one side ; ears and nose cold ; posterior fontanelle fails to close ; child unable to CHRONIC HYDROCEPHALUS. 223 hold up its head ; takes no interest in anything ; always worse about sundown. Helleborus. — Dulness of the senses; somnolency; face pale and sallow ; limbs tremble from weakness ; tottering gait ; spasms and convulsions; suppression of the urine; paralysis; strabismus ; forehead covered with a cold sweat ; dilated pu- pils ; passive congestion of the brain and its membranes, with serous effusion. Kali iod. — Scrofulous constitutions; dilated pupils; blind- ness ; pains in the head, especially in the occiput; stupor, with labored and irregular respiration ; emaciation and prostration ; urine suppressed; paralysis; intercurrent pneumonia ; cerebral congestion, with serous effusion; symptoms aggravated at night. Lachesis. — Symptoms of apoplexy, attended with paralysis ; head enlarged, heavy, and painful; pain worse about the occiput; vertigo; dulness of sight; mental hebetude; ten- dency to fainting; convulsions, with coldness of the feet; face sunken ; moaning during coma ; difficult deglutition. Mercurius. — Great restlessness ; enlargement of the head ; impairment of the special senses ; spasms and convulsions ; paralysis ; dilated pupils ; collapse of the system. Plumbum. — Heaviness of the head from dropsy of the brain, with pressure as though the skull was too full; emaciation, with trembling of the limbs ; restlessness and sleeplessness, or somnolence with dulness of the senses ; weariness and increas- ing debility ; nausea and vomiting ; obstinate constipation ; retention, or involuntary emission of urine ; spasms, convul- sions, and paralysis ; pulse small and frequent, or slow and feeble. Phosphorus. — Dull and inclined to somnolency ; coldness of the extremities ; child vomits as soon as the drink becomes warm in the stomach ; stool voided with difficulty ; convul- sions, followed by collapse ; pneumonic symptoms ; very rest- less, and always worse after sleep ; great weakness, so that he has to lie down ; emaciation ; paralysis, with difficult respira- tion and fear of suffocation. Psorinum. — Stuporfaction and mental dulness from cerebral 224 INTRACRANIAL DISEASES. congestion; aversion to having the head uncovered; anxious dyspnoea, worse when sitting up ; painful pressure in the occiput; profuse sweating when asleep or on making the least exertion; vertigo with headache; ulcers on the legs ; extreme prostration ; trembling of the limbs from weakness ; scrofu- lous subjects. Silicea. — Head enlarged, and feeling as if it was filled with living things ; dulness of the senses ; face pale ; stool and urine suppressed ; suffocative breathing ; great prostration and muscular weakness ; convulsions ; numbness, with para- lytic weakness of the limbs ; scrofulous constitution. Sulphur. — Especially valuable as an intercurrent remedy, especially in scrofulous subjects; head enlarged; gait totter- ing ; dulness of the senses ; face pale and emaciated ; consti- pation ; retention of urine ; paralysis. Zincum met. — Head enlarged, with great outward pressure; stupefying headache, with dulness of the senses ; restlessness, especially at night, with frightful dreams ; vertigo, with sud- den obscuration of sight ; sudden loss of consciousness, with coldness of the body, small, weak pulse, oppression of breath- ing, and great prostration ; tremor of the limbs, with sense of heaviness in them; constipation; nausea with trembling; cerebral paralysis; symptoms worse in the afternoon and evening. FOREIGN PRODUCTS. 225 CHAPTER VIII. FOKEIGN PEODUCTS. Having in the respective chapters on cerebral tumors and syphilis (q. v.) treated in detail of the various new growths, not only of the cerebrum itself, but also of its membranes — includ- ing the important subjects of cancer, tubercle, and syphilis — it only remains for us here to discuss certain adventitious pro- ducts belonging more especially to the cerebral membranes. 1. Serum. — This fluid, as we have just seen, is present in the greatest quantity in chronic hydrocephalus. We also meet with it in excess in two other conditions. First, within the so- called cavity of the arachnoid (external hydrocephalus), or, what is the same thing, between that membrane and the epithelial lining of the dura mater. It is difficult to account for its pres- ence in this situation, unless we regard it either as the result of a previous chronic inflammation of the inclosing mem- branes, or else as having escaped in some manner from the ventricles during an attack of internal hydrocephalus. The latter supposition is the more probable, at least in the majority of instances. (See Chronic Hydrocephalus) Secondly, the fluid is met with beneath the arachnoid, or between that membrane and the pia mater, in cases where the cerebral convolutions have become atrophied from pressure or senile degeneration. To this class, also, belong those cases sometimes met with in old people who have died suddenly from what is called "serous apoplexy" — a misnomer arising from mistaking the effect for the cause. For the excess of serum beneath the arachnoid in these cases doubtless results, not from vascular congestion, but from an exosmosis caused by the shrinkage of the cerebral convolutions in senile atrophy. 15 22G INTRACRANIAL DISEASES. 2. Thrombi. — Thrombosis of the cerebral sinuses occurs for the most part in two situations, namely, in the longitudinal sinus, and in the lateral sinuses. a. The symptoms of thrombosis of the longitudinal sinus are ex- tremely variable and uncertain ; for whilst oedema of the fron- tal veins, exophthalmus, epistaxis, and even insanity, have been attributed to this cause, instances are on record where the lon- gitudinal sinus has been found entirely blocked by a throm- bus, without having given rise to any recognizable symptoms during life. In other cases, on the other hand, in addition to the symptoms already mentioned, abscesses have been formed in different parts of the body. This is explained by the fact that the thrombus sometimes sets up an inflammatory action in the sinus, in consequence of which pus gains access to the general circulation, and thereby leads to the formation of abscesses in remote parts. b. The symptoms attending the formation of a thrombus in one of the lateral sinuses, are just as indefinite and unreliable as in the case of the longitudinal sinus. Thus, Gerhardt* attributes to this cause a difference in the size of the external jugular veins, that of the affected size being smaller than the other ; whilst Prichardf and others have reported cases of the kind attended by delirium, convulsions, coma and paralysis. It appears, therefore, that thrombus of the cerebral sinuses is not accompanied by any such characteristic symptoms as will identify the disease, or lead to anything more than a mere sus- picion of its existence. It sometimes happens that a thrombus of the longitudinal sinus becomes prolonged through the straight sinus to the tor- cular Herophili, and thence into one or both of the lateral sinuses. In these cases more or less extensive softenings of the brain are apt to be produced. These sometimes consist of small superficial patches, of a reddish color, in the cerebral cortex; but occasionally they embrace considerable portions of the brain substance. Ventricular and subarachnoidean * Deutsche Klinik, 1857, JS T o. 45. f Treat, on Bis. of Nerv. Sys., London, p. 176. FOREIGN PRODUCTS. 227 effusions of serum also occur, as well as capillary haemorrhages ; the latter are likewise occasionally found in the grey matter of the hemispheres. Thrombosis of the lateral sinuses is generally secondary to caries of the cranial bones, or to the extension of inflamma- tion from the cerebral tissues to the sinuses. Suppurative otitis is a prolific cause of the affection, no less than three- fourths of the recorded cases being referred to this origin. Thrombosis of the longitudinal sinus, however, may result from any cause capable of retarding the general circulation, or of rendering it slow, feeble, and irregular, as this favors the coagulation of the blood in the veins and sinuses. This is especially true of those diseases which obstruct the flow of blood from the head, such as tumors of the neck, or exces- sively developed Pacchionian bodies, wdrich have been known to project into the sinus. Old age appears to favor the pro- duction of meningeal thrombi, especially the primar} 7 form ; they are not, however, by any means confined to the aged, but are also met with in the early as w 7 ell as in the middle periods of life. 3. Parasites. — These are known as cysticerci and hydatids. They are both larval forms of different species of tape-worm. («) Cysticercus is the larval state of Tenia solium. It has the appearance of a small bladder, and is about the size of a pea or bean. It is situated for the most part in the grey or cortical substance of the brain, but is sometimes found in the men- inges. Griesinger, who examined upwards of fifty cases, found the symptoms exceedingly variable, and occasionally entirely wanting. In the former class, the leading symptom is epilepsy, either with or without mental disturbance ; but sometimes the mental disorder may exist without giving rise to epilepsy. But since there is nothing peculiar about either the epilepsy or the psychical phenomena in these cases, it is scarcely possible to found a diagnosis upon them. This is of less importance, however, since they are comparatively short- lived, calcareous degeneration setting in within eight months or less from the time of their first appearance. Infection is probably due to the eating of " measly " pork in a raw or in- 228 INTRACRANIAL DISEASES. sufficiently cooked condition — the so-called pork-measle being specifically identical, according to most authorities, with the form usually found in man. Dr. Giacomini, however, says that the human measle commonly carries thirty-two cephalic hooks, whilst the pork-measle displays only twenty-four. (0) Hydatids are larval states of Tenia echinococus, a minute tape-worm infesting the alimentary canal of the dog and wolf. As met with in the brain, they are always in the aborted or sexually immature condition (acephalocysts). They vary in size from that of a small grape up to a large apple or orange. Usually they are solitary ; but sometimes several exist in the same brain. Out of seven hundred cases in the human sub- ject collected by Devaine and Cobbold, six per cent, were intra- cranial. Out of twenty-four recorded cases in which the age was stated, Bastian found that no less than eighteen of them were persons between the ages of ten and thirty years ; of the remainder, three were above and three below these extremes.* The fondling of dogs is doubtless a fruitful means of infection ; and so, also, is the drinking of water or the eating of salad contaminated by the ova voided by these animals. When we remember that nearly one- sixth of all the inhabitants dying in Iceland fall victims to hydatids, and that the disease is rapidly on the increase in our own and other countries, it be- comes a serious question whether any one is justified in mak- ing a household pet even of so noble an animal as the dog. Prognosis. — The peculiar circumstances attending each case must be considered in forming a prognosis; for, as we have seen, some of these adventitious products are not always accompanied by grave symptoms, whilst others sometimes exist without giving rise to any serious or even recognizable disturbances. Moreover, in the case of hydatids, it is not im- possible for a spontaneous cure to take place. Nevertheless, as a general rule, foreign products within the cerebral mem- branes are attended with the most serious consequences to the health, and eventually, also, to the life, of the patient. Treatment. — Medical treatment, in these cases, generally * Quain's Die. of Med., p. 755. FOREIGN PRODUCTS. 229 resolves itself into the relief of individual symptoms, that is to say, it is merely palliative. There can be no specific curative treatment, homoeopathic or otherwise, for those suffering from the existence of intracranial parasites, or from the occurrence of thrombi in the longitudinal or lateral sinuses. We may be able to mitigate to some extent the severity of convulsions, relieve headache, and promote sleep in such cases, but more than this we are not likely to accomplish. The proper reme- dies to meet these several indications, will readily suggest themselves to every practitioner. 230 INTRACRANIAL DISEASES. SECTION III. SYMPTOMATIC AFFECTIONS. CHAPTER I. CEPHALALGIA, OK HEADACHE. Headache is a symptomatic affection in every sense of the word. It may or it may not be associated with structural changes in the head or elsewhere, but it is nevertheless a func- tional disturbance, dependent upon some physical or mental condition of which it is a symptom, and not the disease itself. Such, however, is its prominence in many cases, coupled with the fact that it oftentimes constitutes the only symptom of which the patient complains, that it even takes high rank as a distinct affection, and is justly entitled to receive special con- sideration at our hands. Varieties. — Headache presents numerous varieties, which may be classified as follows : 1. Accession. — Sudden, gradual, etc. 2. Intensity. — Slight, moderate, severe, etc. 3. Character. — Dull, sharp, stinging, shooting, cutting, stu- pefying, etc. The headache may be simple, or associated with other symptoms, such as vertigo, disorders of vision, derange- ment of the stomach, etc. 4. Duration. — Continual or periodic ; intermitting, remitting, weekly, monthly, etc. It may be momentary, or it may last many hours, days, or months. 5. Location. — Superficial or deep-seated ; general, more or less CONGESTIVE HEADACHE. 231 diffused, or confined to particular parts of the head, as the forehead, temples, vertex, occiput, etc, 6. Nature. — Congestive, anaemic, nervous, toxaemic, etc. (a) Species. — Eheumatic, syphilitic, menstrual, hysterical, neuralgic, etc. (,?) Claims. — Limited to a particular spot, with the sensation as of a nail being driven into the head at that point. (y) Hemicrania. — Limited chiefly to one side of the head, and of a nervous character. For convenience of reference, we shall treat of the several kinds of headache under their respective names. 1. Congestive Headache. Many forms of headache are attended with a greater or less degree of cerebral hyperseinia, but only those are entitled to be regarded as congestive, that depend upon an increased fulness of the vessels of the brain. They are of two kinds. In one the congestion is active ; in the other, passive. In the active form, the pain is of a throbbing, pulsative character, and may be either sharp or obtuse. It may be general, involving the whole brain, or it may affect only a part of the head, as the forehead, vertex, occiput, etc. There is in these cases usually more or less flushing of the face, ring- ing and throbbing in the ears, glistening of the eyes, sensitive- ness to noise and light, and vertigo or giddiness, especially on stooping. The condition may be caused by a plethoric state of the system, menstrual irregularities, emotional excite- ment, excessive mental exertion, hypertrophy of the left ven- tricle, and many other influences. In the passive form of congestive headache, the pain is usually of a dull, oppressive character, and is attended by a sense of fulness or distention, and by a tendency to stupor. Vertigo is generally present, and not unfrequently there are slight mental irregularities, such as illusions, delusions, and hallucinations. But the tendency to somnolency is the most marked and characteristic symptom. Sleep, even when most natural, is apt to be accompanied by frightful dreams. When 232 INTRACRANIAL DISEASES. caused, as it frequently is, by debility or exhaustion, the pain is usually in the top of the head, or across the forehead. When produced by leucorrhoea, diseases of the uterus, etc., the pain is generally in the vertex or occiput. Congestive headaches of a passive character may also be caused by any condition or affection which impedes the return of blood from the head, such as tight collars, tumors in the neck, valvular defects of the heart, dilatation of the right ventricle, dyspnoea, deficient action of the liver, constipation, drunkenness, a de- pendent position of the head, etc. Special Indications. — Aconite. — Cerebral congestion in san- guine or plethoric persons, especially when characterized by violent, unbearable, or stupefying pains, chiefly in the temples and forehead ; also when there is fever, with nausea and vom- iting; excessive sensibility and fearfulness; intolerance of light, noise, or touch ; burning headache, as if the brain were too hot; throbbing and piercing pains in the forehead, temples, and top of the head. Agaricus. — Headache with fever and delirium : dull oppres- sive pains, chiefly in the forehead, causing the patient to close his eyes ; disposition to constantly move the head to and fro ; vertigo, especially when brought on by excessive mental exer- tion ; nervous twitchings about the face and head. Ailanthus. — Headaches characterized by fulness of the head, with burning pains, heat, darting in the temples and occiput, vertigo, and nausea ; severe headache, with dizziness, and hot, red face ; darting pains through the temples and occiput, with mental confusion ; vertigo when stooping. Aluminum. — Headache attended by congestion of blood to the head and face, heavy, oppressive feeling in the forehead, rush of blood to the eyes and nose, or with nausea and epis- taxis ; throbbing frontal pains, worse on movement, especially on going up stairs ; amelioration from pressure. Ammonium carb. — Congestive headache characterized by beating, pulsating, and pressing pains in the forehead and top of the head, feeling as though it would burst; nausea, especially in the morning before rising; rush of blood to the head; aggra- CONGESTIVE HEADACHE. 233 vated by eating, or by walking in the open air ; ameliorated by pressure ; fat persons who lead sedentary lives. Amyl nitrite. — Congestive headache attended with heat and violent throbbing in the head, and accompanied with a feeling of intense fulness, as though it must burst; flushing of the face, with visible pulsation in the carotids, which extends to the head and temples ; aggravated by motion, and by being in a warm room. Apis mel. — Headache attended by congestion to the head and face ; sense of fulness in the head, accompanied by ver- tigo and heaviness ; burning, throbbing headache, aggravated by motion, and ameliorated by temporarily pressing the head with the hands, or with a tight bandage. Arnica. — Congestive headache in sanguine plethoric sub- jects ; aching, darting, and pressive pains, mostly in the fore- head ; pressive headache, feeling as though the head were being distended; burning on top of the head and in the brain; vertigo, especially when walking; headache aggravated by motion and by mental exertion. Asclepias syrica. — Congestive headache, with vertigo, dul- ness, and somnolency ; violent headache accompanied by ex- treme nausea; urine scanty. Adapted to cases of passive congestion, especially where the headache has been caused by suppressed perspiration. Atropine. — Headache attended by flushing of the face, rush of blood to the head, and tendency to bleeding at the nose ; aggravated by motion, especially walking or stepping. This remedy is especially valuable in cases where Belladonna has been tried and failed, or only afforded temporary benefit, though apparently indicated by the symptoms. Belladonna. — Congestive headache accompanied by red, bloated face, injected eyes, vertigo, sensitiveness to light, noise, or contact, and with tendency to stupor; pressive frontal headache almost closing the eyes, and feeling as if the brain would be pressed out; violent throbbing in the head, with pains extending in every direction ; great fulness, and violent expansive pains, feeling as though the head would split open, or as if the contents would be forced through the head, espe- 234 INTRACRANIAL DISEASES. cially the forehead; carotids throb violently and the jugular veins are swollen ; loss of consciousness ; pain aggravated by stooping, or rising from a stooping position. Bryonia. — Headache attended by rush of blood to the head, vertigo, pressure and great heaviness in the head, especially when caused by derangement of the stomach ; heat in the head, with burning pains in the forehead ; vertigo and mental confusion on the least motion ; nausea and vomiting ; worse after eating, in the evening, and on stooping. Cactus grand. — Headache from congestion to the brain, espe- cially when accompanied by, or dependent on, cardiac disturb- ances; eyes red and injected, face flushed, and sensitive to light and noise; sense of constriction about the heart, as if held by an iron hand ; palpitations of the heart, attended by headache, and aggravated by mental emotion ; pulsations in the head, especially in the temples, and accompanied by a bursting feeling, as though the skull would give way. Caladium. — Headache, with heat in the head, which ascends from below and becomes an internal, burning heat ; pressive headache after dinner ; bursting headache, especially in the forehead ; stupefying pressure in the right temple on waking; vertigo, with confusion and whirling sensation in the head. Calcarea carb. — Congestive headache, associated with an im- poverished condition of the blood ; the pains are chiefly felt in the forehead, vertex, and sides of the head ; throbbing pains in the middle of the brain, lasting all day ; stupefying, oppres- sive headache in the forehead ; pains, accompanied by nausea, vomiting, anxiety,' difficulty in thinking, and dimness of vision; worse from mental exertion, talking, walking, or going up stairs ; ameliorated by tight bandaging, vomiting, lying down, and from cold applications to the head. Camphor. — Congestive headache, characterized by throbbing, which beats like a hammer in the occiput ; head hot, face red, but limbs cool ; anxiety, with great restlessness ; frontal head- ache, pressing outward ; vertigo, with heaviness in the head ; pains excited and aggravated by motion. Capsicum. — Headache, accompanied by a sensation of ful- ness in the head ; throbbing, pressing, and tearing pains ; CONGESTIVE HEADACHE. 235 pains chiefly in the forehead and temples ; sensation as if the head would burst ; vertigo, with nausea and vomiting ; con- fusion of the head, and mental dulness ; burning in the eyes, with redness and lachrymation ; amelioration from warmth, and from lying with the head elevated. Carbo an. — Headache of a congestive character, attended by heat in the head, vertigo, confusion of thought, and throbbing, bursting, or pressing pains, chiefly in the forehead and top of the head ; vertigo, with nausea, dimness of vision, and pros- tration ; ameliorated by pressing the hands upon the vertex, or going into the open air. Carbo veg. — Pressing, throbbing pains in the head, especially over the eyes; beating headache in the afternoon; heat and pain in the forehead, with confused feeling in the head, re- lieved by epistaxis ; vertigo, especially on stooping. Suitable to weak, cachetic, and aged people, and also children, especially after exhausting diseases. Causticum. — Headache, with sensation of heat and fulness in the head ; throbbing, tearing pains, chiefly in the vertex, spreading to the forehead and sides ; pain occurs in paroxysms, moving forward ; accompanied with nausea, palpitation of the heart, and hurried respiration ; rush of blood to the head, with vertigo and anxiety ; aggravated by stooping, reading, shaking the head, and in the evening ; ameliorated in the open air, and by applying cold water to the head. Chamomilla, — Headache of a pressive character, the press- ure extending from the top of the head to the forehead and temples ; pressure increasing and decreasing, especially in the right half of the brain ; pressing headache as from a stone in the head, worse in the evening ; vertigo, with a tendency to faintness ; pains aggravated by mental exertion and by sudden stooping. China — Congestive headache in anaemic individuals, or from loss of animal fluids ; violent pressive headache deep in the brain ; pressure from within outward, especially over the eyes ; intense throbbing headache coming on after the loss of blood ; headache following sexual excesses or onanism ; ameli- orated by hard pressure and by lying down. 236 INTRACRANIAL DISEASES. Cimicifuga. — Congestive headache, especially of a passive character ; constant dull pain in the head, beginning in the occiput and extending to the vertex ; dull frontal headache, relieved by pressure; severe pain in the eyeballs, extending into the forehead, and increased by any movement of the head or eyes ; intense throbbing pain, as if a ball were driven from the neck to the vertex with every throb of the heart ; rush of blood to the head, with vertigo, impaired vision, dul- ness, and aching fulness in the vertex ; aggravated by move- ment ; ameliorated in the open air and by pressure. Cocculus. — Tearing, throbbing headache, especially in the evening ; a violent headache which compels the patient to sit up, aggravated by talking, laughing, noise, or a bright light ; noise excites vomiting ; ameliorated b} r quiet and warmth. Cuprum. — Headache with fulness, heaviness, and dulness ; congestion to the head, with convulsions ; face purplish-red ; vertigo when looking upward, with vanishing of sight, as though a mist was before the eyes ; delirium, fearfulness, cold- ness of the limbs ; aggravated by motion, pressure, and even contact. Digitalis. — Throbbing headache in the forehead ; pressure in the forehead and temples, or in the whole head, disappear- ing and reappearing periodically in different parts ; headache, pressure and weight, as if caused by congestion of blood to the head ; fainting fits with inclination to vomit ; vertigo, with anxious sensation, as if fainting would occur ; pulse ir- regular or intermitting, and excited by the least movement or emotion ; worse also when exerting the mind, or when in a w T arm room. Especially suited to cardiac complications. Dulcamara. — Dull, heavy, stupefying headache, aggravated by the least movement, or by speaking; congestion to the head, with buzzing in the ears, and dulness of hearing ; con- dition aggravated by cold and damp weather, and especially by getting the feet wet ; ameliorated by lying down. Ferrum acet. — Congestive headache in anaemic persons, or those who have lost much blood, or other animal fluids; hammering and throbbing headache, especially in the frontal region; feeling as if the head would burst; rush of blood to CONGESTIVE HEADACHE. 237 the head, with swelling of the veins of the head, and slight flushes of heat; severe frontal headache, with cold feet. Fluoric acid. — Congestion of blood to the head, especially the forehead ; severe pressing pain in both temples from within outward ; vertigo with nausea, heat and pain in the head ; sensation of numbness in the head, with heaviness and compressive pains; heaviness above the eyes, with nausea, aggravated by motion. Gelsemium. — Headache associated with stupor and heavi- ness; sense of weight and pressure in the head; excruciating headache, accompanied by slight nausea; pain most fre- quently in the occiput, or else in the forehead and temples ; heaviness of the head, alleviated on profuse emission of urine; intense congestion of the brain in children during denti- tion ; great heaviness of the eyelids ; disposition to sleep, with great prostration of the whole muscular system ; aggravated by lying down, or by bandaging ; ameliorated by bending the head forward or backward, or by shaking it. Glonoin. — Great heat and throbbing in the whole head, es- pecially in the temples and over the eyes ; pressive pain from within outward in both temples ; extreme congestion in the head, with red face, and violent beating in the temporal arteries ; brain feels as if moving in waves and expanding itself; vertigo during and after stooping, lasting several min- utes, with nausea ; congestion to the head and face, with red- ness of the e} T es, and roaring in the ears; aggravated by shaking or jarring the head, stooping, mental exertion, or wine ; ameliorated in the open air and by pressure. Gratiola. — Congestive headache, with fulness and heavi- ness in the forehead, throbbing in the temples, burning in the face, and vertigo with nausea ; rush of blood to the head, with throbbing in the forehead ; vertigo, with black before the eyes, aggravated by motion ; heat in the head after rising from a stooping posture. Gymnocladus. — Feeling of fulness in the head, with throb- bing in the forehead and temples, and accompanied with heat in the face, pain in the eyes, and vertigo ; face swollen and hot, with burning sensation, as in erysipelas; fulness and 238 INTRACRANIAL DISEASES. pressure in and over the eyes, extending to the vertex ; gen- eral tired feeling, with numbness of the body ; worse in the evening. Hamamelis. — Headaches resulting from passive congestion of the venous system generally, especially in the lungs and portal system ; flushing of the face, with throbbing, aching, and sense of fulness in the head, which feels as though it would burst; bursting headache, aggravated by bending for- ward ; passive congestion of brain, accompanied by vertigo, nausea, and tendency to epistaxis ; bleeding haemorrhoids. Iodine. — Violent, almost unbearable headache, with confu- sion of mind ; throbbing pains in the head at every motion ; violent aching in the occiput ; rush of blood to the head, with vertigo ; palpitation of the heart ; bluish lips, with swelling of the superficial veins; glandular swellings. Adapted to cases of passive congestive headaches ; also to chronic cases, espe- cially in old people. Kali carb. — Congestive headache, with violent throbbing and hammering; aching, pressing pain in the back of the head ; determination of blood to the head, producing a sense of intoxication ; sensitive to noise, irritable, and peevish ; gid- diness with nausea ; constipation ; aggravated by stooping, moving the head, eyes, or jaw. Especially suited to aged people; particularly if inclined to obesity. Kali iod. — Violent beating, hammering pains in the fore- head, with a sensation as though the head were greatly en- larged ; pain in the vertex as though it would burst ; vertigo after meals ; flushes of heat, with dulness of the mind ; throb- bing and burning pains in the nasal and frontal bones ; swell- ing of the cervical glands ; pains worse in the afternoon and at night. Adapted to cases arising from suppression of long- standing nasal discharge, especially in scrofulous subjects. Lachesis. — Headache characterized by throbbing or beating in the temples, drowsiness, and nausea, especially when accom- panying menstrual irregularities ; severe pressing pain in the forehead, feeling as though it would give way, especially when stooping ; pressure in the forehead which increases to a violent beating in the evening, with nausea and inclination to vomit ; CONGESTIVE HEADACHE. 239 worse in the evening or after sleeping ; also from motion or from stooping. Lachnanthes. — Congestive headache, accompanied by burning heat, with redness of the face, drowsiness, and ill-humor ; head feels greatly enlarged, the head hot, and the body cold ; vertigo, with sensation of heat in the chest ; burning of the palms of the hands and soles of the feet ; great thirst ; circumscribed redness of the cheeks, especialty on the right side. Lilium tig. — Fulness in the head, especially in the temples, with outward pressure, ameliorated by compression ; blinding pain in the forehead, aggravated in the evening, with strange, muddled feeling in the head, general weakness, and desire to lie down; dull frontal headache; vertigo, with confusion of mind, or wild feeling ; aggravated by blowing the nose, or walk- ing in the open air. Especially adapted to cases arising from, or accompanied by, mental irregularities. Lycopodium. — Headache, as if the brain were loose and va- cillating, and as if the bones of the head were being driven asunder ; throbbing pain near the orbits, from within outward; rush of blood to the head early in the morning before rising, followed by headache ; aggravated by stooping, walking, and by mental exertion ; ameliorated by lying down, or by being in the open air. Magnesia carb. — Congestive headache, with throbbing in the forehead ; rush of blood to the head, especially when smoking; heat in the head and hands, w r ith redness of the face, alternat- ing with paleness; mental dulness ; vertigo; w T orse towards evening, or when smoking. Mercurius cor. — Violent rush of blood to the head, severe pain in the forehead and temples, and burning of the cheeks; face flushed, with burning in the eyes; heaviness of the head, with depression of spirits ; profuse prespiration on the forehead ; unquenchable thirst; aggravation at night, and also when stooping. Natrium sulph. — Headache characterized by cerebral conges- tion, with sense of fulness ; pressure in and through the head ; heat in the top of the head ; heaviness of the head, with epis- taxis, not relieved by the bleeding ; vertigo, with heat extend- 240 INTRACRANIAL DISEASES. ing from the body to the head, relieved on the appearance of perspiration ; headache, causing heat and sweat, the latter re- lieved by motion, but not the headache; eyes sensitive to light ; dulness of the mind, and depression of spirits ; headache aggra- vated by motion, stooping, and mental exertion. The attacks are periodical, occurring during the menses ; menses late and scanty. Xaja. — Dull pains in the head, especially in the forehead and temples; heaviness over the eyes; dryness of the throat; ach- ing, throbbing pain about the orbit, followed by vomiting; pain extending from sinciput to back of the head ; congestive headache arising from organic disease of the heart ; cardiac hypertrophy. Nitric acid. — Headache caused by cerebral congestion ; heat in the head, with throbbing in the temples ; heaviness'and dulness of the head, with nausea ; sensitive to noise; worse at night, better on lying down. Nux worn. — Heaviness of the head, especially when moving the eyes or thinking, with sensation as if the skull would split ; congestive headache with nausea and vomiting, worse from coughing and stooping : headache caused or aggravated by thinking or studying, feeling as if the head would burst open; vertigo, with pain in the forehead, heat and redness of the face^ determination of blood to the head, and constipation; aggra- vated by motion, stooping, coughing, thinking, light, noise, eating, or drinking coffee. Especially suitable for the seden- tary, the intemperate, and those troubled with piles. Opium. — Extreme drowsiness, with great heaviness of the head ; tendency of blood to the head with constipation, espe- cially in elderly persons ; throbbing, beating pains in the head, especially in the temples ; headache, worse on moving the eyes; vertigo, with dulness of the head and drowsiness: red, bloated face, with red, glistening, and projecting eyeballs. Especially suited to recent cases in old people, or where the symptoms have set in suddenly, with great depression of the vital power. Phosphorus. — Chronic congestive headache, attended with burning and throbbing pains, especially in the occiput ; burn- CONGESTIVE HEADACHE. 241 ing pain in the forehead, with throbbing in the temples ; dull, aching pain in the forehead, better in the open air: headache accompanying softening of the brain, and attended by weak- ness, numbness and formication of the limbs, vertigo, and slow answering of questions; head dizzy, heavy, and painful, with confusion of mind : general debility resulting from sexual abuse, or loss of animal fluids ; aggravated by music, violent motion, mental exercise, and by washing in cold water. Phosphoric acid. — Violent pressive headache, especially in the forehead; stupefying headache with somnolency ; school-girls' headache, resulting from brain-fag ; aggravated by the least noise, even music; also by shaking the head, and by grief. Particularly suited to those persons who have become debili- tated by acute diseases, loss of animal fluids, or protracted sorrow. Psorinum. — Rush of blood to the head, with redness and heat of the face ; pressive pain in the forehead, as if the brain was too large for the skull ; throbbing, hammering pain in the head, caused by mental labor; fulness in the top of the head, as if the brain would burst out; headache, with the sensation as if the eyes were being pressed out of their orbits; headaches caused by repelled eruptions; also chronic head- aches which have resisted other indicated remedies, or where there is a psoric taint of the system. Pulsatilla. — Throbbing, pressing headache, especially when caused by anaemia, or by mental exertion, and relieved by pressure ; also where there are menstrual irregularities, or where the headache is the result of excessive study, rich, fat food, abuse of coffee, chamomile tea, quinine, alcoholic stimu- lants, or mercury ; worse in the evening, or in a close, warm, room; better in the open air, or by bandaging the head. Sanguinaria. — Headache attended by rush of blood to the head, whizzing in the ears, and transitory feeling of heat, fol- lowed by nausea or vomiting; headache as if the head would burst, or as though the eyes would be pressed out ; pain most severe in the forehead and temples; pain begins in the morn- ing, increases during the day, and lasts until evening, passing off with a free flow of light-colored urine ; aggravated by 16 242 INTRACRANIAL DISEASES. motion, light, noise, and touch ; ameliorated by hard pressure, quiet, and sleep. Sepia. — Pulsating headache in the back of the head, worse from the least motion ; violent pressive headache, as though the head would burst ; surging sensation in the forehead, like waves of pain welling up and beating against the frontal bone; headache caused by portal congestion, or by derange- ment of the digestive or female sexual system; chronic con- gestive headache, with sensitiveness to light, and dropping of the upper lids ; aggravated by motion ; ameliorated by rest, darkness, and sleep. Silicea. — Determination of blood to the head, with hot cheeks, and slight burning in the soles of the feet; pulsating, beating headache, most violent in the forehead and top of the head, with chilliness ; severe pressive headache, extending from the occiput to the forehead, causing an aching in the eyeballs, which are sore and painful when revolving ; worse from noise, motion, and light; better from heat, but not from pressure; better also from rest, darkness, and sleep. Spongia. — Headache as if the head would burst, especially in the forehead and vertex; rush of blood to the head, with throbbing and pressure in the forehead ; vertigo at night, or when awaking, with nausea ; anxious oppression in the region of the heart; dull headache, caused by entering a warm room from the open air; aggravated by lying with the head low. Stramonium. — Congestive headache, beginning in the morn- ing, increasing until noon, and gradually decreasing until evening ; headache accompanied by heat, face bloated and turgid, with pulsations in the vertex ; sensation of heat in the head, especially in the vertex, with great dulness; vertigo, especially when walking in the dark ; ameliorated by warmth, and by lying quiet, Sulphur. — Headache caused by rush of blood to the head, and attended by roaring in the ears, heat and redness of the face, and cold feet; throbbing headache, especially at night; dull, pressive, stupefying headache, with tired and tight feel- ing in the brain, especially after severe mental exertion; head- ache from abdominal plethora, or when caused by suppressed NERVOUS HEADACHE. 243 eruptions, abuse of spirits, or haemorrhoids; aggravated by motion, coughing, stooping, eating, cold weather, and the open air; ameliorated by warmth and pressure. Theridion. — Violent throbbing headache, extending from the forehead to the occiput; throbbing pain in the forehead, with nausea ; worse on rising, from lying, and from the least noise; vertigo, with flickering before the eyes; disposition to faint after every exertion. Veratrum vir. — Headache, with fulness of the head, and throbbing of the arteries ; face flushed, burning in the head, and feeling as though the head would burst open; severe frontal headache, with vomiting; headache causing mental confusion and loss of memory; vertigo, with cold sweat on the forehead, sudden fainting, and collapse ; anguish and fear of death ; amelioration toward evening. 2. Nervous Headache. We shall include under this head every form of headache of nervous origin, instead of simply confining it, as is generally done, to that particular variety known as hemicrania, or me- grim. ^The term "sick headache," by which nervous head- aches are commonly known, though more expressive, is per- haps too general and comprehensive, as it is sometimes made to include several secondary affections, such as the headache associated with so-called bilious attacks, the headache which follows a debauch, and that which accompanies acute diseases, such as fevers, albuminuria, apoplexy, etc. Nervous head- aches, therefore, it will be seen, are not only of nervous origin, but they are primary, not secondary affections, and are due, probably, to nervous exhaustion, or to the idiosyncrasy of the patient. Nervous headaches generally set in early in the morning, on rising. The attack is characterized by a severe, deep-seated headache, often limited to one side of the head (hemicrania), or to one spot, as the temple, forehead, over the eyes, etc. The pain is generally increased by movement, strong light, noise, or any kind of mental exercise or perturbation. The patient 244 INTRACRANIAL DISEASES. usually suffers more or less from glimmering before the eyes, giddiness, swimming in the head, and throbbing in the tem- ples; and is generally greatly depressed, pale, dark around the eyes, and looks and feels very ill. The attack is usually complicated with certain gastric symptoms, such as a coated tongue, clammy mouth, anorexia, nausea and vomiting, or rather retching, which is often very severe and persistent. These symptoms are not necessarily, nor even ordinarily, con- nected with a disordered state of the digestive apparatus,- but are secondary to the nervous trouble, whatever it may be, that causes the headache. The chief predisposing cause of this form of headache, is the age, sex, and idiosyncrasy of the patient, especially the latter. This disease belongs emphatically to the. nervous temperament, w 7 hich is often hereditary, or runs in families. It occurs most frequently in females, and between the ages of ten and twenty- five. As age advances, the attacks usually become less and less frequent until the age of fifty or sixty, when they die out. In women they commonly cease at the change of life. Whatever weakens or deranges the nervous system may also act as a predisposing cause, as the excessive use of tea and coffee, unhealthy occupations, malaria, a sedentary life, etc. The exciting causes are equally numerous and varied. The predisposed are very liable to have an attack whenever a pow- erful impression is made upon the nervous system by fright, sudden or loud noises, storms of wind, thunder and lightning, and even extremes of temperature. Nervous exhaustion, also, — whether produced by fatigue, worry, family matters, the pressure of business, grief, over-nursing, loss of animal fluids, self-abuse, deprivation of food or of sleep, or in any other way — is a very common exciting cause, producing what is some- times termed "asthenic headache," which is. but another name for this protean disorder. Special Indications. — Acetic acid. — Nervous headaches resulting from nervous excitement, chronic gastric irritation, or the abuse of narcotic stimulants; giddiness, with or without symp- toms of cerebral congestion ; heaviness of the head, with sense NERVOUS HEADACHE. 245 of intoxication ; severe paroxysmal headache, attended with dull, aching pains in the frontal regions and vertex; disten- tion of the temporal blood-vessels; confusion of mind; vomit- ing soon after eating ; aggravated by nervous excitement. Aconite. — Nervous headache, with violent pain over the left eye, and attended by nausea and vomiting ; giddiness when stooping, looking up, or rising from a seat, with nausea; fear and anxiety, with great nervous excitability ; gets desperate and says she cannot bear the pains ; bitter, greenish vomiting, with anxiety ; aggravation by motion, light, noise, and rising from a recumbent position. Agaricus. — Nervous headaches with semilateral pains ; dull headache in the frontal region ; must move the head constantly to and fro, and close the eyes; twitching in the skin of the fore- head above the right eye ; vertigo and confusion of the head, as if intoxicated ; sensation of coldness on right side of fore- head, though warm to the touch ; aggravated in the morning, and by the heat of the sun ; ameliorated by gentle movements of head or body. Agnus cast. — Nervous headaches characterized by tearing pains above the right eye and temple, attended with soreness to the touch, increased by motion, aggravated in the evening, and lasting two or three days ; tearing and chilliness in the scalp, which, however, is warm to the touch ; headache in the vertex which is relieved by looking to one point ; food dis- agrees, and causes a feeling of nausea in the pit of the stomach ; worse from motion, and in the evening. Especially suited to nervous headaches caused by sexual excesses, spermatorrhoea, or nervous debility. Ailanthus. — Nervous headache characterized by darting pains in the temples and occiput, with vertigo and nausea ; severe headache, with confusion of ideas, and giddiness; wild looking eyes, with intolerance of light ; suitable for nervous, sensitive people, especially those troubled with vertigo when stooping. Anacardium. — Constrictive nervous headache in the frontal region, with very irritable mood ; pain increases hourly ; mo- mentarily relieved by hard pressure, finally whole head affected ; pains from without inward, spreading from the fore- 24G INTRACRANIAL DISEASES. Lead over the whole head; vertigo when stooping: nausea with retching soon after drinking cold water; internal chilli- ness even in a warm room; aggravated by motion, bending the head backward, and after eating; ameliorated in the even- ing, in bed. Apis mel. — Constant pressive pain around and above the eyes, with dizziness, and confusion of the head; dull, heavy, tensive headache over the eyes, with pain through the orbits ; neuralgic pain in the left temple; nervous, restless, and irri- table disposition ; aggravated by motion or stooping, and only temporarily benefited by hard pressure. Argentum met. — Deep left-sided headache, at first slightly drawing, gradually becoming more violent, and at last culmi- nating in a raging pain as if a nerve was being torn, ceasing suddenly; feels suddenly giddy, with a mist before the eyes; anxious, restless, and irritable mood ; aggravation at noon, also from pressure and contact. Argentum nit. — Hemicrania, with pressive, screwing, throb- bing pain in one frontal protuberance and temple; violent pressive pain in the forehead, commencing over the eyes, and spreading upward to the vertex; almost constant boring- cutting pains in the forehead, vertex, temples, and face; head- ache accompanied by chilliness, or by an increased heat of the body; giddiness as if intoxicated; ameliorated by bandaging the head. Arnica. — Xervous headaches characterized by pressive-draw- ing pains over the eyes and towards the temples, with a feel- ing as though the skin of the forehead was sj3asmodically contracted; pains over one eye, with compression in the fore- head, and greenish vomiting; pain as if a knife was drawn through the head from the left side, immediately followed by internal coldness of the head ; sensation of a nail being thrust into the temple, followed by faintness; vertigo, with nausea and obscuration of sight ; moving the head causes stitches in it ; worse in the morning, and on rising or sitting up. Arsenicum. — Periodical semilateral headaches, characterized by beating pains with nausea, buzzing in the ears, and vomit- ing; worse after eating, in the morning, or in the evening, or NERVOUS HEADACHE. 247 at night in bed ; patient weeps and moans with the pain, which sometimes becomes maddening ; severe and exhausting pain over the left eye, ameliorated by warm applications, or by wrapping the head warmly ; burning intermittent pains, hav- ing a tendency to periodicity, with small pulse and cold skin, worse from continuous applications of cold water ; paroxysms of very severe hemicrania, with great weakness and icy-cold feeling in the scalp; oedema of the head or face, the parts having a natural color; excessive thirst, nausea, and vomiting or retching; great anxiety, restlessness, and weakness; aggra- vated by eating, motion, rising up in bed, light, and noise ; ameliorated by warmth, and by wrapping up the head warmly. Asafoetida. — Nervous headaches occurring in weak, nervous, and very sensitive persons, especially women; semilateral headaches on either side, particularly the left ; crampy pain in the forehead, above the eyebrows ; pain as if a nail was being driven into the head; involuntary muscular twitchings; hysterical restlessness and anxiety. Asarum. — Pain of a contractive nature in the forehead and temples, with watering and burning of the eyes ; headache in the left side of the forehead, with dizziness; vomiting of a small quantity of a greenish, somewhat sour fluid, with great straining; after vomiting, relief of the headache symptoms; great nervous, irritation, with alternate flashes of heat and coldness; aggravated by motion or shaking the head; ameli- orated by sitting, vomiting, or walking in the open air. Asdepias syr. — Violent headache between the eyes, with a sense of constriction across the forehead; sharp, cutting pain from one temple to the other, with weak pulse and cool skin ; nervous headache followed by profuse diuresis; violent head- ache attended by excessive nausea. Atropine. — Periodical nervous headaches, coming on sud- denly, increasing rapidly, and finally causing blindness and delirium; sharp neuralgic pains in and about the eyes; vertigo on rising in the morning; sticking pains over the eyes on every motion, especially on stepping; right side most fre- quently affected ; a valuable substitute for Belladonna, espe- cially when the latter has been used unsuccessfully in cases where it is indicated. 248 INTRACRANIAL DISEASES. Aurum. — Hernicrania returning every three or four days, with burning, beating, and stitching pains in one side of the forehead, with nausea and vomiting; very despondent, and disposed to commit suicide; easily angered and disposed to quarrel; pains worse from motion, and on being touched. Belladonna. — Nervous headaches, of a semi lateral character, affecting especially the right side; the pains are of a boring, cutting, tearing, and shooting character, worse on the right side and in the forehead ; aggravated by movement, espe- cially of the eyes, and by currents of air, the recumbent posture, and warmth of the bed ; aggravated also by light, shock, noise, or contact; ameliorated by lying down, and by strong pressure on the forehead. Calcarea carb. — Hernicrania, with inclination to vomit ; tear- ing pains on the right side of the forehead ; frequent one-sided headache, with eructations; icy-coldness of the scalp, which is nevertheless sensitive to the touch ; aggravated by movement, and by mental exertion; ameliorated by tight bandaging, closing the eyes, vomiting, or by lying down. Caulophyllum. — Neuralgic headaches dependent on uterine irritation or disturbance ; sensation of pressure over or behind the eyes, especially the left, with dimness of vision ; aggra- vated by stooping, light, noise, and fright ; worse also in the afternoon. Causticum. — Nervous headache, with tension of the scalp across the forehead and temples ; pains moving forward from the vertex in paroxysms, with vertigo and nausea ; headache associated with neuralgia of the left side of the face; vertigo with loss of consciousness on looking up ; sudden blindness, with a sensation of a film before the eyes ; giddiness, with a feeling of intoxication ; aggravated by shaking the head, stooping, looking up, reading, and in the evening. Chamomilla. — Headache increasing and decreasing, espe- cially on the right side of the head, with dull, sticking pains, which sometimes extend from the temples and forehead to the occiput like electric sparks ; the pains are of a pressing, sting- ing, 'tearing, or sticking character, frequently recurring, and affect especially the left temple and forehead, or the region in NERVOUS HEADACHE. 249 and around the eye ; one-sided drawing headache; wandering pains in the temples, worse at the commencement; worse in the evening, from stooping, and from mental exertion. Chlorahnn. — Headache over both e} T es, extending to the eyes, left side worse, with feeling as if the eyes were constricted; feeling as if a hot band was drawn across the forehead directly over the eyes, with sensation of a burning ring around each eye ; severe pain in frontal region over supraorbital ridge, aggravated by motion ; dull, heavy, aching pain in the fore- head and occiput, aggravated by motion. China. — Violent pressive headache, with sense of constric- tion, especially in the right side of the forehead and in the occiput ; compressive headache, followed by a bruised sensa- tion in the sides of the head, aggravated by motion; jerking, tearing pains in several parts of the head, worse from motion; whole head feels sore and bruised; aggravated by the slightest movement, touch, or mental exertion. Especially suited to anaemic patients, and those who have become debilitated by sexual excesses, loss of animal fluids, or intermittent fever. Cicuta. — Semilateral headache, of a pressive character ex- ternally; rending, cutting pain in one side of the head; stupe- fying headache in the forehead and then in the occiput ; vertigo on rising from bed, as if everything was moving from side to side; violent shocks through the head, causing it to jerk sud- denly; head sinks forward when looking steadily at anything. Clmicifuga. — Periodical and remittent headaches; severe pains over the left or right eye, extending from the eye and base of the brain to the occiput; headache, with severe pain in the eyeballs, extending into the forehead, and increased by the slightest movement of the head or eyes; aching pains in the eyes, extending to different parts of the head; headache, with eructations, nausea, and vomiting; dizziness, impaired vision, and sensation as if a heavy cloud enveloped the head, pro- ducing darkness and confusion; aggravation from movement; amelioration from pressure. Coca.— Headache in the morning, in the right temple, sharp on first rising, and all day when looking up ; the pain darts from the temple to the top of the head, leaving a sore feeling 250 INTRACRANIAL DISEASES. behind; headache just above the eyebrows, increased by elevat- ing the bead and turning the eves up; dull feeling over the whole brow; nervous, restless, and confused; worse in the morning, when coughing or blowing the nose, and on looking up ; better in the evening, and after eating. Cocculus. — Violent headache, in which the patient is unable to lie on the back of the head, but is forced to lie on the side ; unable to bear the least noise ; noise excites vomiting ; violent headache, which compels the patient to sit up, aggravated by talking, laughing, noise, or a bright light ; sick headache from riding or sailing; headache with vertigo, nausea, and inclina- tion to vomit; vertigo as if from intoxication; aggravated by eating, drinking, talking, smoking, noises, bright light, and cold air; ameliorated by quiet and warmth. Coffea. — Semilateral headache, as if a nail were driven into the parietal bones, or as if the whole brain were torn and bruised; great sensitiveness, with general excitability; worse from motion, noise, light, and mental exertion; ameliorated in the open air. Colocynthis. — Hemicrania, with nausea and vomiting; pain- ful tearing through the brain, becoming unbearable when moving the upper eyelids; pressing, burning pains in the left orbit, temple and nose, and in the upper teeth; severe burning, boring pain in the right side of the head; violent pressure in the left temple; aching, compressive pains in the forehead, with great anguish and restlessness, obliging one to leave the bed ; aggravated by moving, stooping, lying, moving the upper lids, and being in the open air; ameliorated by pressure and touch. Crotalus hor. — Headache in the forehead above the eyes, and in the temples, worse in the night, with nausea and bilious vomiting; is obliged to lie down; severe frontal headache, with delirium and coma; tremulous weakness all over, as if from some apprehended evil; ameliorated by walking in the open air. Formica. — Nervous, sick headache, with shooting, neuralgic pains in the forehead and temple; headache in the left forepart of the head and temples, extending back to the occiput, every NERVOUS HEADACHE. 251 day earlier, with a sore pain over the eye, beginning gradually, increasing and extending with a cutting pain into the ear; headache with crackling in the left ear, followed by pain in left temple, then in vertex, with nausea, and abating of pain in the forehead ; worse in the afternoon, when stooping, when washing in cold water, and from coffee; better from combing the hair. Gelsemium. — Nervous, remittent, and intermittent headaches, with pain over the eyes, across the forehead, and in the tem- ples, accompanied by a slight nausea, and slightly mitigated by shaking the head ; periodic orbital neuralgia, commencing every day at the same hour ; double vision, dimness of sight, and vertigo; aggravated by having anything around the head ; ameliorated by bending the head forward, and by shak- ing it. Glonoin. — Hemicrania attended by hemiopia, sees half light and half dark ; severe pain in the forehead, with throb- bing in the temples; headache beginning with the warm weather, lasting all summer, and increasing and decreasing every day with the sun ; nausea, retching, and vomiting, with great nervous prostration ; pale face, faintness, and loss of consciousness ; aggravated by moving, stooping, shaking the head, mental exertion, and atmospheric heat; ameliorated in the open air, by fanning, and by uncovering. Graphites. — Semilateral headache early in the morning, with inclination to vomit ; violent headache, with eructations and nausea; vertigo during and after stooping, lasting several minutes, with nausea ; headache early in the morning on waking, also after eating, or when moving the head. Hydrastis. — Headache of a nervous, gastric character, with sharp, cutting pains in the temples and over the eyes, more over the left, better from pressing with the hand; severe frontal headache, with soreness of the scalp; face pale, worn, and w T eary looking ; fainting turns, with loss of appetite. Hyoscyamus. — Nervous headache, with pressing, stupefying pain in the forehead ; pressure in the left side of the forehead, changing to shooting; constrictive, stupefying pain in the upper part of the forehead, and general malaise, alternating 252 INTRACRANIAL DISEASES. with freedom from all pain ; sleeplessness from nervous irri- tation; twitching of the muscles of the eyes, eyelids, and face; worse after eating, and after becoming cold; better from mo- tion, heat, and bending the head forward. Ignatia. — Semilateral headache, with nausea, but without vomiting; pain frequently begins behind the mastoid process or in the ear, and runs up the side of the head, or back to the occipital region, leaving a stiffness in the back of the neck ; pressive-drawing pain above the right orbit, and at the root of the nose, renewed by stooping low down ; jerking headache, aggravated by raising the eyes ; pain in the centre of the fore- head, ameliorated by bending the head forward ; dull head- ache, confined to the right half of the forehead, involving the right eye, which is very sensitive to the light; aggravated by smoking, coffee, stooping, moving or raising the eyes, mental exertion, noise, light, and walking in the open air; amelio- rated by lying on the back, or on the painful side. Ipecacuanha. — Semilateral headache, with nausea and vomit- ing ; short attacks of fine stinging pains in the head, increas- ing to aching; stinging headache, with heaviness and drowsi- ness; headache as if the brain was bruised, extending to the scalp and nose, with nausea and vomiting; aggravated by moving the head, and by stooping; ameliorated out of doors. Iris vers. — Sick headaches, beginning with a mist before the eyes, the pains being of a dull, heavy, or shooting character, in the forehead, accompanied with nausea, vomiting, and depression of spirits; tired, aching headache, with violent pains over the eyes, in the supraorbital ridge, occurring on either side, but only on one side at a time ; paroxysms of pain followed by copious emissions of limpid urine and by vomiting, with great distress in the epigastrium ; aggravated by violent motion, coughing, sneezing, and cold air; ameliorated by con- tinuous gentle movements. Natrum mur. — Right-sided headache, coming on at 10 a.m., with dizziness, dull, heavy pains, glimmering before the eyes, fainting and sinking at the pit of the stomach, better in the open air; headache beginning in the morning, increasing till noon, and going off with the sun; pains in and over the right NERVOUS HEADACHE. 253 eye, lasting until sundown; cannot bear any kind of light; pain like a nail driven into the left side of the head ; stitching, pressing, and throbbing pains in various parts of the head, attended with nausea and vomiting; periodic vertigo, with eructations and nausea; constant chilliness and coldness; aggravated by moving the head and eyes, by mental exertion, natural or artificial light, and warmth; ameliorated by gentle exercise, compression, and lying clown. Nux vom. — Hemicrania beginning in the morning, increas- ing through the day, and growing milder or going off in the evening ; sick headache, brought on by coffee, wine, sedentary habits, or severe mental exercise ; accompanied by dimness of vision, sour bitter vomiting, and constipation ; aggravated by noise, light, eating, and the open air; ameliorated toward evening, by covering the head up warmly, and by keeping quiet. Petroleum. — Frontal headache, worse while the nausea con- tinues ; pain extending from the back to the front of the head and the eyes, with transitory blindness; stitches in the head, accompanied by pressure and nausea; scalp very sore to the touch, followed by numbness, worse mornings and on becom- ing heated ; rapid appearance and disappearance of the symp- toms; aggravated by mental exertion, nausea, and rising from a recumbent position, which is attended with vertigo. Phosphorus. — Sick headache, with pulsations and burning, mostly in the forehead, accompanied by nausea and vomiting; headache over the left eye, with burning in the forehead; dull pain in the whole forehead, with vertigo; hemicrania, with pain and swelling in the forehead, which is greatly aggravated by being touched ; headache every other day ; aggravated by turning the head, stooping, eating, mental exertion, violent motion, or being in a warm room; ameliorated by cold wash- ing, and the open air. Platina. — Neuralgic headaches, occurring in sensitive, ner- vous women, with violent pressing, or cramp-like, constrictive pains in the forehead, commencing light, increasing till violent, and ending as they began; cramping pain from with- out inward, with heat and redness of the face, restlessness, 254 INTRACRANIAL DISEASES. roaring in the head, worse from resting, or when stooping; numb feeling in the brain ; vertigo when sitting, or when going down stairs; better from motion, or when in the fresh air. Pulsatilla. — Semilateral sick headache, with tearing pains, stitches, shocks, vertigo, and desire to vomit ; stupefying head- ache, with running chills, and humming in the head, worse lying or sitting quietly, or in the cold ; vertigo especially while sitting, as if intoxicated; aggravated in the evening, from raising the eyes, and when in a close, warm room ; amelio- rated in the open air, and by bandaging the head. Rhus rad. — Semilateral pain in the temples; dull and con- tinued pain in the forehead and above the eyes; quotidian periodical headache; vertigo and confusion of head, with momentary loss of consciousness ; wandering pains in various parts of the body; pains and headache are sharper when lying down ; relieved when in the open air. Rhus tox. — Headache, with tearing, stitching pains extend- ing to the ears, nose, face, and jaws ; scalp sensitive, better on the side laid upon, worse from warmth of bed. touch, and combing the hair ; vertigo and dulness, as though intoxicated ; stupefaction, with tingling in the head and pains in the limbs, better from motion ; aggravated by chagrin, warmth of bed, and lying down ; ameliorated bv bending the head forward, and by motion. Sangv/inavia. — Sick headache, the attacks occurring periodi- cally : begins in the occiput, spreads upward, and settles over the right eye, with nausea and vomiting ; has to be in the dark and lie perfectly quiet ; violent pain over the upper por- tion of the whole left side of the head, especially in the eye; pains begin in the morning, increase during the day, and last until evening ; soreness of the scalp in spots, especially in the temporal regions ; lancinating, throbbing pains through the brain, involving the forehead and top of the head in particu- lar, but most severe in the right side, followed by chills, nausea, and vomiting of food or bile, forcing the patient to lie down and remain perfectly quiet ; aggravated by motion, and only relieved by sleep ; neuralgia in and over the right eye ; vertigo, XERVOUS HEADACHE. 255 headache, and long-continued nausea and vomiting ; aggra- vated by motion, noise, light, and touch ; ameliorated by dark- ness, quiet, pressure, and sleep. Scutellaria. — Nervous headache, caused by mental emotion ; hemicrania, worse over the right eye, relieved by walking in the open air ; tremulousness and muscular twitchings in vari- ous parts of the body ; vertigo, with lightness of head ; wake- fulness and restlessness at night, with frightful dreams ; urine scanty before, and clear and profuse after the headache. Sepia. — Hemicrania, with stinging, stitching, or pressive pains in the forehead, just over the eyes, worse in the left side, with nausea, vomiting, and perspiration ; following the per- spiration, headache in the right side of the head and face, but not so severe, with a sensation in the forehead as of waves of pain welling up and beating against the frontal bone ; stitch- ing, boring, hammering headaches over the right eye, or in one temple, of such severity as to make her scream, with nausea and vomiting ; better from sleep and darkness ; aggra- vated by motion and in the evening. Silicea. — Hemicrania, with loud cries, nausea, and vomiting, followed by obscuration of sight ; severe pain ascending from the nape of the neck to the vertex, thence to the supraorbital region ; also from the occiput to the eyeball, especially the right one ; pains sharp and darting, with a steady aching in the eyes, which are sore and painful when revolving ; worse from noise, motion, even jarring of the room by a footstep, and from light ; relief from heat, but not from pressure ; obstinate morning headache, with chilliness and nausea ; sensitiveness of the scalp ; frequent sweat about the head ; headache ameli- orated by hot compresses, and by wrapping up the head warmly. Spigelia. — Headache commencing with the rising of the sun, reaching its height at noon, and gradually declining until the sun sets, appearing thus even in cloudy weather ; pains darting from behind forward through the eyeball, with pulsating pains in the left temple and over the left eye ; headache, especially on the left side, extending to the eyes, face, and teeth ; worse from motion, stooping, wind, and fresh air ; better from press- 256 INTRACRANIAL DISEASES. ure, and raising the head ; vertigo, worse in the morning, with headache, depriving him of his senses ; eyes look dim, upper lid droops ; neuralgic pains involving the eyes, and accompanied with a pale face, anxious breathing, palpitation, nausea, and vomiting ; patient restless, anxious, and gloomy. Sticta. — Sick headache, worse from light and noise, accompa- nied by nausea and vomiting nearly to fainting; darting pain in the temporal region. Stramonium. — Nervous headache, with tearing pain in the neck and over the head, shunning the light ; better from warmth ; worse on getting up in the morning; spasmodic draw- ing in the head and eyes, with grinding of the teeth ; vertigo when walking in the dark, both day and night; staring, glis- tening eyes, w T ith swollen face ; ameliorated by warmth, and by lying still. Sulphur. — Periodical sick headache, very weakening, occur- ring every one or two weeks; pains lacerating, stupefying, and benumbing ; sticking or tearing pains in the forehead or temples, worse from eating or stooping, better when moving about, or when compressed ; scalp painful to the touch ; pa- tient peevish, irritable and quarrelsome ; aggravated by violent motion, eating, stooping, sneezing, changes in the weather, and mental exertion. Tarantula. — Nervous headache, with sharp, penetrating pains ; intense headache, with sensation as though thousands of needles were pricking into the brain, better from rubbing the head ; hyperesthesia of the special senses; ameliorated by rubbing and pressure. Theridion. — Very severe sick headache, with nausea and vomiting, like sea-sickness, and with shaking chills; violent frontal headache, extending into the occiput; headache in the region of the eyes, with starting in the right eye ; throbbing over the left eye and across the forehead, with sick stomach, worse on rising, or from the least noise, even footsteps over the floor; vertigo, with nausea even to vomiting, also with blind- ness; faintness, and flickering before the eyes. Thuja. — Nervous headache, with tearing pain in the fore- head, temples, and back of the head, worse at night; headache SYMPATHETIC HEADACHE. 257 in the vertex and on the left side, as if something hard, like a button or nail, were pressed upon the part ; scalp sensitive to the touch, and even to the pressure of the pillow, better if rubbed ; violent, burning, tearing, sticking pains, worse in bed; vertigo on shutting the eyes, or moving them upward or side- ways ; aggravated by sexual excesses, overeating, and at night. Veratrum alb. — Nervous, neuralgic, and ordinary sick head- ache, with indigestion, nausea, vomiting, pale face, sunken features, and stiff neck ; violent pains, driving the patient to despair, with great prostration, fainting, and cold sweat, with thirst; rertigo, with cold sweat on the forehead; scalp very sensitive to the touch ; chronic cases, coming on in the after- noon, and lasting through the night; ameliorated towards morning. Veratrum vir. — Severe frontal headache, with vomiting ; dull frontal headache, with sharp neuralgic pains in the right tem- ple, near the eye; vertigo, with dilated pupils, and dimness of vision; mental confusion, loss of memory, and double vision; headache, caused by intense cerebral hyperemia. Zincum. — Semilateral headache, with cramp-like or tearing pain in the right or left temple ; headache in the forehead and occiput, worse in a warm room, after eating, or from drinking even a small quantity of wine ; chronic sick headache, with weakness of sight ; vertigo, dizziness, nausea, and vomiting of bile. Suited to cases arising from brain-fag, anaemia, and men- tal and physical exhaustion. 3. Sympathetic Headache. Under this head we include all secondary forms of headache, or those caused by external conditions of which the headache is symptomatic. AVe shall only treat, however, of the more common varieties, such as the arthritic, catarrhal, gastric, hys- terical, malarial, menstrual, and rheumatic. These headaches are always associated with the special conditions denoted by . their respective names, and are therefore easily recognized by the symptoms belonging to the primary affections. As the headache is purely symptomatic, the disease on which it de- 17 258 . INTRACRANIAL DISEASES. pends should, of course, receive special attention. At the same time, it should be remembered that the primary disease is fre- quently aggravated, through sympathy, with the cerebral dis- order. This is especially the case with gastric and hysterical headaches. Hence, in many cases the headache should be treated as though it were the primary disease, and the latter the secondary. Happily, homoeopathy, by covering the totality of the symptoms, often renders the distinction referred to of but little practical importance. It is always well to bear it in mind, however, in very stubborn cases. General Indications. — Arthritic headache. — Am., Ars., Arm, Bell., Bry., Caps., Caust., Cina, Coloc, Ign., Magn., Nit. ac, Nux v., Petr., Phos., Puis., Sabin., Sep., Spig., Verat., Zinc. Catarrhal headache. — Aeon., All. cep., Alu., Am. mur., Ars., Bell., Bry., Caul., Cham., China, Cina, Cimicif., Dulc, Euphras., Gels., Gym., Hepar, Ign., Kali bic, Kali carb., Kali iod., Lach., Lye, Merc, Mez., Natr. ars., Nat. mur., Nux v., Puis., Ran., Samb., Sang., Stil., Stic, Sulph. Gastric headache. — Act. ac, Aeon., Ail., Alu., Am. carb., Anac, Ant. crud., Apis, Arm, Ars., Asar., Atrop., Bell., Berb., Bism., Bry., Calc carb., Calc phos., Caps., Caust., Caul., Carbo veg., Cham., Cimicif., Cina, Cocc, Coloc, Eupt, Form., Gamb., Gels., Glon., Hyd., Ign., Ip., Ind., Iris, Kali bic, Lach., Lept., Lye, Naj., Nux v., Opi., Paris, Phos., Phyt., Plat., Puis., Robin., Sang., Sep., Sil., Stic, Sulph., Tabac, Tarant., Verat. Hysterical headache. — Arm, Asaf., Bell., Cann. sat., Caps., Cham., Cimicif., Cocc, Com, Gels., Hel., Hepar, Hyos., Ign., Iris, Lach., Lact., Magn. carb., Magn. mur., Nit. ac, Nux v., Phos., Phos. ac, Plat., Rhus tox., Ruta, ScuteL, Sep., Stic, Stram., Tarant., Valer., Verat., Zinc, valer. Malarial headache. — Ars., Chin., Cedron, Chinin. ars., Chinin. sulph., Eucalyp., Eupat. perf., Eupat. purp., Gels., Kali ferro- cyan., Rhus., Verat. Menstrual headache. — Agnus, Apis, Ars., Bell., Berb., Borax, Bov., Brom., Bry., Cact., Calc. carb., Carbo an., Caul., Cham., Cimicif., Cocc, Com, Col., Croc, Gels., Goss, Ham., Hel., Hyos., Ign , Kali carb., Lach., Lib, Lye, Natr. mur., Nux mosch., Nux SYMPATHETIC HEADACHE. 259 v., Plat., Pals., Sang., Sep., Sil., Stram., Sulph., Thuj., Ust., Verat., Zinc. Rheumatic headache. — Aeon., Act. spic., Am. mur., Asclep., Bell., Berb., Bry., Calc. phos., Caul., Caust. Cham., China, Ciini- cif., Coloc, Dulc, Gua., Ign., Kali bic., Kalm., Lach., Led., Lye, Magn. mur., Merc, Nit. ac, Nux v., Phos., Phyt,, Pod., Puis., Rhus rad., Rhus tox., Sep., Sil., Spig., Stic, Stram., Sulph. Special Indications. — Aconite. — Headache with fever, especially when caused by exposure to cold, suppression of perspiration, or currents of air; headache accompanied by coryza, fever, roaring in the ears, chilliness, restlessness, and wakefulness ; pains of a piercing, throbbing, or stupefying character, aggra- vated by noise, light, or motion. Suitable for catarrhal and menstrual headaches, especially at the beginning. Allium cepa. — Severe catarrhal headache, with coryza ; co- pious watery discharge from the nose and eyes; symptoms worse in the evening ; better in the open air. Aluminum. — Chronic catarrhal headache, especially in scrof- ulous subjects; head feels heavy, with oppression in the fore- head ; pressive, stupefying pain in the frontal region ; aggra- vated by being in a warm room, or by going up stairs, or stepping; ameliorated by pressure. Anacardium. — Gastric headache caused by indigestion; nau- sea with retching soon after drinking cold water; weak diges- tion with fulness and distention of the abdomen; symptoms disappear after dinner, and reappear two hours afterwards. Antimonium crud. — Gastric headache, with aversion to food ; tongue coated white; aching of the limbs, nausea, and vomit- ing; anorexia, risings, and inclination to vomit; symptoms relieved in the open air. Asafoetida. — Hysterical headache in the hypersensitive; pains of a darting, stitching, jerking character, which sometimes dis- appear by the touch, or are transformed into other pains; hy- pochondriacal and hysterical restlessness, with anxiety ; ameli- orated by walking in the fresh air. Argent-am nit. — Gastric headache in nervous persons; head- 2G0 INTRACRANIAL DISEASES. ache is usually attended with chilliness and trembling of the body, intense nausea, and vomiting; patient giddy and very restless; headache worse in the open air, but better from ban- daging the head. Arsenicum alb. — Catarrhal, gastric, and malarial headaches, especially when they are of an intermittent or periodical char- acter, and attended with a burning nausea and the arsenic thirst; pains are of a burning, beating, pressive, drawing, or throbbing character, and are relieved by warmth, or wrapping up the head, or by rubbing; cold water only relieves tempo- rarily; sometimes associated with a fluent, burning and exco- riating coryza. Belladonna. — Catarrhal, gastric, and rheumatic headaches, especially in lymphatic or scrofulous subjects; pains are sudden in their appearance and disappearance, but last indefinitely; are often accompanied by stupefaction and vertigo, with red- ness and swelling of the face: aggravated by noise, light, shock, or contact; symptoms caused by cerebral congestion. Berberis. — Arthritic, menstrual, and rheumatic headaches, es- pecially when complicated with hepatic trouble ; pains are of a lacerating, darting, tensive, or aching character; face pale, with sunken cheeks, and eyes surrounded by a dark bluish or blackish circle ; worse from motion, stooping, and in the after- noon; better in the open air. Bismuth, — Gastric headache complicated with gastralgia; pain comes on immediately after eating, and is relieved by vomiting; pains chiefly frontal, and aggravated by motion. Bovista. — Menstrual headache, characterized by deep-seated stupefying pains; putrid, bitter taste, with nausea and empty eructations; morning sickness, relieved by eating breakfast; aggravated by pressure, and by sitting up. Bryonia. — Gastric and rheumatic headaches, especially when associated with indigestion, nausea, and vomiting; pains are of a throbbing, digging, sticking, burning, or pressing character, and may affect any portion of the head; the pain is usually associated with soreness, and is aggravated by stooping, or by quick motion. Calcarea phos. — Gastric and rheumatic headaches, with ml- SYMPATHETIC HEADACHE. 261 ness and pressure in the head, and characterized by vertigo when walking or moving; patient is dull, peevish, quarrelsome, and forgetful; aggravated by every change in the weather, eating, and mental and bodily exertion; ameliorated by cold washing. Carbo an. — Menstrual headache, chiefly in the forehead and vertex; the pains are of a throbbing, pressing, or tearing character, accompanied by vertigo, confusion of the senses, and sometimes by nausea ; sensation in the forehead as if something lay above the eyes, on account of which she could not look up ; dimness or blackness of sight, with vertigo and nausea when raising the head after stooping; menses too early and too long, but not too great, followed by debility and prostration. Caulophyllum. — Menstrual and rheumatic headaches, char- acterized by pressure behind the eyes and dimness of sight ; the pains, which are of a contractive, pressive character, are paroxysmal or intermitting ; menstrual irregularities, with "moth" spots on the forehead; aggravated by stooping, light, and noise. Causticum. — Arthritic and rheumatic headaches, especially where there is a tendency to scrofula ; pains are of a throbbing, tearing, and stitching character; chiefly in the top of the head, and spreading to the forehead and temples, moving forwards in parox} T sms ; accompanied by nausea and vertigo ; aggravated by stooping, reading, looking up, and shaking the head ; ameliorated in the open air. Cedron. — Malarial headaches coming on with clock-like reg- ularity; pains are of a shooting character, and are located chiefly in the frontal region, often extending to the orbits ; when the pains are very severe, the} T are often accompanied by palpitation and quickened respiration. Chamomilla. — Arthritic and rheumatic headaches, especially when attended by vertigo, nausea, and vomiting; headache in sensitive, nervous organizations; especially suited to children, women, and aged people ; pains of a stinging, stitching, tear- ing, and pressing character ; chiefly in the forehead, temples, and vertex ; aggravated by mental exertion ; ameliorated by motion. 262 INTRACRANIAL DISEASES. Chelidonium. — Bilious headaches, affecting especially the right side of the forehead, and the right temple, and accom- panied by nausea and bilious vomiting; pain is. of a heavy, drawing, and pressing character ; aggravated by motion ; ameliorated by rest, pressure, and closing the eyes. Cocculus. — Gastric and menstrual headaches, with a feeling of emptiness in the head ; violent headache which compels the patient to sit up, and is aggravated by talking, laughing, noise, and bright lights. Colocynthis. — Arthritic and rheumatic headaches of an inter- mitting type; pains are of a tearing, aching, drawing, and compressive character; are often semilateral, affecting chiefly the left side of the head ; and are accompanied with more or less restlessness and anguish ; vertigo, with nausea or vomit- ing of bitter, yellowish fluid ; aggravated by motion, stooping, and bending the head forward ; ameliorated by pressure. Crocus. — Menstrual headache, of a pressive, burning, and throbbing character, affecting chiefly the forehead, temples, and top of the head ; excitable and variable disposition ; vertigo, with confusion, and webs before the eyes; headache at the change of life, most severe at the time corresponding to the monthly periods, lasting two or three days, and even during the night. Eupatorium perf. — Bilious and malarial headaches, with violent shooting and throbbing pains, chiefly in the vertex, temples, and occiput ; vomiting of bile, and of whatever has been taken into the stomach ; tongue coated white or yellow ; attacks generally occur in the morning, between 7 and 9 a.m. ; aggravated by heat ; ameliorated by pressure. Euphrasia. — Catarrhal headache, accompanied by profuse watery coryza; profuse, fluent coryza, with smarting of the eyes, lachrymation, and photophobia, or with sneezing and discharge of mucus ; headache from cold in the head, with running from the eyes and nose. Gamboge. — Gastric headache, with compressive and heavy pains in the forehead and temples; and accompanied with vomiting, purging, and fainting; drowsy, heavy feeling in the whole head, with pain in the small of the back ; watery SYMPATHETIC HEADACHE. 263 diarrhoea, with colic and tenesmus ; headache relieved in the open air. Gelsemium. — Catarrhal and hysterical headaches, appearing suddenly with vertigo, dimness of sight and double vision ; head feels enlarged, and either too heavy or too light ; head- ache accompanied by slight nausea, slightly mitigated by shaking the head ; pain in the occiput and back of the neck, extending to the shoulders ; also across the forehead and tem- ples ; headache relieved by profuse urination. Gossypium. — Menstrual headache, with drawing and sting- ing pains extending from the temples to the centre of the forehead ; nausea, with inclination to vomit ; menses last only about twenty-four hours, and are scanty and painful. Gymnocladus. — Catarrhal headache, especially during the early stage, characterized by fulness, throbbing in the fore- head and temples, vertigo, numbness, heat of face, and ex- haustion; frequent violent sneezing, originating high up in the nose; dizziness, with dimness of sight, nausea, and eruc- tation. Hydrastis. — Catarrhal headache, especially in debilitated subjects, with mucous discharges; myalgic headache in the integument of the scalp and muscles of the neck ; pale face, with worn and weary appearance ; constant discharge of thick white mucus from the nose ; cachetic condition, with loss of appetite and fainting turns ; subacute and chronic cases. Ipecacuanha. — Gastric headache, commencing with nausea and vomiting, or in which the gastric irritation is persistent ; stinging, throbbing, lacerating headache, accompanied by nausea and vomiting, heaviness of the head, and drowsiness ; aggravated by stooping or moving the head ; ameliorated out of doors. Iris vers. — Bilious and gastric headaches, always beginning with a blur before the eyes, with dull, heavy, or shooting and throbbing pains in the forehead, accompanied by nausea and vomiting, first of watery, sour fluid, then of bile ; paroxysms of pain, followed by copious emissions of urine and vomiting, with great burning and distress in the stomach. Kali bich. — Catarrhal and rheumatic headaches, the former 264 INTRACRANIAL DISEASES. accompanied by ozcena; frontal headache, complicated by a chronic catarrhal condition of the nasal and other mucous surfaces; aggravated by moving, stooping, or mental exer- tion ; ameliorated by hard pressure. Kali carb. — Catarrhal headache, especially in aged people inclined to obesity; pains are of a sticking character, worse when stooping, or moving the head ; better from raising the head, and from warmth ; constipation. Kali iod. — Catarrhal headache, especially in scrofulous and syphilitic subjects; tensive, stinging, shooting, and tearing pains in every part of the head, especially the forehead; head- ache accompanied with inflammation of the frontal sinuses, nose, eyes and throat; swelling of the cervical glands; violent sneezing, with running of acrid water from the nose, excoriat- ing the skin. Lachesis. — Catarrhal, hysterical, menstrual, and rheumatic headaches, characterized by throbbing, beating, and lacerating pains in the temples, with pressure in the forehead, and accompanied by nausea and vomiting; beating headache with heat, worse on the vertex and over the eyes ; giddiness, with headache, just before the menses; pain in the left ovarian region ; ameliorated by lying down. Lilium tig: — Menstrual headache, especially in those cases where the menstrual irregularity arises from prolapsus or mal- position of the uterus, and causing stranguary and ineffectual urging to stool; pains in the forehead and temples, with vertigo, and depression of spirits ; constant bearing down in the lower part of the abdomen, with severe pressure in the ovaries, rectum, and anus, with constant desire for stool ; bear- ing down pressure in the vagina, as if everything would be pressed out; symptoms worse from rising up, and from standing. Lycopodium. — Gastric, bilious, and rheumatic headaches, characterized by great restlessness and disposition to faint; pains chiefly of a pressive and lacerating character, affecting especially the forehead and temples, and worse in the afternoon. Mercurius. — Catarrhal and rheumatic headaches, especially when occurring in syphilitic subjects; pains of a burning, SYMPATHETIC HEADACHE. 265 stitching, tearing, and pressing character, accompanied by catarrhal affections of the head and throat, and disposed to sweat easily ; chronic cases complicated with ozoena, the pain extending to the root of the nose and frontal sinuses. Mezereum. — Catarrhal headache in scrofulous and syphilitic patients; headache extending from the root of the nose into the forehead, as if everything would press asunder, with pain in the temples when touched ; heat and perspiration on the head, with chilliness and coldness of the rest of the body. Natrum mur. — Menstrual headache occurring before, during, and after the menses, which are either too soon and profuse, or scanty and delayed ; disposition sad and gloomy ; awakes every morning with a violent headache ; almost constant dull headache, especially in the forehead and top of the head. Natrum sulph. — Menstrual headache occurring periodically, during the menses, every spring, and characterized by ful- ness, heat in the vertex, pressure, vertigo, nausea, and vomit- ing; menses late and scanty; sad and depressed mood ; worse in the forenoon. Nux mosch. — Hysterical headache, especially when compli- cated with gastric troubles ; throbbing and tearing pains, chiefly in the forehead and temples, worse in bad weather, before the menses, and during pregnancy ; throbbing, pressing pain, confined to small spots, worse in left supraorbital region; menses too early and too profuse ; bloating of the stomach and abdomen, worse after every unpleasant emotion ; aggravated by eating, emotional excitement, menstrual congestion, and changes in weather. Nux vomica. — Gastric and bilious headaches, attended by constipation, and brought on by a debauch, wine, coffee, seden- tary habits, or too close mental application ; intense pressing, t drawing, stupefying headache, affecting the whole or any part of the head, but especially the forehead, with more or less dizziness, nausea, and inclination to vomit; aggravated by motion, stooping, moving the eyes, noise, light, and mental exertion. Phosphorus. — Hysterical headache, excited or aggravated by anger, chagrin, grief, abuse of stimulants, or excessive mental 266 INTRACRANIAL DISEASES. exertion; dull, burning, or throbbing pains in the forehead or temples, often semilateral, and accompanied by nausea or vomiting, vertigo, with a tendency to fainting, especially in the morning, on rising ; sudden changes of mood, from grave to gay, laughing to weeping ; aggravated by stooping, music, mental and moral disturbances. Phosphoric acid. — Hysterical headache, especially in school girls, and those debilitated from sexual and other excesses ; pressive, stupefying pains in the forehead and top of the head, aggravated by the least noise or jar ; headache from cerebral exhaustion, with mental cloudiness ; great physical weakness and prostration, accompanied by night-sweats and emaciation ; ameliorated by the recumbent position. Phytolacca. — Gastric and rheumatic headaches, especially in syphilitic subjects ; pains of a sharp, shooting, or dull, heavy character, affecting especialty the forehead and temples ; often accompanied with vertigo, dimness of vision, and nausea ; gen- erally aggravated by damp weather. Platina, — Hysterical headache, especially in young girls with erotic desires, or who are suffering from amenorrhcea, or from profuse menstruation ; pains are of a drawing, crampy charac- ter, and affect chiefly the forehead ; face generally red and hot ; numb feeling in the brain ; mood variable, sometimes cheer- ful, at others depressed ; aggravated by stooping, and by being in a warm room ; ameliorated by going into the fresh air. Podophyllum. — Gastric, bilious, and rheumatic headaches, especialty when produced by torpidity of the liver ; headache alternating with diarrhoea ; headache accompanied by bitter taste and risings, giddiness, glimmering before the eyes, nausea, tendency to bilious vomiting and purging ; symptoms worse in the morning ; better from pressure, and from lying quiet in the dark. Pulsatilla. — Gastric, menstrual, and rheumatic headaches, especially when caused by menstrual irregularities, mental ex- ertion, fat food, the abuse of coffee or spirits, or from exposure to damp, cold weather ; pains may be of almost every variety, and are often semilateral ; are generally accompanied by more or less vertigo, nausea, and bad taste in the mouth, but with- SYMPATHETIC HEADACHE. 267 out thirst ; worse in bad weather ; better from pressure or ban- daging the head, also in the open air. Paimex. — Catarrhal headache, with great irritation of the larnyx, and soreness behind the sternum ; pains generally dull, but sometimes sharp and piercing ; aggravated by motion. Sanguinaria. — Gastric and rheumatic headaches, most severe on the right side, affecting especially the frontal region and temples, and accompanied by nausea and vomiting ; the attacks are generally paroxysmal, with more or less chilliness and burning in the stomach ; aggravated by motion, light, and noise ; ameliorated by darkness, quiet, and sleep. Scutellaria. — Hysterical headache, especially when excited by mental emotion ; pain worse over the right eye ; ameliorated by moving about in the open air ; urine scanty before, and pro- fuse after the headache. Sepia. — Gastric, hysterical, and rheumatic headaches, espe- cially when depending on derangement of the digestive or sex- ual systems ; pains generally of a pressive or stinging, stitching character, and often one-sided, usually the right ; nausea and vomiting, with aversion to all food ; aggravated by motion and noise; ameliorated by rest, darkness, and sleep. Silicea. — Gastric and rheumatic headaches, especially in lymphatic constitutions ; pains pulsating, pressing, or tearing, and frequently one-sided ; vibratory sensations in the head, ac- companied by nausea and vomiting, frequent cold sweat about the head ; aggravated by noise, light, and motion, even the slightest jar ; ameliorated by warmth, darkness, and sleep. Stillingia. — Catarrhal headache in syphilitic and scrofulous constitutions ; dull, heavy, stupefying pains in the frontal re- gion ; dizziness, with throbbing in the head ; pains in the head, with inflamed and watery eyes, and general soreness of the muscles; chronic headache which has been aggravated by mercurial treatment. Stramonium. — Hysterical and rheumatic headaches, es- pecially in young and plethoric persons; swollen face with glistening eyes ; vertigo when walking in the dark ; heat and pulsations about the vertex, accompanied by faintness and loss of sight and hearing ; aggravated by cold ; ameliorated by warmth and quiet. 268 INTRACRANIAL DISEASES. Sulphur. — Catarrhal and gastric headaches, especially in scrofulous patients ; headache associated with constipation, morning diarrhoea, or haemorrhoids; headache from abdominal plethora, suppressed eruptions, or mental exertion ; headache beginning, increasing, and ending, with the daily course of sun ; aggravated by motion, stooping, wet and cold weather, heat of the bed, or mental exercise; ameliorated by pressure and moderate warmth. VERTIGO. 269 CHAPTER II. VERTIGO. Perhaps the best definition we have of vertigo is that given by Hughlings Jackson, namely, the consciousness of disordered locomotor coordination. It has long been known that the cerebellum is the chief organ concerned in the normal equilibration of the body. But numerous experiments upon the optic lobes and pons Varolii establish the fact that they, also, are concerned in this function ; electrical stimulation of these bodies causing com- plex movements of nearly all the muscles of the body, and especially of those concerned in progression, and in preserva- tion of the normal attitude. These three parts, therefore, may be considered as forming the general nervous centre from which the power of muscular coordination is derived. For it is by means of this combined mechanism that the eyes, the head, and the limbs are made to act in harmony, whenever a compensatory movement is required to counteract the tendency to displacement which occurs whenever the body is in the erect position, whether standing or progressing. This is well shown by experiments on the cerebellum. For if the anterior part of the middle lobe of this organ be destroyed, it causes a tendency in the animal to fall forwards ; but it is plain that this tendency may be neutralized or prevented by stimulating, instead of destroying, this centre, as this induces just such muscular movements as would counteract that tendency. So, also, destruction of the posterior part of the middle lobe pro- duces a tendency to fall backwards, and of the lateral lobes to fall sideways, whilst stimulation or excitation of these parts excites precisely those muscular actions which are needed to 270 INTRACRANIAL DISEASES. counteract the tendency to fall in these particular directions. But the afferent or sensory part of this coordinating mechan- ism does not consist alone of the visual apparatus, but also includes the auditory and tactile. Experimental researches have established the fact that the semicircular canals are con- cerned in the function of locomotor coordination ; injury and disease of these parts producing a marked and peculiar dis- turbance of normal equilibration. The disorder is temporary when one side only is injured, but permanent when both sides are affected. Flourens has shown, that injury of each canal is followed by its own peculiar disturbance, causing the body to fall, or to tend to fall, as the case may be, forwards, back- wards, or to either side, according to the particular canal involved. Now, the derangement of any part of the senso-motor appa- ratus we have described, may produce vertigo by interrupting its power of adjustment. This adjustment, as we have shown, is generally effected by contrary or counteracting movements to those which give rise to the vertigo. When the movement is continued too long to be effectually compensated in this manner, as in dancing, whirling, etc , vertigo is the inevitable result, and can only subside gradually, as the unequal laby- rinthine tension becomes equalized by rest. But vertigo is not always, nor even generally, the result of exaggerated and prolonged locomotive disturbances. It is usually a purely subjective symptom, being, as already defined, the consciousness of disturbed locomotor coordination. It is often associated with the compensatory movement itself, and hence is often confounded with it. This movement, namely, reeling and staggering, is not directly caused by the vertigo, but is simply the result of the effort made to counteract the tendency to fall ; the motion being rendered more or less irregular by the disturbance of the coordinating power. That this is the true nature of vertigo, is shown by the fact that when a movement actually follows a previous sensation of a movement which is only apparent, the actual movement is always in the direction in which the person felt that he was moving before it took place. VERTIGO. 271 Etiology and Pathology. — It is not always easy to deter- mine with precision which of the sensory impressions is con- cerned in this or that particular case of vertigo. Sometimes the impressions are labyrinthine when they appear to be ocular, and vice versa. Doubtless in some cases the two causes are combined. This is the more probable from the fact that vari- ations in labyrinthine tension may be caused by differences in the vascular tension of the labyrinthine blood-vessels, and a similar case may, and often does, operate in the case of visual disturbances. Not only do labyrinthine, visual, and tactile disturbances give rise to vertigo, but, as is well known, the latter is often caused by derangement of the stomach and other viscera. This is easily explained by the close and important nervous relations which the labyrinth sustains to these organs. For example, the nucleus of the vestibular nerve, which sup- plies the semicircular canals, and which is a branch of the auditory nerve, is in close relation to the nucleus or internal origin of the pneumogastric. Those diseases, also, as well as those medicines which cause variations in the labyrinthine tension, may give rise to vertigo. Varieties. — The principal varieties of vertigo are : 1. The Labyrinthine or Auditor}' ; 2. The Ocular ; 3. The Gastric ; 4. The Nervous ; and 5. The Intracranial. 1. Labyrinthine or Auditory Vertigo. — This form of vertigo is generally known as Meniere's Disease, having been first de- scribed by Meniere, in 1861. Symptoms. — The disease is generally confined to those whose organs of hearing were previously in a sound condition. The first symptom to attract the patient's attention is a loud noise in the ear. Similar noises, and noises of various kinds, may be heard from time to time in the ear, or they may be continuous, but the first attack is usually the loudest, or at least seems so to the patient. This symptom, which is always confined to one ear, is quickly followed by a sense of giddiness, in which both the patient's body and all surrounding objects appear to be moving in one and the same direction, namely, from the affected side. This is generally the case, also, in sub- sequent attacks. Not that the movement is always lateral, as 272 INTRACRANIAL DISEASES. respects the patient's body, for it may be from behind forward, or toward either side, or it may be rotatory ; but whatever course the body may take, or may appear to take, such will be the apparent movement of all other visible objects. The same sensation may occur when the patient is lying down; the bed, room, and everything in it appearing to rise, sink, or revolve, as the case may be. If the patient is standing or w r alking, he at once begins to reel or stagger, and unless he is so situated that he can immediately lay hold of some support, he may be thrown violently to the ground. In this case, however, there is no loss of consciousness, as when a person falls in a fit. In some cases an oscillatory movement of the eyes occurs, but authorities differ as to whether it corresponds to the apparent movement of the surrounding objects, or the reverse. It is highly prob- able, however, that the relative movement is different in differ- ent cases. These symptoms are soon followed by nausea, and in most cases by vomiting. Almost always the attack is attended by more or less shock to the system, manifested by pallor of the face, and by a cold skin, which is bedewed by a clammy perspiration. As the attack passes off, w T hich gen- erally occurs in a few minutes, the tinnitus aurium abates, leaving more or less deafness behind. The symptoms of shock also subside, but vomiting and vertigo are more persistent, lasting in some cases several days. Indeed, occasionally the vertigo continues, but in a milder form, from one attack to another, which in such cases is marked by paroxysmal exacerbations. This condition of constant vertigo, however, is not generally reached until after several distinct attacks, the intervals between which gradually lessen until a perma- nent state of vertigo and deafness is induced. This is a truly distressing condition, but yet cures, both therapeutic and spon- taneous, sometimes occur, .especially when the labyrinthine disturbance is secondary to catarrh of the middle ear, or to some other remediable affection of the auditory apparatus. Diagnosis. — This is not difficult, provided w T e bear in mind that the coexistence of vertigo, tinnitus, and deafness, establish the fact that the labyrinth is involved. This may be also con- firmed by testing the hearing with a tuning-fork and watch. VERTIGO. 273 To determine whether the disease is primary or secondary, we have to consider the presence or absence of certain symptoms. Thus, tinnitus and deafness without vertigo indicate an affec- tion of the middle ear; the same is true of tinnitus and vertigo without deafness. But in order to clear up the diagnosis in these cases, it will generally be necessary to test the condition of the conducting apparatus, ascertain the permeability of the Eustachian tube, and make an otoscopic examination of the membratii-tympani, since it is not until this is done that we are prepared to estimate the significancy of the syncope, nausea, vomiting, and other like indefinite symptoms. Prognosis. — The prognosis should be governed by the nature of the cause. If this is found to be of a temporary and remediable nature, such as altered cerumen, catarrh of the middle ear, etc., it will, of course, be favorable; but if the vertigo arises from disease of the labyrinth, the attack is not only liable to be repeated, but to leave behind it a greater or less degree of permanent vertigo and deafness. 2. Ocular Vertigo. — Ocular vertigo is that form of dizziness, confusion of sight, and swimming in the head, which results from certain kinds of ocular disorders. Any disease of the eye which causes the patient to see double will give rise to this form of vertigo, and even to reeling. This is occasioned, not by the diplopia or double vision, but by the erroneous pro- jection, as it is called, which the squinting or paralyzed eye forms of external objects. This causes confusion of sight; and if the effort at rectification is not successful, or is long-con- tinued, it is liable to produce well-marked vertigo, and even nausea. Moreover, the strain which this constant effort at optical adjustment produces, leads to exhaustion of the ocular muscles, nervous irritation, and vascular congestion — in short, the condition known as asthenopia. This condition of the eye may be brought about in various wavs. One of the most fre- quent is met with in myopia, or short-sightedness. In this case, owing to the extreme convergence of the optic axes neces- sary for distinct vision, there is actual insufficiency of the in- ternal recti muscles. The constant forcible strain to which they are subjected in the attempt to direct the axes of vision 18 274 INTRACRANIAL DISEASES. upon very near objects, which is the only position in which the conformation of the eye will permit of their being distinctly seen, soon fatigues, and finally exhausts them, producing what is called "muscular asthenopia." Another frequent cause of ocular vertigo is an absolute or relative deficiency of energy in the ciliary muscle, or muscle of accommodation. As the fatigued muscle gradually relaxes, after having been unduly exercised, objects become less and less distinct, the effort at ac- commodation is proportionably increased, the retina itself soon becomes more or less exhausted by the steady contest with in- distinct images, and thenceforth objects appear to swim before the eyes. This form of ocular vertigo is known as " accommo- dative asthenopia." Muscular and accommodative asthenopia are not confined to myopia; on the contrary, the greater num- ber of cases are associated with hypermetropia. But while the immediate cause of ocular vertigo is overburdening of one or more of the ocular muscles, the muscular insufficiency is often congenital, and sometimes hereditary. Moreover, it is very often acquired, and .then it generally results from exhausting diseases, such as fevers, diphtheria, anaemia, etc. 3. Grastric Vertigo. — Gastric vertigo is not an uncommon affection, being met with in various kinds of stomach trouble, both functional and organic. It is sometimes caused by indi- gestion, or by overloading the stomach ; but it also occurs when the stomach is empty. In these cases we usually have a variety of gastric symptoms, such as pain in the stomach, heartburn, a feeling of distention, eructations, and even vomit- ing. Pains may also be felt in the chest, the hypochondria, or the epigastric region. The bowels may or may not be dis- turbed. The vertigo generally sets in suddenly, with swim- ming in the head, reeling, and a disposition to faint. The patient, without loosing consciousness, sees everything turning black and apparently revolving around him; his gait becomes tottering, and, unless he is promptly supported, will probably fall to the ground. Vomiting now occurs, and is often trouble- some, especially if it has been preceded by headache, nausea, palpitations, and other evidences of a more general nervous derangement. Occasionally the gastric symptoms are less VERTIGO. 275 pronounced, being masked, as it were, by the cerebral symp- toms ; but as treatment directed to the stomach relieves the vertigo, we may safely conclude that the trouble is of gastric origin. If strongly predisposed to gastric derangement, very slight causes may be sufficient to excite an attack, such as looking at bright objects, or rapidly moving ones ; but such cases may also occur spontaneously, and, moreover, are not strictly cases of gastric vertigo, although the gastric symptoms predominate. Diagnosis. — As gastric symptoms are sometimes associated with auditory vertigo, and may even be so prominent as to mask the aural affection, it is important, in case there is any doubt about the nature of the affection, to institute a thorough examination of the ears. The presence or absence of deafness, and of the physical signs of aural disease, will speedily settle the question as to whether the case is one of auditory, or some other form of vertigo. 4. Nervous Vertigo. — We include under this head not only the vertigo frequently met with in people of weak nerves ; the vertigo sometimes caused by the immoderate use of tea, alcohol, tobacco, and other narcotic stimulants ; and the vertigo asso- ciated with nervous exhaustion and depression, but that also which occurs in connection with hemicrania, which, though sometimes apparently of gastric origin, is nevertheless pre- dominately and essentially nervous. The vertigo is generally slight in degree, though it may be severe. It usually mani- fests itself by dizziness, or a sensation of confusion in the head, of objects apparently moving or revolving, and of a tendenc} T , it may be, to fall. It is not often that the patient actually reels, but he feels insecure upon his feet, and if standing upon an elevated position, experiences a dread of falling. It is caused, as well as intensified, by emotional excitement, by the presence of a large company, or the reception of disagreeable news. It bears some resemblance to the " aura" of epilepsy and some other nervous affections, and the resemblance is heightened by the gastric disturbance, flatulency, and palpita- tion of the heart, which sometimes accompany it. Hence the subjects of it are apt to imagine that they are in danger of 276 INTRACRANIAL DISEASES. falling victims to some serious intracranial disorder. But the fact that there is neither deafness nor loss of consciousness, is sufficient to distinguish it from both auditory vertigo and epilepsy. When associated with hemicrania, its intimate re- lation to the other symptoms of that complaint is amply suffi- cient to identify it. 5. Intracranial Vertigo. — Vertigo is sometimes associated with epilepsy, apoplexy, cerebral tumors, and other forms of intra- cranial disease. It is an invariable symptom of ataxy, whether of cerebral or of spinal origin; and its connection with epi- lepsy, and other cortical diseases of the brain, renders it highly probable that it may be due in some cases to cortical lesions. It may coexist with epilepsy, or it may take the place of the epileptic fit. It is sometimes difficult to distinguish this form of vertigo from that of Meniere's disease, but the latter is more apt to be followed by vomiting, and besides, is not usually accompanied by loss of consciousness. Treatment. — General Indications. — Labyrinthine or Auditory Vertigo. — Aeon., China, Chin, sulph., Cicuta, Con., Colch., Kalmia, Natrum salicyl., Rosa damas., Salic, ac. Ocular Vertigo. — Arm, Argent, nit., Caust, Cuprum acet., Euphras., Gels., Kali iod., Merc, Nux vom., Opium, Paris quad., Phos., Physost. ven., Rhus tox., Senega, Spig. Gastric Vertigo. — Apomorph., Ars., Bry., Calc, Carbo veg., China, Ipec, Igna., Natr. mur., Xux vom., Phos., Puis., Sep., Sulph., Tarant., Verat. Nervous Vertigo. — Ars., China, Chin, sulph., Fer., Igna., Nux vom., Phos., Phos. ac, Puis., Silic, Zinc Epileptic Vertigo. — Ars., Amyl. nit., Bell., Calc. carb., Cocc, Glonoin, Hyosc, Laches., Stram., Tarant. Special Indications. — Aconite. — Auditory vertigo, w r ith reeling ; worse when bending forward or going down stairs ; vertigo on raising the head, or on rising from a recumbent position; vertigo with sensation of intoxication, the patient staggering like a drunken man ; great fear of falling ; nausea. Amyl nitrite. — Auditory vertigo, with a bursting sensation VERTIGO. 177 in the ears, as if the drum of each ear would be forced out with each beat of the heart ; great throbbing in the ears and head, with confusion ; vertigo, with sensation as if a vapor spread from her, through her head, and renders her powerless; slight nausea, with uncomfortable feeling of the stomach ; precordial anxiety; she turned deadly pale, felt very giddy, then became partially unconscious, remaining so for ten minutes ; mental confusion and a dream-like state. Apomorphia. — Labyrinthine or gastric vertigo, attended with giddiness, singing in the ears and slight deafness ; nausea, with vomiting and retching ; nausea coming on at intervals ; sudden vomiting, almost without nausea; syncope, with lessen- ing of blood pressure. Argentum nit. — Ocular vertigo caused by weakness or pa- ralysis of the ciliary muscle ; transitory blindness, nausea, and confusion of the senses ; sensation of expansion when looking high up in the street ; trembling weakness when walking with shut eyes, or when walking in streets with high houses, as though they would fall upon him. Arsenicum. — Gastric, nervous, or epileptic vertigo, with reel- ing, as if intoxicated ; vertigo as if one would fall, especially when closing the eyes ; nausea and disposition to vomit in a recumbent position, less when sitting up; burning in the stomach, with vomiting ; vertigo coming on periodically, with coldness, followed by fever, loss of appetite, and vomiting. Belladonna. — Epileptic vertigo, caused by rush of blood to the head, with heat and redness of the face, buzzing in the ears, dimness of vision, and loss of consciousness; vertigo accompanied by luminous vibrations before the eyes, espe- cially when stooping or bending the head : vertigo, with vanishing of sight, and a tendency to fall backward or to the left side ; aggravated in a warm room ; ameliorated in the open air. Bryonia. — Gastric vertigo, with nausea and disposition to faint ; weakness and distention of the stomach, flatulence, and constipation ; burning in the stomach and vomiting ; aggra- vated by rising from a recumbent position and by motion ; ameliorated by rest and by lying down. 278 INTRACRANIAL DISEASES. Calcarea carb. — Gastric or epileptic vertigo ; distention of the stomach and bowels, flatulence, and constipation ; stupefaction of the head, with vertigo ; sensation of coldness in the brain ; vertigo with roaring in the ears and nausea, especially when stooping or rising up suddenly ; vertigo caused by congestion of blood to the head. Causticum. — Ocular vertigo caused by paralysis of any of the ocular muscles ; congestion of blood to the head, with heat ; vertigo brought on by taking cold ; sudden and frequent loss of sight, with a sensation of a film before the eyes ; inclination on stooping to fall backward, on looking up to fall towards the left side. China. — Auditory, gastric, or nervous vertigo, especially when caused by debility from loss of animal fluids; vertigo, nausea, and fainting, with pale face and ringing in the ears, from anaemia ; vertigo, with nervous weakness and debility ; vertigo, with an empty stomach. Chininuw sulph. — Auditory vertigo, with hammering and humming in the ears, and partial deafness; vertigo, with head- ache, cerebral congestion, and deafness; vertigo occurring pe- riodically, with chills and fever, especially when of malarious origin. Cicuta. — Auditory vertigo, associated with aural disease, dis- charge of blood from the ears, loud sounds when swallowing, and hardness of hearing ; tinnitus aurium, worse in the room than in the open air. Cocculas. — Epileptic vertigo, with reeling, nausea, loss of consciousness, and sudden falling to the ground ; vertigo ag- gravated by motion, noise, smoking, coffee, sitting up in bed, and riding in a carriage. Colchicum. — Auditory vertigo, with chronic discharge from the ears, and hardness of hearing ; vertigo, with roaring and stoppage of the ears ; ameliorated by rest. Conium. — Ocular or auditory vertigo, with sensation as if turning in a circle ; vertigo caused by looking steadily at an object; vertigo on rising up or going down stairs; also when lying down or turning over in bed ; great debility and incli- nation to sleep. VERTIGO. 279 Cuprum. — Ocular vertigo caused by paralysis of the nervus abducentis ; vertigo when looking up, with loss of sight, as if gauze were before the eyes ; vertigo, with sensation of turning round, or revolving vertigo ; vertigo from cerebral conges- tion ; vertigo with extreme weakness, especially of the lower extremities. Euphrasia. — Ocular vertigo from paralysis of the ocular muscles, especially when caused by taking cold, or when asso- ciated with coryza ; blurring of the eyes, relieved by winking. Gelsemium. — Ocular or nervous vertigo ; vertigo from para- lysis of the ocular muscles ; vertigo with reeling and stagger- ing, even unto falling ; heaviness of the head, with imperfec- tion of sight and dulness of mind ; aggravated by smoking. Hyoscyamus. — Epileptic or ocular vertigo, with reeling, loss of sight, hearing, and consciousness; diplopia, or double vision; red, sparkling, staring, and distorted eyes. Ipecacuanha. — Gastric vertigo, with nausea and vomiting; abdominal distention, with flatulency, colic, and diarrhoea; ver- tigo, with loss of appetite, empty retching, and qualmishness. Ignatia. — Gastric, nervous, or epileptic vertigo ; vertigo fol- lowed by nausea, and vomiting of slimy, sourish fluid ; burn- ing in the stomach ; abdominal distention, with flatulency, and constipation ; restless, changeable disposition ; vertigo caused by mental emotion; worse from stooping or moving the head. Kali iod. — Ocular vertigo in syphilitic individuals; dimness of vision, with twitching of the eyeballs ; burning in the eyes, with sensation of a film before the sight, relieved by winking. Kalmia. — Auditory vertigo, with sensation when turning as of something loose in the head; vertigo while stooping or looking downward ; palpitation of the heart. Lachesis. — Epileptic vertigo, with reeling, foiling, and loss of consciousness; frequent momentary vertigo, particularly on closing the eyes, sometimes with paleness, nausea, and vomit- ing ; vertigo with headache, congestion of blood to the head, and cold extremities. JSfatrum mur. — Gastric vertigo, with reeling, and obscuration of sight; sensation of everything turning in a circle when 280 INTRACRANIAL DISEASES. walking: nausea and sudden sinking of strength; burning and feeling of pressure in the stomach : want of appetite and aversion to food; vertigo, with nausea and heartburn after eating. Natrwm salicyl. — Labyrinthine vertigo, with tendency to fall to the affected side, whilst surrounding objects appear to move in the opposite direction : noises in the affected ear, with de- fective hearing : vertigo, with inclination to fall towards the left side. V . ■;■. i. — Ocular, gastric, or nervous vertigo: vertigo from paresis of the ocular muscles, especially when aggravated by stimulants or tobacco : vertigo,, with tendency to faint, wc during and after meals: vertigo associated with dyspepsia and constipation : vertigo brought on by mental exertion, seden- tery habits, high living, or haemorrhoids: vertigo in hysterical and nervous subjects. um. — Ocular vertigo depending on paralysis of the ac- commodation : vertigo with stupefaction of the senses, or ai fright : apoplectic symptoms with vertigo : pale or bloated face, with dimness of sight, and tendency to faint: amelio- rated by rest. Phosphorus. — Ocular, gastric, or nervous vertigo, especially when caused by nervous debility, sexual abuse, spermator- rhoea, haemorrhoids, etc. : vertigo accompanied by reeling, nausea, and vomiting: vertigo occurring in the morning, with an empty stomach, after eating or sleeping, during or after the menses, or with fainting and trembling. Phosphoric acid. — Xervous vertigo, especially when caused by cerebral or nervous exhaustion : vertigo, with great dispo- sition to sweat during the day: night-sweats, with vertigo; vertigo from onanism, loss of animal fluids, or mental exer- tion, anxiety, or overwork. Physostigma. — Ocular vertigo from partial or complete ralysis of the ciliary muscle ; has been applied with benefit as a local application. P IsaiULa. — Gastric or nervous vertigo, with reeling, espe- cially in the evening, when walking, when lying down, or before the menses : vertigo followed bv vomiting or a ten- VERTIGO. 281 dency thereto; worse stooping, or rising up quickly from a recumbent position. Senega. — Ocular vertigo, especially when caused by paresis or paralysis of the superior rectus or superior oblique muscle of the eye, or when the vertigo and double vision are relieved by bending the head backward. Sepia. — Gastric or nervous vertigo, especially when caused by a dyspeptic condition ; vertigo, with flatulency and consti- pation; worse when drinking, while looking upwards, or while looking from a great height, a large assemblage of people, or an extended plain. Silicea. — Nervous or ocular vertigo, especially when brought on by severe physical or mental labor, reading, writing, or sew- ing; vertigo accompanied by nausea, and aggravated by mo- tion or by looking upwards; vertigo during sleep, or when ris- ing from a recumbent position. Spigelia. — Ocular or epileptic vertigo, especially when as- sociated with sharp, stabbing pains through the eyes and head; vertigo, with reeling or staggering, followed by loss of consciousness. Stramonium. — Epileptic vertigo, especially when walking in the dark, day or night ; vertigo followed by stupefaction of all the senses and complete insensibility; vertigo accompanied by strange fancies. Sulphur. — Gastric vertigo, especially in the morning after breakfast, with nausea; dimness of vision, with inclination to fall to the left ; chronic vertigo, especially if preceded by a suppressed eruption. Tarantula. — Gastric, nervous, or epileptic vertigo, so severe as to cause him to fall, but without losing consciousness ; nausea, bloating of the stomach, and disposition to vomit; vertigo after breakfast, with a bad taste in the mouth ; vertigo from fixing the sight on any object. Veratrum. — Gastric vertigo, with cold perspiration on the forehead ; vertigo, with sensation as if everything in the head was loose ; loss of appetite, with burning stomach, distended abdomen, flatulency, vomiting, and diarrhoea. 282 INTRACRANIAL DISEASES. CHAPTER III. INSOMNIA. Sleep may be defined to be, a normal suspension of the functions of the cerebral hemispheres. True sleep is just as much a normal condition of the organ of the mind as its opposite, the state of true consciousness, or voluntary mental activity. These two conditions alternate with each other at regular periods during a state of health, and cannot be greatly disturbed without causing disease. If the former state is prolonged much beyond its natural duration, it constitutes sopor or stupor; if the latter, wakefulness or insomnia. Insomnia may be either partial or complete. Partial in- somnia is when the patient is able to obtain only a portion of his usual allowance of sleep. He either lies awake one or more hours before he can get to sleep, or he awakes some hours earlier than is his natural habit, so that he obtains con- siderably less than the normal quantity of sleep. In this respect, however, every individual is a law unto himself. The amount of sleep that is normal for one person may be abnormal for another, and vice versa. On the other hand, the patient may not be able to obtain any sleep wmatever, for several suc- cessive nights, as in acute mania, violent fevers, or when suf- fering from severe pain, profound grief, or great mental disturbances. This constitutes complete insomnia, and always indicates a dangerous degree of mental activity. Disturbed or restless sleep is a defect in quality, rather than in quantity, of sleep, though the two conditions frequently coexist. This state, as well as that of insomnia, may be caused by fatigue of the body or mind ; by anxiety or mental excitement ; by indigestible food, food taken in undue quan- INSOMNIA. 283 tity, or at unreasonable hours; uncomfortable conditions of the body induced by exposure to cold, heat, etc.; loud or continu- ous noises; pain of any kind; and anaemia and hyperemia of the brain, both of which conditions of the cerebral circu- lation are obnoxious to healthy and quiet sleep. It is true there is a less active circulation in the brain during healthy sleep than during the waking periods, but this is not the condition known as cerebral anaemia, w T here the blood is either deficient in quality or quantity, and which is as unfriendly to sleep as is the opposite state of hyperemia. Treatment. — The removal or avoidance of the cause is a matter of the highest importance in the treatment of insomnia ; one, the neglect of which will, in the majority of cases, result in failure, notwithstanding the greatest care in the selection of indicated remedies. Moreover, sleeplessness is generally a symptom of some other disease, the removal or relief of which is necessary for the cure of the secondary affection. Hence, we do not deem it necessary to give many remedies or sympto- matic indications for this disorder, which is often best treated on physiological principles. General Indications. — Sleeplessness before Midnight: Ars., Bell., Bry., Cale carb., Carbo an., Carbo veg., Chin., Con., Cycl., Graph., Ign., Kali carb., Laches., Lye, Merc, Natr., Nitric ac, Phos , Puis., Khus tox., Selen., Sep., Sil., Spig., Staph., Sulph., Valer. Sleeplessness after Midnight: Ars., Asafcet , Aur., Caps., CofT., Hep., Hyosc, Kali carb., Laches., Lye, Mere, Natrum, Nitric ae, Nux vom., Plat., Puis., Rhodod., Rhus tox., Samb., Sep., Sil., Sulph. ae, Thuja. Waking too early: Ars., Asafcet., Bry., Cale carb., Coff., Croc, Dule, Hep., Ign., Kali carb., Lye, Magn., Mur. ae, Natr. carb., Nux vom., Phos. ae, Ran. bulb., Rhod., Sep., Sil. Waking frequently : Ant. crud., Arm, Ars., Bell., Bism., Cale carb., Cann., Carbo. an., Caust., Cham., Chin., Cie, Coff., Digit., Fluor, ae, Graph., Hep., Kali carb , Lye, Mang., Mere, Nitric ae, Nux vom., Phell., Phos., Puis., Rhus tox., Ruta, Samb., Selen., Sep., Sil., Staph., Sulph., Sulph. ae, Tereb., Teue, Zinc. Retarded Sleep : Alum., Anae, Ant. tart., Ars., Bell., Bry., 284 INTRACRANIAL DISEASES. CalacL, Carbo an., Carbo veg., Caust., Chin., Creos., Gels., Graph., Guaj., Ign., Lach., Led., Lye, Merc., Natr. carb., Xatr. mur., Nux vom., Petr., Phos., Puis., Rhus tox., Selen., Sep., Sil., Spig., Stann., Sulpli. Special Indications. — Aconite. Sleeplessness from anxiety ; sleeplessness of infants and aged people ; sleeplessness in con- sequence of febrile symptoms ; great restlessness and tossing about. Belladonna. — Insomnia with drowsiness ; congestion of blood to the head. Cocculus. — Sleepless from mental activity or from night- watching ; sleep retarded, restless, and frequently interrupted by wakings and startings. Coffea. — Sleeplessness of infants; sleepless from joy, long watching, overexcitement of mind. Gelseminum. — Drowsy and sleepless, or else wide-awake and unable to get to sleep ; insomnia from Cerebral irritation and congestion. Hyoscyamus. — Sleepless from nervous excitement; wild, star- ing eyes ; tendency to delirum. Ignatia. — Sleepless from grief or depressing emotions ; sleep- lessness from nervous exhaustion. Moschus. — Nervous excitement preventing sleep ; is awakened by sense of heat, rendering the covering uncomfortable ; re- lieved by throwing off the covering. Nux vom. — Sleepless from overwork, mental or bodily ; too close study at night ; abuse of narcotic stimulants. Opium. — Great wakefulness or drowsiness, with inability to get to sleep; insomnia with acuteness of hearing, the ticking and striking of the clock, cock crowing, and other noises, keep- ing the patient awake. Phosphorus. — Gets to sleep too late ; insomnia from nervous debility, especially when brought on by onanism or sexual abuse. Pulsatilla. — Sleeplessness after late suppers, or from indiges- tion ; determination of blood, especially to the head and sur- face of the body, rendering the patient extremely restless, sleep- less, and uncomfortable. INSOMNIA. 285 Stramonium. — Sleepless from nervous excitement; sleep in- terrupted by frightful screams ; restless sleep full of dreams ; tendency to delirium. Sulphur. — Sleepless from nervous excitement, cutaneous irri- tation, and external heat. Veratrum vir. — Sleeplessness from determination of blood to the brain, or from a general febrile condition. Zinc, valer. — Sleeplessness with pains in the head, especially in children ; frequent waking in the night ; drowsy, with pale and tired expression of the countenance. 286 INTRACRANIAL DISEASES. CHAPTER IV. COMA. Coma is often regarded as a profound state of sleep, or the opposite of insomnia, and in one sense this definition is true ; for as insomnia is a state of extreme wakefulnes (pervigilium), so coma, a term derived from a Greek word signifying " deep sleep," is a state of profound insensibility, somewhat allied to sleep, but in which the loss of consciousness is more complete and absolute than in any form of true sleep. Hence the terms sopor, lethargy, and stupor are employed to designate the lesser degrees of insensibility, from that of sleep, properly so called, up to that of profound anaesthesia, in wdiich there is complete loss of consciousness, that is to say, true coma. And as there are different degrees of stupor, so there are different degrees of coma, namely, what is known as the comatose state, coma, and profound coma, the last of which was called by the older writers cams, the gravest of the graver states of unconscious- ness and insensibility. In this condition the breathing is very slow and stertorous, accompanied by puffing of the cheeks ; the pulse, which at first is strong and regular, becomes feeble and irregular ; there is often lividity; and the pupils, which are generally excessively dilated, are immovable and totally insensible to light. But in the lighter forms of coma there is usually more or less delirium; the patient mutters slightly, and grasps feebly, but unconsciously and without purpose, at any object in his way. This is the form of coma met with in many low fevers, whilst the former is the coma of apoplexy. Diagnosis. — The symptoms of coma above given are suffi- ciently characteristic, in most cases, to distinguish this affection from every other. It is important, however, to remember that coma. 287 even complete insensibility is not always coma. Thus, in syncope we have insensibility or unconsciousness resulting from a cutting off of a due supply of blood to the brain ; whilst in asphyxia we have a similar result from an interference with the function of respiration. Again, we may have a condition of profound narcosis, resulting from the poisonous effects upon the brain of opium, alcohol, and other drugs, or of certain urinary products which the kidneys have failed to eliminate (ursemia). In all these cases we have, in addition to the coma- tose state, certain characteristic symptoms belonging to each affection, the presence of which will always serve to distinguish the condition from that of simple coma. Thus, in syncope there is fainting ; in asphyxia, deficient respiration ; in nar- cosis, the peculiar effects of the agent or drug producing it ; and in uraemia, convulsive movements, vomiting, etc. Causes. — The most common cause of coma is cerebral haemorrhage (apoplexy). Coma may also result from sunstroke, long exposure to severe cold, typhoid and other low fevers, epilepsy, erysipelas of the head and face, inflammation of the cerebral meninges, and various organic diseases of the brain and its membranes, such as tumors, multiple embolisms, etc. Prognosis. — Coma, in whatever way it may be produced, is always an extremely dangerous condition ; for if the patient cannot be roused at all within one or two days at farthest, or if the coma does not gradually diminish in intensity by pass- ing into the state of simple stupor, it will probably soon ter- minate in death. Treatment. — One of the most important matters relating to the treatment of coma is that of food or nourishment. Nothing should be allowed to the patient, in the way of aliment, except water and the juice of oranges and grapes. Anything more than this is certain to do harm. It is folly to suppose that coma can be relieved by medicine, or in any other way, while the blood-vessels are kept in a state of repletion by the ingestion of any form of nutriment. I should not deem it necessary to mention so obvious a matter, were it not that I have more than once seen the lives of patients placed in the greatest jeopardy by this senseless course on the part of nurses, and, I am sorry to say, of intelligent physicians also. 288 INTRACRANIAL DISEASES. Special Indications. — Belladonna. — Stupor with snoring, dark red face, swelling of the cheeks, and congestion of blood to the head ; deep sleep, attended by screaming, singing, muttering, or frequent startings; eyes half open, but insensible to light. Bryonia. — Great drowsiness or heavy stupor, with or without delirium; moanings and startings in sleep, with fever, and sometimes with loud cries. Camphora. — Sopor and delirium, with chilliness and coldness of the body; talking and snoring in the sleep; congestion of blood to the head; face red, but sometimes pale. Chamomilla. — Soporose condition, with feverish restlessness, especially in children; snoring and starting in the sleep; de- lirium, with moaning, talking, or screaming; comatose condi- tion of children during dentition, especially when caused by diarrhoea. Helleborus. — Sopor, especially when resulting from an attack of acute or chronic hydrocephalus; fever, with hot head and cold hands and feet; urine scanty or suppressed. Lachesis. — Comatose symptoms, especially when resulting from erysipelas of the head and face; constant sopor after the cessation of the pains; tossing about, particularly in children, with moaning. Phosphoric acid. — Sopor, especially in the daytime; being roused, he answers correctly, but immediately falls asleep again ; typhoid fever, particularly when accompanied by pro- fuse sweating. Pulsatilla. — Deep sleep, wuth snoring inspirations; valuable in cases complicated with erysipelas. Rhus tox. — Especially valuable in the coma of typhoid fever and erysipelas; sopor, with snoring, muttering, and grasping at flocks. Nux moschata. — Sopor, with or without delirium; valuable in low forms of fever, especially wdien accompanied by putrid or colliquative diarrhoea; also in children during the diarrhoea of teething. Opium. — Profound coma, such as occurs in apoplexy, with stertorous breathing, dilated pupils, dark red and bloated face, and feeble, irregular pulse; mouth open, eyes half closed, and insensible to light. coma. 289 Secede cor. — Long-continued stupor, with, delirium and start- ings; cold, viscid sweat; face red or pale; foetid and colliqua- tive diarrhoea ; suppression of urine. Stramonium. — Deep sleep, with stertorous respiration, and a bloody froth at the mouth ; epileptic coma. Tartar emet. — Coma with constant yawning and stretching, especially when arising from irritation or congestion of the brain ; great prostration, with trembling of the limbs ; coma of delirium tremens. Veratrum alb. — Protracted stupor, especially when accompa- nying the collapse of diarrhoea or cholera; coldness of the whole body. 19 290 INTRACRANIAL DISEASES: CHAPTER V. SUNSTROKE. Syn. : Coup de Soleil ; Insolatio ; Thermic Fever. Sunstroke and thermic fever are certain forms of cerebral exhaustion resulting from prolonged exposure to solar or arti- ficial heat. They are accompanied by one or another of the three primary forms of insensibility and unconsciousness, namely, syncope, asphyxia, or coma. Varieties. — The differences above noted give rise to three well-marked varieties of insolation, namely : 1. The syncopal form, from exhaustion and failure of the heart's action ; 2. The asphyxial form, from shock communicated chiefly to the respiratory centre, and interfering with the action of the lungs ; and 3. The hyperpyrexial form, from shock communicated chiefly to the heat centre, causing vaso-motor paralysis and intense fever. 1. The Syncopal Form. — This form of sunstroke, sometimes called " heat-exhaustion," is the kind of nervous depression re- sulting from exposure to a high temperature, and # causing syn- cope. The muscular and nervous systems are completely prostrated ; the skin is moist, pale, and cold ; the pulse, feeble and quick. This form of the disease is most apt to occur in fatigued, overworked, and delicate persons, especially those who faint easily, or who have previously suffered from sun- stroke. The nervous exhaustion may be so great that the S3 7 stem can never rally from the collapse produced by the failure of the heart's action, but on the other hand complete recovery is more common in this form than in either of the others. 2. The Asphyxial Form. — This is the form to which the term SUNSTROKE. 291 sunstroke is commonly applied. The symptoms are those of extreme depression following exposure of the head and spine to the direct rays of the sun, at a time when the body is greatly fatigued and overheated, and the atmospheric tempera- ture is very high. The attack may or may not be preceded by premonitory symptoms, such as extreme thirst, giddiness, faintness, frequent disposition to urinate, stupidity, and drowsi- ness. Unless relieved, the patient either gradually or sud- denly, but generally suddenly, sinks into a state of uncon- sciousness and insensibility, with cold skin, feeble pulse, ster- torous breathing, and a more or less rapid failure of the respiration and circulation. Death may take place speedily, or reaction may set in, and life be preserved, but at the ex- pense, in many cases, of various injuries to the cerebro-spinal system, such as chronic headache, weakness of memory, great nervous prostration and irritability, partial or complete blind- ness, paralysis, meningitis, insanity, or dementia. But the most common sequla of the disease is an extreme intolerance of the sun's heat, or indeed any form of heat, and this intoler- ance may endure for years, and even for life. 3. The Hyperpyrexial Form. — This form of insolation, some- times called "heat-fever" or "thermic fever," is an intense fever resulting from the influence of heat upon the nerve- centres, thereby causing vaso-motor paralysis, and Consequent overheating of the body generally. Although the attack is caused, primarily, by exposure to undue heat, either solar or artificial, it does not necessarily depend upon the immediate action of the sun's rays, as it frequently occurs at night, or in the shade. The nerve-centres generally, but especially the respiratory centre, are overstimulated by the heat, and this is soon followed by exhaustion. The vaso-motor paralysis thus induced causes the temperature of the body to rise to 108°, 109°, and, in some cases, to 110° F., and even higher. This gives rise to intense fever, extreme thirst, and frequent mictu- rition ; there is a burning skin, which may be either dry or moist; dyspnoea, with quick, gasping, and irregular respira- tion, and great restlessness ; a strong determination of blood to the head, attended by visible pulsations of the carotids, and 292 INTRACRANIAL DISEASES. dark, livid appearance of the face and neck. The pupils, which are at first contracted, sometimes become widely dilated. The pulse also varies, being in some cases rapid and jerking, in others, full, slow, and labored. Unless relief is soon obtained, convulsions, delirium, paralysis, with relaxation of the sphincters and suppression of urine, set in, followed by death from asphyxia and coma. Like the other forms of sunstroke, this variety of insolation is often attended by premonitor} T symptoms, such as headache, giddiness, thirst, loss of appetite, nausea, vomiting, frequent micturition, hurried respiration, precordial anxiety, and a general feverish state of the system, but differs from the first two forms in the length of time that the prodromata may manifest themselves before the attack culminates, which is often several hours, and in some cases clays. Morbid Anatomy. — In rapidly fatal cases of sunstroke, neither the brain, lungs, nor heart are apt to exhibit any very marked morbid appearances after death. The brain and its membranes are sometimes slightly congested, and the same may be said of the lungs. The greatest changes, how- ever, are observed in the venous trunks, especially those of the abdomen, the right side of the heart, and the pulmonary vessels, all of which are sometimes overloaded with dark, grumous blood ; patches of ecchymoses are also scattered over the surface of the body, rendering it more or less livid. These appearances are chiefly the effect of nervous shock, which, by paralyzing the heart and lungs, leaves the venous system in an engorged condition. In thermic cases a similar condition often exists, but usually in a more pronounced form, together with a more or less congested state of the brain and its membranes. Cerebral haemorrhage and serious ventricular effusions may also exist, but the real cause of death in these cases is asphyxia, and not apoplexy, as was once thought. This is forcibly illustrated by the post-mortem appearances in the three fatal cases ob- served by surgeon Eussel at Madras. " The brain," he says, "was, in all, healthy; no congestion or accumulation of blood was observable ; a very small quantity of serum was effused SUNSTROKE. 293 under the base of one, but in all three the lungs were con- gested even to blackness through their whole extent ; and so densely loaded were they, that complete obstruction must have taken place. There was also an accumulation in the right side of the heart, and the great vessels approaching it." * Causes. — A hot, close and moist atmosphere, overexercise, tight and unseasonable clothing, the breathing of vitiated air, and whatever tends to produce suffocation, all conspire to produce an attack; especially if there be superadded, great bodily fatigue, a heated atmosphere, or prolonged exposure to the direct rays of the sun. Hence soldiers, especially those serving in hot climates, often suffer from sunstroke, their warm, tight-fitting uniforms, heavy accoutrements, and long, weary marches, predisposing to, and frequently precipitating, such attacks. Certain classes of out-door laborers are also liable to become sun struck in very hot weather, especially harvest hands, common laborers upon our railroads and in our large cities, very few of whom take the precaution to properly guard themselves against the effects of the sun's rays. Prognosis. — Statistics show that sunstroke proves fatal to nearly one-half of those attacked ; but even of those who re- cover a large proportion are permanently injured by it, whilst some of them, as we have seen, are rendered complete wrecks, both in body and mind. Treatment. — The syncopal form of sunstroke generally requires but little active treatment, further than removing the patient to a cool and shady place, loosening the clothing, and administering by inhalation a few drops of Amyl nitrite. But in ordinary cases of sunstroke, where the patient has long been exposed to the direct rays of the sun, or where the tem- perature of the body is greatly elevated above the normal standard, the burning temperature of the surface should be reduced as quickly as possible by the free application of the cold water douche, ice and ice-water to the head and neck, cool air, fanning, etc, at the same time endeavoring to over- come the great nervous depression and consequent embarrass- * Graves' Clinical Medicine, 3d Am. ed., p. 118. 294 INTRACRANIAL DISEASES. ment of the circulation, by the cautious administration of stimulants, especially Camphor, which is homoeopathically indicated. Whenever practicable, the cold effusion to the head, neck, and shoulders, continued until the temperature sinks to 98° or 100° F., is the most speedy and effective way of rescuing the patient from the impending danger. At the same time, care should be taken not to continue cold applica- tions too long, as danger may result from reducing the tem- perature below the normal standard. After the patient has recovered from the immediate effects of the stroke, the nervous depression and other sequels of the disease will be best met by time, which is always an essential element of cure in these cases, aided by proper medication. These after-results, as before stated, are often extremely per- sistent, and give rise to great physical prostration, which often lasts for years — a condition which, aside from mere medical treatment, calls for the exercise of sound discrimination and judgement as to clothing, climate, and other hygienic influ- ences. The clothing in particular should be carefully adapted to the season and the sensibility of the patient, being neither too thick and warm, nor too thin, since both heat and cold are oppressive and injurious. For this reason, whenever practicable, the patient should go north in summer and south in winter, and this should be repeated, if necessary, from year to year, until such time as the patient can safely bear the varying temperature of his own home. Where a change of climate cannot be had, underclothing made of soft buckskin, fur, or other warm material, may be worn in winter, and such other precautions taken to guard against the injurious effects of cold and heat, as the peculiar circumstances of the patient may render necessary. Finally, in those cases where nervous exhaustion is the chief difficulty to be overcome, the patient should be encouraged by the assurance that time, which, as already stated, is an essential element of cure, will, in con- junction with suitable remedial measures, finally restore him to perfect health. General Indications. — Premonitory Symptoms. — Aeon., Ant. crud., Ars., Bry. ; Carbo veg., Gels., Laches., Verat. vir. SUNSTROKE. 295 During the Attack. — Amyl nit., Bell., Camph., Glonoin, Opium, Verat. alb. For the Sequelae. — Agar., Anac, Ars., Baryta carb., Bell., Gels., Glon., Laches., Nat., Stram. Special Indications. — Aconite. — Thermic form, accompanied by burning heat, especially in the head and face, dryness of the skin, redness of the eyes and cheeks, thirst, headache, restless- ness, anxiety, nausea, vomiting. Amyl nit. — Violent determination of blood to the head and face; head feels as though it would burst; violent beating of the carotids ; vertigo, with sense of intoxication ; anxiety ; dyspnoea ; prostration. Antimonium crud. — Syncopal form, with fainting, loss of ap- petite, furred tongue, nausea, vomiting; aggravated by ex- posure to the sun. Antimonium tart. — Thermic fever, with much gastric dis- turbance, great prostration, tendency to fainting, convulsions, paralysis. Arsenicum. — Excessive thirst, burning skin, fainting, nausea and vomiting, great prostration, diarrhoea. Belladonna. — Indicated when the brain symptoms pre- dominate, such as headache, giddiness, delirium, sensitiveness to light and sound, great anguish, etc.; also apoplectic symp- toms, such as coma, stertorous breathing, lividity, etc. Bryonia. — Tendency to syncope, thirst, gastric disturbances, weakness of the limbs, great uneasiness and apprehension. Cactus. — Violent determination of blood to the brain, with pulsations in the temples, bloodshot eyes, stupor, flushed face, epistaxis, cold sweat, fainting, oppression of the chest, great prostration. Carbo veg. — Extreme prostration of the vital power; vertigo, with heaviness of the head ; pulsative pains and pressure above the eyes; heat-exhaustion. Camphora. — Great depression of both the nervous and cir- culatory systems; oppression of breathing; coldness of the body ; tremors, cramps, and diarrhoea. Glonoin. — Intense headache, with throbbing in all parts of 296 INTRACRANIAL DISEASES. the head and vertigo, especially when followed by loss of con- sciousness; painful constriction of the heart; sensation as if all the blood had gone to the head, which feels as though it would burst ; fainty feeling, with complete muscular relaxation ; convulsions; numbness in the limbs ; oppression of breathing; precordial anxiety. Veratrum vir. — Thermic fever, with congestion to the head and chest, gastric disturbances, coldness of the limbs ; faint- ness ; convulsions ; paralysis. CONCUSSION OF THE BRAIN. 297 CHAPTER VI. CONCUSSION OF THE BEAIN. Concussion of the brain is usually regarded as a surgical disease, but it is so only when complicated with cerebral or other injuries. The symptoms are in the main the same, whether traumatic lesions exist or not ; and as the treatment is medical rather than surgical, we think it is fully entitled to a place among intracranial disorders. Cerebral concussion may be denned to be a shock communi- cated to the brain and nervous system by some external vio- lence, such as a fall or blow, whereby their functions are temporarily suspended, and the vital power more or less depressed. Symptoms. — The leading symptoms of concussion are: unconsciousness and insensibility, accompanied by a greater or less degree of pallor, coldness, and flaccidity of the volun- tary muscles. Sometimes the depression is very slight, and the patient quickly recovers ; at others, the shock is so severe as greatly to depress the system and retard recovery ; whilst at other times the depression continues and the patient sinks. In the more severe cases all power of motion is lost ; and if the patient is capable of being partially aroused, he immedi- ately relapses again into the former state of insensibility and unconsciousness. In this, the first stage of concussion, the pulse is slow and feeble, the pupils dilated or uneven, and the surface pale and cold. The second stage is characterized by the symptoms of reaction ; warmth and color gradually return, consciousness and the power of motion are restored, and the circulation is reestablished. This stage is usually accompanied by more or less vomiting, depending upon the severity of the 298 INTRACRANIAL DISEASES. concussion. This vomiting is a favorable symptom, as it tends, by equalizing the circulation, to promote recovery. The third stage is marked by extreme physical prostration, a cold, clammy, semi-moribund condition, which sometimes continues for hours, and at last gradually yields to recover} 7 , or terminates in death. Morbid Anatomy. — As might be inferred, every degree of injury has been observed in fatal cases, and the instances are comparatively few in which no intracranial lesion is to be found. Sometimes actual rupture occurs ; at others, a soft or semi-diffluent state of the cerebral tissue is produced, whilst occasionally, even in those cases in which the shock and con- sequent depression are the greatest, no lesion whatever can be discovered. The visible lesions may be equally visible, from a contused, ecchymosed, or lacerated wound, with or without a broken skull, to a mere abrasion, or even a total absence of external injury. Pathology. — In those cases in which no lesion can be dis- covered after death, it is probable that the patient dies from the effect of shock alone; but of course this cannot be proven, because it cannot be shown that the cerebral tissue has entirely escaped injury. A minute haemorrhage or other injury at the internal origin of the pneumogastric nerve would be sufficient, no doubt, to produce speedy death, and the same may be true of other parts of the great nervous centre. Nevertheless, it is more reasonable to refer the fatal issue in these cases to shock alone, than to causes which may have no existence. In other cases, the injury to the brain interferes with the circulation through it, and though the effects of the concussion upon the general system may be no greater in these than in the former cases, the character of the injury is such as to permanently depress the vital power, and death sooner or later is the inevi- table consequence. Prognosis. — The prognosis differs greatly in different cases. As we have said, some cases quickly recover ; others rally slowly, the paralyzed brain gradually regaining its power and functions; and the patient, after remaining, it may be, for hours in a cold and semi-moribund condition, gradually re- CONCUSSION OF THE BEAIN. 299 covering his activity and senses, but suffering for a longer or shorter period from headache, confusion of thought, giddiness, and impairment of the mental powers. In other cases, again, should the patient survive the immediate effects of the injury, an irritable state of the brain may remain, or such an impair- ment of its functions, as to render it liable to inflammation under the operation of almost any exciting cause, such as ex- cesses in eating and drinking, mental excitement, etc. On the other hand, if paralysis ensues, or if there is incontinence or retention of faeces and urine, it is highly probable that the case is complicated with cerebral laceration or contusion, and that the final result will be fatal. Treatment. — This should be similar to that recommended for the syncopal form of sunstroke (q. v.). Amy! nitrite by inhalation furnishes the speediest way of overcoming the depression of the vital powers, but care should be taken not to overstimulate the circulation by this or any other method, the aim being simply to reestablish the normal condition. In most cases it is not only safest, but sufficient, to wrap the patient in warm blankets, apply friction to the surface, and use dry heat to the extremities. In the case of young chil- dren, however, the warm bath may be employed with great advantage, care being taken to prevent their getting chilled during its administration. In the case of adults, on the con- trary, dry heat is the handiest mode of applying heat to the surface, the patient being surrounded by hot bottles, Chap- man's bags, or some other equivalent substitute. As soon as the patient is able to swallow, he may, if his friends so desire, be allowed to drink moderately of simple warm teas ; but alco- holic stimulants should be carefully avoided, as they are apt to have a highly prejudicial effect. So far as the concussion is concerned, the case is now one for medical treatment only, no other form of stimulation being required. General Indications. — First Stage. — Amyl nit., Arm, Ars., Cic, Coca, Camph.j Con., Lauroc, Verat. Second Stage. — Arm, Bry., Camph., Chin., Euphra., Hep., Hyos., Ign., Nux vom., Phos., Rhus tox., Sulph., Yerat. 300 INTRACRANIAL DISEASES. Third Stage. — Cic, Cocc., Con., Dig., Ignat., Merc, Phos. ac. Rhus tox., Sulph. Muscular System. — Angus., Euphra., Phos. ac, Puis., Sulph. ac. : trembling — Angus., Cic, Cin., Hep., Ign , Nux vom. : con- vulsions — Am., Ars., Cocc, Con., Lauroc, Rhus tox., Sulph., Verat. : paralysis. Sensorium. — Dig., Euphra., Hep., Ign., Phos. ac, Ruta. Sulph., Verat. : giddiness — Angus., Cin., Con., Puis., Rhus tox., Sulph. ac : drowsiness — Am, Ars., Cic, Cocc, Laches., Lauroc, Merc, Opium : insensibility and unconsciousness. Special Indications. — Arnica. — Concussion from traumatic in- injury to the brain, attended with insensibility and uncon- sciousness : if fever ensues, alternate with Aconite. Belladonna. — Second stage, when accompanied by excessive reaction : delirium, convulsions, flushed face, intense head- ache : if high fever ensues, alternate with Aconite. Cicuta. — First stage of cerebral concussion, attended by insensibility and unconsciousness : lies in a state of complete insensibility, like a dead person ; face cold and deadly pale, with cold hands; inability to swallow: delirium; profound depression of the vital power ; convulsions. Gonium. — Apoplectic symptoms, with trembling of the limbs; want of animal heat: delirium: convulsions; paralysis; numb- ness ; slow, weak pulse ; dilatation of the pupils : collapse. Euphrasia. — Second stage, with great weakness of the whole body: soreness from falls or blows: body is very cold and can- not get warm : headache, with sensation as if the brain were bruised; numbness and cramps in the limbs. Gelsemium. — Stupid, drowsy condition, with pain in the back of the head, dilated pupils, and paralysis of the lower sphincters. Hyoscyamus. — Second stage, attended with violent reaction, and low or furious delirium. Lachesis. — Apoplectic symptoms, with low, muttering delir- ium, pale face, cold extremities, and paralysis of the left side. Liurocerasus. — Loss of consciousness, loss of speech, and loss of motion; sunken countenance; slow, feeble pulse ; moaning CONCUSSION OF THE BRAIN. 301 and rattling breathing ; skin cold and blue ; trembling of the limbs ; paralysis of the sphincter ani, with unconscious dis- charge of faeces. Phosphoric acid. — The best remedy, in most cases, for the nervous debility remaining after concussion of the brain; fre- quent cold spells, with general chilliness; pulse irregular; weakness of memory, with confusion of mind ; bruised sensa- tion in all the limbs ; dull headache, especially in the fore- head and temples; restlessness, with pain in the back, and great despondency ; profuse sweating. Veratrum alb. — Cold, pale, disfigured face, as of a dead per- son ; limbs cold and trembling from weakness ; speechlessness, with unperceived discharge of loose faeces ; palpitation of the heart, with anxiety, and arrested breathing ; loss of sensation and motion ; tendency to collapse. Vipera redi. — Sopor, with loss of sight and difficult breath- ing ; pulse slow, feeble, and irregular, with coldness and sweat; constant disposition to faint ; delirium ; convulsions ; paraly- sis of single limbs, or of one-half of the body ; difficulty of swallowing ; vomiting and diarrhoea. 302 INTRACRANIAL DISEASES. CHAPTER VII. HYDKOCEPHALOID. This is the name given by Sir Marshall Hall to a group of symptoms closely resembling those of acute hydrocephalus. The symptoms are not peculiar to any one disease, though most frequently met with in infants that have fallen into an anaemic state, in consequence of an exhausting diarrhoea. It is but justice to this eminent author to describe the condition referred to in his own language : " Hydrocephaloid may be divided into two stages : the first, that of irritability ; the second, that of torpor. In the former there appears to be a feeble attempt at reaction ; in the latter the powers appear to be more prostrate. These two stages re- semble, in many of their symptoms, the first and second stages of hydrocephalus respectively. "In the first stage the infant becomes irritable, restless, and feverish ; the face flushed, the surface hot, and the pulse fre- quent ; there is an undue sensitiveness of the nerves of feeling, and the little patient starts on being touched, or on hearing any sudden noise; there are sighing and moaning during sleep, and screaming ; the bowels are flatulent and loose, and the evacuations are mucous and disordered. "If through an erroneous notion as to the nature of this affec- tion, nourishment and cordials be not given, or if the diarrhoea continue, either spontaneously or from the administration of medicine, the exhaustion which ensues is apt to lead to a very different train of symptoms. The countenance becomes pale, and the cheeks cool or cold ; the eyelids are half closed, the eyes are unfixed and unattracted by any object placed before them, the pupils unmoved on the approach of light; the HYDEOCEPHALOID. 303 breathing, from being quick, becomes irregular and affected by sighs; the voice becomes husky, and there is sometimes a husky, teasing cough ; and eventually, if the strength of the little patient continue to decline, there is a crepitus or rattling in the breathing. The evacuations are usually green; the feet are apt to be cold." If it is important to distinguish this condition as met with in anaemic children suffering from summer complaint, it is equally so to recognize and properly estimate it when met with under other forms. We frequently observe precisely this train of symptoms during the initial stage of pneumonia in infants, and also in helminthiasis. In fact the irritation caused in children by intestinal worms, crude ingesta, and sometimes even by cold alone, is not only of the same nature, but appar- ently identical with that of hydrocephaloid. This, however, is not to be wondered at, since the symptoms mentioned are of a purely reflex character. The important point to remember is, that symptoms resembling those of acute hydrocephalus may present themselves in the course of almost any exhausting disease, especially in the case of children, and that in most in- stances they simply denote cerebral irritation, and not menin- geal inflammation. The point is one of great practical im- portance, since the removal of the cause, though far distant from the seat of irritation, will generally put an immediate stop to the symptoms, as we ver) f often see in the case of infan- tile remittent fever. Treatment. — It follows from what has just been said, that whenever the physician meets with the symptoms of hydro- cephaloid, he should, first of all, be careful to make a correct diagnosis, with a view to ascertain, and prescribe for, the cause, which in the great majority of cases will be found to be seated somewhere in the intestinal or respiratory tract. If, as very frequently happens, the symptoms are due to ver- minous irritation, Cina or Santonine will be found to be a very effective remedy; if due to cold, Gelsemium will generally relieve ; and if summer complaint be the cause, Mercurius, either with or without the more specifically indicated remedy, as the case may require, will often allay the intestinal, and with it the cerebral irritation. 304 INTRACRANIAL DISEASES. Special Indications. — JEthusa cyn. — Great debility and pros- tration, with drowsiness; greenish watery stools in the morn- ing, during dentition, with much pain and tenesmus ; vomiting of white, frothy matter, or of coagulated milk ; eyes turned up, or fixed and staring; face pale, with a painful facial expres- sion, especially about the mouth ; child dozes and cries alter- nately; or utters piteous moans from time to time; spasms and convulsions. Apis met. — Thin yellow, or offensive watery diarrhoea in teething infants, accompanied by great prostration; hands and feet blue and cold ; tenderness of the abdomen on press- ure; stools frequent but odorless, generally worse in the morning ; urine very scanty or suppressed ; child very feeble and drowsy, frequently uttering shrieks or plaintive cries. Arsenicum. — Greenish or yellowish stools, often watery, with extreme prostration, frequent sinking spells, and violent vomit- ing ; child wants to lie with the head low ; great thirst, but drinks little at a time, and generally vomits as soon as the water becomes warm in the stomach; rapid emaciation; rapid and feeble pulse ; dilated pupils ; sunken abdomen ; involun- tary stool and urine. Belladonna. — Green stool, voluntary or involuntary, followed by tenesmus ; head hot and feet cold ; drowsy with frequent startings; tongue with red tip and edges; mouth and lips dry ; spasms and convulsions. Borax ven. — Stools variously colored, painful or painless; odorless or cadaverous-smelling ; constant vomiting, gagging, and retching; abdomen soft or flabby and sunken; very drowsy and emaciated ; child starts as if frightened on being lowered into the crib or cradle. Bryonia. — Offensive diarrhoea, especially in the morning, or after nursing, which the child constantly wants ; lips dry and parched ; child turns pale on being disturbed or raised up ; very feverish and fretful, especially when disturbed. Calcarea phos. — Poor, scrawny-looking children, with dry, dirty-white skin, and aged countenance; thin greenish stools, with a great deal of offensive flatulence ; pus-like stools, which have a cadaverous odor. HYROCEPHALOID. 305 Camphora. — Involuntary watery diarrhoea, with frequent vomiting; skin cold and clammy; child appears to be in a collapsed state, stupid, senseless, and almost without life; lies with its mouth open and the eyes half closed. Chamomilla. — Stools watery, green, or like chopped eggs; child very restless and wants to be continually carried about in the nurse's arms; symptoms produced by cold or teething. China. — Painless diarrhoea, worse in the morning ; great de- bility, with disposition to faint after every stool; diarrhoea increased by frequent nursing; child cries and bends double with colic; body alternately hot and cold. Cina. — Constipation or diarrhoea in young children, during or after dentition, accompanied by a broad white circle or space around the mouth and nose, in strong contrast with the deep-red cheeks ; high fever, worse towards evening, better in the morning; loss of appetite; frequent picking at the nose; bloated abdomen; bad breath; starting in the sleep; diarrhoea, with greenish, slimy, or white mucous stools; first stage of hydrocephaloid. Cuprum. — Violent diarrhoea, with vomiting and cramps; collapsed condition with sunken features, cold sweat, and weak, small pulse ; stools watery, copious, with greenish flakes, often accompanied by flatulence; spasms and convulsions. Ferri phos. — Frequent green, watery or hashed stools, mixed with mucus, and scanty; tenesmus; retching; child moans and rolls its head; starts in sleep; face pinched; eyes half open; urine scanty; pulse and respiration quickened. Helleborus. — Watery or jelly-like stools, with colic and tenes- mus; urine scanty and high colored; pale and puffed appear- ance of the face; tenesmus; vomiting of mucus, mixed with a greenish or blackish watery fluid; great drowsiness, with cold sweat; incontinency of urine; swelling of the feet. Ignatia. — Sudden development of hydrocephaloid symptoms during dentition ; child moans and rolls its head, or screams violently, with convulsive action of eyes and lips; face pale; great difficulty in swallowing; spasms and convulsions. Kreosotum. — Stools greyish-white, chopped, and very offen- sive ; great thirst, with constant vomiting ; face cold, with a 20 306 INTRACRANIAL DISEASES. pale border around the nose and mouth ; child moans and starts in sleep ; emaciation and great prostration ; rapid and weak pulse ; hurried and feeble respiration. Lachesis. — Undigested watery stools, which are very offen- sive, accompanied with rumbling in the bowels and violent straining; abdomen hot and bloated ; stools sometimes mixed with pus. Lycopodium. — Loose, brown, or thin, pale stools, also mucous stools, green, stringy, and odorless ; abdomen distended with gases; pale, wretched complexion; cold feet; drowsy, with frequent startings and jerkings of the limbs ; eructations and hiccough. Phosphorus. — Hydrocephaloid symptoms, with great depres- sion of the vital power ; violent watery diarrhoea, with con- stant straining ; anus constantly remains open ; stools exces- sively foetid ; cold drinks ejected from the stomach as soon as they become warm ; emaciation and sudden loss of strength. Podophyllum. — Frequent, violent, watery stools, ejected with a gush ; painless diarrhoea, with cramps in the legs or feet ; stools followed by tenesmus and prolapsus ani ; child moans and rolls its head from side to side ; disposed to faint after every evacuation of the bowels ; frequent retching and vomiting ; worse in the morning, at night, and after taking nourishment. Sulphur. — Scrofulous children with hydrocephaloid symp- toms; stools extremely offensive, slimy, watery, frothy, and putrid ; constant thirst, with frequent vomiting ; white tongue, with red tip and borders; abdomen distended with flatus; great debility and prostration, with difficult breathing, and involuntary stools. Veratrum alb. — Frequent, profuse, greenish, watery stools, with flakes ; violent vomiting, followed by coldness and great prostration, with cold sweat on the forehead, and cold tongue; extreme thirst, but drinking increases the nausea and diarrhoea; collapse, with cold breath and suppression of urine. Zincum. — Hydrocephaloid symptoms, with great nervous depression ; stools frothy, with or without tenesmus ; during sleep the child cries out, starts, and jumps; on awaking it appears frightened, and rolls its head from side to side. INDEX. Abscess, cerebral, 101. Acetic acid in nervous beadacbe, 24.4. Aconite in cerebral hyperaemia, 87 ; in cere- bral haemorrhage, 10S : in simple acute meningitis, 175 ; in cerebro-spinal menin- gitis, 207; in congestive beadacbe, 232; in nervous headache, 24.5; in catarrhal and menstrual headaches, 259 ; in ver- tigo, 276 ; in insomnia, 2S4 : in sunstroke, 295. Adamiik on the nates, 33. iEthusa cyn. in simple acute meningitis, 176 ; in hydrocephaloid, 304. Agaricus in epidemic meningitis, 207 ; in con- gestive headache, 232 ; in nervous head- ache, 245. Agnus cast, in nervous headache, 245. Ailanthus in congestive headache, 232 ; in nervous headache. 245. Albuminuria. 59. Allium cepa in catarrhal headache, 259. Aluminum in congestive headache, 232 ; in catarrhal headache, 259. Althaus, Dr., on arachnitis, 191. Amaurosis, 33. 54. Ammonium carb. in congestive headache. 232. Amyl nitrite in cerebral anaemia, 69 : in cere- bral hyperaeinia, S7 ; in congestive head- ache, 233 ; in vertigo, 277 ; in sunstroke, 295. Anacardium in nervous headache, 245 ; in gastric headache, 259. Anarthia, 56. Anaemia, cerebral, 62; symptoms of, 63; syn- cope in, 64 ; vaso-motor, 65 : paralysis in, 65 ; causes. 65 ; diagnosis, 67 ; prognosis, 67 : morbid anatomy, 6S ; pathology, 68 ; treatment, 69. Andral on cerebral haemorrhage, 104. Aneurisms, miliary, 105. Angular gyrus, motor centres in, 20, 26 ; re- lated to vision, 33. Antimonium crud. in gastric headache, 259 ; in sunstroke, 295. Antimonium tart, in coma, 2S9 : in sunstroke, 295. Aphasia, 42, 44, 123. Aphonia, 61. Apis mel. in simple acute meningitis, 176; in epidemic meningitis, 20S; in congestive headache, 233: in nervous headache, 246; in hydrocephaloid, 304. Aplasia, progressive laminar, 151. Apoplexy, central pontine, 59; cerebral, 91-93; symptoms, 91; hemiplegia in. 92; causes, 92; cerebral haemorrhage in, 93. Appetite, seat of, 28. Arachnitis, 191; symptoms and morbid anat- omy, 191; etiology, diagnosis, prognosis and treatment, 192. Argentum met. in nervous headache, 246; in gastric headache, 259. Argentum nit. in paralysis of the ciliary muscle, 201; in epidemic meningitis, 208; in nervous headache. 246 : in vertigo, 277. Arnica in cerebral hyperaemia, S7; in cerebral haemorrhage, 10S; in epidemic meningitis, 20S; in congestive headache, 233; in nerv- ous headache, 246; in cerebral concus- sion, 300. Arsenicum in cerebral anaemia, 70; in simple acute meningitis, 176; iu epidemic menin- gitis, 208; in chronic hydrocephalus, 222: in nervous headache, 246: in sympathetic headache. 260; in vertigo. 277: in sun- stroke, 295: in hydrocephaloid, 304. Articulation, 35, 61; "centre for. 40. Asafoetida in nervous headache, 247; in hys- terical headache. 259. Asarum in nervous headache, 247. Asclepias syr. in congestive headache, 233; in nervous headache, 247. Atheromatous degeneration in cerebral haem- orrhage. 105: in cerebral thrombosis, 113. Athetosis. 51. 145-150; symptoms, 145: causes, diagnosis and prognosis, 149; morbid anatomy, pathology and treatment, 150. Atrophy, cerebral, 139-142: symptoms. 139; partial, 139; general, 140; causes, diag- nosis and prognosis, 140; morbid anatomy, pathology and. treatment, 141; galvanism in, 142: progressive facial, 151. Atropine in congestive headache, 233; in nervous headache. 247. Auditory vertigo, 36, 271. Aurum in nervous headache, 24S. Automatic movements, 35. Baptisia in epidemic meningitis, 203. Baryta in cerebral haemorrhage, 10S; in tuber- cular meningitis, 1S6. Basilar meningitis, chronic, 198; symptoms, 19S: morbid anatomy, 199; pathology and etiology, 200; diagnosis, prognosis and treatment. 201; general and special indi- cations, 201, 202. Basal ganglia, functions of the, 30; lesions of. 47. Bastion. Dr., on the genital functions, 54; on lesions of the cms cerebri, 57; on intra- cranial hydatids. 225. Bed-sores, acute, 97. Belladonna in cerebral hyperaemia, 57: in cerebral haemorrhage, 10S; in simple acute meningitis, 176; in epidemic meningitis, 208; in congestive headache, 233; in nerv- ous headache, 24S; in sympathetic head- ache, 260; in vertigo, 277; in insomnia, 254: in coma, 2SS; "in sunstroke, 295; in 308 INDEX. cerebral concussion, 300; in hvdrocepha- loid, 304 Berberis in sympathetic headache, 260. Betz on giant cortical cells. 24. Bismuth iu gastric headache, 260. Blood-clots, intracranial, 104. Borax in hydrocephaloid, 304. Bouchard on miliary aneurisms, 105. Bovista in menstrual headache, 250. Broadhent, Dr., theory of, 25. Broca's convolution, 21, 29, 42. Bromides in cerebral hyperemia, S6. Brown-Sequard on cerebral localization, 22 ; on crossed paralysis, 23. Bryonia in cerebral hyperemia, S7; in simple acute meuicgitis, 176 ; in epidemic men- ingitis, 210; in congestive headache, 234 ; in gastric and rheumatic headaches, 260 ; in vertigo, 277: in coma, 2SS ; in sunstroke, 295 ; in hydrocephaloid, 304. Budge on the peristaltic movements of the oesophagus and stomach, 37. Bulb, functions of the, 3S. Cactus in cerebral hyperemia, SS ; in conges- tive headache. 234: iu sunstroke. 295." Caladium in congestive headache, 234. Carville and Buret on functional substitution, 25; on heinianaesthesia, 31. Calcarea carb. in tubercular meningitis. 187; in chronic hydrocephalus, 222 ; in conges- tive headache. 234 ; in nervous headache, 24S; in vertigo, 278. Calcarea phos. in tubercular meningitis, 1S7; in chronic hydrocephalus, 222; in gastric and rheumatic headaches, 260; in hydro- cephaloid, 304. Calmeil on the morbid anatomy of cerebral hyperemia, S4. Camphora iu cerebral anaemia, 70: in epidemic meningitis. 210; iu congestive headache, 234; in coma. 2SS; in sunstroke, 295; iu hydrocephaloid, 305. Cancer, cerebral, 15S. Cannabis ind. in epidemic meningitis, 210. Cantharadis iu simple meuiugitis, 177; in epi- demic meningitis, 210. Capsicum in congestive headache, 234. Carbo an. in congestive headache, 235; iu menstrual headache, 261. Carbo veg. in congestive headache, 235: in suustroke, 295. Cardiac affections, 100. Cardio-inhibitory centre, 3S. Caulophyllum in nervous headache, 245: iu menstrual and rheumatic headaches, 261. Causticum in ocular paralysis, 201; in conges- tive headache. 235: in nervous headache, 24S; in arthritic and rheumatic headaches, 261; in vertigo, 278. Cedron in malarial headache, 261. Cephalagia, 230-250. Centrum ovale, lesions of, 46. Cerebellum, functions of, 35; lesions of, 57,58. Cerebrum, functions of, 17. Cerebral cortex, motor centres in, 17-26, 38; sensory centres in, 26-2S. Cerebral ganglia, functions of, 30-32; lesions of, 47. Cerebral lesions, 41. Cerebritis, 130. Cerebro-spinal isthmus, lesions of, 57. Cerebro-spinal meningitis, 202-210: symptoms, 203; complications and sequelee. 204; mor- bid anatomy and pathology, 205; etiology and diagnosis, 206; prognosis and treat- ment, 207; special indications, 207-210. Chamomilla in congestive headache, 235; in nervous headache, 24S; in arthritic and rheumatic headaches, 261; in coma, 2SS; in hydrocephaloid, 305. Charcot on secondary contractions, 99; on miliary aneurisms, 105; on the vascular system of the brain, 42, 47, 57; on the basal ganglia, 47. China in cerebral anaemia, 70; in epidemic meningitis, 210 ; in congestive headache, 236; in nervous headache, 249; iu vertigo, 278; hydrocephaloid, 305. Chelidonium in bilious headache, 262. Chloralum in nervous headache, 249. Cholesteatoma, 157. Chorea, 146; post-hemiplegic, 149. Cicuta in epidemic meningitis, 210; in nervous headache, 249; in vertigo, 27S; in cerebral concussion, 300. Cimicifnga in cerebral hyperemia, SS; in epi- demic meningitis, 210; in congestive head- ache, 236; in nervous headache, 249. Cina in cerebral anaemia, 71; in simple menin- gitis, 177; in hydrocephaloid, 305. Clark, Dr., on the vaso-motor centre, 39. Cocculusin cerebral haemorrhage, 10S; in epi- demic meningitis, 211; in congestive head- ache, 236 ; in nervous headache, 250 : in gastric and menstrual headaches, 262; in vertigo. 27S: in iusomnia, 2S4. Coffea in nervous headache, 250; in cerebral hyperemia, SS; in insomnia, 2S4. Cohnheim on cerebral softening, 127. Colocynthis in nervous headache, 250; in ar- thritic and rheumatic headaches, 262. Coma, 100, 101, 256-259; hysterical, 102; urae- mic, 192; symptoms. 2S6: diagnosis, 256: causes. 2^7: prognosis, 2>7; treatment. 257: special indications, 2SS. Concussion, cerebral, 102, 297-301; symptoms, 297; morbid anatomy, 29S; patko'logy, 298; prognosis, 29S; treatment, 299: general in- dications, 299; special indications, 300. Coordination, optic, 34, 52: pontine, 35; cere- bellar, 36, 55; reflex, 38; general centre for, 40. Contractions, late, 48, 99. Convulsive centre, 38; lesions of, 44. 46. Consciousness, intelligent, seat of, 29. Convexital meningitis, chronic, 195: symp- toms, 195: morbid anatomy and pathology, 196; etiology and diagnosis, 197; prognosis and treatment, 19S. Corpora quadrigemina, functions of, 33. Corpora striata, functions of, 30, 32; lesions of, 45. 49. 52. Cortical lesions. 45. Crocus in menstrual headache, 262. Colchicum in vertigo, 278. Conium in vertigo, 27S; in cerebral concus- sion, 300. Crotalus in epiilemic meningitis, 211; in nerv- ous headache, 250. Crura cerebri, functions of, 34: lesions of, 57, 60. Cuprum in simple meningitis, 177: in paraly- sis of the nervus abduceutis, 202; in epi- demic meningitis, 211; in congestive head- ache, 236: in vertigo, 279; in hydrocepha- loid, 305. Cysticerci, cerebral, 227. Deglutition, centre for, 39. Devaine and Cobbold on intracranial hyda- tids, 225. Diabetic centres, 37, 40, 59. Digitalis in simple meningitis, 177: in epi- demic meningitis, 211; in congestive head- ache. 236. Dittmer on the vaso-motor centre, 39. Dowse, Dr., on cerebral syphillis, 164, 167, 169. INDEX. 309 Dropsy, cerebral, 21S-224: symptoms, 218; mor- bid anatomy and pathology, 217; causes, 221; diagnosis, 221: prognosis and treat- ment, 222; special indications, 222-224. Dulcamara in congestive headache, 236. Durand-Fardel on the morbid anatomy of cer- ebral hyperemia, S4. Dnret and Carville on functional substitu- tion, 2-5. Eckard on vicarious action, 22; on excitable cortical fibres, 23. Electrical stimulation of the cerebral cortex, 17-40. Embolism, cerebral, 101, 116; symptoms, 116; causes, 117; diagnosis and prognosis. US; morbid anatomy and pathology, 119, treat- ment, 120. Emotional centres, 33, 39, 60. Emotional weakness, 60. Encephalitis, 130; symptoms, 130-133; causes, 133; diagnosis and prognosis, 134; morbid anatomy and pathology, 13.5: treatment, 136. Epidemic meningitis, 202. Epileptic moaning and crying, 34, 38. Epileptiform convulsions, 46, 59, 159, 160. Ergot in cerebral hyperemia, S6. Equilibrium, disorders of. 35, 36, 52. Eupatorium perf. in bilious ' and malarial headaches, 262. Euphrasia in paralysis of the oculo-motor nerve, 202; in catarrhal headache, 262; in vertigo, 279; in cerebral concussion, 300. Eyes, centres for the movements of the, 20. Facial atrophy, progressive, 151-153: symp- toms, 151; "etiology, diagnosis and pathol- ogy, 152; treatment, 153. Facies hydrocephalica, 220. Ferrier on cortical centres and lesions, pas- sim; his methods of research, 19, 20. Ferrum in cerebral anemia, 71; in congestive headache, 236: in hydrocephaloid, 305. Fleming on cerebral anemia, 6S. Fluroric acid in congestive headache, 237 Foreign products, intracranial. 22.5-229: symp- toms, 227-22S; prognosis, 22S: treatment, 229. Formica in nervous headache, 250. Fritsch and Hitzig on cerebral centres, 17. Functional substitution, law of, 26. Functions of the cerebral hemispheres, 77; of the cerebral ganglia, 30. Fungus dure matris, 15S. Galvanism in cerebral anaemia, 69; in cere- bral hyperemia, 85: in cerebral atrophy, 142. Gamboge in gastric headacbe, 262. Ganglia, basal, 30. Gastric and cesophagal centre, 39. Gelsemium in cerebral hyperemia, SS; in simple meningitis, 177; in paralysis of the ocular muscles, 202; in epidemic meningitis, 211; in congestive headache, 237; in nervous headache, 251; in catarrhal and hysterical headaches, 263; in vertigo, 279; in insomnia, 284; in cerebral concus- sion, 300. Giacomini on the human measle, 22S. Giant-pyramidal cells in the cerebral cortex, 24. Glioma. 157. Glonoin in cerebral hyperemia, S8; in simple meningitis, 177; in epidemic meningitis, 212; in congestive headache, 237; in nerv- ous headache, 251; in sunstroke, 295. Goltz on cortical paralysis, 23; his method of research: 20. Gossypium in menstrual headache, 263. Graphites in nervous headache, 251. Gratiolain congestive headache, 237. Gumma syphiliticum, 169. Gymnocladus in congestive headache, 237; in catarrhal headache, 263. Hammond, Dr., on cerebral diseases, passim; on strong magnets in hemiplegia. 107. Hamamelis in congestive headache, 238. Headache, 230-26S; congestive 231; nervous, 243; sympathetic, 257. Hearing, centre for, 26. Helleborus in simple meningitis, 178; in chronic hydrocephalus, 223; in coma, 2SS; in hydrocephaloid, 305. Heminesthesia, 31, 47-50. Hemichorea, 50, 51. Hemiopia, 44; homonymous, 51. Hemiplegia, partial, 45; from lesion of the basal ganglia. 47. 50; from lesion of the crus cerebri, 55; pontine, 5S; in cerebral apoplexy, 92, 94, 97; causes, 99; diagnosis, 100; prognosis, 102; morbid anatomy, 103; pathology, 105; treatment, 105: general indications, 107; special indications, 108. Hermann on vicarious action, 22; on cortical paralysis, 24. Heubner on cerebral thrombosis, 114; on cerebral syphilis, 164, 170. Hensen on the corpora quadrigemina, 33. Hemorrhage, cerebral, 93; symptoms, 93; apoplectic, 94; temperature" in, 96; local- ization of, 93 Hematoma. 214-217; symptoms, 214; morbid anatomy and pathology, 215; causes, 216; diagnosis, 216; prognosis and treatment, 217. His on perivascular canals, S4. Hitzig on cerebral centres, 17; his method of research, 19; on temperature, 29. Huguenin on hematoma, 216. Hydatids, cerebral. 22S. Hydrastis in nervous headache, 251; in ca- tarrhal headache, 263. Hydrocephaloid, 302-306; symptoms, 302; diagnosis and treatment, 303; special in- dications, 304. Hydrocephalus, acute, 179-1SS; symptoms, 179-1S2; prodromic stage, 179;" stage of excitement, ISO; stage of depression, 181; closing stage. 182; morbid anatomy, 182; pathology and etiology, 1S3; diagnosis, 1S4; prognosis, 1S5; treatment, 1S6; gen- eral and special indications, 1S6-1SS: chronic. 21S-224. Hydrocvanic acid in epidemic meningitis, 212.* Hyoscyamus in cerebral hyperemia, S8; in simple meningitis, 178; in epidemic men- ingitis, 212; in nervous headache, 251; in vertigo, 279: in insomnia, 2S4; in cere- bral concussion, 300. Hypertrophy, cerebral, 137; symptoms, 137; etiology, diagnosis, prognosis, morbid anatomy, pathology and treatment, 13S. Hyperemia, cerebral, 73-87; symptoms, 73; cardiac disturbances in, 76;" varieties of, 7S; delirium in, 78; convulsive and apo- plectic forms of, 79; causes, SO; diagnosis, SI; prognosis, S2; morbid anatomy. S3; pathology. S4; treatment, 85; general in- dications, 86; special indications, S7. Hyperesthesia, unilateral, 59. Hysteria, 60. Ignatia in nervous headache, 252; in vertigo, 310 INDEX. 279; in insomnia, 284; in hydrocephaloid, 305. Incoordination, 40, 55, 145. Insomnia, 282-285: symptoms, 282; treatment and general indications, 283; special in- dications, 2S4. Internal capsule, lesions of, 47, 49, 50. Iodine in congestive headache, 238. Ipecacuanha in cerebral anaemia, 71; in nerv- ous headache, 252; in gastric headache, 263; in vertigo, 279. Iris vers, in nervous headache, 252; in bilious and gastric headaches, 263. Jacobi on cerebral anaemia, 68. Jaws and tongue, centre for, 21. Kali bich. in catarrhal and rheumatic head- aches, 263. Kali carb. in congestive headache, 238; in catarrhal headache, 264. Kali iod. in tubercular meningitis, 187; in paralysis of ocular muscles, 202; in chronic hydrocephalus, 223; in conges- tive headache, 238; in catarrhal head- ache, 264; in vertigo, 279. Kalmia in vertigo, 279. Kolliker on the arachnoid, 191. Kreosotum in hydrocephaloid, 305. Krishaber on cardiac disturbances in cerebral hyperemia, 76. Kussmaul and Tenner on faradization of the cervical sympathetic, 6S. Lachesis in cerebral haemorrhage, 108; in chronic hydrocephalus, 223; in congestive headache, 238; in sympathetic headache, 266; in vertigo, 279; in coma, 288; in cere- bral concussion, 300; in hydrocephaloid, 306. Lachnanthes in congestive headache, 239. Landouzy on athetosis, 150. Landois on temperature, 29. Language, centre for, 29. Lateral sinuses, thrombosis of the, 226. Laurocerasus in cerebral haemorrhage, 109; in cerebral concussion, 300. Lepto-meningitis, cerebral, 172; tubercular, 179; traumatic, 193; symptoms and morbid anatomy, 193; pathology, prognosis and treatment, 194. Lesions, diagnostic, 41; systemic, 42; latent, 44; irritative, 46; ganglionic, 47; cerebel- lar, 53. Lilium tig. in congestive headache, 239; in menstrual headache, 264. Lips and mouth, centres for the, 21. Longet, hypothesis of, 26; on the optic thala- mus, 32. Longitudinal sinus, thrombosis of the, 226. Lower extremity, centres for the, 22. Lussana and Lemoigne on the cortical centres, 23; on the optic thalamus, 32. Lycopodium in tubercular meningitis, 1S7; in epidemic meningitis, 212; iu congestive headache, 239; in sympathetic headaches, 264; in hydrocephaloid, 306. Magnesia carb. in congestive headache, 239. Mai-antic thrombosis, 112. Medulla oblongata, lesions of, 60. Meningeal affections, 117-209. Meningitis, simple acute, 171-17S; 'symptoms, 171; morbid anatomy, 173; pathology, eti- ology and diagnosis, 174; prognosis, treat- ment and general indications, 175; special indications, 176-178; tubercular, 179; trau- matic, 1S9-194; chronic, 195-202; convexi- tal, 195; basal, 198; epidemic, 203. Mental disorder, 43. Mercurius in cerebral hyperaemia, 88; in cere- bral haemorrage, 109; in simple meningitis, 178; in paralysis of ocular muscles, 202; iu chronic hydrocephalus, 223; in conges- tive headache, 239; in catarrhal and rheu- matic headaches, 264. Meso-cephalon, functions of, 34. Meynert on cerebral ganglia, 30, 32. Mezereum in catarrhal headache, 265. Miliary aneurisms, 105. Moaning and crying, epileptic, 34. Monkey, experiments on the, 20. Monoplegia, 45. Moschus in insomnia, 284. Motor centres, cortical, 17-40; tracts, 38. Motor-oculi nerve, paralysis of, 34. Mouth and lips, centre for, 21. Multiple sclerosis, primary, 143-147; secon- dary, 146-147. Muscular coordination, 34-54; rigidity, 46, 60. Myxcedema, 154; symptoms, 154, diagnosis, prognosis and pathology, 155; treatment, 156. Naja in congestive headache, 240. Nates, functions of, 33; lesions of, 51, 52. Natrum mur. in cerebral anaemia, 71; in nerv- ous headache, 252; in menstrual headache, 265; in vertigo, 279. Natruin sulph. in congestive headache, 239; in menstrual headache, 265. Neuroma, 157. Nceud vital, 38. Nitric acid in congestive headache, 240. Nitrite of amyl in cerebral anaemia, 69; in cerebral hyperaemia, 87. Nothnagel on the basal ganglia, 49-52; on cerebellar lesions, 55, 56; on lesions of the cms cerebri, 57; on lesions of the medulla oblongata, 60, 61; on cerebral anaemia, 68. Nux mosch. in hysterical headache, 265; in coma, 288. Nux vomica in cerebral anaemia, 71; in cere- bral hyperaemia, 89; in cerebral haemor- rhage, 109; in paralysis of ocular muscles, 202; in epidemic meningitis, 212; in con- gestive headache, 240; in nervous head- ache, 253; in gastric and bilious head- aches, 265: in vertigo, 280; in insomnia, 2S4. Nystagmus, 112. Ocular troubles in cerebral thrombosis, 112. Opium in cerebral hyperaemia, S9; in cerebral haemorrhage, 109; in simple meningitis, 178; in vertigo, 280; in paralysis of ciliary muscle, 202; in epidemic meningitis, 212; in congestive headache, 240; in insomnia, 284; in coma, 2S8. Optic ganglia, 33, 51. Optic thalami, functions of, 31; lesions of 49-51. Ord, Dr., on myxcedema, 154. Oulmont and Brousse on double athetosis, 149. Ocular troubles in cerebral thrombosis, 112. Pachymeningitis, 189-191; symptoms, 189; treatment, 190; hemorrhagic, 214-217. Pagenstecher on cerebral compression, 84. Pain, occipital, 53. Paracentral lobule, lesion of, 46. Paralysis, cortical, 24, 25, 45; facial, 34, 35, 45, 59. Parasites, cerebral, 227. Paris quad, in paralysis of the iris and ciliary muscle, 202. INDEX. 311 Petroleum in nervous headache, 253. Phosphorus in cerebral hypersemia, 89; in paralysis of ocular muscles, 202; in epi- demic meningitis, 213; in chronic hydro- cephalus, 223; in congestive headache, 240; in nervous headache, 253; in hysteri- cal headache, 265: in vertigo, 2S0; in in- somnia, 2S4; ia hydrocephaloid, 306. Phosphoric acid in congestive headache, 241; in hysterical headache, 266; in vertigo, 280; in coma, 288; in cerebral concussion, 301. Phytolacca in gastric and rheumatic head- ache, 266. Physiological considerations, 17. Physostigma in vertigo, 2S0. Piorry on heredity, 99. Platina in nervous headache, 253; in hysteri- cal headache, 266. Plumbum in epidemic meningitis, 213; in chronic hydrocephalus, 223. Podophyllum" in sympathetic headache, 266; in hydrocephaloid, 306. Polyuria, 60. Pons Varolii, functions of, 34; lesions of, 58, 60. Priapism, 37. Psammoma, 157. Psorinum in chronic hydrocephalus, 224; in congestive headache, 241. Pulsatilla in cerebral hyperemia, 89; in cere- bral haemorrhage, 109; in congestive head- ache, 241; in nervous headache, 254: in sympathetic headaches, 266; in vertigo, 280; in insomnia, 2S4; in coma, 288. Reflex coordination, 3S. Regional diagnosis in brain diseases, 41; mat- ters relating to, 17-32. Respiratory centre, 38. Rhus rad. in nervous headache, 254. Rhus tox. in cerebral hyperaemia, 89; in sim- ple meningitis, 178; in paralysis of ocular muscles, 202; in epidemic meningitis, 213: in nervous headache, 254; in coma, 28S. Ringer, Dr., on the causes of athetosis, 149; on the pathology of athetosis, 150. Robin on perivascular canals, 84. Rotation, uniform, 55, 56. Rumex in catarrhal headache, ^267. Salivary centre, 40. Sanguinaria in cerebral haemorrhage, 110; in congestive headache, 241; in nervous headache, 254; in gastric and rheumatic headaches, 267. Sanderson, Dr., experiments of, 30. Schiff on vicarious action, 22; on a very acute form of intestinal inflammation, 37. Sclerosis, diffuse cerebral, 139; primary mul- tiple, 143; symptoms, 143, 144; tremor in, 144, 145; causes, 145; diagnosis, prognosis and morbid anatomy, 146; secondary mul- tiple sclerosis, 147; pathology and treat- ment, 147. Scutellaria in nervous headache, 255; in hys- terical headache, 267. Secale cor. in cerebral anaemia, 72; in coma, 289. Secondary degeneration, 46. Sensory centres, 26-28; sensory tracts, 3S. Sensory disturbances, 44. Senega in paralysis of ocular muscles, 202; in vertigo, 2S1. Sepia in cerebral haemorrhage, 110; in con- gestive headache, 242; in nervous head- ache, 255; in sympathetic headache, 267; in vertigo, 281. Serum, intracranial, 225. Sexual appetite, centre, 37, 54. Silicea in tubercular meningitis, 1S7; in chronic hydrocephalus, 224; in congestive headache, 242; in nervous headache, 255; in gastric and rheumatic headaches, 267; in vertigo, 2S1. Smell and taste, centre for, 27. Softening, cerebral, 115, IIS, 121; symptoms, 121-124; etiology, diagnosis and prognosis, 125; red, yellow and white, 122; morbid anatomy and pathology, 126; treatment, 127; general and special indications, 128. Spigelia in paralysis of ocular muscles, 202; in nervous headache, 255; in vertigo, 281. Spongia in tubercular meningitis, 1S8; in con- gestive headache, 242. Sticta in nervous headache, 256. Stillingia in catarrhal headache, 267. Stomach and oesophagus, centre for, 37, 39. Strabismus, 58, 112. Stramonium in cerebral haemorrhage, 110; in simple meningitis, 178; in paralysis of ocular muscles, 202; in congestive head- ache, 242; in nervous headache, 256; in hysterical and rheumatic headaches, 267; in vertigo, 2S1; in insomnia, 285; in coma, 2S9. Sturges, Dr., on athetosis, 150. Sulphur in cerebral anaemia, 72; in simple meningitis, 17S; in chronic hyrocephalus, 224; in congest-ive headache, 242; in nerv- ous headache, 256; in catarrhal and gas- tric headaches, 268: in vertigo, 281; in in- somnia, 2S5; in hydrocephaloid, 306. Sunstroke, 290-296; varieties, 290; syncopal, 290; asphyxial, 291; hyperpyrexia!, 291: morbid anatomy. 292; etiology, prognosis and treatment. 293; general indications, 294; special indications, 295. Syphilis, cerebral, 164-170; varieties, 164; symptoms, 165; causes, 166; diagnosis, 167; prognosis, 168; morbid anatomy and pathology, 169; treatment, 170. Syphilitic thrombi, 114, 167. T&che cerebrale, 1S4. Tactile sensibility, centre for, 27. Taste and smell, centre for, 27. Tarantula in nervous headache, 256; in ver- tigo, 281. Temperature, variations in, 43, 59; in cerebral haemorrhage. 96; in cerebral softening, 122; in tubercular meningitis, 1S1; in epi- demic meningitis, 204; in sunstroke, 291. Testes, lesions of, 51. Theridion in congestive headache, 243; in nerv- ous headache, 256. Thrombosis, cerebral, 101, 111; symptoms, 111; marantic, 112; causes, 112; diagnosis, prognosis and morbid anatomy, 113; pa- thology, 114; venous, 226. Thuja in nervous headache, 256. Tongue and jaws, centre for, 21. Tophus syphiliticum, 169. Tremor, unilateral, 51; in multiple sclerosis, 144. Trismus, 60. Trousseau on tubercular meningitis, 184, 185. Tumors, cerebral, 101, 157; tuberculous, 15S; cancerous, 15S; gliomatous, 157; symp- toms, 15S; causes and diagnosis, 160, 161, prognosis, morbid anatomy and pathology, 161; treatment, 162; general indications, 163. Tiirck on secondary contractions, 99. Upper extremity, centres for the, 21, 22. Yaso-motor disturbances, 39, 50, 60; in cere- bral anaemia, 65. 312 INDEX. Vcratrum alb. in cerebral anaemia, 72; in epi- demic meningitis, 213; in nervous head- acbe, 2o7; in vertigo, 281; in coma, 2S9; in cerebral concussion, 301; in hydro- cepbaloid, :306. Veratrum vir. in cerebral hyperemia, 90; in epidemic meningitis. 213; in congestive headache, 243; in nervous headache, 257; in insomnia, 2S5; in sunstroke, 296. Vertigo. 36, 55, .56, 269-273; etiology and pa- tbology, 271; varieties, 271; auditory, 271; ocular, 273; gastric, 27-1: nervous, 275; intracranial, 276; treatment, 276; general and special indications, 276-2S1. Vipera redi in cerebral concussion, 301. Visceral sensibilities, seat of, 2S. Vision, true centres of, 33; impairment of, 54, 56; double, 58. VircliDW on cerebral thrombosis, 113; on gli- oma, 157; on hematoma, 215. Voelkers on the corpora qnadrigemina, 33. Volition. Beat of, 29; huw differentiated, 43. Vomiting, centre for the act of, 39: cerebellar, 53, 55. Vulpian on systemic lesions, 42; cerebellar lesions, 55; on secondary contractions, 99; on progressive facial atrophy, 152. Word-deafness, 44. Zincum met. in cerebral haemorrhage, 110; in epidemic meningitis, 213; in chrooic hy- drocephalus, 224; in nervous headache, 257; in hydrocephaloid, 306. Zincum valer. in insomnia, 2S5. New Catalogue (1SS3) of the Hahnemann Publishing" House. F. E. BOERICKE'S (LATE BOERICKE & TAFEL) j^omceopattiic Publications; PHILADELPHIA. ALLEN, DR. TIMOTHY F. The Encyclopedia of Pure Materia Medica; a Record of the Positive Effects of Drugs upon the Healthy Human Organism. With contributions from Dr. Richard Hughes, of England ; Dr. C. Hering, of Philadelphia ; Dr. Carroll Dun- ham, of New York ; Dr. Adolph Lippe, of Philadelphia, and others. Ten volumes. Price bound in cloth, $60.00 ; in half morocco or sheep, $70.00 This is the most complete and extensive work on Materia Medica ever attempted in the history of medicine — a work to which the homoeopathic prac- titioner may turn with the certainty of finding the whole pathogenetic record of any remedy ever used in homceopathy, the record of which being published either in book form or in journals. " With the Volumes IX. and X. now before us — Aleex's Encyclopedia of Pure Materia Medica— is completed. It comprises all remedies proved or applied by Homoe- opaths. AVith truly wonderful diligence everything has been carefully collated from the whole medical literature that could be put under com ri Union to Homoeopathy, thus enabling anyone who wants to make a thorough study of Materia Medica. or who wants to read up a special remedy to find what he needs and where to look for it. . . . As regards printing, paper, and general get-up, the house of. Boericke & Tafel has fully upheld its old established reputation." — From the Allgemeine Homoeopathische Zeitung. ALLEN, DR. TIMOTHY F. A General Symptom Register of the Homoeopathic Materia Medica. — 1,331 pages. Large 8vo. Cloth, ... . " 812.00 Half morocco or sheep, . . . . . . . . 814.00 This valuable work was eagerly welcomed by the homoeopathic profession, and a large portion of the edition has already been disposed of. The work can be obtained through every homoeopathic pharmacy, and those desiring to secure a copy should send in their orders without delay,' as but a limited number of copies remain available. " The long hoped for ' Index ' has come, and now lies before us in all the glory of a comely volume of 1,331 pages, beautifully printed on good, clear paper, and bound in cloth. 2 F. e. boericke's "Every scientific practitioner in the world will heartily thank the indefatigable author for crowning his pharmaco-encyclopedic edifice so promptly with a workable repertorial index. The thing we are most thankful for is that the arrangement is strictly alphabetical. First, the part affected ; second, the sensation, conditioned or modified. No fads or fancies, theories or hypotheses. Of course even-body has a copy of the ' Encyclopedia,' and now everybody will get a copy of the Index. We cannot pretend to review such a work. It bears every mark of care, capability and conscientiousness, and to hunt about for specks of dirt on such a grand picture is not the kind of work for us. The only piece of advice we offer to intending purchasers is that they ask for it bound in leather, for common cloth binding, no matter how nice to the eye, soon begins to tear at the back, and becomes the source of endless annoyance. This applies, of course, to a work for frequent reference, and Allen's ' Index ' is practically a dictionary to his ' Encyclopedia,' and as such will be used many times a day." — From the Homoeopathic World. ALLEN AND NORTON. Ophthalmic Therapeutics. See Nor- ton's Ophthalmic Therapeutics. ALLEN, WILLIAM A. Repertory of the Symptoms of Inter- mittent Fever. Arranged by William A. Allex. 107 pages. 12mo. Cloth. Price, Sl.OO We give a letter of Timothy F. Allen, M.D., recommending the publication of this little work : " I have carefully examined the repertory of Dr. Wm. Allen, of Flushing, and assure you that it is exceedingly valuable. It should be printed in pocket form. I should use it constantly. Dr. Allen has a large experience in the treatment of intermittents, and his own observations are entitled to great respect." BAEHR, DR. B. The Science of Therapeutics according to the Principles of Homoeopathy. Translated and enriched with numer- ous additions from Kafka and other sources, by C. J. Hemfel, M.D. Two volumes. 1387 pages. Half morocco, .... S9.00 " The descriptions of disease — no easy thing to write — are always clear and full, some- times felicitous. The style is easy and readable, and not too prolix. Above all, the rela- tions of maladies to medicines are studied no less philosophically than experimentally, with an avoidance of abstract theorizing on one side, and of mere empiricism on the other, which is most satisfactory." — From the British Journal of Homoeopathy. BELL and LAIRD, DRS. The Homoeopathic Therapeutics of Diarrhoea, Dysentery, Cholera, Cholera Morbus, Cholera Infantum, and all other Loose Evacuations of the Bowels; by James B. Bell, M.D. Second edition. 275 pages. 12mo. Cloth, . . . $1.50 "This little book, issued in 1869, by Dr. Bell, has long been a standard work in Homoeopathic Therapeutics. We feel quite within bounds in asserting that it has been the means under our law, of saving thousands of lives. Than this no greater commendation could be penned. ... In this second edition, Dr. Bell has been assisted by Dr. Laird, of Maine ; also by Drs. Lippe, William P. Wesselhoeft and E. A. Farrington. Thirty- eight new remedies are given; the old text largely re-written; many rubrics added to the repertory; a new feature, the 'black type,' for especially characteristic symptoms, introduced. " This is a typical homoeopathic work, which no homoeopathic physician can afford to be without. The typographical setting is worthy of the book." — From the Homozopaihic Physician. EERJEAU, J. PH. The Homoeopathic Treatment of Syphilis, Gonorrhoea, Spermatorrhoea, and Urinary Diseases. Revised, with numerous additions, bv J. H. P. Frost, M.D. 256 pages. 12mo. Cloth, . . . $1.50 " This work is unmistakably the production of a practical man. It is short, pithy, and contains a vast deal of sound practical instruction. The diseases are briefly described ; the directions for treatment are succinct and summary. It is a book which might with profit he. consulted by all practitioners of homoeopathy." — North American Journal. HOMOEOPATHIC PUBLICATIONS, 6 BREYFOGLE, DR. W. L. Epitome of Homoeopathic Medi- cines. 383 pages, $1.25 We quote from the author's preface : " It has been my aim, throughout, to arrange in as concise form as possible, the leading symptoms of all well-established provings. To accomplish this, I have compared Lippe's Mat. Med. ; the Symtomen-Codex ;. Jahr's Epitome ; Bcenninghausen's Therapeutic Pocket- Book, and Hale's New Kemedies. BRIGHAM, DR. GERSHAM N. Phthisis Pulmonalis, or Tuber- cular Consumption. Pp. 224. 8vo. Cloth. Price, . . $2.00 This interesting work on a subject which has been the "Opprobrium Med- icorum" for generations past, has met with a favorable reception at the hands of the profession. It is a scholarly work and treats its subject from the stand- point of pure homoeopathy. " Just now a fresh move of interest in consumption is passing over the world, and hence we may say Dr. Brigham's monograph comes apropos; but on the other hand it comes too early, as the parasitic nature of phthisis is now the great phthisiological question which be- littles and dwarfs every other. "Our author's work must be pronounced as decidedly able, and its principal defects are those of the subject itself in its present state of development. In our opinion the whole question is still involved in too much doubt and difficulty to admit of its being handled very lucidly at present. Dr. Brigham tries very hard to clear the deck of all notions that might be in the way of handlinK the subject scientifically, but he does not quite succeed even in defining clearly one single form of phthisis. Why? because in the present state of the sub- ject it is impossible for any man to do so, and we question whether a much better book on phthisis is possible at present." — From, The Homoeopathic World, for October, 1882. BRYANT, DR. J. A Pocket Manual, or Repertory of Homoeo- pathic Medicine, Alphabetically and Nosologically arranged, which may be used as the Physicians' Vade-mecum,, the Travellers' Medical Com- panion, or the Family Physician. Containing the Principal Remedies for the most important Diseases; Symptoms, Sensations, Characteristics of Diseases, etc. ; with the principal Pathogenetic Effects of the Medicines on the most important Organs and Functions of the Body, together with Diagnosis, Explanation of Technical Terms, Directions for the Selection and Exhibition of Remedies, Rules of Diet, etc. Compiled from the best Homoeopathic authorities. Third edition. 352 pages. 18mo. Cloth, $1.50 DR. BURNETT'S ESSAYS. Ecce Medicus; Natrum Muriati- cum ; Gold; The Causes of Cataract; Curability of Cataract; Diseases of the Veins; Supersalinity of the Blood. Pp. 296. 8vo. Cloth. Price, $2.50 Dr. Burnett's essays were so favorably received in this country, that they would undoubtedly have commanded a very large sale, had they not been so high in price. As it was the six essays would have cost over five dollars, and in order to bring them within reach oi' the many we reprinted them, by special arrangement with the author, who contributed a new essay, "The Causes of Cataract," not hitherto published, and a general introduction to the volume. The book is printed in good style on heavy toned paper and well bound, and we are able to furnish it at less than half the price of the imported volumes. We feel sure that these suggestive and sprightly monographs will be highly appreciated by the profession at large. BUTLER, DR. JOHN. A Text-Book of Electro-Therapeutics and Electro-Surgery; for the Use of Students and General Practitioners. By John Butler, M.D., L.R.C.P.E., L.R.C.S.L, etc., etc. Second edition, revised and enlarged. 350 pages. 8vo. Cloth, $3.00 4 F. E. BOERTCKES "Among the many works extant on Medical Electricity, we have seen nothing that eomes so near 'filling the bill' as this. The book is sufficiently comprehensive for the stu- dent or the practitioner. The fact that it is written by an enthusiastic and very intelligent homceopathist, gives to it additional value. It places electricity on the same basis as other drugs, and points out by specific symptoms when the agent is indicated. The use of elec- tricity is therefore clearly no longer an exception to the law of similia, but acts curatively only when tised in accordance with that law. We are not left to conjecture and doubt, but can clearly see the specific indications of the agent, in the disease we have under ol tion. The author has done the profession an invaluable service in thus making plain the pathogenesis of this wonderful agent. The reader will find no difficulty in followh _ the pathology and treatment of the cases described. Electricity is not held up as the cure- all of disease, but is shown to be one of the most important and valuable of remedial agents, when used in an intelligent manner. We have seen no work which we can so heartily recommend as this." — Cincinnati Medical Advance. BUTLER, DR. JOHN. Electricity in Surgery. Pp. 111. 12mo. Cloth. Price, $1 00 Tins' interesting little volume treats on the application of Electricity to Surgery. The following are some of the subjects treated of: Enlargement of the Prostate; Stricture; Ovarian Cysts; Aneurism; Naevus; Tumors; Ulcers; Hip Disease; Sprains; Burns; Galvano-Cautery ; Hemor- rhoids; Fistulye; Prolapsus of Kectum; Hernia, etc., etc. The direc- tions given under each operation are most explicit and will be heartily welcomed by the practitioner. DUNHAM, CARROLL, A.M., M.D. Homoeopathy the Science of Therapeutics. A collection of papers elucidating and illustrating the principles of homoeopathy. 529 pages. 8vo. Cloth, . . $3.00 Half morocco, $4.00 "More than one-half of this volume is devoted to a careful analysis of various drug- provings. It teaches ns Materia Medica after a new fashion, so that a fool can understand r not only the full measure of usefulness, but also the limitations which surround the drug. . . We ought to give an illustration of his method of analysis, but space forbids. We not only urge the thoughtful and studious to obtain the book, which they will esteem as second only to the Oryanon in its philosophy and learning.'' — The American Homceopathist. DUNHAM, CARROLL, A.M., M.D. Lectures on Materia Medica. 858 pages. 8vo. Cloth, 85.00 Half morocco, 86.00 " Vol. I. is adorned with a most perfect likeness of Dr. Dunham, upon which stranger and friend will gaze with pleasure. To one skilled in the science of physiognomy there will be seen the unmistakable impress of the great soul that looked so long and stea out of its fair windows. But our readers will be chiefly concerned with the contents of these two books. They are even better than their embellishments. They are chieiiy such lectures on Materia Medica as Dr. Dunham alone knew how to write. They are preceded quite naturally by introductory lectures, which he was accustomed to deliver to his classes on general therapeutics, on rules which should guide us in studying drugs, and on the therapeutic law. At the close of Vol. II. we have several papers of great interest, but the most important fact of all is that we have over fifty of our leading remedies presented in a method which belonged peculiarly to the author, as one of the most successful teacheis our school has yet produced. . . . Blessed will be the library they adorn, and the wise man or woman into whose mind their light shall shine." — Cincinnati Medical Advance. EDMONDS on Diseases Peculiar to Infants and Children. By W. A. Edmonds, M.D., Professor of Paedology in the St. Louis Homoeo- pathic College of Physicians and Surgeons, etc., etc., etc. 1881. Pp. 300. 8vo. Cloth, $2.50 This work meets with rapid sales, and was accorded a flattering reception by the homoeopathic press. " This is a good, sound book, by an evidently competent man. The preface is as manly as it is unusual, and engages one tp go on and read the entire work.. In the chapter on the HOMOEOPATHIC PUBLICATIONS. O examination of sick children we read that 'no physician will ever have full and comfort- able success as a psedologist who has a brusque, reticent, undemonstrative manner. It is indispensable that a physician having children in charge should convince them by his manner that he likes them, and sympathizes with them in their whims, foibles and peculi- arities. Their intuitions as to whom they ought to like and ought not to like are marked and wonderfully accurate at a very tender age.' The physician who writes thus is a born paedologist, and most assuredly a very successful practitioner ''After the examination of children has been dwelt upon, our author proceeds to dis- cuss of the hygiene of children in a very able and sensible manner. He then discourses upon the various diseases of children in an easy and yet didactic manner, and any one can soon discover that he knows whereof he writes." — From the Homoeopathic World. EGGERT, DR. W. The Homoeopathic Therapeutics of Uterine and Vaginal Discharges. 543 pages. 8vo. Half morocco, $3.50 The author here brought together in an admirable and comprehensive arrangement everything published to date on the subject in the whole homoeo- pathic literature, besides embodying his own abundant personal experience. The contents, divided into eight parts, are arranged as follows : — Part I. Treats of Menstruation and Dysmenorrhea. Part II. Menorrhagia. Part III. Amenorrhea. Part IV. Abortion and Miscarriage. Part V. Metror- rhagia. Part VI. Fluor albus. Part VII. Lochia, and Part VIII. General Concomitants. No w r ork as complete as this, on the subject, was ever before attempted, and we feel assured that it will meet with great favor by the profes- sion. GUERNSEY, DR. H. N. The Application of the Principles and Practice of Homoeopathy to Obstetrics and the Disorders Pe- culiar to Women and Young Children. By Henry N. Guernsey, M.D., Professor of Obstetrics and Diseases of Women and Children in the Homoeopathic Medical College of Pennsylvania, etc., etc. With numerous Illustrations. Third edition, revised, enlarged, and greatly improved. Pp. 1004. 8vo. Half morocco, $8.00 In 1869 this sterling work was first published, and was at once adopted as a text-book at all homoeopathic colleges. In 1873 a second edition, considerably enlarged, was issued; in 1878 a third edition -was rendered necessary. The wealth of indications for the remedies used in the treatment, tersely and suc- cinctly expressed, giving the gist of the author's immense experience at the bed- side, forms a prominent and well appreciated feature of the volume. " This standard work is a credit to the author and publishers. ***** The instructions in the manual and mechanical means employed by the accoucheur are fully up to the latest reliable ideas, while the stand that is taken that all derangements incidental to gestation, parturition and post partum are not purely mechanical, but will in the majority of cases, if not all, succumb to the action of the properly selected homoeopathic remedy, shows that Prof. Guernsey has not fallen into the rut of methodical ideas and treatment. The appendix contains additional suggestions in the treatment of suspended animation of newly-born children, hysteria, ovarian tumors, sterility, etc., suggestions as to diet during sickness of any kind, etc., etc. After the index is a glossary, a useful appendix in itself. Every practitioner should have a copy of this excellent work, even if he has two or three copies of old school text-books on obstetrics and diseases of women." — From the Cincinnati Medical Advance. GUERNSEY, DR. E. Homoeopathic Domestic Practice. With full Descriptions of the Dose to each single Case. Containing also Chap- , ters on Anatomy, Physiology, Hygiene, and abridged Materia Meclica. Tenth enlarged, revised, and improved edition. Pp. 653. Half leather, $2.50 HAGEN, DR. R. A Guide to the Clinical Examination of Patients and the Diagnosis of Disease. By Richard Hagen, M.D., Privat D F. E. BOERICKE.S docent to the University of Leipzig. Translated from the second revised and enlarged edition, by G. E. Gramm, M.D. Pp. 223. 12mo. Cloth, $1.25 " This is the most perfect guide in the examination of patients that we have ever seen. The author designs it only for the use of students of medicine before attending clinics, I wt we have looked it carefully through, and do not know of 2'2o pages "of printed matter any- where of more importance to a physician in his daily bedside examinations. It is simplv invaluable." — From the St. Louis Clinical Review. HAHNEMANN, DR. S. Organon of the Art of Healing. By Sam- uel Hahnemann, M.D. Aude Sapere. Fifth American edition. Trans- lated from the fifth German edition, by C. Wesselhoeft, M.D. Pp. 244. 8vo. Cloth, §1.75 "To insure a correct rendition of the text of the author, they (the publishers) selected as his translator Dr. Conrad Wesselhoeft, of Boston, an educated physician in every respect, and from his youth up perfectly familiar with the English and German languages, than whom no better selection could" have been made." "That he has made, as he himself declares, 'an entirely new and independent translation of the whole work,' a careful com- parison of the various paragraphs, notes, etc., with those contained in previous editions, gives abundant evidence ; and while, he has, so far as possible, adhered strictly to the letter of Hahnemann's text, he has at the same time given a pleasantly flowing rendition that avoids the harshness of a strictly literal translation." — Hahnemanman Jlonthly. HAHNEMANN, DR. S. The Lesser Writings of. Collected and Translated by E. E. Dudgeon, M.D. With a Preface and Notes by E. Marcy, M.D. With a Steel Engraving of Hahnemann from the statue of Steinhauser. Pp. 784. Half morocco, .... 83.00 This valuable work contains a large number of Essays of great interest to laymen as well as medical men, upon Diet, the Prevention of Diseases, Venti- lation of Dwellings, etc. As many of these papers were written before the dis- covery of the homoeopathic theory of cure, the reader will be enabled to peruse in this volume the ideas of a gigantic intellect when directed to subjects of gen- eral and practical interest. HALE, DR. E. M. Lectures on Diseases of the Heart. In three parts. Part. I. Functional Disorders of the Heart. Part II. Inflamma- tory Affections of the Heart. Part III. Organic Diseases of the Heart. Second enlarged edition. Pp. 248. Cloth, .... 81.75 " After giving a thorough overhauling to the lectures of Dr. Hale, •with the full inten- tion of a close criticism, I acknowledge myself conquered. True there are text books on the same subject of thrice the number of pages— more voluminous, but not so concise; and in this very conciseness lies the merit of the work. Students will find there everything they need at the bedside of their patients. It fills just a want long felt by the profession, and we can only congratulate Dr. Hale to have found in Messrs. Boericke & Tafel, pub- lishers who have done their work equally well." — Xorth American Journal of Homoeopathy. HALE, DR. E. M. Materia Medica and Special Therapeutics of the New Remedies. By Edwix M. Hale, M.D., Professor of Materia Medica and Therapeutics of the New Remedies in Hahnemann Medical College, Chicago, etc., etc. Fifth edition, revised and enlarged. In two volumes — Vol. I. Special Svmptomatologv. With new Botanical and Pharmacological Notes. Pp. 770. 1882. " Cloth, . . . So.00 Half morocco, $6.00 " Dr Hale's work on New Remedies, is one both well known and much appreciated on this side of the Atlantic. For many medicines of considerable value we are indebted to his researches. In the present edition, the symptoms produced by the drug investigated, and those which they have been observed to cure, are separated from the clinical observa- tions, by which the former have been confirmed. That this volume contains a very large HOMOEOPATHIC PUBLICATIONS. 7 amount of invaluable information is incontestable, and that every effort has been made to secure both fulness of detail and accuracy of statement, is apparent throughout. For these reasons we can confidently commend Dr. Hale's fourth edition of his well known work on the New Remedies to our homoeopathic colleagues." — From the Monthly Homoeopathic Review. HALE, DR. E. M. Materia Medica and Special Therapeutics of the New Remedies. By Edwin M. Hale, M.D. Late Proiessor of • Materia Medica and Therapeutics of the New Eemedies in Hahnemann Medical College, Chicago ; Professor of Materia Medica in the Chicago Homoeopathic College, etc. Fifth edition, revised and enlarged ^thirty- seven new remedies), in two volumes. Vol. II. Special Therapeutics. With illustrative cases. Pp. 901. 8vo. Cloth, . . . $5.00 Half morocco, $6.00 " Hale's New Remedies is one of the few works which every physician, no matter how poor he may be, ought to own. Many other books are very nice to have, and xery desir- able, but this is indispensable. This volume before us is an elegant specimen of the printers' and binders' art, and equally enjoyable Avhen we consider its contents, which are not only thoroughly scientific, but also as interesting as a novel. Thirty-seven new drugs are added in this edition, besides numerous additions to the effects of drugs, previously dis- cussed. * * * * * We must say and reiterate if necessary, that Dr. Hale has hit the nail on the head in his plan for presenting the new remedies. It does well enough to tabu- late and catalogue,- for reference in looking up cases, barren lists of symptoms, but for real enjoyable study, for the means of clinching our information and making it stand by us, give us volumes planned and executed like that now under consideration." — From the New Eng- land Medical Gazette. HALE, DR. E. M. Medical and Surgical Treatment of the Dis- eases of Women, especially those causing Sterility. Second edition. Pp. 378. 8vo. Cloth, $2.50 " This work is the outcome of a quarter of a century of practical gynaecological experi- ence, and on every page we are struck with its realness. It is one of those books that will be kept on a low shelf in the libraries of its possessors, so that it may be found readily at hand in case of need. It is a work that soon will be well-thumbed by the busy practitioner who owns it, because in many a difficult obstetric case he will pace his study, tug at the favorite button a little nervously, and suddenly pause and exclaim, 'Let us see what Hale says about it ! ' and in seeing what Hale does say about it he will feel strengthened and com- forted, as one does after a consultation with a hi'ilfreicher colleague in a difficult or dangerous case, in which the enormous responsibility had threatened to crush one. " In many obstinate uterine cases we shall reach this book down to read again and again what this clinical genius has to say on the subject. We have never seen Professor Hale in the flesh, but we have had scores of consultations with him in the pages of his New Remedies, and he has thus feelessly helped us cure many an obstinate case of disease. " When we get a good book we mentally shake hands with the author, and think grate- fully of him for giving us of his great riches. This is a good book, and thus we act and feel towards its gifted author, Professor Hale.' — From the Homoeopathic World, London. HART, DR. C. P. Diseases of the Nervous System. Being a Treatise on Spasmodic, Paralytic, Neuralgic and Mental Affections. For the use of Students and Practitioners of Medicine. By Chas. Porter Hart, M.D., Honorary Member of the College of Physicians and Sur- geons of Michigan, etc., etc., etc. Pp. 409. 8vo. Cloth, . • $3.00 "This work supplies a need keenly felt in our school — a work which will be useful alike to the general practitioner and specialist ; containing, as it does, not only a condensed compilation of the views of the best authorities on the subject treated, but also the authors own clinical experience ; to which is appended the appropriate homoeopathic treatment of each disease. It is written in an easy, flowing style, at the same time there is no waste of words. * * * * * We consider the work a highly valuable one, bearing the evidence of hard work, considerable research and experience," — Medico-Chirurgical Quarterly. " We feel proud that in Hart's ' Diseases of the Nervous System ' we have a work up 8 f. e. boericke's to date, a work which we need not feel ashamed to put in the hands of the neurologist or alienist for critical examination, a work lor which we predict a rapid sale." — North Ameri- can Journal of Homoeopauty. HELMUTH, DR. W. T. A System of Surgery. Illustrated with 5(58 Engravings on Wood. By Wm. Tod Helmutii, M.D. Third edition. Pp. 1000. Sheep, S8.50 This standard work, for many years used as a text-b >ok in all homoeopathic colleges, still maintain^ i.;s rank as the best work ever brought out by our school on the subject. Ever since it was issued the necessity, for the student or prac- titioner, to invest in allopathic works on the subject ceased to exist. It is up to date, and abounds in valuable hints, for it gives the results of the author's ripe and extensive experience with homoeopathic medication in connection with sur- gical operations. I ace of diction our author has never been approached. . . . . " We have in this work a condensed compendium of almost all that is known in practical surgery, written in a terse, forcible, though pleasing style, the author evidently ha .are gift of saying a great deal in a few words, and of, saying these few words in a graceful, easy manner. Almost every subject is illustrated wit'. m the doctor'* own practice; nor has he neglected to put be I advantage of homoe- opathic treatment in surgical diseases. The Avork is in every respect up to the require- ments of the times " Taken altogether. do book in our literature that we are more proud of. •' One word of commendation to the publisher- is nat irally drawn from us as we com- pare this handsome, clearly-printed, neatly-bound volume with the last edition. The dif- ference is so palpable that there is no necessity of making further comparisons." — Horaceo- pathic Times. HELMUTH, DR. W. T. Supra-Pubic Lithotomy. The High Operation for Stone — ■ Epicystotoruy — Hypogastric Lithotomy — "The High Apparatus." By Wm. Tod Helmuth, M.D., Professor of Surgery in the X. Y. Horn. Med. College ; Surgeon to the Hahnemann Hospital and to Wards Island Homoeopathic Hospital, X. Y. 98 quarto pp. 8 lithographic plates. Cloth. Price, 84.00 A superb quarto edition, with lithographic plates, printed in five colors, and illustrated by charts and numerous wood-cuts. HEINIGKE, DR. CARL. Pathogenetic Outlines of Homoeo- pathic Drugs. By Dr. CAel Heixigke, of Leipzig. Translated from the German by Emll Tietze, M.D., of Philadelphia. Pp. 576. 8vo. Cloth, 83.50 ' : The reader of this work will gain more practical knowledge of a given drug from its pages in the same space of time than from any other book on the same subject. •• The publishers' part of the work has been executed with the usual elegance, neatness and durability which L-haracvcrizes all their publications which we have seen. "To the English reading portion of our colleagues, this book will be a boon to be appreciated, in proportion that it is consulted, and will save thsm many weary researches when in doubt of the true homoeopathic remedy.'" — American Homoeopath. HEMPEL, DR. C. J., and DR. J. BEAKLEY. Homoeopathic Theory and Practice. With the Horace roathic Treatment of Surgical Diseases. Designed for Students and Practitioners of Medicine, and as a Guide for an intelligent public generally. Fourth edition. Pp. 1100. S3.00 HERING, DR. CONSTANTINE. Condensed Materia Medica. Second edition, more Condensed, Revised, Enlarged and Improved. 806 pages, large 8vo. Half morocco, ...... $7.00 This, the most complete work issued from the pen of the late illustrious author, has a very large sale, having been adopted from its first appearance as Text-book in all Homoeopathic Colleges in the United States. HOMOEOPATHIC PUBLICATIONS. \) "This work, the author tells us, is made up from the manuscript prepared 'for the ' Guiding Symptoms/ and is intended to give the student an idea of the main leatures of each drug in as narrow a compass as possible. It is, in fact, the ' Guiding Symptoms' boiled down. It has therefore a value of its own in enabling the student or practitioner to see quickly the chief symptoms of each medicine. Its name indicates its nature exactly, the condensation being more valuable from the hands of Dr. Hering than it might be from others of smaller experience. To those who wish to have such an aid to the Materia Medica beside them, we can recommend it.'' — Monthly Homoeopathic Meview for September, 1880. " The favor with which this work has been received, and the rapidity with which it has been adopted as a text-book in all the homoeopathic medical colleges, attests most fully its value. Embracing the rich experience and the extensive learning of the author, its author- ity is unquestioned. The relationship of the drugs is peculiarly valuable, and can be found • nowhere else outside of Bcenninghausen. The schema is accordino- to Hahnemann, simi- larity in symptoms being clearly indicated. Hering's Materia Medica has now become the leading work of its kind in our school. Its broad pages lie invitingly before you. You read over the symptomatology of each drug with the consciousness that each and every line has been well considered before incorporation, and that it is a storehouse of wealth from which every worker can draw his supplies. The appearance of the work reflects credit upon the publishers, who have already gained their reputation as book publishers of the first rank." — Homoeopathic News. HERING, DR. CONSTANTINE. Domestic Physician. Seventh American Edition. 464 Pp. . . . . . . 82. 50 The present editor, Claude E. Norton, M.D., a former assistant of Dr. Hering, undertook, at his desire, the task of superintending the publication of the work. Some additions to the text have been made, a few remedies intro- duced, and, at times, slight alterations in the arrangement effected, but the well- known views of the author have been respected in whatever has been done ; but for unavoidable reasons, the issue of the present edition has been delayed until this time. HOMCEOPATHIC POULTRY PHYSICIAN (Poultry Veteri- narian) ; or, Plain Directions for the Homoeopathic Treatment of the most Common Ailments of Fowls, Ducks, Geese, Turkeys, and Pigeons, based on the author's large experience, and compiled from the most reliable sources, by Dr. Fr. Schroter. Translated from the German. 84 pages. 12mo. Cloth, S0.50 We imported hundreds of copies of this work in the original German for our customers, and as it gave good satisfaction, we thought it advisable to give it an English dress, so as to make it available to the public generally. The little work sells very fast, and our readers will doubtless often have an oppor- tunity to draw thf attention of their patrons to it. HOMCEOPATHIC COOKERY. Second edition. With additions by a Lady of an American Homoeopathic Physician. Designed chiefly for the Use of such Persons as are under Homoeopathic Treatment. 176 pages. §0.50 HULL'S JAHR. A New Manual of Homoeopathic Practice. Edited, with Annotations and Additions, by F. G. Snellixg, M.D. Sixth American edition. With an Appendix of the New Eemedies, by C. J. Heupel, M.D. 2 vols. 2076 pages, 89.00 This iirst volume, containing the symptomatology, gives the complete pathogenesis of two hundred and eighty-seven remedies, besides a large number of new remedies added by Dr. Hempel, in the appendix. The second volume contains an admirably arranged Repertory. Each chapter is accompanied by copious clinical remarks and the concomitant symptoms of the chief remedies for the malady treated of, thus imparting a mass of information, rendering the work indispensable to every student and practitioner of medicine. 10 F. E. BOERICKK'.S JAHR/DR. G. H. G. Therapeutic Guide; the most Important results of more than Forty Years Practice. With Personal Observations regard- ing the truly reliable and practically verified Curative Indications in actual cases of disease. Translated, with Notes and New Kemedics, by C. J. Hempel, M.D. 546 pages, $3.00 "With this characteristically long title, the veteran and indefatigable Jahr gives us another volume of homoeopathies. Besides the explanation of its purport contained in the title itself, the author's preface still further sets lorth its distinctive aim. It is intended, he says, as a 'guide to beginners, where I only indicate the most important and decisive points for the selection of a remedy, and where 1 do not oner anything but what my own indi- vidual experience, during a practice of forty years, has enabled me to verily as absolutely decisive in choosing the proper remedy.' The reader will easily comprehend that, in carry- ing out this plan, I had rigidly to exclude all cases concerning which I had no experience of my own to offer We are bound to say that the book itself is agreeable, chatty, and full of practical observation. It may be read straight through with interest, and referred to in the treatment of particular cases with advantage." — British Journal oj Homoe- opathy. JAHR. DR. G. H. G. The Homoeopathic Treatment of Diseases of Females and Infants at the Breast. Translated from the French by C. J. Hempel, M.D. 422 pages. Half leather, . . . 82.00 This work deserves the most careful attention on the part of homoeopathic practitioners. The diseases to which the female organism is subject are de- scribed, with the most minute correctness, and the treatment is likewise indicated with a care that would seem to defy criticism. Ko one can fail to study this work but with profit and pleasure. JONES, DR. SAMUEL A. The Grounds of a Homoeopaths Faith. Three Lectures, delivered at the request of Matriculates of the Department of Medicine and Surgery (Old School) of the University of Michigan. By Samuel A. Jones, M.D., Professor of Materia Medica, Therapeutics, and Experimental Pathogenesy in the Homoeopathic Medical College of the University of Michigan, etc., etc. 92 Pages. 12mo. Cloth (per dozen, $3), . . . ' ■ 80.30 The first Lecture is on The Law oj Similars; its Claim to be a Science in that it Enables Perversion. The second Lecture, The Single Remedy a Necessity of Science. The third Lecture, The Minimum Dose an Inevitable Sequence. A fourth Lecture, on The Dynamization Theory, was to have finished the course, but was prevented by the approach of final examinations, the prepara- tion for which left no time for hearing evening lectures. The Lectures are issued in a convenient size for the coat-pocket ; and as an earnest testimony to the truth, we believe they will find their way into many a homoeopathic house- hold. JOHNSON, DR. I. D. Therapeutic Key; or Practical Guide for the Homoeopathic Treatment of Acute Diseases. Tenth edition. 347 pages. Bound in linen, . $1.75 Bound in flexible leather cover, 2.25 The same including twelve insets properly lined and headed for daily visits, $3.25, or the insets separately at $1 per set of twelve. Each inset will be found sufficient for a month's visits in ordinary practice and well supplies the usual visiting list, and this without a perceptible increase in bulk. This has been one of the best selling works on our shelves ; more copies being in circulation of this than of any two other professional works put to- gether. It is safe to say that there are but few homoeopathic practitioners in this country but have one or more copies of this little remembrancer in their possession. HOMOEOPATHIC PUBLICATIONS. 11 " This is a wonderful little book, that seems to contain nearly everything pertaining to the practice of physic, and all neatly epitomized, so that the book may be carried very com- fortably in the pocket, to serve as a source for a refresher in a case of need. " It is a marvel to us how the author has contrived to put into 347 pages such a vast amount of information, and all of the very kind that is needed. No wonder it is in its tenth edition. "Bight in the middle of the book, under P, we find a most useful little chapter, or article, on ' Poisonings/ telling the reader what to do in such cases. — Homoeopathic World, London. JOHNSON, DR. I. D. A Guide to Homoeopathic Practice. De- signed for the Use of Families and Private Individuals. 494 pages. Cloth, $2.00 This is the latest work on Domestic Practice issued, and the well and favor- ably known author has surpassed himself. In this book fifty-six remedies are introduced for internal application, and four for external use. The work con- sists of two parts. Part I is subdivided into seventeen chapters, each being devoted to a special part of the body, or to a peculiar class of disease. Part II contains a short and concise Materia Medica. The whole is carefully written with a view of avoiding technical terms as much as possible, thus insuring its comprehension by any person of ordinary intelligence. " Family Guides are often of great service, not only in enabling individuals to relieve the trifling maladies of such frequent occurrence in every family, but in the graver forms of disease, by prompt action to prepare the way for the riper intelligence of the physician. " The work under notice seems to have been carefully prepared by an intelligent physi- cian, and is one of the handsomest specimens of book-making we have seen from the house of Boericke & Tafel, its publishers." — Homoeopathic Times. LAURIE and McCLATCHEY. The Homoeopathic Domestic Medicine . By Joseph Laurie, M.D., Ninth American, from the Twenty- first English edition. Edited and revised, with numerous and important additions, and the introduction of the new remedies. By P. J. Mc- Clatchey, M.D. 1044 pages. 8vo. Half morocco, . ' . $5.00 " We do not hesitate to endorse the claims made by the publishers, that this is the most complete, clear, and comprehensive treatise on the domestic homoeopathic treatment of dis- ease extant. This handsome volume of nearly eleven hundred pages is divided into six parts. Part I is introductory, and is almost faultless. It gives the most complete and exact directions for the maintenance of health, and of the method of investigating the con- dition of the sick, and of discriminating between different diseases. It is written in the most lucid style, and is above all things wonderfully free from technicalities. Part II. treats of symptoms, character, distinctions, and treatment of general diseases, together with a chapter on casualties. Part III. takes up diseases peculiar to women. Part IV. is devoted to the disorders of infancy and childhood. Part V. gives the characteristic symptoms of the medicines referred to in the body of the work, while part VI. introduces the reper- tory." — Hahnemannian Monthly. " Of the usefulness of this work in cases where no educated homoeopathic physician is within reach, there can be no question. There is no doubt that domestic homoeopathy has done much to make the science known ; it has also saved lives in emergencies. The prac- tice has never been so well presented to the public as in this excellent volume." — New. Eng. Med. Gazdte. LILIENTHAL, DR. S. Homoeopathic Therapeutics. By S. Lilienthal, M.D., Editor of North American Journal of Homoeopathy, Professor of Clinical Medicine and Psychology in the New York Homoe- opathic Medical College, and Professor of Theory and Practice in the New York College Hospital for Women, Etc. Second edition. «835 pages. 8vo. Cloth, $5.00 Half morocco, 6.00 " Certainly no one in our ranks is so well qualified for this work as he who has done it, and in considering the work done, we must have a true conception of the proper sphere 12 F. e. boericke's of such a work. For the fresh graduate, tills hook Avill he invaluable, and to all such we unhesitatingly and very earnestly commendit. To the older one, who says he has no use for this book, we have nothing to say. He is a good one to avoid when well, and to dread when ill. We also hope that he is severely an unicum." — Prof. Samuel A. Jones in American Observer. " .... It is an extraordinary useful book, and those who add it to their library will never feel regret, for we are not saying too much in pronouncing it the best work on therapeutics in homoeopathic (or any other) literature. With this under one elbow, and Ilering's or Allen's Materia Medica under the other, the careful homoeopathic practitioner can refute Niemayer's too confident assertion, 'I declare it idle to hope for a time when a medical prescription should he the simple resultant of known quantities.' Doctor, by all means buy Lilienthal's Homoeopathic Therapeutics, It contains a mine of wealth." — Prof. Chas. Gaichel in Ibid." LUTZE, DR. A. Manual of Homoeopathic Theory and Practice. Designed for the use of Physicians and Families. Translated from the German, with additions by C. J. Hempel, M.D. From the six- tieth thousand of the German edition. 750 pp. 8vo. Half leather, $2.50 MALAN, H. Family Guide to the Administration of Homoeo- pathic Remedies. 112 pages. 32mo. Cloth, . . . $0.30 MANUAL OF HOMCEOPATHIC VETERfNARY PRACTICE. Designed for all kinds of Domestic Animals and Fowls, prescribing their proper treatment when injured or diseased, and their particular care and general management in health. Second and enlarged edition. 68± pages. 8vo. Half morocco, 85.00 " In order to rightly estimate the value and comprehensiveness of this great work, the reader should compare it, as we have done, with the best of those already before the public. In size, fulness, and practical value it is head and shoulders above the very hest of them, while in many most important disorders it is far superior to them altogether, containing, as it does, recent forms of disease of which they make no mention." — Hahnemannian Monthly. MARSDEN, DR. J. H. Handbook of Practical Midwifery, with full Instructions for the Homceopathic Treatment of the Dis- eases of Pregnancy, and the Accidents and Diseases incident to Labor and the Puerperal State. J. H. Marsden, A.M., M.D., 315 pages. Cloth, $2.25 " It is seldom we have perused a text-hook with such entire satisfaction as this. The author has certainly succeeded in his design of furnishing the student and young prac- titioner, within as narrow limits as possible, all necessary instruction in practical midwifery. The work shows on every page extended research and thorough practical knowledge. The style is clear, the array of facts unique, and the deductions judicious and practical. We are particularly pleased with his discussion of the management of labor, and the management of moiher and child immediately after the birth, hut much is left open to the common sense and practical judgment of the attendant in peculiar and individual cases." — Homoeo- pathic Times. MORGAN, DR. W. The Text-book for Domestic Practice; being plain and concise directions for the Administration of Homoeopathic Medi- cines in Simple Ailments. 191 pages. 32mo. Cloth, . . SO. 50 This is a concise and short treatise on the most common ailments, printed in convenient size for the pocket; a veritable traveler's companion. NORTON, DR. GEO. S. Ophthalmic Therapeutics. By Geo. S. Norton, M.D., Professor of Ophthalmology in the College of the New York Ophthalmic Hospital, Senior Surgeon to the New York Ophthalmic Hospital, etc. With an introduction by Prof. T. F. Allen, M.D. Sec- ond edition. Re-written and revised, with copious additions. Pp. 342. 8vo. Cloth, . $2.50 HOMOEOPATHIC PUBLICATIONS . 13 The second edition of Allen & Norton's Ophthalmic Therapeutics has now been issued from the press. It has been re-written, revised and considerably en- larged by Professor Norton, and will, without doubt, be as favorably received as the first edition — out of print since several years. This work embodies the clinical experiences garnered at the N. Y. Ophthalmic Hospital, than which a better appointed and more carefully conducted establishment does not exist in this country. Diseases of the eye are steadily on the increase, and no physician can afford to do without the practical experience as laid down in the sterling work under notice. RAUE, DR. C. G. Special Pathology and Diagnosis, with Thera- peutic Hints. Second edition, re-written and enlarged. Pp. 1,072. Large 8vo. Half morocco or sheep, $7.00 Tiiis second edition is brought down to date, and, rendered in Dr. Pane's own pregnant, terse style. These thousand pages will be found to be encyclopedic as to the comprehensiveness, and epitomatic as. to the condensed form of the in- formation imparted. " . . . . The first edition has 644 pages ; this new has 1,072, and if Raue has added 428 pages it was because tour hundred and twenty-eight pages of something solid had to find a place in this universe The present fdition is written up to date, tersely it is true, but so far as I have read, in consonance with the latest teachings i envy the practitioner who can read this second edition without learning something ; and I would say to the young graduate, in an expressive AVestern phrase, ' Tie to it.' It has become a platitude to compliment publishers, but, really, Boericke & Taiel, and the Globe Printing House, may well be proud of this book." — S. A. Jones in American Observer. REIL, DR. A. ACONITE, Monograph on, its Therapeutic and Physiological Effects, together with its Uses and Accurate Statements, derived from the various Sources of Medical Lit- erature. By A. Reil, M.D. Translated from the German by H. B. Millard, M.D. Prize essay. 168 pages, $0.60 " This Monograph, probably the best which has ever been published upon the subject, has been translated and given to the public in English, by Dr. Millard, of New York. Apart from the intrinsic value of the work, which is well known to all medical German scholars, the translation of it has been completed in the most thorough and painstaking- way; and all the Latin and Greek quotations have been carefully rendered into English. The book itself is a work of great merit, thoroughly exhausting the whole range of the subject. To obtain a thorough view of the spirit of the action of the drug, we can recom- mend no better work." — North American Journal. RUSH, DR. JOHN. Veterinary Surgeon. The Hand-book to Veteri- nary Homoeopathy; or, the Homoeopathic Treatment of Horses, Cattle, Sheep, Dogs and Swine. From the London edition. With numerous ad- ditions from the Seventh German edition of Dr. F. E. Gunther's "Homoeo- pathic Veterinary." Translated by J. F. Sheek, M.D. 150 pages. 18mo. Cloth, " . $0.50 SCHAEFER, J. C. New Manual of Homoeopathic Veterinary Medicine. An easy and comprehensive arrangement of Diseases, adapted to the use of every owner of Domestic Animals, and especially designed for the farmer living out of the reach of medical advice, and showing him the way of treating his sick Horses, Cattle, Sheep, Swine and Dogs, in the most simple, expeditious, safe and cheap manner. Translated from the German, with numerous additions from other veterinary manuals, by C. J. Hempel, M.D. 321 pages. 8vo. Cloth, .... $2.00 SHARP'S TRACTS ON HOMCEOPATHY, each, . . 5 Per hundred, $3.00 14 F. e. boericke's No. 1. What is Homoeopathy ? No. 7. The Principles of Homoeopathy. No. 2. The Defence of Homce No. 3. The Truth of No. 4. The Small Doses of No. 5. The Difficulties of No. 6. Advantages of opathy. No. 8. Controversy on No. 9. Remedies of No. 10. Provings of No. 11. Single Medicines of No. 12. Common sense of SHARP'S TRACTS, complete set of 12 numbers, .... $0.50 Bound, $0.75 SMALL, DR. A. E. Manual of Homoeopathic Practice, for the use of Families and Private Individuals. Fifteenth enlarged edition. 831 8vo. Half leather, . $2.50 Manual of Homoeopathic Practice. Translated into German by C. J. Hempel, M.D. Eleventh edition.. 643 pages. 8vo. Cloth, $2.50 STAPF, DR. E. Additions to the Materia Medica Pura. Trans- lated by C. J. Hempel, M.D. 292 pages. 8vo. Cloth, . $1.50 This work is an appendix to Hahnemann's Materia Medica Pura. Every remedy is accompanied with <*xtensive and most interesting clinical remarks, arid a variety of cases illustrative of its therapeutical uses. TESSIER, DR. J. P. Clinical Remarks concerning the Homoeo- pathic Treatment of Pneumonia, preceded by a Retrospective View of the Allopathic Materia Medica, and an Explanation of the Homoeo- pathic Law of Cure. Translated by C. J. Hempel, M.D. 131 pages. 8vo. Cloth, .... . . .... ... $0.75 TESTE. A Homoeopathic Treatise on the Diseases of Children. By Alph. Teste, M.D. Translated from the French by Emma H. Cote. Fourth edition. 345 pages. 12mo. Cloth, . . . . $1.50 This sterling work is by no means a new applicant for the favorable con- sideration of the profession, but is known to the older physicians since many years, and would be as well known to the younger had it not been out of print for nearly eight years. However, as orders for the work were persistently re- ceived from all quarters, we concluded to resurrect the book as it were, and purchasing the plates from the quondam publishers, we re-issued it in a much improved form, i. e., well printed on excellent paper. Dr. Teste's work is unique, in that in most cases it recommends for certain affections remedies that are not usually thought of in connection therewith; but, embodying the results of an immense practical experience, they rarely fail to accomplish the de- sired end. VERDI, DR. T. S. Maternity, a Popular Treatise for Young Wives and Mothers. By Tullio Suzzara Verdi, A.M., M.D., of Washington, D.C. 450 pages. 12mo. Cloth, . . . $2.00 " No one needs instruction more than a young mother, and the directions given by Dr. Verdi in this work are such as I should take great pleasure in recommending to all the young mothers, and some of the old ones, in the range of my practice." — George E. Ship- man, M.D., Chicago, III. "Dr. Verdi's book is replete with useful suggestions for wives and mothers, and his medical instructions for home use accord with the maxims of my best experience in prac- tice." — John F. Gray, M.D., New York City. — — Mothers and Daughters : Practical Studies for the Conservation of the Health of Girls. By Tullio Suzzara Verdi, A.M , M.D. 287 pages. 12mo. Cloth, ........ $1.50 HOMOEOPATHIC PUBLICATIONS. 15 "The people, and especially the women, need enlightening on many points connected with their physical life, and the time is fast approaching when it will no longer be thought singular or 'Yankeeish' that a woman should Le instructed in regard to her sexuality, its organs and their functions Dr. Verdi is doing a good work in writing such books, and we trust he will continue in the course he has adopted of educating the mother an 1 daughters. The book is handsomely presented. It is printed in good type on fine paper, and is neatly and substantially bound." — Hahnemannian Monthly. VON TAGEN. Biliary Calculi, Perineorrhaphy, Hospital Gan- grene, and its Kindred Diseases. 154 pages. 8vo. Cloth, $1.25 " Von Tagen was an industrious worker, a close observer, an able writer. The essays before us bear the marks of this. They are written in an easy, flowing, graceful style, and are full of valuable suggestions. While the essay on perineorrhaphy is mainly of interest to the surgeon, the other essays concern the general practitioner. They are exhaustive and abound in good things. The author is especially emphatic in recommending the use of bromine in the treatment of hospital gangrene, and furnishes striking clinical evidence in support of his recommendation. " The book forms a neat volume of 150 pages, and is well worthy of careful study." — Medical Counselor. WILLIAMSON, DR. W. Diseases of Females and Children, and their Homoeopathic Treatment. Third enlarged edition. 256 pages, . . . . . SJ.00 This work contains a short treatise on the homoeopathic treatment of the diseases of females and children, the conduct to be observed during pregnancy, labor and confinement, and directions for the management of new-born infants. WILSON, DR. T. P. Special Indications for Twenty-five Reme- dies in Intermittent Fever. By T.' P. Wilson, M.D., Professor of Theory and Practice, Ophthalmic and Aural Surgerv, University of Michi- gan. 1880. 53 pages. 18mo. Cloth, . ; . . . $0.40 ' This little work gives the characteristic Indications in Intermittent Fever of twenty-live of the mostly used remedies. It is printed on heavy writing paper, and plenty of space is given to make additions. The name of the drug is printed on the back of the page containing the symptoms, in order that the student may the better exercise his memory. WINSLOW, DR. W. H. The Human Ear and Its Diseases. A Practical Treatise upon the Examination, Recognition and Treatment of Affections of the Ear and Associate Parts, Prepared for the Instruction of Students and the Guidance of Physicians. By W. H. Wixslow, M.D., Ph.D., Oculist and Aurist to the Pittsburg Homoeopathic Hospital, etc., etc., with one hundred and thirty-eight illustrations. Pp. 526. 8vo. Cloth. Price, . $4.50 "It would ill-become a non-specialist to pass judgment upon the intrinsic merits of Dr. Winslow's book, but even a general reader of medicine can see in it an author who has a firm grasp and an intelligent apprehension of his subject. There is about it an air of self- reliant confidence, which, when not offensive, can come only from a consciousness of know- ing the matter in hand, and we have never read a medical work which would more quickly lead us to give its author our confidence in his ministrations. This is always the conse- quence of honest and earnest and inclusive scholarship, and this author is entitled to his meed." — Dr. S. A. Jones in American Observer. WORCESTER, DR. S. Repertory to the Modalities. In their Re- lations to Temperature, Air, Water, Winds, Weather and Sea- sons. Based mainly upon Hering's Condensed Materia Medica, with ad- ditions from Allen, Lippe and Hale. Compiled and arranged by Samuel Worcester, M.D., Salem, Mass., Lecturer on Insanity and its Jurispru- 16 F. e. boericke's dence at Boston University School of Medicine, etc., etc. 1880. 160 pages. 12mo. Cloth, $1.25 "This Repertory to the Modalities is indeed a most useful undertaking, and will, without question.be a material aid to rapid and sound prescribing where there are prominent modal- ities. The first chapter treats of the sun and its effects, both beneficial and hurtful, and we see at a glance that strontium carb., anacardium, conium mac, and kali bich. are likely to be useful to patients who like basking in the sun. No doubt many of these modalities are more or less fanciful; still a great many of them are real and of vast clinical range. '"The book is nicely printed en good paper, and strongly bound. It contains IbO pages. We predict that it will meet with a steady, long-continued sale, and in the course of time be found on the tables of most of those careful and conscientious prescribes who admit the philosophical value of (for instance) lunar aggravations, effects of thunder-storms, etc. And who, being without the priggishness of mere brute science, does not ?" — Homoeopathic World. WORCESTER, DR. S. Insanity and Its Treatment. Lectures on the Treatment of Insanity and Kindred Nervous Diseases. By Samuel Worcester, M.D., Salem, Mass. Lecturer on Insanity, Nervous Dis- eases and Dermatologv, at Boston University School of Medicine, etc., etc. 262 pages, $3.50 Dr. Worcester was for a number of years assistant physician of the Butler Hospital for the Insane, at Providence, R. L, and was appointed shortly after as Lecturer on Insanity and Nervous Diseases to the Boston University School of Medicine. The work, comprising nearly five hundred pages, will be wel- comed by every homoeopathic practitioner, for every physician is called upon sooner or later to undertake the treatment of cases of insanity among his pat- ron's families, inasmuch as very many are loth to deliver any afflicted member to a public institution without having first exhausted all means within their power to effect a cure, and the family physician naturally is the first to be put in charge of the case. It is, therefore, of paramount importance that every homoeopathic practitioner's library should contain such an indispensable work. "The basis of Dr. Worcester's work was a course of lectures delivered before the senior students of the Boston University School of Medicine. As now presented with some alter- ations and additions, it makes a very excellent text-book for students and practitioners. Dr. Worcester has drawn very largely upon standard authorities and his own experience, which has not been small. In the direction of homoeopathic treatment, he has received valuable assistance from Drs. Talcott and Butler, of the New York State Asylum. It is not, nor does it pretend to be, an exhaustive work; but as a well-digested summary of our present knowledge of insanity, we feel sure that it will give satisfaction. We cordially recommend it." — New England Medical Gazette. [mm?' m n ROB II