ere .- -.. 1 1 ijj :, :; A: V ;:; ;:,,;.: 1 g ; iKI ":v % I -" "-'. 1 PK - ; : .- ' NEBVOUS DISEASES: THEIR DESCRIPTION AND TREATMENT. BY ALLAN McLANE HAMILTON, M.D., FELLOW OF THE NEW YORK ACADEMY OF MEDICINE ; ONE OF THE ATTENDING PHYSICIANS AT THE EPILEPTIC AND PARALYTIC HOSPITAL, BLACKWELL'S ISLAND, NEW YORK CITY J AND A T THE OUT-PATIENT DEPARTMENT OF THE NEW YORK HOSPITAL ; MEMBER OF THE AMERICAN NEUROLOGICAL ASSOCIATION, ETC. ETC. ETC. WITH FIFTY-THREE ILLUSTRATIONS. PHILADELPHIA: HENEY O. LEA. 1878. W L ( 00 \\ 2 i 1 ^ Entered according to Act of Congress, in the year 1878, HENRY C. LEA, in the Office of the Librarian of Congress. All rights reserved. PHILADELPHIA : COLLIX8, PRINTER, 700 Jayne Street. FORDYCE BARKER, M.D., JOHN T. METCALFE, M.D CONTENTS. ix CHAPTER XIII. CEREBRO-SPINAL DISEASES. PAGE Cerebro- Spinal Meningitis Cerebro- Spinal Sclerosis Alcoholism Acute Chronic Hydrophobia Hysteria Hystero- Epilepsy Catalepsy 343-3 9 CHAPTER XIV. CEREBRO-SPINAL DISEASES (CONCLUDED). Chorea Paralysis Agitans Exophthalmic Goitre . 393-412 CHAPTER XV. DISEASES OF THE PERIPHERAL NERVES. Neuralgia, facial, cervico-occipital, cervico-brachial, intercostal, or pleuro- dynia Sciatic Crural, visceral, ovarian, urethral, renal, etc. . 419-443 CHAPTER XVI. DISEASES OF THE PERIPHERAL NERVES (CONTINUED). Neuritis Anaesthesia Tumors of Nerves ..... 444452 CHAPTER XVII. DISEASES OF THE PERIPHERAL NERVES (CONTINUED). LOCAL PARALYSIS Facial paralysis Traumatic paralysis Diphtheritic paralysis ........... 453-469 CHAPTER XVIII. DISEASES OF THE PERIPHERAL NERVES (CONCLUDED). Lead Poisoning Functional Spasm Tetany Functional spasm with voluntary movements Reflex spasm Facial spasm without pain Torti- collis Professional Cramp Writer's Cramp Dancer's Cramp Tele- grapher's Cramp, etc. etc 470-489 FORMULAS ..... 490-505 LIST OF ILLUSTRATIONS. FIG- PAGE 1. Dr. Seguin's surface thermometer . . . . .22 2. Sieveking's aesthesiometer ...... 23 3. Diagram for making records ...... 52 4. Beard and Rockwell's piesmeter . . . . .26 5. Mathieu's dynamometer ...... 26 6. The author's dynamometer ...... 27 7. Loring's ophthalmoscope ...... 28 8. The author's gas cautery . . . . .33 9. Osteoma of dura mater .... (Lancereaux) 39 10. Tuberculous matter about a vessel . . (Cornil and Ranvier) 60 1 1 . Distended perivascular spaces with atrophy . . (Fothergill) 78 12. The topography of lesions . . . . . .97 13. IVIiliary aneurisms ....... 98 14. Multiple lesions with tongue atrophy . . . . .102 15. Instrument for applying heat and cold . . . .111 16. Tissue changes in softening ...... 158 17. Handwriting of an agraphic patient . . . (Bourneville) 166 18. Handwriting of agraphia and cerebro-spinal sclerosis . . . 166 19. Location of island of Reil .... (Bateman) 168 20. External indication of island of Reil . . . (after Turner) 179 21. Choked disk ..... (after Leibreich) 188 22. Tubercular deposit . . . . . . .191 23. Sarcoma ........ 191 24. Gumma . . . . . . . .191 25. Psammoma . . . . . . . . 191 26. Encephaloid . . . ., . . . .192 27. Glioma . . . . . . . .192 28. Cerebellar aneurism . . . . . (Bristowe) 197 29. Deformity of hand in cervical pachymeningitis . (Charcot) 206 30. The consequences of spinal section . . . . .214 31. Changes in muscular tissue in antero-spinal paralysis of infancy (Duchenne) ....... 245 32. Changes in muscular tissue in antero-spinal paralysis of infancy (Duchenne) . . . . . . . 245 33. Changes in muscular tissue in antero-spinal paralysis of infancy (Duchenne) ....... 245 Xii LIST OF ILLUSTRATIONS. FIO. PAOE 34. Changes in muscular tissue in antero-spinal paralysis of infancy (Duchenne) . ..... 245 85. Antero-spinal paralysis of adults . . . (Seguin) 248 36. "Main engriffe" ..... (Roberts) 256 37. Atrophy of left shoulder ...... 258 88. Partial facial atrophy . . . . . . .267 89. The spinal curve in pseudo-hypertrophic paralysis . . .272 40. Appearance of muscular tissue in pseudo-hypertrophic paralysis (Charcot) ........ 274 41. Appearance of trophic bone-changes in locomotor ataxia (Charcot) 283 42. The course of posterior nerve-roots . . . (Clarke) 285 43. Pathological changes in locomotor ataxia and antero-lateral sclerosis (after Charcot) ....... 292^ 44. Lateral sclerosed patches . . . . (Charcot) 294 45. Region of endemic tetanus on Long Island .... 301 46. The pathology of hysteria ...... 382 47. Hystero-epilepsy ....... 386 48. Dr. Yeo's case of exophthalmic goitre . . . (Yeo) 413 49. Chart for the application of electricity . . (after Henle) 440 50. Trophic change of the skin ...... 445 51. Sarcomatous neuroma ..... (Foucault) 452 52. Wire hook for the treatment of facial paralysis . . . 458 53. Reflex spasm from genital irritation . . . .- .481 NERVOUS DISEASES. INTRODUCTION'. HINTS IN REGARD TO METHODS OF EXAMINATION AND STUDY. IN beginning our consideration of the diseases which are to form the subject of the succeeding pages, it is well to start with systematic rules for investigation, and it is of paramount importance that we should pursue some plan which will enable us to avoid confusion, and assist us in making an accurate diagnosis by exclusion. One of the greatest misfortunes that can happen to the student is the possession of a large accumulation of badly-arranged facts, which are stored away in the brain, like odds and ends in a garret. I, therefore, propose a scheme to be used in the exami- nation of patients, and would add a word of caution in regard to the error many of us make in too readily accepting and isolating nervous symptoms as distinct, which, after all, may be expressions of some general disorder. We are to determine the existence and relation of disorders of motility and sensation, as well as mental symptoms, defects of speech, sight, or hearing, together with the causes which enter into their production. EXAMINATION OF THE PATIENT Sex, age, temperament, appearance, duration of present disease, existence of complicating maladies, previous history, hereditary predisposition, habits. SYMPTOMATOLOGY Motility, location of loss or increase (one side or one-half of body?), groups of muscles or single muscles, face, trunk, or extremities, lateral or bilateral, symmetrical or unsymmetrical, loss or exaggeration of electro-muscular contractility, fibrillary contractions, mus- cular power, deformities or contractures ; atrophy or hypertrophy, general or partial ; spasms, tonic or clonic, attended or unattended by loss of con- sciousness ; pain ; degree of violence. TREMOR. Local or general, increased or controlled by will, " fine" or " coarse;" time of day, continuous or at intervals; subsidence or continu- ance during sleep. INCOORDINATION of upper or lower extremities, variety of action in which it occurs ; gait ; aggravation by closure of eyes ; loss of muscular ense ; loss of locating power. 2 18 INTRODUCTION. VERTIGO. Variety ; concomitant phenomena. SENSATION General or partial anaesthesia ; dysaesthesia or hyperaes- thesia ; condition of reflex excitability ; susceptibility to painful impres- sions ; temperature ; tactile sensibility ; sensibility to pressure ; pain, localized or general ; character of pain, neuralgic, terebrating, dull, or paroxysmal ; time when aggravated ; its associations ; time of transmission. DISORDERS OF ORGANS OF SPECIAL SENSE. Eyes. Nystagmus, strabismus, conjugate deviation (see article Cere- bral Hemorrhage), retinal changes, pupillary changes, ptosis, diplopia, amaurosis. Ear. Deafness, subjective noises, discharge. Speech. Aphasia, slow speech, clumsy speech, ataxia, loss of speech (mutism). PSYCHICAL DISORDER Illusion, hallucination, delirium, mania, me- lancholia, delusions, loss of memory, loss of consciousness, imbecility, idiocy, excitability, dementia. MISCELLANEOUS. Character of cutaneous surface, changes in tempera- ture, variation in salivary secretions, changes in pigmentation and appear- ance of hair, perspiration, etc. EXCITING CAUSE ; DIAGNOSIS ; TREATMENT. This list, though imperfect, will, I think, enable the observer to pursue a systematic course in examining his patient. He should, at the same time, take careful notes for future reference, so that variations in the symptoms and changes of treatment may be remembered. Before leaving the subject of examination, I wish to refer to the value of j>ost-mortem examination and microscopical investigation of the morbid anatomical changes. These subjects belong more properly to special works upon pathology and microscopy, but it may not be amiss to add a few hints to those already given in regard to certain important steps to be taken. In removing the calvarium the thickness of the cranial bones should be noted, s well as the condition of the diploe; but extreme care should be employed, in sawing through the bone, not to wound the meninges and brain-sub- stance beneath ; for the saw-teeth may unexpectedly tear through, lace- rating and injuring these parts, so that they may be almost useless for sub- sequent examination. After the skullcap has been removed, the observer should be on the lookout for Pacchonian bodies, and ready to recognize any adventitia that may be attached to the dura mater. The condition of the longitudinal sinus and veins which are contained in the dura mater should be examined as to their fulness, etc. ; the thickness, vascularity, color, and opacity of their tissue should also be carefully noted and then an incision POST-MORTEM EXAMINATFON. 19 may be made, and this membrane slit up with a pair of blunt-pointed scissors, or it may be cut around at the level of the saw cut. The arach- noid and pia mater are then to be inspected: the existence of effusion, either serous, purulent, or bloody; and the presence of granular deposit or vascular changes noted. The brain should be lifted back, and the cranial nerves carefully cut as near as possible to their points of exit from the skull, the optic first, and then the carotid arteries and posterior nerves ; next the tentorium, and finally the other nerves, vertebral arteries, and the spinal cord as low down as possible, taking care not to make pressure by insinuating the finger into the foramen magnum. The brain may then be removed. 1 If it is desired to remove the cord, the skin and muscular tissue of the .back should be divided and thrown back, and the spinous processes and laminae exposed. These latter should be sawn through on each side and carefully raised by the blade of the chisel. When the brain is removed, it should be placed with the base downwards, and the appear- ance of the convolutions noted, the membranes having been removed. Evidences of pressure are to be looked for, and color is to be noticed, as well as the depth of the sulci and superficial evidences of softening or scle- rosis, morbid growth, and infiltration. The organ may be turned over, and the arteries at the base inspected in regard to the existence of anom- alies, aneurisms, degeneration, thrombosis, or embolism. The fissure of Sylvius may be gently examined, and the middle cerebral traced up for some distance. The cranial nerve-trunks are to be carefully noticed, and if any suspicious appearance is observed, a section may be removed for microscopical examination. The crura and pons are to be examined care- fully for softening extravasations and the like, and the appearance of the basal parts of the hemispheres next noticed. The brain-substance may be inspected after cutting through the corpus callosum, and turning each hemisphere gently back, or by slicing off the brain-substance with a broad sharp knife previously dipped in water or alcohol, so that the white matter may be examined at different levels. The condition of the ventricles should be noticed as to the effusion of serum or blood. The parts at the floor of the lateral ventricles deserve special study, and the corpora striata should be inspected very attentively, the extra-ventricular and intra-ventricular parts being carefully sliced. The fulness of the vessels in the deep parts of the brain, the existence of patches of softening or induration, and the pressure of cysts, tumors, or morbid growths should be looked for. It is always advisable in cases where aphasia has been a symptom during life, to care- fully inspect the anterior convolutions, particularly the third frontal, which is the generally acknowledged seat of the lesion, and we may do this by entering the fissure of Sylvius. It is hardly necessary to allude to the importance of carefully examining the medulla and the roots of the various cranial nerves, and for this pur- 1 Removal, en masse, of the brain and its membranous coverings should never be attempted ; the result of such a procedure being mechanical injury, which reduces the organ to a pultaceous mass, rendering it unfit for examination. 20 INTRODUCTION. pose it is advisable to remove such parts as are wanted for subsequent microscopical examination. The cord must be examined critically in cases of spinal disease, and the same directions are given for its inspection. Sus- pected portions may be cut out and laid aside, care being taken to secure as much of the external roots as possible. In special cases nerve trunks or peripheral nerves may be exsected for future examination, and in cases attended by muscular atrophy and degeneration it is well to ascertain the morbid changes in the muscles. If we desire to use the microscope it is generally necessary to harden the tissues, although fresh nervous substance may be teased apart in glycerine or serum by needles prepared for the pur- pose. If we prefer the first method we may put such masses of the brain or cord as we desire to harden into Miiller's fluid, which is prepared as fol- lows : R. Potass, bichromat. 50 grammes, Sodic sulphate, 20 grammes, Water, 50 cubic centimetres : Or, what is better, the solution recommended by Prof. J. W. S. Arnold, of the Medical Department of the University of the City of New York : R. Ammon. bichromate, 11 grammes, Methyl alcohol, 320 grammes, Water, 640 grammes. Care should be taken not to secure too large specimens, as they do not harden thoroughly, the exterior becoming hard while the interior is dif- fluent and useless. They should be left in this solution for a month or six weeks, but not till they become granular or cheesy, for then it is impossible to make a good section, as the tissue is apt to crumble under the razor. At the end of this time, or when the tissue is quite firm, it may be removed and placed in a fifty per cent, solution of alcohol and water. The speci- men may be examined to test its hardness by making sections with a razor from time to time. If a very thin section can be made with a moistened ra/or without parting, adhesion, or crumbling, it may be considered to be in fit condition for removal from the hardening solution. A solution of bichromate of ammonium, 1/i grains to the ounce of water, is an excellent hardening solution, in which the specimen may remain until it has been uniformly saturated, and hardening has commenced, and then it is to be removed and placed in a solution of chromic acid, two grains to the ounce of water, where it is to remain until hard enough for cutting. This is the process recommended by Dieters. The specimens may be taken out and kept for use in dilute alcohol till they are needed. When the hardened tissue is to be examined, it is to be imbedded in pith or paraffine, and either placed in a section cutter, or held in the hand. By practice, this latter procedure becomes quite easy, and very thin sections may be made. A piece of brain or a length of cord of a convenient size is surrounded by elder pith previously prepared to receive it, and bound in place by a string or piece of fine copper wire. When moistened, the pith swells so that the tissue receives uniform pressure and support. If the MICROSCOPIC EXAMINATION. 21 paraffine process is to be employed, the tissue is to be carefully dried and placed in a small paper mould which is afterwards filled with melted paraf- fine, which should not be too hot, 1 and care should be taken to exclude air- bubbles when cool and solid the upper part of the paper may be torn away, and the specimen is ready for cutting. A flat razor is the best instrument of which I know r for ordinary work. Its blade should be dipped in a saucer containing alcohol placed conveniently by, and the face of the section should be moistened from time to time. The individual holding the mould firmly between the thumb, forefinger, and second finger of the left hand, cuts away a portion of mould and tissue so that a level surface is left exposed ; then, with moistened razor, he plants the blade, and slowly cuts a thin slice of paraffine and tissue together ; this is removed by a camel's hair brush which has been dipped in alcohol, and next dropped into a small vessel containing dilute alcohol, and then placed in the stain- ing fluid, which may be the following : R. Carmine (pure), gr. xx, Liq. ammoniae, q. s. ut dissolve, Glycerinae, Aquae, aa 51). M. After being allowed to soak for several hours or days, the sections are removed and dropped into w r ater slightly acidulated with acetic acid. They are now to be placed in absolute alcohol for a short time," and afterwards placed in oil of cloves until they become transparent. A perfectly clean slide is procured, upon which one of them is placed and a drop (not too large) of Canada balsam is next applied. It is then covered by a thin glass cover, care being taken to exclude air-bubbles. Various preparations are used to stain nervous tissues ; for instance, a solution of chloride of gold will stain the nerve fibres, and render them more distinct ; hsematoxylin and osmic acid are also used, and the black anilin process of Herbert Major 3 produces the most beautiful results. These manipulations, however, are out of place here, and I would refer the reader to any one of the excellent text- books that have appeared during the past few years for more explicit direc- tions. It is often necessary to make sections in all possible directions and posi- tions, and to do this properly the microscopist must not only have practice but patience and care. It is advisable to procure at least two objectives, one for coarse appearances, and the other for minute changes, and I would suggest that these should be an " inch" and a "quarter inch." 1 I have recently used metallic bottle caps, which may be easily procured. AVhen the paraffine is cool the metal may be stripped off. 2 West Riding Reports, vol. v. 22 INTRODUCTION. INSTRUMENTS USED FOR THE DIAGNOSIS OF NERVOUS DISEASE. It is essential that we should possess certain instruments which shall be more valuable and exact than our unaided senses, so that we may not only make reliable investigations, but compare from time to time Fig. 1. guch variations as may occur in the patient's condition. Those I propose to describe are intended for examinations of temperature and sensory changes, and for the detection of altered motility. THE THERMOMETER There are several instruments made for the purpose of determining variations in tempe- rature, and though some are of extreme delicacy, I do not think it will be worth while to recommend them, as they are bulky and troublesome, and are better adapted for experimental purposes than actual clinical use, and among these is Lombard's instrument. In Dr. Seguin's surface thermometer we possess an admi- rable little instrument for testing the surface temperature. It has an expanded base, and may be applied to the surface of the body, taking care to cover the top by a perforated piece of thin rubber or leather. A coat or two of shellac varnish to the upper part of the bulb will answer the same purpose, viz., that of preventing the mercury from being affected by the temperature of the room. For the determination of deep temperature we may avail ourselves of any of the good self- registering instruments. Two surface thermometers should be used, one on the sound, and the other on the affected side of the body, and the deep temperature may be taken at the same time for comparison. A new form of surface ther- mometer has recently been made in England. The glass tube is spirally coiled upon itself and inclosed in a circular surface . Thermometer. box. This form has the merit of being unaffected by other than the body temperature. BecquereFs disks I have found to possess extreme delicacy, and if pro- |)crly constructed the variation of a fraction of a degree may be readily appreciated. They consist of delicate strips of two sensitive electro-nega- tive and positive metals, imbedded in a handle. Copper and bismuth are generally used. By proper connections they are put in communication with a delicate galvanometer which registers the feeble thermo-electric current which is generated. The vEsTHEsioMETER was first suggested by Sieveking, and has since been modified by different individuals. We have several different varie- ties to choose from, but no one is better than the original instrument of THE jESTHESIOMETER. 23 Sieveking, which is also used and recommended by Brown-Sequard. It is made of brass or steel, and very closely resembles a shoemaker's mea- Fig. 2. Sieveking's JEsthesiometer. sure. The movable slide and permanent arms at the end are sharp pointed. The bar upon which the free slide moves is ruled in centi- metres. The other aesthesiometers are mostly shaped like dividers, and whether they be Hammond's or Carrol's, they are open to the objection that the points are liable to be unconsciously approximated when the instrument is removed, so that the result of investigation is somewhat unreliable. Carrol's festhesiometer has one advantage. The points are bifurcated, one arm ending in a bulb, while the other is sharp, so that analgesia as well as anaesthesia may be tested. 24 INTRODUCTION. Dr. E. C. Seguin has made a very decided improvement upon the original instrument of Sieveking. He has had it constructed of aluminum, and of a smaller size, so that it is light, and may be easily carried in the pocket- case. The principle upon which the aesthesiometer is constructed is the fol- lowing : The normal receptivity of tactile impressions enables the subject to distinguish two points which are brought simultaneously in contact with the skin. This susceptibility varies greatly in different regions in proportion to the delicacy of tactile sensation located therein. If there be loss of sensation as an accompaniment or result of nervous disease, of course the distance between them will have to be increased before the points will be felt as two. In hypenesthesia they may be much more nearly approximated and distinguished as two than in the amesthetic state. The average distance at which the two points of the instrument can be felt in the normal state are as follows : Point of tongue ........ line. Red surface of lips 2 lines. Palmar surface of third finger . .... 1 line. Tip of nose 3 lines. Metacarpal bone of thumb 4 " Skin of cheek 5 Mucous membrane of hard palate ..... 6 Dorsal surface of first finger ...... 7 Dorsum of hand over heads of metacarpal bones . . 8 Mucous membrane of gums ...... 9 Lower part of forehead . . . . . . .10 Lower part of occiput 12 Back of hand 14 Neck under lower jaw 15 Vertex 15 Skin over the patella . . . . . . .16 Skin over the sacrum . . . . . . .18 Skin over the sternum ....... 20 Skin over cervical vertebrae ...... 24 Skin over middle of back ...... 30 Skin over middle of the arm . . . . . . 80 ' Skin over middle of the leg . . . . . . 80 " Certain precautions must be taken when using the aesthesiometer, or else our examination will be unsatisfactory in the extreme ; we must not depend in all cases upon the patient's statement, but exercise tact in getting from him satisfactory answers, and not guesses. There seems to be in some individuals a discouraging stupidity which prompts them, in answer to the question, " How many points do you feel?" to oftentimes reply "Three," when they know that the instrument has but two points. It is of the greatest importance that the patient's eyes should be covered, or that he should close them, as he will unconsciously look at the instrument during its application. It is also of moment that the points should be fairly and -ffiSTHESIOMETER DYNAMOMETER. 25 at the same time applied to the skin, one not being pressed more than the other, and finally, it may be stated that they should not be applied at any place where the clothing has rubbed or chafed the surface. Fig. 3. 3 2. Diagram for making records. Roman numerals show anaesthetic indications, the others nor- mal sensibility. The BAR^ESTHESIOMETER of Eulenburg, modified by Beard & Rock- well, has been used as a means for the determination of the individual sense of application of weight which is lost in various forms of paralysis and anaesthesia. It consists of a spiing which is impinged upon a piston, both being placed in a tube or cylinder, and the rod connected with the piston having a broad expansion at its outer end. This disk is placed upon the body, and the spring impinged, registers on a scale the amount of pressure made before it is recognized by the individual. The DYNAMOMETER Various forms have been devised, that in general use being the invention of Mathieu. It consists of an elliptical spring which when compressed in the hand registers upon an index the force ex- erted. When the needle is forced ahead it remains at the point it had reached when pressure was remitted, and the spring expands. Its disad- vantage lies in the inequality of pressure made at different times, the bulky character of the apparatus, and its inadaptability to other uses. 26 Fig 4. INTRODUCTION. Fiff. 5. Board & Rockwell's Piesmeter. Mathien's Dyaamometer. Having recognized the necessity for an instrument that would meet the therapeutical requirements not possessed by those of Mathieu or Duchenne, I have de- vised that figured in the appended illustration. It con- sists of a long glass tube (2) which dips into a small bottle filled with mercury. In connection with a bent brass pipe (3) is a rubber tube which terminates in a closed rubber bulb (5). When this bulb is compressed the mercury is forced up in the glass tube, the end of which is closed (1). Attached to the tube is a scale marked on one side in pounds, and on the other by marks separated by regular intervals for the purpose of making comparative estimates. As fifteen pounds' pres- sure to the square inch is required to compress a given body of air into one-half its original space, of course a force of fifteen pounds' pressure brought to bear upon the bulb would be required to press the column of mer- cury half way up the scale. The advantages of this apparatus are the following : 1. Its simplicity. 2. The adaptability of the rubber bulb to receive pressure exerted by all flexors of the hand. Mathieu's spring is only acted upon by a limited number; at the same time, therefore, the test is not a true one. 3. The action of the muscles is the same at different times. The same group of muscles always being brought in play, accurate comparative tests may be made from day to day. 4. The part receiving the pressure is of a convenient shape to be used by persons with either small or large hands. 5. It is accurate and always gives reliable indication of the pressure brought to bear. An instrument styled the dynamograph, which is a combination of the dynamometer and the writing part of the sphymograph, is advocated as a valuable aid in diagnosis. The variation of imperfectly sustained pressure is recorded upon a slowly-moving card. I consider the apparatus a use- less invention, as the results obtained must be of the clumsiest kind. In fact no instrument but the myograph, of which there are several forms, is of any use for delicate observation. THE DYNAMOMETER. 27 I have combined the rubber bulb with the drum of Marey, and am enabled to obtain gross variations with tolerable accuracy. The drum has two pipes, one of which is connected with the rubber bulb, while another is attached to the lower end of an open glass tube. The bulb-drum cavity Fig. 6. The Author's Dynamometer. and a part of the tube are filled with colored fluid, so that the fluid in the latter reaches a mark at about the middle of its length. The patient grasps the bulb and makes enough pressure to force the fluid in this tube to a mark slightly above the other. The sustained voluntary effort required to keep the fluid at this point necessitates some delicacy of muscular coordination, and should this be impaired there will be expansion of the drum-head and consequently irregular tracings upon the cylinder of the registering^ appa- ratus. This cylinder should be covered by a piece of smoked paper, and the stylet placed in apposition thereto. In alcoholic tremor, commencing sclerosis, and the metallic tremors, we may obtain very beautiful tracings. 28 INTRODUCTION. THE OPHTHALMOSCOPE The parts composing the ordinary ophthal- moscope are the following : A concave mirror perforated at its centre, a series of lenses by which the refraction in the subject's or observer's eye may be corrected, and a bi-convex lens. The three forms in common use are those of Liebreich, Loring, and Knapp. The two latter are essentially alike in construction, and the first is quite primitive, usually of bad con- struction and quite unreliable. Fig. 7. Loriug's Ophthalmoscope. Iii the examination with this instrument great care should be taken by the observer to determine whether he or his subject possesses errors of refraction, and if so to correct them with the proper lenses. In the modern ophthalmoscope a number of lenses are held in a revolving disk beliind the mirror. For more specific directions the reader is referred to Dr. Loring's ad- mirable little work. 1 To examine the eyes of a patient properly, the observer may follow the concise directions laid down by Ilutchinson. 1 1 Determination of Errors of Refraction with the Ophthalmoscope. E. G. Loring. Win. AYood & Co., N. Y. 2 Jonathan Ilutchinson. Clinical Reports of London Hospital 1867-8, p. 182. THE OPHTHALMOSCOPE. 29 " Having placed the patient's head in such a manner that the light (a lamp, candle, or gas-light) is on a level with his temple, and slightly be- hind it, and his face, as a consequence, in shadow, the observer sits in front and applies the ophthalmoscope mirror to his own eye. He should keep both eyes open that he may see where the light falls, and then move the mirror until the light falls full on the pupil of his patient. In a mo- ment he will perceive the first fact which this instrument reveals, that the f'undus is not black, as it has always appeared to be before, but that it is of a brilliant fire-red. He will, however, see nothing of the fundus dis- tinctly, only a general red reflex. Now at this point the student must stop awhile and use his mirror, to inspect, first, the transparency of the cornea, and, next, that of the lens and- vitreous, and to do this he must make the patient move his eye in various directions. After a little prac- tice he will be able to manage his light well, and to throw it with preci- sion wherever he may wish, and to keep it steadily on any given part. At a first lesson he may even, with advantage, practise for a while by illumi- nating the second button of the patient's waistcoat. Tact in directing the light having been obtained, we may now proceed further. Instruct the patient to look, not full in your face, but over one shoulder ; if you are inspecting his right eye, over your left shoulder. You will, when he does this, notice at once that the tint of the light reflected from his fundus is changed, that it is no longer fire-red, but canary-yellow. The reason of this is that a different part of the fundus is exposed to view, that, namely, of the optic disk itself, which is much lighter in color than the rest. The area of yellow is very large occupies, indeed, the whole of the field, while we know that the disk itself is very small. This proves that the objects thus indistinctly seen are immensely magnified. Magnified by what ? By the patient's own eye, which, as we have said, is equivalent to a lens of one inch focus. " Hitherto we have seen nothing distinctly, but if the observer now brings his head very close to his patient's face, he will be able with more or less facility to observe the details at the bottom of the eye, the trunks of vessels of the retina, the optic disk, etc. etc. All these will be seen very large indeed, being still magnified by the patient's eye. What he sees now is equivalent to type looked at through a one-inch lens, placed exactly one inch in front of it." Without entering into an extended discussion as to the value of this instrument as a means of diagnosis, it will be well to state frankly that I do not believe that it possesses any positive value in the diagnosis of brain disease, except where the condition of the fundus is the result of an or- ganic disease of the brain or cord, or when it is possible to connect such disorders with errors in refraction. In making this statement I shall, perhaps, find many opponents, but I nevertheless have many powerful allies. A distinguished author recently took it into his head to call those who differed with him, in regard to the diagnostic value of the ophthalmoscope in functional circulatory disturb- ances, " pert pretenders." How far this accusation is true the reader 30 INTRODUCTION. may determine after consulting the really convincing articles of Loring, 1 Arbuckle,* Albutt, and others, which prove beyond question that the fundus of the eye is rarely any index of the cerebral circulation.* Bouchut, 4 Panas, 6 Albutt,' Hammond, 7 Bell, and others, have written extensively, and have furnished a large number of clinical reports of oj>li- thalmoscopic changes coexistent with cerebral tumors, meningitis, soften- ing, effusion, cerebral hemorrhage, general paralysis, locomotor ataxia and other forms of sclerosis, epilepsy, and the syphilitic and uraemic neu- roses. Hutchinson, 8 of Philadelphia, in an admirable article, gives many of these cases, and shows the real value of the ophthalmoscope, especially when an examination of the fundus reveals choked disk and optic neuritis. but I will speak more fully in regard to this subject when we come to the discussion of special diseases. APPARATUS FOR THE TREATMENT OF NERVOUS DISEASE. ELECTRICAL. Two forms of apparatus are required one for the gal- vanic, the other for the induced or Faradic currents as well us the necessary electrodes. As we know, the galvanic current is derived directly from a battery or pile, the first ordinarily consisting of two elements, which are contained in a vessel filled with some exciting solution, and the latter of plates of metal placed one above the other, and separated by disks of felt or paper moistened with a solution of salt or acid. This last apparatus is rarely used. One vessel or cell of the form I first described constitutes a simple bat- 1 Am. Psychological Journal, Nov. 1876. 2 West Riding Reports, vol. v. p. 148. 3 Dr. Loring says, in concluding an admirable paper: "By the experiments considered in the foregoing remarks two alternatives are forcibly presented to our mind : either that the circulation of the eye is not a reflex of the circulation of the brain, though derived directly from it ; and thus agents which affect pro- foundly the one have little or no influence on the other ; or, if the retinal circu- lation is a reflex of the cerebral, it follows that the influence exerted on the cir- culation of the brain by agents at our command, remedial or otherwise, is very much less than heretofore supposed. "I cannot but think that the former alternative is the more rational, and from that very independence of the two circulations there is reason to fear, soiiir as functional, and especially mental diseases, are concerned, that there never will !><. any more than there now is, any art to read the mind's construction in the eye." 4 Du Diagnostic des Maladies du System Nerveux par 1' Ophthalmoscope. Paris, 1876. 5 La France Medicale, Feb. 26, 1876. 6 Med. Times and Ciaz., vol. i., p. 495, and seq. 7 Diseases of the Nervous System. New York, 1876. 8 Phil. Med. Times, May 8, 1875. APPARATUS FOR TREATMENT. 31 tery, and two or more, with the poles alternately connected, a compound battery. Two qualities of electric force are generated by a battery of this kind : 1. Quantity; 2. Intensity. The latter is the characteristic which makes it valuable as a means for the production of muscular contraction and nerve stimulation. The Faradic current is derived from a galvanic cell primarily, and is developed by its passage through a coil of wire wound about a central core or bundle. Two currents are induced therein : one the primary induced, the other the secondary induced. The first is less coarse and violent in its effects than the other. For a more extended description of electro-physics, physiology, and therapeutics, I would refer the reader to any of the works mentioned at the foot of this page. 1 For the production of the galvanic current, we may avail ourselves of either one of the permanent batteries ; the cells of which may be set up in the cellar, and the wires carried to a proper board in the office, con- taining apparatus for their selection ; or we may use the ordinary portable galvanic battery, many styles of which are made. I have given the Leclanche battery a fair trial, and now do not recom- mend it, as it is dirty, inconstant, and rapidly loses power. The " maga- zine" battery of Chester, in which the peroxide of lead is substituted for the black oxide of manganese in the porous cell, is much better. The old Daniel's cell is, I am convinced, the best of all, and whether in the form of the Siemens and Halske, or Hill modification, is all that can be desired. The table board of Fleming and Talbot, of Philadelphia, or the arrange- ment known as the " cabinet battery," which is made by the Galvano- Faradic Company of New York, is admirable for office use. The Galvano-Faradic Company of New York construct a very good portable battery of thirty-two cells, and I would recommend it for general use, as it is admirably simple and effective. The Faradic instrument should be provided with an attachment for the slow or rapid interruption of the current, an addition to the ordinary bat- tery, which will be found of immense advantage in certain forms of 1 Either of these works will be found practically useful to the student : Tibbit's Handbook of Medical Electricity. Reynolds' Clinical Uses of Electricity. Althaus's Electricity, Theoretical and Practical. Poore : A Text Book of Electricity, etc. Lincoln's Electro-Therapeutics. Beard and Rockwell's Medical and Surgical Electricity. Hamilton's Clinical Electro-Therapeutics. Duchenne's de 1' Electrisation localise, 1872. Onimus et Legros, Trait6 d'Electricite Med. Benedikt Elektrotherapie, 1874-5. Ziemssen, Die Electricitat in der Med., 1872. Besides, the -works of Rosenthal, Erb, Meyer, Eulenburg, and others. 32 INTRODUCTION. paralysis. The instruments of the two firms I have mentioned, besides those of Dreschcr and Kidder, are all good. Two or three cotton-cloth covered electrodes of different sizes, or flat sponges with rubber backs, with fine wire pole cords instead of the flimsy gold-thread connections in present use, which oxidize and break, will be needed, as well as a bundle of fine wires held in a handle, which is known as the electric brush. RUBBER MUSCLES, ETC Dr. Van Bibber, of Baltimore, has devised a very useful Apparatus for the treatment of paralysis, especially of lead paralysis. It consists of a strap for the hand or other part which needs support, and one for a point of attachment of the muscle. When properly applied, the rubber pipe, which takes the place of the paralyzed muscle, raises the hand, so that the strain upon the enfeebled muscle is relieved. Dr. Van Bibber has also used court plaster for the treatment of ptosis and other minor paralyses. THE HYPODERMIC SYRINGE, ETHER SPRAT APPARATUS, and SPINAL and CRANIAL ICE BAGS, should be procured by every physician who has occasion to treat this class of diseases. CAUTERIES Until a few months ago the old form of cautery was used almost exclusively. These are of iron, and are sometimes platina covered. When they are needed, they are heated in the flame of a Bunsen burner, Russian blast lamp, or some such contrivance, but lose their heat very rapidly, and generally assume a dead red color when they are to be ap- plied. The glass rods, heated in a like manner, though somewhat more convenient, become very quickly cool. Dr. J. J. Putnam, of Boston, exhibited at a meeting of the American Neurological Association the first gas cautery which was seen in this country. In some respects it was imperfect. It produced a noise which was harrowing to the patient, and it was expensive and cumbersome. The apparatus consists of two pipes (one within the other), which convey air or oxygen and illuminating gas to a common burner. These tubes are connected with stopcocks (Fig. 8, A, 2, 2), which enable the operator to control the size of the flame. A handle (1) covered at one end by a shield, completes the body of the instrument. At the end of the burner is a dome of platinum, which is fastened to the end of the burner by a ring and clump (li< 4), so that, by a simple movement, the dome can be removed and replaced by another. About the lower edge of tfe pla- tinum, is a small collar of wire gauze, expanded at its lower end, which prevents the escape of any return flame (B). From the two stopcocks pass rubber tubes, one to the gas-burner, the other to a T of brass pipe, the middle branch of which extends into a large spinal ice-bag (A, 3). This is covered by a strong net. To the other branch a rubber tube is attached. This tube terminates in an ordi- nary rubber atomizer-bulb. CAUTERIES. 33 At the T-piece is a small hook (A, 4), by which the ice-bag or air- reservoir can be attached to the button-hole of the operator. Fig. 8 The Author's Gas Cautery. The advantages I claim for the modification of the instrument I have described are the following : 1. The adoption of a jet which prevents all hissing or noise, and still produces a very powerful blast. 2. The apron of wire gauze, which prevents the return of flame, thus obviating the danger of burning parts that we do not wish to affect. 3. The large bag, which acts as a reservoir, so that the operator need not use the rubber bulb nor watch the burner after it is filled. 4. The hook, which enables him to suspend the bag and tubing from his person, thus removing all drag. The general advantages of this form of cautery are important. A uni- form heat may be kept up for hours with very little exertion. The fur- nace, which is not only inconvenient, dirty, and alarming to timid people, but is a slow method, is done away with. In less than a minute the platinum dome can be heated to whiteness. 3 34 INTRODUCTION. The cauteries of Pacquelin and Guerard, of Paris, are both good. In them the \n\tor of benzine (which should be very pure) is forced with air upon a piece of hot platinum. These are excellent substitutes for tin- cautery I have just described, in the country where there is no gas. Dr. Hammond has recommended that the spinal ether spray be used to deaden pain ; but not only is there danger of an explosion when this pro- cedure is tried, but it seems to me that the very object of the operation, revulsion, is not accomplished, as the peripheral filaments are of necessity benumbed. ACUTE PACHYMENINGITIS. 35 CHAPTER I. DISEASES OF THE CEREBRAL MEXINGES. ALL of the investing membranes of the brain may be the seat of inflam- matory action, but it is almost impossible in certain instances to make distinctions between inflammation of the arachnoid and pia mater, though this lias been attempted by Parent-Duchatelet, Lallemand, and others. We will, therefore, have to content ourselves with a division founded upon the duration, intensity, and coexisting diseases of the general system, and limit our regional diagnoses to forms which may be called meningitis of the convexity and meningitis of the base. In respect to certain circumstances which modify the appearance of the disease we may divide these neuroses as follows : ... ( Acute, Cerebral pachymemngitis, \ ,1 n A. ' , j N < Chronic, (Inflammation or the dura mater), (^ Chronic, with lutmatoma. f Basilar, Acute cerebral meningitis, ^ Of the convexity, (. Granular. Chronic cerebral meningitis. PACHYMENINGITIS (INFLAMMATION OF THE DURA). Two forms of pachymeningitis are to be met with, one of which is acute and is the direct result of injury or disease of the cranial bones, and is generally fatal in a short time ; and the other, of a chronic nature, which may either remain after injury, or arise from some intracranial cause, or perhaps be the result of general disease, or old age. ACUTE PACHYMEXIXGITIS. Symptoms After the traumatism, or when the external disease has invaded the intracranial cavity, the first symptom is usually severe and localized pain, which finally extends with the inflammation, and becomes diffused over the entire head. Rigors, alternating with elevation of temperature, which may sometimes attain 105 or 10G F., occasionally spasms of the arms or legs, are ordi- nary symptoms ; and if the condition be a very acute one, there may be general convulsions, or perhaps a partial paralysis, which is unilateral. Delirium usually supervenes in from three days to a week, and coma 36 DISEASES OF THE CEREBRAL MENINGES. ends the disease, should an effusion of blood take place, and this is a com- mon termination. The pulse during the first two or three days varies from 60 to 70, while towards the end it becomes much more frequent and very full. During the invasion, and after the disease is fully established, especially if the inflammation extends to the base, the head may be drawn backwards and downwards. Ramskill 1 has called attention to the hyper-sensitiveness of the cornea, and I have been often impressed by another symptom, viz., the redness of the conjunctiva and the constant tendency to lachrymation. Vomiting very commonly takes place, and is always quite a suggestive symptom of meningeal trouble. When the disease follows otitis its onset is not so sud- den us when it is the result of injury, but a train of symptoms of gradual appearance marks the extension of the morbid process step by step, though in some instances rigor with sudden coma may be the first indica- tion of mischief. This is in most cases the purulent form. Cases of the idiopathic variety of pachymeningitis are quite rare, although several have been reported by Abercrombie and other older writers. One case related by the former authority may be worth mentioning. This writer also gives six others which originated from middle ear disease or abscesses in other bony cavities. These latter cases are not uncommon, if we may accept the experience of aurists and surgeons. AbercrombieV patient, in whom the disease was idiopathic, died in fifteen days. The first indication was severe pain in the left temple, which continued for two weeks, when a " swelling" appeared beneath the left upper eyelid. Four days before her death violent convulsions took place, which were preceded by slight rigors. The swelling was punctured, and a considerable quantity of pus escaped. A probe passed into the opening came in contact with bone, and could be inserted for some distance, the end being in contact with the roof of the orbit. During previous days her condition had varied to a great degree, and at times she seemed to be very comfortable. On the day before her death she complained of vertical headache, became semi-comatose, and died in this state. Extensive discoloration, thickening, and other changes in the dura mater were found with adventitious membrane and pus. Fizeau 8 mentions a case which closely resembles this one, and another quoted by Abercrombie, and seen by Prathernon, was also of idiopathic origin. Abercrombie'a other cases present common symptoms which were traced to assignable causes. Dr. Clark* has presented five cases of the acute form, due to otitis. Dr. Banduy 8 another which followed scarlet fever, and many of the same kind may be found mentioned by other authorities. 1 Russell Reynolds' System of Medicine, vol. ii. page 325. 2 Abercrombie on the Brain, page 21. 3 Journal de M6decine, torn, ii., New Series, page 523. 4 Transactions New York Pathological Society, 1876. 5 St. Louis Clinical Record, March, 1876. CHRONIC PACHYMEX1NGITIS. 37 CHROXIC PA.CHYMEXINGITIS. A far more interesting class of cases are those which have lasted for some time, have invaded the underlying membranes, ending in involve- ment of the cortex cerebri. The following is a fair example : Symptoms John McM., age 30, of temperate habits. The patient was a young man of the laboring class, and was employed in a machine- shop at the time of the accident. Three years ago, while turning a piece of metal, it caught upon the end of his turning tool and flew out of the lathe (which was driven by steam-power), striking his head, and cutting a scalp wound over the upper part of the right parietal bone. He fell un- conscious, and was carried to his home, remaining in the same state for about eight hours. After this he recovered slowly, was delirious, and evi- dently had had convulsions. From this period to the time when I saw him his history was not very clear, but he had had convulsive paroxysms from time to time, and severe headache, which he complained of when he came for advice. This pain was limited to the right side of the head, and prin- cipally centered at the injured spot. His face was quite puffed and swollen, and his eyes were red and watery. Pressure upon the cicatrix caused intense pain. His right pupil was slightly enlarged, and he com- plained that his vision was imperfect. Sleep was disturbed by the pain which would often occur in paroxysms of a very intense character. He complained that his left arm felt stiff, and that his fingers were cold, but I was unable to find any loss of power. He continued in this state for a year or more, and when I next saw him his speech had become slow and hesitating, and his face wore rather a silly expression. He then com- plained of some feebleness of the left arm and leg. The headache had not abated, and the convulsions had been much more frequent. His friend who came with him stated that his mind had greatly changed, that his be- havior was eccentric, and that he had had delusions of various kinds. I subsequently lost sight of him. In some features this case resembles one of softening. This form of chronic pachymeningitis is much more obscure when it is connected with syphilis. There is not only a great dispropor- tion between the severity of the symptoms and the extent of the morbid process, but symptoms of great variety may be evinced as expressions of pachymeningitis of syphilitic origin. 1 Lagneau fils 2 reports a case in which this inconsistency was shown. The only symptom was headache, which was most violent at night. Post-mortem examination revealed pachy- meningitis over the anterior lobes of the cerebrum, with bony plates and some sclerosis of the brain-substance. There was, in addition, extensive perforation of the ethmoid bone. Instances are related by Gama where the patients had died conscious, and their meninges Avere found to be de- cidedly affected. Keyes, 3 in a most complete and exhaustive memoir, pre- 1 Trans. X. Y. Path. Soc., vol. i. p. 13. 2 Observation 3, Lagneau, Maladies syphilitiques du Systeme nerveux. Paris, 1860. 3 Syphilis of the Nervous System. New York, 1870. 38 DISEASES OF THE CEREBRAL MENINGES. sent.* a number of cases of hemiplegia which were the ultimate result of the meningeal inflammation, and calls attention to the pain which pre- cedes the hemiplegia, and which is always produced when pressure is made upon the cranium. A feature of the hemiplegia is the absence of any loss of consciousness. A form of syphilitic pachymeningitis may follow external syphilitic dis- ease of the cranial bones. I may illustrate the features of such an attack by the following case, reported by Dr. Jas. R. Wood : Marie C., aged 20, was admitted to Bellevue Hospital, Jan. 7th, on ac- count of an eruption of two weeks' duration, which had steadily progress ,1 from a few points until it had become general, being most profuse on tin- face, neck, arms, and scalp. The eruption presented a distinct coppery hue, and was of two varieties. There were three rupitic phlegma on the head, each of which contained a little pus, and three or four on the shoulders and back of the same cha- racter. The rest were tubercular. She stated that, though often exposed, she had never suffered from pri- mary syphilis, but that there was a sore on her thigh, near the vulva. which appeared two weeks before the eruption. On examination, a simple chancre was found at the point complained of; there was also a chancre of limited extent in the vagina. Soon after admission she was observed to have a shuffling gait, and when questioned about it stated that her right arm and leg " seemed to be getting weak." The treatment consisted in the use of the corrosive chloride of mercury in Huxham's tincture of bark, combined with generous diet. The eruption on the scalp was left undisturbed. The quantity of pus contained in each point was quite small, and it was deemed best to let them alone. One of them situated over the parietal bone of the left side was something larger than its fellows ; none of them, however, increased in sixe materially. There was very little improvement in the eruption, but the hemiplegia steadily increased. Her appetite became poor, she began to have vomiting, and exhibited n cachectic appearance. The bichloride was necessarily discontinued, and mercurial vaporization substituted. The hemiplegia became more complete, and her mind began to be ob- scured. The stupidity gradually deepened into profound coma, in which condition she died on the 30th. Autopsy There was a denudation of the parietal bone of the left side of the periosteum, at a point corresponding with the rupitic spot above spoken of. On removing the calvarium, the dura mater was found inflamed and firmly adherent to the skull, just beneath the denuded spot on the panfetal bone and the eruption. A small opening was found communicating between them, perforating the cranial walls, and looking very much like a worm -hole. The brain at a point corresponding with the inflamed dura mater pre- sented a greenish appearance. There was also an evident fulness and fluctuation. On making an in- cision an abscess was discovered which contained about ^iij of pus. The other organs were healthy. CHRONIC PACHYMENINGITIS. 39 As a result of continued congestion we may have a form of pachy- meningitis such as follows chronic mania. I have seen this change repeat- edly as a secondary condition, but it must be confessed that the other iiH'ninges were as well affected. Causes They may be briefly enumerated as external injury, otitis, syphilis, alcoholism, and various acute diseases, among them rheumatism. Morbid Anatomy and Pathology In the majority of cases the inflammation is transmitted to one or more of the important sinuses. The most favorable points for the extension of disease of the temporal bone are the narrow space between the mastoid cells of this bone and the transverse sinus, and that between the cavity of the tympanum and the jugular fossa ; and the proximity of the auditory meatus to the petrosal sinus, and the different canals which contain the nerves, to adjacent intra-cranial parts. The bony walls between these locations are of a perforated and lamellar character, and when attacked by caries are very apt to be destroyed. If the disease be of a syphilitic nature there is generally a gummatous deposit scattered through the tissues, and the under surface of the dura mater is often covered by a syphilitic exudation which can rarely be mis- taken. If the disease be the result of a traumatism, the membrane is seen to be thickened, opalescent, and congested. In old cases it is found to be closely adherent to the cranial bones, or it may contain long plates. Osteoma of Dura Mater (Lancereaux). a. Bony Plate. 6. Perforation, c. Falx. d. Dura Mater, e. Parietal Bone. /. Scalp. In this form of inflammation the morbid changes may be seen best at the convexity. Prognosis The outlook is invariably bad, for in one variety the patient is carried off in a few days, or, should the disease become chronic, its progressive nature must lead us to expect an ultimate implication of other parts, and cortical softening or sclerosis and atrophy are probable terminations. 40 DISEASES OF THE CEREBRAL MENINGES. Treatment Treatment should be directed in the beginning to the cause, and if there be otitis, a free escape of pus should be provided for, and counter-irritants, topical applications, and leeches should be em- ployed. If the pachymeningitis be attended by much pain, cold to the liead and free administration of the bromides will be of service. The leeches may be applied to the tragus of the ear, or to the mucous mem- brane of the nostril. CHRONIC PACHYMENIXGITIS WITH H^EMATOMA. It has been the custom, among certain writers lately, to speak of luema- toma as an inevitable result of pachymeningitis. This, I think, is a mis- take, for the production of blood-cysts is not the invariable rul*. If, however, the thickening of the dura mater is excessive, there may be a gradual destructive process, which will be described when we come to speak of the morbid anatomy and pathology of the affection. The disease may begin as I have already described, and may advance to a certain point before the grave symptoms which indicate rupture and consequent meningeal hemorrhage are expressed. These may vary in intensity in proportion to the extent of the effusion, which may be even so great as to produce sudden death, but such an early result is excep- tional. The course of the disease is generally more gradual, and there is at first an initial hemorrhage of slight extent, which is followed in a great number of cases by two or three others. In some respects this effusion re- sembles cerebral hemorrhage in the production of acute symptoms, but they are nearly always less profound ; and it is not so frequently followed by complete paralysis. Symptoms The early symptoms of pachymeningitis which I have enumerated are those preceding the immediate evidences of the effusion. They may be reinforced by loss of memory and stupidity, and after a few months there may be a transitory loss of consciousness and incomplete hemiplegia which is characterized by much hyperaesthesia. The phenomena of the attack are thus described by Huguenin : l " Se- vere headache just before the attack ; after loss of consciousness has occurred, contracted pupils, not reacting ; in a few cases, paralysis of the facial nerve, on the side opposite to that of the haematoma ; sometimes hemiplegia. These latter symptoms only occur in one-sided hemorrhages. A marked change in the color of the face is another of the symptoms re- j>orted. At the commencement of the attack, which is usually suddeo ; the face becomes flushed ; the pulse is full and rapid, but soon grows small and irregular, and pallor succeeds the flushing. In some cases the pulse is slow ; in others there is an increase in rapidity, continuing up to the time of death. Contractures of the extremities, and slight transitory twitchings, were present in a few cases." 1 Zicmssen, Cyclopedia of the Pract. of Mod., translation, vol. xii. page 409. CHRONIC PACHYMENINGTTIS. 41 Instead of hemiplegia there may be one-sided convulsions, but these depend very much on the degree of pressure exerted upon the cortex- cerebri. The condition, strange to say, is sometimes arrested after an indefinite period, and there is a return to the normal state, but traumatic htematoma is usually fatal. Schuhberg 1 assents to the view held by Herschl, Virchow, and Cruveil- hier, that ha?matoma is always the result of fibrinous inflammation, and believes that the prognosis is grave. In this paper he considers the dura- tion of a fatal case to be about one month. Causes Ha?niatoma is a disease of adult life, and twenty-two per cent, of the cases collected by Huguenin were between the seventieth and eightieth years, and Durand-Fardel found that 77.4 per cent, of all cases were men, and 22.6 per cent, were women. As causes may be mentioned various cachectic and other diseases, among them Bright's disease, scurvy, syphilis, typhus fever, rheumatism, smallpox and scarlatina, alcoholism and sunstroke, or any condition which is conducive to continued hyperzemia of the dura mater. Morbid Anatomy and Pathology The process involved in the production of hrematoma is an exceedingly complicated one, consisting in the production of new vessels and new layers of fibrine due to the ex- travasation of blood. The first layer of this new tissue-formation takes place in contact with the arachnoid, and ultimately others form and be- come organized. The formation of the blood-cyst is due to the rupture of one of the new vessels, and the extravasation becomes surrounded by a layer of tissue which may be so firm as to preserve the cyst contents un- changed. This is particularly the case in the smaller cysts. The skull is sometimes found to be thin as seen by Hyrtl, 2 but this is not common, and some writers, among them Textor 3 and Rokitansky,* consider that the reverse is to be seen in a greater number of cases. I may briefly enume- rate the post-mortem appearances as follows : Beneath the dura mater may be found a layer of coagulum which contains fibrinous shreds binding it to the membrane itself. If the case be of long duration several layers of false membrane containing bloodvessels are to be found attached to the dura, and the late formations may be distinguished from those of early origin. Between these layers it is not unusual to find the results of inter- stitial hemorrhages which exist as blood-clots in different styles of organi- zation. The thickening of the dura mater is thus described by Fox : " In the non-purulent form of the new formation, the result of inflamma- tion becomes very quickly the seat of vessels and is composed of several layers ; those nearest the dura mater being composed of compact lustrous connective tissue fibres almost as dense as the dura mater itself, whilst the layer further removed from the dura mater is rich in cells with small 1 Schmidt's Jahresbericht, vol. 104, pp. 164, 165. 2 Hyrtl, see Ziemssen's Encyl., vol. xii. Am. Tran., Art. " Meningitis." 3 Textor, AVlirzburg Yerhandlung, vii. 1857. * Rokitansky, quoted by Huguenin. 42 DISEASES OF THE CEREBRAL MENINGES. iwrrow vessels, and the layer nearest the arachnoid, often firmly uniting the arachnoid to the dura mater, is remarkable for very large capilla- ries." The size of the lurmatoma may vary from that of a small bean to that of an orange, and in one case, the autopsy of which was made by Dr. Huber of the Colored Home, the blood-cyst covered one entire side of the brain, and was fully an inch in depth. The patient was under the care of Dr. "Whitall, who kindly contributes the following notes : P. B., 00, widower, X. Y. ; mulatto; father, mother, and one brother died of phthisis. The patient has been intemperate, but now drinks only in moderation. He denies venereal disease; twenty-five years ago he had smallpox, and has since had intermittent fever and cholera. His trouble dated from an injury seven years ago. He was thrown from a hay-truck to the ground, falling upon his head, and causing blood to flow from his left ear; but he was able to walk to his home, one mile distant. He seems to have received no very serious injury, if we may judge from the immediate symptoms. Since the fall he has been troubled with head- ache oft' and on, increased by approaching a fire. He cannot appreciate the ticking of a watch pressed to his left ear. About a fortnight ago he had a chill, fever, and cough, some pain in back, with soreness around the whole gluteal region. Urination was slow, disturbed, and at one time he was unable to pass water; at another it would be too free; has been growing weaker since. June 15, 1874. On admission patient was confined to bed; owing to apparent weakness in lumbar region he was unable to stand. In a few days he began to improve under the administration of iodide of potash. "Walks with a staggering gait, and cannot follow a straight line. On closure of eyes does not have a tendency to fall. Heavy expression of countenance. No diminution in acuteness of sensibility can be discovered over any portion of the body. Had incontinence of urine on admission; is not so troubled at present time. Can walk about the ward ; at times can dress without assistance. To-day complains of frontal headache; sleeps very soundly, with stertorous breathing. Appetite good ; bowels constipated. 24M. Staggering gait, and inability to walk in a straight line, still pre- sent. If he closes his eyes while standing, there is a tendency (which by an effort he can overcome) to fall backward. Complains of pain on right side of head and face; sleeps most of the day in a chair; at night snores loudly. Bowels constipated. Nocturnal incontinence of urine exists. Feb. fi, 187"). To-day, while patient was sitting in a chair, he had a convulsion, and then becamo comatose. Urine albuminous. Ordered ol. tiglii n\\\, after the action of which he appeared much better. 15th. Very little change in patient's general condition since above note. Is still apathetic, and complains of pain in head, on right side especially. There is still right facial paralysis, with somewhat di- minished sensibility in this region. The tongue deviates, if any, to the right. Pupils normal in size and reaction. No notable change in hear- ing. No loss of motion, though the right arm and leg are weaker than the left. The lower limbs (left more readily than right) can be drawn upwards, and extended with little trouble. lie is unable to walk or stand without being supported, as the right leg gives way ; complains of con- CHRONIC PACHYMENINGITIS. 43 sidorable pain in the upper portion of the limb. Has occasional involun- tary passages of urine and feces ; as a general thing, however, the bowels are confined ; urine evacuated with considerable force. March 19. Appears to be losing strength very rapidly. Will not an- swer when spoken to. Temp. 99. 21 st. Died about 9 P.M. comatose. Autopsy, 36 hours post-mortem Rigor mortis marked. Body slightly emaciated. The dura mater was found very firmly adherent to the calvarium to the right of the longitudinal sinus, and over a considerable portion of the con- vexity. After removing the dura mater, the pia mater on the left side was discovered to be unusually dry and somewhat congested, with here and there slight patches of lymph. The convolutions throughout this hemi- sphere were greatly flattened, and the sulci nearly obliterated. In the right cranial cavity a large haematoma existed. The tumor pear-shaped, with larger extremity anteriorly, extended from the anterior portion of the second frontal convolution to the posterior portion of the second tem- poral, and from within an inch of longitudinal fissure to junction of lateral portion with base of skull. The right hemisphere was correspondingly compressed downwards, backwards, and to the left. The depression corresponded to the shape of the tumor, and was so situated that the greatest amount of pressure came upon the left lateral ventricle. The dimensions of this growth were as follows : 6^ inches antero-posteriorly ; 4 inches vertically in greatest diam- eter ; and about 2 inches in thickness. In addition to the luvmatoma, a serous cyst (about the size of a hickory- nut), evidently originating from an old hemorrhage in the subjacent brain structure, the cicatrice of which still remains, was seen beneath the an- terior lobe. Back of this another cyst, the walls of which were chiefly composed of softened brain tissue, was discovered, which, upon closer investigation, was ascertained to be continuous with the right lateral ven- tricle through the middle cornua. The right ventricle was greatly dis- tended by serum, w r hile comparatively little could be detected in the left. In the left ophthalmic artery a long, slender clot, partly dark and partly translucent and yellowish, existed. No thrombi were noticed in the slightly atheromatous arteries at the base of the brain. No connection existed between the pia mater and the hoematoma ; the relations between it and the dura mater were so intimate as to require dissection before a separation was possible. The petrous portion of the right temporal bone was considerably larger than the left, and, upon section, proved to be much more porous. No other abnormalities were present; no evidence of fracture at the base. The way in which the tumor, though situated on the right side of the brain, pressed upon the left ventricle, explained the symptoms which, during life, pointed to an involvement of the left side ; and also offered an explanation as to the manner in which the fluid was forced through the middle cornua of the right ventricle. Heart Very flabby; cavities dilated, and filled with dark coagula. Aortic valves were slightly thickened, and the artery was atheromatous. Mitral valves thickened. Lungs The right was firmly bound to chest; very soft and congested. The surface was studded with pigment. 44 DISEASES OF THE CEREBRAL MENINGES. The left had also become adherent to parietes, and, at the apex, a few softened, cheesy points were discovered. Spleen Enlarged and congested. Liver. Normal. Kidneys Cortex somewhat thicker than usual; both organs \\. TV waxy. Weight of the organs. Heart, 10 oz. ; spleen, 7 ox. ; liver, 55 oz. ; right lung, 29 oz. ; left lung, 18 oz. ; right kidney, 6 oz. ; left kidney, 5 oz. Prognosis The existence of a blood tumor of this kind is not always a serious matter. Even after two or three extravasations have occurred, a retrogressive course takes place ; but this is rare. Griesinger 1 reports a case in which partial recovery has taken place; and in 1870 the patient was still alive, and presented slight evidences of his former serious trouble. This termination of the disease is exceptional, however. Treatment What has been said in regard to the management of uncomplicated pachymeningitis is applicable in this disease ; and, in addi- tion, venesection has been advocated by more than one authority. It should be employed during the comatose stage which marks the occurrence of an effusion, and at the same time a drastic cathartic will be found to be of excellent service. High living and excessive use of tobacco and alcohol are to be interdicted, and iodide of potassium may be given with the idea of producing absorption of the new growth. ACUTE CEREBRAL MENINGITIS. The term meningitis has been applied, clinically speaking, to that form of inflammation which involves chiefly the arachnoid and pia mater, and in its acute form may be expressed by the following grave and alarming symptoms : Symptoms These may be divided in regard to their appearance into three stages: 1st. The stage of excitement or irritation; 2. The stage of delirium ; 3d. The stage of stupor. An hypothetical case may be presented. The patient complains of a slight headache, which increases towards the end of the first twenty-four hours. It may not be attended by much annoyance, and he is usually able to attend to his daily duties. But during the succeeding six or eight hours it may become greatly aggravated, and is attended by restlessness, flushing of the cheeks, throbbing of the temporal vessels, and general dis- comfort. After a few hours there may be slight rigors or a severe chill, which is often mistaken for ague; and the rapid elevation of temperature, and hard, bounding pulse may strengthen the suspicion. The headache continues, and is still not confined to any particular locality, but is so intense that the patient peeks his bed, where he may lie, moaning, sighing, or toss- ing restlessly to and fro. The muscles of the legs may twitch, and the 1 Archiv der Hcilkunde, 1862. ACUTE CEREBRAL MENINGITIS. 45 least noise, such as the creaking of a door, invariably irritates and startles the invalid ; bright lights distress him, and he closes his eyes instinctively. He keeps his hands over his ears so that he may not hear noises in the room, or firmly presses his aching temples. There maybe vomiting which is not dependent upon the condition of the stomach, is not attended by retching, and occurs whether the stomach be empty or full. If the patient be a child, there are generally convulsions of a very violent character. These constitute the first stage. Active delirium usually appears during the first two days, and continues through the greater part of the second stage. The patient screams in an agonizing manner, and alarms those who may be with him, adding greatly- to the distressing character of his sufferings. The delirium now begins to subside, or may be supplanted by coma. The temperature becomes lower, and the pulse loses much of its force and rapidity. The head is hot, and the respiration becomes irregular and sighing. The bowels, which were constipated in the first stage, still continue so, and the tongue is coated with a dirty-white fur. There may be convulsions at this time which Txamskill 1 says may precipitately throw the patient into the third stage, which is one of collapse. This stage may resemble that of advanced ty- phoid. Sordes on the teeth, pinched features, dark circles about the eyes, fluttering pulse, great prostration with loss of muscular power, dilated pupils, stertorous breathing, and the unconscious passage of feces and urine, are all forerunners of death. Should the force of the inflammation be exerted at the base, the symptoms are much more violent, and para- lyses of cranial nerves are not uncommon. Causes In considering the predisposing causes of acute meningitis it will be well to inquire what are the influences of sex and age. The re- ports of the New York Board of Health show that during the years .1867, 1868, 1870, 1871, 1872, and 1873 there were 4321 deaths from menin- gitis in the city of New York, 2506 of whom were males, and 1815 females ; 3434 were children under 5 years; of these 1873 were males, and 1561 females. It will therefore be seen that males are more often affected than the other sex, and that the large proportion of cases occur among children. Eilliet and Barthez take an opposite view of the matter, and consider the disease to exist more frequently after the fifth year. My own expe- rience and the Health Board's statistics lead me to think that after this period of early life, the adult cases are comprised in the interval between the twentieth and fiftieth years, and I am unable to find the records of many cases after the sixtieth year, and am therefore disposed to believe that the disease is rare after that time. Various predisposing causes give rise to the affection, and none, I think, plays a more important part in the production of the adult variety than continued dram-drinking and hard work in warm places. Over-use of the mental powers, and various disorders, such as syphilis and gout, are favorable to its development. Croupous pneumonia, acute rheumatism, diphtheria, extension of dis- 1 Article in Reynolds' System of Medicine, p. 369, vol. ii. 46 DISEASES OP THE CEREBRAL MENINGES. ease from the tympanic cavity, blows upon the head, and sudden changes of temperature of any kind, are the direct causes of acute meningitis. In one of my cases the disease was the result of a sea-luith/ The patii-nt. after bathing, sat for some time with uncovered head upon the bench < x- posed to the heat of a noonday sun. Haeddeus 1 reports a case of this disease which resulted from typhoid fever. Diagnosis Acute cerebral meningitis may be mistaken or con- founded with cerebritis, typhoid fever, or delirium tremens. The th of February to the 3d of March sixteen baths were administered at a temperature varying from twenty-one to twenty-five degrees (Centi- grade), and the duration of each bath was twenty minutes on the average. The patient always raised the temperature of the water from one to two degrees, and, on leaving the bath, his own temperature fell to thirty-six degrees. After several fluctuations and much anxiety on the part of the medical attendants, the patient eventually recovered completely. MENINGITIS OF THE AGED. According to Prus, 1 meningitis of the aged rarely presents the same symptoms as do the forms of early or middle life. In the morning the old man or woman is stupid, but conscious ; speech is thick, and there is general headache and moderate fever. The warmth of the body is nearly normal, except at the head, where it is markedly increased. In the even- ing it is elevated. The eyes are injected, and there is low delirium. Incoherency and restlessness, during the night, and an uneasiness which is expressed by walking about the house and going from one bed to the other, are mani- festations which are characteristic. 8 If the disease is to end fatally, the patient becomes comatose, and dies within a week, or twenty days at the longest, from the commencement of the disease. These patients very often suffer for some time before the actual attack, when there may be partial paralysis, slight wandering of the mind, and insomnia. The gene- ral indications for treatment of the other forms are applicable in these cases. ACUTE GRANULAR (TUBERCULAR) MENINGITIS. Dr. Robert "VVhytt'was the first to describe this disease, and so satisfac- torily did he do so, that even after a hundred years there is very little to add to his accurate description. AVe shall have to study the disease as occurring in two different ways. It may be primary, and have a doubt- ful tubercular character, or may occur in connection with some thoracic 1 Quoted by Grisollc, vol. i. p. 430. * Kamskill speaks of the eccentric behavior of these patients, who may use the spittoon instead of the chamber pot, or commit other violations of decency. In one case which came to my knowledge, the patient urinated against the bed-post, and went about the house with his trowsers unbuttoned. 3 Works of Dr. Whytt, Edinburgh, 1768. ACUTE GRANULAR MENINGITIS. 53 or abdominal disease, and like the other forms of meningitis, may be con- fined to the base or convexity. Symptoms Though many of the symptoms are the same, there are a few general points of difference, which are the following : Predominant Symptoms. BASAL. VERTICAL. Vomiting, constipation, infrequent or Convulsions with intervals occupied irregular pulse, unequal pupils, stra- by^remor, twitching of limbs and mus- bismus. cles 'of face, turning of thumbs in on palms, clenching of fists, frequent pulse. "When the base is involved, the symptoms may be grouped in three stages, which run their course in from four to twenty-one days. The child may be puny and delicate. He may lose flesh and complain of headache. His skin may be white and waxy, and there may be a ten- dency to flushed cheeks, loss of appetite, and capriciousness about food, and at night he does not sleep soundly, but starts and cries out. I have known children to seek the companionship of some other member of the family, fearing to be left alone. The child may moan in its sleep, grind- ing his teeth and lying with eyes widely opened. During the day he is disinclined to play, and seeks some quiet place in which to fall asleep or remain by himself. Study is irksome, and so are all other forms of men- tal application. Irritable or languid, he attracts the attention of the mother by his behavior, which is so markedly changed. During this period I have found that headaches and crying-spells are not uncommon precursors of the next stage, which may begin after two or three months. Stage of Development Marshall Hall, 1 in his description of the hydrocephaloid diseases, alludes to the importance of vomiting as an early symptom. " The most frequent and formidable in appearance is vomiting. Never, never allow vomiting in an infant to pass without paying the utmost attention, and making the strictest inquiry in refer- ence to the functions of the brain." Vomiting is generally the first and most important symptom, and convulsions are next in importance, but these two may be associated or appear alone. Vomiting may be frequent, and is nearly always accompanied by an aggravation of the symptoms of the premonitory stage. Headache and increased temperature are pre- sent, and are very decided evidences of the gradual development of the trouble. When we arrive at this stage, which lasts two or three days, we may expect the appearance of the following symptoms : A marked rise of temperature, say from 101 to 105 F., with greatly increased pulse. The bowels are still constipated, and there is but little appetite. The patient is delirious at night, and shrieks, cries, and tosses continu- ally. At about the sixth or seventh day, there are various local troubles, such as unequally dilated pupils, slight strabismus, but no actual loss of consciousness as yet. There is a slight increase in the evening tempe- 1 Lecture on the Nervous System and its Diseases, L. and E. Philadelphia, 1836, p. 92. 54 DISEASES OF THE CEREBRAL MENINGES. rature, and the pulse is irregular and ranges from 110 to 120. The tenth day finds him much worse ; his excited condition being supplanted by one of stupidity. He does not recognize those in the room, and is utterly indifferent to the kind attentions of his mother or nurse. "When the finger is drawn across the skin it leaves a vivid red mark, which lias been considered one of the strong pathognomonic signs. The pulse is greatly accelerated, and perhaps reaches 170, while the temperature may be found to be 104 or 105. His condition during the tenth and eleventh days is very little changed, though the apathy is if anything exaggerated. The belly is retracted, and his facies is highly characteristic, the patient having a worn and pinched look. The skin is dark and congested, and his eyes may be fixed and immobile, and there may be either strabismus or a rolling upwards of both eyeballs, so that a large part of the sclerotic is exposed. Subsultus tendinum and " picking at the bedclothes," with involuntary passage of feces and urine, are grave forerunners of a fatal ter- mination. The pupils are dilated, the pulse small, thready, and quick, and respiration is very slow. The temperature is still high, though the surface may be cold and clammy, and just before death the pulse quickens and becomes almost imperceptible. Slight rigidity now becomes apparent, the patient cannot swallow, stertor follows, and then death. Marshall Hall 1 tersely describes this last stage as follows : " The third stage is denoted by coma and its concomitant diminution of the sentient and volun- tary system, and eventually of the powers of the excito-motory system. There are blindness, deafness, deep stupor, absence of voluntary motion. At first the eyelids are constantly half closed, but still close completely on touching the eyelash. Afterwards this excito-motory phenomenon ceases. The respiration becomes irregular, alternately suspended and sighing, and at length stertorous. The sphincters lose their power, and the feces and urine are passed unconsciously." The appearance of the little patient just before death, is unmistakable. He lies with knit brow and flushed face, one side of which is drawn, while the eyes are fixed and glassy, and utterly devoid of expression. The duration of the disease rarely exceeds twenty-four days. It will be well to dwell more fully upon certain symptoms. Temperature. There seems to be at first an elevation of temperature, which lasts through the first few days, say three or four, and after this time the temperature falls, until the sixteenth or eighteenth day, when it may either go much lower, or be again increased. The variations are between the normal standard 98.2, and 105. It however rarely reaches this high point. The sur- face temperature of the body is much diminished during the latter stages, but the head is always hot. Pulse Infrequent and irregular pulse is characteristic of the earlier stages of this disease, and during the last days there is increased frequency and more evenness. During the first two weeks this infrequency is to be observed, but after this it may steadily increase ten, twenty, or thirty beats more each day until at last it cannot 1 Op. cit., p. 93 ACUTE GRANULAR MENINGITIS. 55 be counted. This rule is not without its exception, and I have found intervals when both temperature and pulse would fall to the normal stand- ard, and continue so for some days, and afterwards rise. The pulse is Illustrative Chart of Temperature. Pulse and Respiration Variations in Acute Granular Meningitis. Days of Disease. Sjior S |106 C H 105 * 104 103 99 98 180 170 160 150 120 110 100 90 80 70 60 50 I 45 ! I 40 35 30 _?! 2Q_ 15 ^ \ 2. /q/3/4 MEMEMEME /6 n X. B- A. Indicates sthenic chai-acter. B. Indicates irregularity. perhaps more rapid when the disease is being developed. I append a chart, which will enable the reader to see at a glance the condition of 56 DISEASES OF THE CEREBRAL MENINOES. pulse, temperature, and respiration in a typical case. Various modifica- tions of the cutaneous circulation have been dwelt upon by Trousseau and various writers. There seems to be an extensive disturbance of the vaso- motor distribution of the skin, and when the surface is brushed or rubbed ever so lightly, or even when slight pressure has been made by the pillow, there will remain a bright red mark. This condition of the cutaneous cir- culation is not limited to the integument of the head, but may be present, especially towards the end of the disease, over the whole body. Trous- seau 1 has called attention to the " tache-cerebrale," which is the name given to the appearance presented when the finger is passed over the sur- face, and a red line remains. This author finds that when he made cross-markings upon the abdomen, in less than half a minute the portion of skin which he had touched was suffused with a very bright red tint, which disappeared slowly, the lines made by the finger-nails remaining after the others had faded out. The regions where this redness is produced most easily are the anterior parts of the thighs, the abdomen, and face. Respiration There are the usual fall and irregularity which accompany collapse of all kinds ; and sighing and diminished respiration are features of the later stages. Sensorial Dis- turbances Headache of a deep and throbbing character is very severe and continuous, lasting until coma supervenes. Various indications of the patient's sufferings are conveyed by his behavior. He presses his thumbs against his temples, or locking his finger on top of his head, holds his head in his hands, and gives vent to suppressed groans or shrieks, holding his breath sometimes as if fearing that the very effort of expiration might increase the pain. The cry of the patient is heart-rending, but I am not disused to agree with Trousseau that it has any decided periodicity, though there may be intervals of silence. Hyperaesthesia of the scalp, photophobia, and tenderness of the muscles at different parts of the body are usual accompaniments. Bertalot 2 of Pfeddersheim, in an analysis of 24 cases, has found photophobia to be more commonly a symptom of the later stages, in which conclusion I am inclined to concur. The psychical symptoms are present in every case, though delirium is not so common among very young children, and when it does occur is followed by a state of semi-consciousness, and finally by coma. The patients will not speak, rebel against food and interference of any kind, and after a time it is very difficult to arouse them. One very interesting fact is that the coma is never sudden, but is preceded in every instance by either somno- lence or delirium of the muttering variety. The coma sometimes becomes less profound in character, and there may be a lucid interval before death. Mot o rial Disturbances The eyes are nearly always affected; and the ocular trouble is either strabismus, ptosis, or a pupillary change. The former is an early symptom, and is probably the first indication of para- lysis of any kind, and is seen most perfectly when a patient is awakened 1 Lectures upon Clinical Medicine, Am. edition, vol. i. p. 877. 2 Jahrbuch Air Kinderheilkunde, B. 9, H. 3. ACUTE GRANULAR MENINGITIS. 57 or aroused. The pupils are sometimes unequally dilated, but when the coma supervenes dilatation is complete ; pupillary changes are, however, by no means constant. Unilateral paralysis is not rare ; some of the facial muscles being alone affected, or there may be extensive hemiplegia, which is an advanced symptom. Spastic contractions are evidences of a condition of central irritability; and rigid flexion of the muscles of the thumb, or muscles of the sub-occipital region, are examples of this kind. The patient com- monly lies with his thumbs drawn into the palm of the hand and covered by the fingers, and it is sometimes difficult to open the hands. I have alluded to convulsions, and in addition may say, that they are more prominent in the first four days, and vary in severity if the coma be either, very deep or there is a condition of semi-consciousness. In the latter case they may involve isolated groups of muscles. Ophthalmoscopic Signs Bouchet, 1 Galezowski, 2 and numerous ob- servers have called attention to the value of the ophthalmoscope as an instrument for diagnosis in tubercular meningitis. The latter has found two forms of neuritis as evidences of this disorder ; one a peri-neuritis, and the other an inflammation of the optic nerve itself. "Whiteness about the papilla, deposits of granular matter in the choroid, and tortuosity of the retinal vessels, are appearances which have been described by others. Frankel 3 and Steffen found tubercle in the choroid some weeks before the invasion of the disease ; and Broadbent, 4 in examining the fundus, dis- covered that the optic disks were dusky red, and mottled by white spots ; and the retinal veins were enlarged, while the arteries were very small. Tubercular meningitis of the convexity presents no Ophthalmoscopic signs. ACUTE GRANULAR MENINGITIS OF THE CONVEXITY. In the table I presented when speaking of the basal division of this dis- ease, I mentioned the prominent symptoms of this variety. When I add that delirium and other decided psychical symptoms are highly charac- teristic of inflammation of the vertical region, I have described the differ- ence between the two forms. This variety runs its course in a much shorter time, death generally resulting in from a week to ten days. When the malady (either basal or vertical) occurs in conjunction with certain tubercular affections of the lungs or peritoneum, there are local symptoms which precede those of the meningeal disorder, but the invasion of the disease is often very sudden. Constipation, followed by a typhoid state and drowsiness, are the precursors of meningitis when antecedent 1 Du Diagnostic des Maladies du Systfeme nerveux par 1' Ophthalmoscope. Paris, 1866. 2 Arch. G6n., 1867, vol. ii. p. 262. 3 Virchow's Jahresbericht, 1869, p. 621. 4 Trans, of London Pathological Society, vol. xxiii. p. 216. 58 DISEASES OF THE CEREBRAL MENINGES. lung disease has existed. Not only may children be subject to this dis- ease, but adults are as well ; and we sometimes find it as a sequence of various zymotic diseases, typhus or typhoid, remittent and other fevers, as well as pulmonary tuberculosis. A marked elevation of the evening tem- perature, incomplete hemiplegia, vomiting, or convulsions, are the promi- nent features of such a termination. Strabismus, unequal mydriasis, high pulse, and temperature, with some of the other symptoms which charac- terized the disease in the child, that have already been described, are generally present. It is sometimes so insidious in its approach and development as to puz- zle the observer. The phthisical patient may become listless, drowsy, or complain of headache. He often wanders and gives way to a mild form of delirium, which appears during the latter part of the day. This com- plication may occur during the early stages of the pulmonary affection. Causes The question of diathesis naturally arises before any other, and we are immediately puzzled, for on one side we find that Rokitansky, Robin, Empis, Clark, and others consider the disease hot to be directly connected with the tuberculous diathesis, and they go so far as to question the identity of the granular deposit in the brain with tubercle; while arrayed against them are Rilliet, Barthez, Grisolle, and a host of others who are equally positive that it is in every case an expression of tubercu- losis. Leaving the discussion, which is by no means settled, as the nature of the deposit needs much more investigation than it has received, we may assume that the affection is usually associated with a "scrofulous" cache- xia; that it appears among children who are badly nourished, and in whom the nervous diathesis is well developed. That exposure, insufficient food, and various exciting causes, such as dentition and over-study, produce it, no one will, I think, deny. In some instances and these are by no means few it is impossible to find any hereditary tuberculous history. As to age, we may consider that the so-called primary tubercular menin- gitis rarely occurs after the fourteenth year, and it is probable that a great many of such cases are unattended by tubercle, but by a granular deposit of simple character ; and primary tubercular meningitis in after life is, I think, a genuine tubercular disease. Watson 1 makes the statement that fifty children are attacked within the first five months of life to every one after that time. I have found it to be more common after the first year, between the first dentition and the fifth year, though general practitioners who see more of these cases undoubtedly find them before that time. In large cities the mortality is undoubtedly greatest in the summer months, when diarrhoeal as well as other diseases and high temperature are conducive to its development. In the year 1871, in the city of New York, 84 deaths from "tubercular meningitis" (the reported exciting cause being "teething") are recorded in the Health Board Reports, and the greatest number were found be- tween the sixth and fourteenth years, a fact which seems to be irre- 1 Practice of Physic, p. 270. ACUTE GRANULAR MENINGITIS. 59 concilable with the statement that it is generally connected with the first dentition. 1 The table presented below demonstrates that males are much more frequently affected than females, and of 169 deaths 91 were of males and 78 of females. Bertalot, already referred to, found that of his 24 cases fourteen were boys and ten were girls. Two cases occurred in the first year of life, seven in the second, five in the third, three in the fourth, three in the twelfth, and one each in the fifth, ninth, tenth, and fourteenth years. The youngest patient was ten weeks old. Twenty-two out of the twenty-four were attacked between November and the end of June. The children were all more or less delicate, they had frequently grown up under bad hygienic conditions, and were generally scrofulous or scrofulo- rachitic. In twelve there was a distinct hereditary predisposition to tuberculosis ; two cases supervened upon chronic coxitis ; one upon trau- matic erysipelas; two upon pertussis; one upon measles; and one upon the first signs of dentition. Morbid Anatomy and Pathology From the immense mass ot confused testimony before us (for the disease has been described by nearly every writer, from the time of Hippocrates), it is extremely difficult to say whether the post-mortem appearances are always those of a tuberculous character, or whether the granular substance is non-tuberculous, or again whether in some cases there is tuberculous deposit and in others simple granular collections. Paisley, who, Watson says, was the first to clearly describe the affection without saying much about its tuberculous nature, has given us a very admirable collection of facts bearing upon its morbid anatomy. Gerhard, 2 one of the early medical writers of this country, says : " It was not known, previously to the researches of Dr. Rufz and myself, that the tuberculous character of the disease was anything but a mere compli- cation." Guersent, Dance, Hennis, Greene, and others shared in Ger- hard's opinion, that tubercular meningitis was a " strumous" disease. Rufz 3 collected 40 cases, and in every instance there was complicating pulmonary tuberculosis. 1 An inspection of the table prepared by Dr. C. P. Russell, in the Report of the Board of Health of the City of New York for 1870, will enable the reader to perceive the preponderance of mortality before the second year of life. Nativity. Color- Pm lor ed. 1 1 2 3 4 5 10 13 20 25 L'. S. For'n. year. M. P. M F. M. F. *r V. M. F. M. F. M. F. M. F. M. F M. F. M. F. M. F. M. F. 82 76 92.. ;; ) 2S 17 i!l 14 8 A 4 7 7 3 4 4 1 Also five males of 30, one of 50, and one of 55; this cause of death was .62 per cent, of the combined cause. 2 Dunglison's Prac. of Med., vol. ii. p. 243. 3 Quoted by Marshall Hall, p. 94. 60 DISEASES OF THE CEREBRAL MENINGE8. FenwicW tables are valuable in displaying the distribution of tubercle in the affection. In one of these, sixteen cases of meningitis occurring in tubercular patients are detailed in which tubercle was found in the lungs and other organs, but not in the brain. In these cases, of which ten were males and six females, there was tu- berculous dej>osit in the lungs in every instance, and in some of them other organs were affected. Positively nothing like tubercle could be found in the brain, but this organ was either congested or anaemic. The membranes were " wet," and the ventricles contained fluid. Four cases were under ten years of age ; three between ten and twenty, and three between twenty and thirty ; four were in the fourth decade, and one in the fifth and sixth. In other cases brought forward by him of general tuberculosis, it was found that of fifty-four examined, nearly four-fifths of the number were below twenty-five years. All of these fifty-four had tuberculous deposits, both in the brain and other organs. The seat of the granular deposit seems to be chiefly the arachnoid and pia mater, though the dura mater has been found as well to be the site of granular accumulation. It is scattered mostly along the base of the brain and about the large arteries, where it may be found to consist of masses of little round pearly or yellowish bodies which may be almost as small as grains of coarse corn meal. The meningeal arteries are dotted over with these granules, and when the arachnoid is raised numerous underlying miliary granules are exposed. Fig. 10. Tuberculous Matter about the Vessel*. (Cornil and Ranvier.) A. Tuberculous deposit. B. White blood-corpiiHcles. C. Granular contents of vessel. The membranes are all more or less congested and dotted with opaque spots or patches. The cortex is hyperaemic and the ventricles distended by fluid. Their ependyma is toughened and rough, and presents a granu- lar apj>earance which may be likened to that of a piece of white shark's skin. Softening of various parts of the brain, the nerve trunks and optic 1 St. George's Hosp. Reports, vol. vii. p. 35. ACUTE GRANULAR MENINGITIS. 61 commissure are not uncommon evidences of the violence of the disease. Patches of false membrane which contain in their meshes these granular bodies are scattered over the convexity and base, and render the removal of the brain or its membranes separately a somewhat difficult matter. The lungs, or other organs, may also present indications of tuberculous matter. Rendu 1 affirms that whenever there is paralysis of permanent form there must be some arterial obliteration from fibrinous exudation and consequent softening, and he does not believe that scattered granulations or ventricu- lar effusion are alone sufficient for its causation. It is rarely possible to very closely localize limited deposit before death, but occasionally this may be done. A very interesting case is reported by Raymond which presented seve- ral suggestive points. One was that the motor centre of the right arm was the seat of granular lesion, and that there was paralysis of that mem- ber. This, then, is an exception to the rule to which I have just re- ferred. " The patient, a man twenty-two years of age, was admitted into the hospital in the early part of the month of January last, and then presented obvious symptoms of pulmonary tuberculosis, not, however, very pro- nounced. The affection, indeed, seemed fib be progressing slowly. He was thin, pale, coughed a good deal, and was a little feverish. " On January 28 he began to complain of violent pain in the right hy- pochondrium, and two days later vomiting came on. This recurred fre- quently, the ejected matter having a greenish color. At the same time he suffered from severe headache, which affected chiefly the left side of the head. Fever then showed itself, the temperature rising to 140; the pulmonary lesions developed more rapidly, and the general condition be- came much worse. On March 24 he complained of great pain in his right arm, which seemed to be very heavy ; at times he had great difficulty in moving it. On March 25 there were fresh pains in the arm, and motor paralysis was complete, sensibility being retained. In the evening, with a great effort, he succeeded in raising his arm to his head. The paralysis of the arm, up to the time of his death, presented the character of inter- mittence. There never existed any trace of paralysis in the right leg nor in the left arm or leg. Perhaps there was a slight degree of loss of power in the bucco-labial muscle of the right side, and a slight deviation of the tongue to the left, but these symptoms were a little doubtful. In the whole case, there was nothing else comparable with the paralysis of the arm, which was indisputable. The patient died on April 4. " At the necropsy, far advanced tubercular lesions were revealed in the right lung, and the membranes of the brain were found to be the seat of tubercular granulations. These were found in the pia mater over the right lobe, and there they were disseminated along the parietal branch of the Sylvian fissure. On the left side, in addition to the tubercular granu- lations, there existed some meningitis with purulent deposits. The men- ingitis was, if it may be so said, circumscribed and localized on two con- volutions, the anterior and posterior marginal near the paracentral lobe. 1 Review in Gaz. des H6pitaux, Jan. 15, 1873. 62 DISEASES OP THE CEREBRAL MENINGES. There the tubercular granulations were very numerous, and formed a sort of tumor. The piu muter, covered with pus, adhered closely to the sub- jacent cerebral tissue. In other parts, where there were granulations, there was no vestige of meningitis. No other cerebral lesions, foci of softening, or obliteration of capillaries, could be discovered. There was a small amount of fluid in the ventricles, but nothing to note in the spinal cord or nerves of the arm. " Such are the facts of this case, which may be summed up as follows : Motor paralysis of the right arm, somewhat intermittent in the sense that it was at times complete, and at other times less absolute ; and to explain this paralysis no other lesion than the tubercular meningitis in the region of the motor centre of the arm." 1 Prognosis No inflammatory disease of the brain or its membranes is more serious or rapidly fatal than is this. The termination is in death in from two to three weeks, though very rarely recovery may take place be- fore the disease has gone beyond the period of invasion. The ophthal- moscope is our best friend at this time. If there be optic neuritis, and basilar meningitis is suspected, there is very little comfort to be derived from such an examination. If the child recover, it will be with impaired intellect, epilepsy, or some other serious life-long trouble. An anonymous writer in the Gazette Medicale upon the treatment of tubercular meningitis, says that, in a practice of thirty years, he has seen 'between eighty and ninety cases, and during that time there were but two recoveries. 2 Bierbaum* has reported three recoveries. Diagnosis. This disease may be mistaken at different stages for several other acute conditions, viz. : A. Typhoid fever typhus fever. B. Scarlet fever or smallpox. C. Pleurisy or pneumonia. D. Eccentric irritation, such as that produced by worms, etc. E. Other forms of meningitis. F. Exhaustion. A. Typhoid, in some of its forms, or typho-pneumonia, may resemble f tubercular meningitis, either of the primary or secondary forms. This is especially the case when typhoid symptoms are added to those of phthisis. The irregular varieties of typhoid are attended by absence of diarrhoea, tympanites, and other abdominal symptoms. The eruption of typhoid may also resemble the tache ce're'brale of this form of menin t. i. d. Sept. 14, entirely relieved. A menstrual period was afterwards passed without pain. CASE II G. J., 31, clerk. At his desk many hours daily. Complains of confusion of ideas, inability to fix his mind upon his work, indisposed to exertion, smokes to excess, insomnia, and incapacity for work. The top of his head is hot, and the conjunctivas injected. HBr. 5j t. i. d. Complete relief in a week. This condition had lasted several months. CASE III Mr. D., 36, " man about town." His habits are bad ; drinks hard, and keeps very late hours. Is being treated for syphilitic trouble. Has had head-fulness, insomnia, indisposition to take exercise, gradual loss of memory for the past ten years. He formerly masturbated. Very hysterical and worried about himself. There are many dysaesthesiae, but also .evidences of head-trouble. The eyes are red, prominent, and watery, and the temporal vessels stand out like cords. At night his sleep is troubled, and it is some time before he can forget himself. His urine contains phosphatic deposits. HBr. 3J? t. i. d., before eating. Two months after (Sept. 15), perfectly well, except syphilis. CASE IV Miss M. E. R., 22. Insomnia is the condition which most annoys this patient, and when in bed her feet become cold. " It seems," she said, " as if all the thoughts I ever had were crowded into the long weary hours I pass before sleep comes." She fears insanity, and is in a pitiable mental state. The bromides have lost their effect. A drachm and a half of hydrobromic acid procured sleep the first night. With regard to diet and indulgence in alcohol and tobacco, tea or coffee, it is impossible to lay down any arbitrary rules. I may begin, however, by interdicting all the meats difficult of digestion, and recommending a non -nitrogenous diet. Veal, corned-beef, pork, and certain vegetables, such as cabbage, cauliflower; or nuts, spices, bananas, and other aromatic or fatty substances, are not to be thought of. Simplicity of diet is to be insisted upon. Meats should be broiled, roasted, or baked ; and vegeta- bles Iwiled. If the patient's comfort is dependent upon tea or coffee, it would be well to permit him to indulge in them to a reasonable extent. I do not consider tobacco is the dangerous agent that it is often said to be. If the individual be a smoker, I think his after-dinner cigar need not be cut off, and a glass or two of wine is not in the least harmful. Burgundy, Port, or other full-bodied wines should be given up as a matter of course. The abuse of alcohol and tobacco is to be looked after and stopped, if we have any reason to think that the patient has these bad habits. Open-air exercise ; cold baths, with friction ; or the Turkish bath, and other agents that tend to improve the cutaneous circulation, do a great deal of good, and are to be indulged in. We must insist upon the avoidance of excite- ment, dissipation, and late hours and theatre-going; and it may be well to lay before our patient what may be the result of such imprudence. Should we be called in to find that the disease has manifested itself in either of CEREBRAL HEMORRHAGE. 83 the forms I have alluded to (the apoplectic, convulsive, paralytic, or maniacal), we must order perfect quiet, darken the room, and use every means in our power to reduce the cerebral blood pressure. CEREBRAL HEMORRHAGE. Synonyms Apoplexy. Haemorrhagia cerebria (Lat.). Apoplexie cerebrale; hrematcencephalie ; coup de sang; haemorrhagie cerebrale (Fr.). Hirnapoplexieen (Ger.). Definition When through disease of a vessel its walls are unable to withstand the pressure of contained blood, a hemorrhage takes place, and the nervous substance in the neighborhood may be subjected to pres- sure. The severity of the resulting symptoms depends, of course, upon the importance of the parts which may be the seat of the accident, and upon the extent of the hemorrhage. Symptoms I have already alluded, when speaking of cerebral con- gestion, to light forms of hemiplegia of temporary duration, which were dependent upon slight hemorrhages resulting from cerebral congestion. We will now deal with a form of cerebral hemorrhage of a more serious character, and it may be stated that the brain is probably more liable to hemorrhage than any other organ, with the exception, perhaps, of the spleen. 1 Bastian has made the classification which I think it well to follow. He divides cerebral hemorrhage into three forms, in regard to the onset of symptoms : (1) The apoplectiform ; (2) the epileptiform ; (3) the simple, in which there is neither loss of consciousness, nor convulsions. The first may be considered as a sudden and profound loss of consciousness, which may or may not disappear ; but, if it does, a certain amount of hemi- plegia will remain. The epileptiform resembles the first, but, in addition to the coma, there are convulsions. As I have said, the simple variety may not be connected with any loss of consciousness, the patient, perhaps, awaking in the morning and finding himself deprived of power, or noticing such a loss when some movement is attempted. Prodromata Cerebral hemorrhage occurs generally in individuals in whom some well-developed chronic trouble has paved the way. This is the rule, although in many cases it may be the result of some recent dis- ease. When we come to speak of pathology and morbid anatomy, these general diseases, and their influence in the production of degeneration of the cerebral arteries, will be discussed ; it is only necessary now to describe the forms of expression of the preparatory stages. It is not always neces- sary to look for indications spoken of by Hughlings Jackson.* " The careful clinical observer considers minor degenerative changes, baldness, grayness of hair, the state of skin, and worn teeth. He inquires for the history of gout and intemperance." 1 Paralysis from Brain Disease, p. 14. * Cerebral Hemorrhage, "Reynolds' System of Medicine." 84 DISEASES OF THE CEREBRUM AND CEREBELLUM. The appearance of these individuals in whom an apoplectic effusion may be looked for, may be of two kinds. 1. The thick-necked, red-fac-< (). The patient, who is of full habit, short, red-faced, :md corpulent, had probably led a rather dissipated life. While reading his paper, after an unusually hearty dinner, he suddenly fell to the floor in an unconscious condition ; his breathing is stertorous, the cheeks and lips being puffed out by each expiration ; his face is dark, or perhaps very pale, the pupils dilated and insensible to light, and his eyeballs are fixed, turned upward, and drawn to one side. If the nostril be tickled no reflex movements follow, and the same is the case if the soles of the feet be titillated. He is limp, and lies upon the floor in an inanimate heap ; the pulse will be found to be hard and full, but not very rapid, and if his tem- perature be taken it will probably not exceed 97, or perhaps is half a degree lower. He is taken up and placed in bed, and after a while may make some slight voluntary movement with the limbs of one side of the body. It will be seen that the others are without power, for if the leg or arm of the paralyzed side be lifted and released it will fall to the bed as CEREBRAL HEMORRHAGE. 85 a dead weight. After an hour or two, tickling of the sole of the unaffected foot will be followed by a drawing up of the sound leg. The eyes are still rolled up and turned away from the paralyzed side of the body, and the edges of the ii-ides are covered by the inner canthus of one palpebral commissure, and by the outer canthus of the other. The eyeballs may be sometimes slightly agitated by a feeble movement of a nystagmic character. It will be found, on removing the patient's clothing, that he has unconsciously voided his urine and feces. This condition may last for a few hours, the coma remaining profound, and the temperature rising to 103 to 105 degrees, and the pulse advancing, when death takes place ; or it may be followed in an hour or two by slight signs of returning intelli- gence, an increase of temperature, say to 100, with slight abatement of the regular respiration, disappearance of stertor, and the unnatural devia- tion of the eyes, when his temperature may return to the normal standard, and the patient so far recover consciousness as to be able to recognize those about him, and express himself by simple words, as "yes" or "no." The urine has to be drawn for a day or two, and the bed-pan used, as the bladder and rectum are implicated. This form of cerebral hemorrhage may be connected with an epilepti- form attack in the beginning, and the convulsion may be either confined to one side or be general. It would be well, before going further, to dwell upon certain elements of the apoplectic attack and analyze the symptoms. THE PSYCHICAL DISTURBANCES. Sudden compression of the cerebral mass is always attended by uncon- sciousness, but it is a curious fact that slowly developed growths, such as large tumors or abscesses, seem to accommodate themselves to the sur- rounding tissues, so that sometimes no loss of consciousness occurs what- ever. I have seen a large abscess occupying an extensive tract of one hemisphere without producing the least loss of consciousness. The large effusions which produce unconsciousness are, in the opinion of Mr. Hutch- inson, 1 productive of the psychical condition, by inducing anemia of other parts through sudden pressure. Small clots are undoubtedly pro- ductive of suspended consciousness, by cutting off either a large vessel, or by injury to some important sensory ganglion at the base of the brain, such as the corpus striatum. Consciousness is either restored through the re-establishment of the blood supply or the subsidence of shock, except where the hemorrhage has taken place in the medulla.' 8 1 London Hospital Reports, vol. iv., 1867. 2 The variation in the loss of consciousness is of great importance to the ph ysi- cian, especially in regard to prognosis. In severe cases there may be slight improvement in this respect. The patient's intelligence returns to such a degree as to inspire his friends with some degree of hope ; but there is often a sudden relapse to the original state of coma, dependent upon fresh hemorrhage. 86 DISEASES OF THE CEREBRUM AND CEREBELLUM. RESPIRATORY DISTURBANCES. Stertor is an important symptom, and should always be looked upon with alarm. It is indicative generally of some lesion of the base, and nearly always lasts until death, if there be a very large effusion, but dis- appears after a few hours if recovery is to take place. Respiration under- goes very decided modification. Hughlings Jackson, 1 in speaking of disturbed respiration, says : " Again, not only is the rate of respiration to be considered, but the character of the respiratory movements are to be noted. As they quicken in rate, so do they become more extensive in range, though such respiration is still short. Thus in the first stage there may be only quiet action of the diaphragm, but at length the sides of the chest evert strongly in inspiration, the abdominal movement being less obvious, and at length the upper thorax takes part in the process. In severe cases the epigastrium sinks in during inspiration. This is probably partly owing to elevation of the attachments of the diaphragm from in- creased action of the sides of the thorax, and partly to pushing down of the diaphragm by increasing bulk of the lungs from congestion or oedema." CONDITION OF THE EYES. Prevost, 8 Vulpian, Lockhart Clark, and others were among the first to call attention to a peculiar diagnostic point which, though not always pres- ent, is of great value when it occurs. This has been known as " conjugate deviation." During the apoplectic condition the eyes of the individual will be fixed, so that they look upwards and outwards, towards the side of the lesion, and away from the paralyzed side of the body ; the only exception being when the lesion is in or behind the pons. It is more often seen when the attacks are sudden, and it is a phenomenon of short duration, Lasting at the most but a few days. During sleep the condition subsides, and the eyeballs are restored to their normal state, but imme- diately on awaking they return to this position, and in spite of the pa- tient's effort the axis of vision cannot be changed. When the effusion is a large one, or when the onset is epileptiform, the pupils are at first very wildly dilated ; but when there exists a lesion in the pons the pupil which corresponds to the side of the lesion is greatly contracted. Unequal dilatation, however, is not of very great diagnostic value. If a lesion in the pons be extensive, both are contracted. TEMPERATURE AND PULSE. Thanks to Bourneville, 3 we are enabled to study systematically the variations of temperature. He divides the cases into four groups: 1. 1 Op. cit., p. 548. * Gazette Hebdom., Oct. 13, 1865. 3 Etudes cliniques et thcrmometriques sur les Maladies du Systeme nerveux, Paris, 1872. CEREBRAL HEMORRHAGE. 87 Copious cerebral hemorrhage, rapidly fatal, and attended by lowered tem- perature. 2. Cerebral hemorrhage, terminating fatally in from one to two days, in which the temperature is primarily lowered and afterward height- ened. 3. Fatal cases in which death takes place in from two to six days. In these, as in other forms, there is at first depressed temperature, next a return to the normal standard, with slight variations, and finally a decided rise. 4. Favorable cases, in which there are the primary lowering, a sec- ondary rise, and final return to the standard of health. These variations in temperature range between 96 and 108 degrees Fahrenheit (rectal temperature). ,The pulse variation bears but slight relation to the fluctuation of the body heat. In the four classes spoken of, we may consider in the first, that the pulse is full and slow, ranging from 55 to 65. With the rise of temperature which characterizes the others, it becomes greatly accelerated, beating oftentimes 120 or 130 per minute, losing its full character, and becoming small and irritable, and if death occurs, grows gradually weaker. If recovery follows the attack, there is a gradual return to its normal rate. Of course, this must be a very unsatisfactory consideration of the state of the pulse, for the apoplec- tic condition is not always the same, collapse and reaction varying greatly in regard to their occurrence and duration ; so the pulse, as well as respira- tion and temperature, undergoes many irregular modifications. ATTACKS WITHOUT LOSS OF CONSCIOUSNESS. The other form, in which the individual preserves his consciousness, is not so serious a condition as that just described. The person may present some of the premonitory symptoms already mentioned, or, on the other hand, may receive no warning, but while engaged in any ordinary occu- pation may suddenly find one-half of his body to be paralyzed, and be un- able to communicate with those about him, there being slight aphasia. With the paralysis there may be anaesthesia. This state of affairs may begin during the night, and on awakening in the morning he may find it impossible to leave his bed. The paralysis is sometimes gradual, the loss of power affecting one member, and afterwards the other, an unexpected feebleness being suddenly noticed as he is about to perform some act. One of my patients, an acrobat of dissolute habits, while preparing for the performance, found, when he attempted to put on his tights, that his right leg was quite powerless ; he made an effort to stand, but became dizzy, and grasped for support a pole that was near. After repeated efforts to dress he abandoned the attempt, summoned assistance, and was taken home ; the same night the right upper extremity was affected. He had never had any previous warning. Attacks of this kind may be. the fore- runners of others of a more serious nature. In illustration, may be men- tioned the case of S. C., a married woman, aged 41. She was drawing water at a sink, when she became suddenly giddy, and had to take hold of the banisters to steady herself. She stood thus until some friends put her into a chair and carried her to her room. She sat there that day, and 88 DISEASES OF THE CEREBRUM AND CEREBELLI M. was helped to bed, but did not discover her paralysis until next inorninjr. Was not unconscious at any time of the attack. Her paralysis, when -In- discovered it, was somewhat worse than it is at present, and she could not speak as well as she now does. A few days after the attack she went to a hospital, where she remained one month. She entered the Epileptic Hospital July 6, 1875, and was put upon strychnine and belladonna., then- existing an inability to retain her urine. I take the notes of her subse- quent history from the case-book of the hospital. " Sept. 22. At 7.30 last night it was noticed that she could not speak as well as formerly. It was quite difficult for her to speak so as to be under- stood. She laughed a little immoderately at her inability to clearly enun- ciate the words. " An hour afterwards, in attempting to leave her bed, she fell, and since then has been scarcely able to speak, and can only say a few words. No other symptoms were noticed. Her strength of muscle and sensibility seem unaffected. She cries now continually, and seems to be depressed because she cannot speak. " Oct. 13. Patient can tell her name, and can name every article shown her. A little thickness in articulation. " Pupils react well. Lenses of eyes are a little opaque the left a little more than the right. Face palsy almost passed away. Lower facial muscles act well. Sensibility in face fair. Tongue points slightly to the right. " Voluntary motion abolished in right upper extremity, the least motion in shoulder excepted. Articulations are all flexed in the right upper extremity, and the contracture is greatest in the hand, the fingers almost touching the palm. Elbow and shoulder are less rigid. " Extension is not painful, and there are no spontaneous pains in arm. Sensibility to contact in hand good. On finger tips feels the points of jESthesiometer at three millimetres. There is no numbness in hands. Pa- tient considers the paralyzed hand the warmer of the two. Between index finger and middle finger of right hand in three minutes' time the tempera- ture is 98. Same place on left hand in three minutes' time temperature is 98. Right lower extremity, no motion in toes and ankles, consider- able motion in knee and hips, no numbness, no contraction. " An interesting feature of this case was exaggerated emotional disturb- ance, which is usually quite marked in right hemiplegia." THE RESIDUAL PARALYSIS. A paralysis, remaining after the " apoplectic stroke," is generally uni- lateral, though in rare cases, where the pons is affected at the central portion, the paralysis may exist on both sides of the body; this one-sided paralysis is known as Hemiplegia^ and may be complete or incomplete as regards sensation and motion. When we examine our patient after the immediate grave symptoms have to some degree subsided, we will find the limbs of one side limp, powerless, and generally without sensation ; the CEREBRAL HEMORRHAGE. 89 face paralyzed on the same side, and its other half drawn up by the healthy muscles, as their antagonists are unable to perform their functions. If the patient be sensible enough to put out his tongue, it will point to the para- lyzed side, while the eyes, if conjugate deviation exists, will turn in an opposite direction in a manner already described. Gastrowitz 1 has called attention to a peculiar symptom, the tendency of the patient to slip out of bed on the unaffected side. This is caused by the inability of the paralyzed limb to support the weight of the sound part of the body. He also alludes to the fact, when pressure is made on the saphena nerve, at the point where the vastus externus makes a groove with the vastus internus, that the cremaster muscle on the paralyzed side will not draw up the testicle, which is not the case on the other side of the body. In other forms of paralysis, to be hereafter described, there is not the same uniformity of symptoms, there being perhaps paralysis of special cranial nerves, or those of the muscles of the face on the side opposite to the body paralysis. This variety has been called cross paralysis. Both sides of the face or both sides of the body may be involved, in which event there is a speedy fatal termination. Occasionally the muscles of the pharynx may be paralyzed, and sometimes the larynx. A case of this latter kind is reported by Luys. 2 He mentions the case of " a woman who had a sudden attack of apoplexy with hemiplegia of the left side, but with no disturbance of sensibility or of the organs of special sense. The con- gestive phenomena of the onset being calmed little by little, the patient regained consciousness, and stated that four years previously she had been struck for the first time with left hemiplegia, and since then had been aphonic. Her intelligence was good, and she spoke distinctly, but in a low voice. She had no paralysis of the tongue, the soft palate, or the lips. A few days later, she was seized with new congestive symptoms, and died insensible." This laryngeal paralysis is undoubtedly a much more common affection than it is generally supposed to be, and the probability is that many of the cases reported as aphasic are in all probability simple aphonia. Our patient, after his return to consciousness, will then be found to be hemi- plegic, and, if he is amused and attempts to laugh, we will plainly notice facial distortion which follows any such efforts. The surface temperature of the paralyzed parts is usually higher than on the other side, and the limbs may seem to be of greater contour. This appearance has been noticed by Hitzig, 3 who, in referring to Charcot's cases, presents seven of his own, in all of which there was incomplete dislocation of the head of the humerus, with irregular pains of the arm, increased by pressure. The paralyzed arm was swollen, warmer and more moist than its fellow, and the pains alluded to began about six weeks after the apoplectic attack. 1 Berliner Klin. Woch., Aug. 2, 1875. 2 La France M6dicale, Sept. 28, 1875. 3 Yirchow's Archiv, xlviii. p. 345. 90 DISEASES OF THE CEREBRUM AND CEREBELLUM. Hitzig is of the opinion that this condition of affairs is not directly de- pendent upon the central lesion. Voluntary power is lost in proportion to the extent and situation of the lesion. Should it be in the corpus striu- tum, a very small lesion may produce very decided impairment of motility, while such is not the case in the white matter of the hemispheres. It will generally be found necessary to draw the patient's urine for a few days, for the bladder loses its expulsive force, and, if this procedure be not re- sorted to, there may be incontinence. Electric contractility seems to be exaggerated at first in the paralyzed limbs, and a very weak electric cur- rent may provoke the most energetic contractions. In certain cases there may be an increase of reflex excitability and tactile sensibility. Sensa- tions may be even sometimes reversed, warmth being felt as cold, or vice versd, or, as in the case quoted by Bastian, 1 a warm object may be appreciated as a weight. " A hot body on the face was recognized as pressure only ; on the arm it was felt as such, though the sensation was not distinctly localized, whilst on the left leg the same hot body was recog- nized correctly as regards situation, though it gave rise only to a feeling of tingling." I have often witnessed hyperaesthesia of the paralyzed limbs, which were often very tender to the touch. Anaesthesia generally exists, however, and electro-sensibility is greatly diminished. At the end of a few days it is not uncommon to find marked rigidity of the paralyzed limbs, increased reflex excitability, and other evidences of slight cerebritis at the seat of the clot. Gradually there is a return to the normal condi- tion, and articulation, which was imperfect in the beginning, may become more distinct, or, should there be aphasia, the patient will begin to com- mand a greater number of expressions. A week or so passes, and he is able to protrude his tongue in a much straighter line than before, while the paralyzed muscles of the face slowly recover their lost power ; but when the levator palpebrae is paralyzed and ptosis results, restoration is much more slow. In regard to this paralysis, Bastian has reminded us that very often deformities exist, such as the absence of teeth on one side, which may produce an appearance of facial paralysis, when in reality none exists. This is seemingly a trivial matter, but its neglect is likely to lead to grave errors in diagnosis and prognosis. As months go by, gradual amelioration of the patient's condition takes place, the limbs regain their power, the leg first, and finally the arm, and the patient may be at first able to move his toes, then to raise his leg, and, when he leaves his bed, gradually begins to acquire power of locomotion. The walk of the hemi- plegic is not to be mistaken ; his gait is shuffling, the toe of the boot is dragged over the ground, and the leg thrown outwards and forwards, the knee being stiff, and the arm is swung helplessly by the side. As the gait improves, and the patient gains more control over his limbs, he is able to perform "movements which require the action of the muscles of the hip- joint, knee-joint, and finally the ankle and toes. Should the patient only 1 Op. cit., p. 128. CEREBRAL HEMORRHAGE. 91 partially recover, numerous secondary conditions may follow, as results of non -improvement of the cerebral condition. These are chiefly of a moto- rial character, and consist of spasms, permanent contractures, atrophy, and inflammations of nerve-trunks. Such sequela may be called THE POST-PARALYTIC STATES. T may enumerate these as 1. Permanent contractures; 2. Trophic alterations ; 3. Tremor (post-paralytic chorea of Mitchell and Charcot) ; and, 4. Slow clonic spasms (atheotosis of Hammond). Of 32 cases of old hemiplegia seen by Bouchard 1 at La Salpetriere, in 31 there were paralytic contractures. The other case presented what he called I'hemiplegie flasque. This form is of slow appearance, and affected in the beginning the muscles of the forearm. The fingers were flexed, and the forearm was pronated and flexed on the arm, and at the same time the humerus was drawn to the trunk. According to Strauss, 8 this form presents several variations, and some- times the hand is brought in contact with the trunk, either on its palmar, dorsal, or radial aspects. Of a large number of cases that have come under my observation, I have found that deformities of the upper extremi- ties are much more common than of the lower; the fingers are commonly flexed arid rarely extended, while the muscles of the trunk seem to be exempt from this change ; and, indeed, I cannot call to mind a single in- stance of this kind. Contractures of the muscles of the lower extremities are apt to produce deformities which resemble talipes, equinus varus or valgus, and the toes are flexed upon the sole. Contractures of the facial muscles are quite rare, and of late appearance. The deformities are always quite striking, because of the antagonistic action of unaffected mus- cles, and usually no amount of force can overcome them. Trophic changes are by no means rare, either in connection with contractured muscles or alone. I have now several patients under observation who are hemiplegic. In one of these the skin of the paralyzed hand is white and puffed up ; the heads of the phalanges and metacarpal bones are reduced in size, so that there is no enlargement at their points of articulation, and a consequent depression exists. In other cases there is considerable muscular atrophy to be witnessed in the palm of the hand ; and in others, the bones of the arm are greatly diminished in size, and the interossei quite wasted away. Charcot 3 has written extensively about a form of neuritis following cerebral lesions, which is supposed to be of a central nature. That ascend- ing (from the periphery to the centre) neuritis sometimes takes place after cerebral hemorrhage there can be no manner of doubt ; and in one case, at present under observation, the neuritis began at several different peri- 1 Strauss, des Contractures, Paris, 1875, p. 16. * Op. fit. 3 Legons sur les Maladies, etc. Fasc. 1, and previous articles. 92 DISEASES OF THE CEREBRUM AND CEREBELLUM. phcral points of the nerve, and there were consequent atrophic muscular changes.' Various irregular movements of partially paralyzed limbs are by no means uncommon. Dr. Gowers' presents the following excellent table, which embraces all the disturbances of motility which may occur after the hemiplegic attack. POST-HEMIPLEGIA DISORDERS OF MOVEMENT. ( Fine. f Tremor < I Coarse. f Regular (continuous, or on movement) J | Certain, regular move- ments due to interos- Un'rk. rlonic spasm, of sei, pronators, etc. intermitting type; Choreoid C Continuous I spasm, or L Regular (continuous, or on movement) { -{ inro-ordi- | nation of L Jerking I, movement. I* Continuous = ;< Athetosis" SI >w, mobile spasm, of remitting type ] On movement = slow, cramp-like inco- 1 t ordination ! " Spastic contracture" of I hemiplegic children. Tonic spasm, varying f Of interossei, conspicuous j Fixed rigidity, unvarying (. Of flexor longus digitorum, conspicuous =* late rigidity. The will does not always retain its control over the affected muscles, though voluntary power exists usually to a variable extent, and the motor troubles are generally unilateral ; still there are rare exceptions. The influence of the will generally increases spasmodic movements. Spasms and tremor affect first the smaller muscles, while tonic spasms affect the larger muscles of the limbs. One form of tremor of a post-hemiplegic character has been called by Mitchell "post-paralytic chorea;" the tre- mor is suggestive of sclerosis, and may begin within a period ranging from one to several months, affecting generally the upper extremities. It is aggravated by any exercise of volition. It may affect both extremities, but very randy the face, and the movements are quite coarse, and may be associated with a certain amount of hcmi-ansesthesia. A variety of move- ment of a clearly post-hemiplegic character has been elevated to a distinct position, and given the name " atheotosis" by Hammond. As this con- 1 Those trophic changes are of a most interesting nature. Duncan* found in one case that an eruption had appeared on the thigh of the paralyzed side which disappeared with the return of power ; and Charcotf and PayneJ another. In a ease mentioned by the former, a vesicular eruption appeared, which followed the distribution of the superficial ramifications of the peroneal nerve, and was coincident with the hemiplegia. In this ease the hemiplegia followed embolism, and a branch of a spinal artery (rami medulla; spinales, of Rlidingcr) was found obstructed by a plug. Pressure had been made on the spinal ganglion from which one of the branches of the sciatic originates. o 2 Med. Chir. Trans., vol. lix. * Journ. of Cutaneous Med., Oct. 1868, p. 69 ; quoted by Charcot. t Op. cit., p. 72. J Br. Med. Journ., Aug. 1871. CEREBRAL HEMORRHAGE. 93 dition is ordinarily a secondary affection to other neuroses as well as hemiplegia, the undue prominence which it has received is entirely unde- served. Gowers says : " Neither clinical history nor supposed pathology of atheotosis affords ground for separating it from other forms of disordered movement commonly seen after hemiplegia, but any one of which might occur in the primary affection." Charcot 1 refuses to acknowledge its dis- tinct character. He presents several cases, all of which followed some form of hemiplegia ; and the literature of neurology is replete with exam- ples of so-called atheotosis which are generally connected with hemiplegia, chorea, or even hysteria. I have myself seen a case of the latter kind which disappeared spontaneously in a few weeks after its appearance. This form of movement is considered by Hammond to consist of a spas- modic agitation of the fingers, and is "characterized by an inability to re- tain the fingers and toes in any position in which they may be placed, and by their continual motion." The following case is one of post-paralytic chorea, connected probably with embolism, and with a certain amount of neuritis of a very painful character : Jane C.. 35 ; Ireland ; single ; domestic. Entered hospital May 22, 1876. Family history good, as far as known by the patient. She states that her health has always been good, with the exception of an attack of rheumatism a year ago. Two weeks ago, while dressing, she fell, and thinks that she remained unconscious for eight minutes. On recovery she was unable to use her right hand or leg, and was placed in bed, where she remained for seven days. She vomited everything taken into the stomach. She was brought to the hospital a few days ago, suffering from paralysis of the right side, which was complete and affected both limbs. There was some rigidity, decided headache, and paralysis of the muscles supplied by the portfeGMlura upon the right side. She was intensely emotional, and moaned and cried. July 12. Patient has been quite sick for the past four weeks. There have been high evening temperature, abdominal tenderness, diarrhoea, and other evidences of typhoid fever. She has been kept on milk diet, with quinia and stimulants. Aug. 18. Patient has improved somewhat. She is very weak, but able to go about the ward. The hand and forearm of the right side are rather rigid, and the fingers are flexed, but it is possible to extend them. Pa- tient still emotional, and cries readily when excited. There is decided tremulousness of this extremity. Pain in the shoulder, which shoots down the arm. These pains are more intense at night. Aphasia disappears. Nov. 23. The patient's hand shakes whenever any voluntary movement is made. She cannot feed herself, for when she takes up her fork or spoon she cannot carry food to her mouth. The pains are still severe, and seem centered more in the shoulder. She can move her right arm nearly as well as the left, but cannot hold any large object placed therein. Exami- nation of heart revealed a heart murmur, with second sound heard with greatest intensity over aortic valves, and not transmitted in either direc- tion. A murmur is also heard with first sound, which is transmitted into the carotids. There are probably both aortic stenosis and insufficiency. 1 Op. eit., 4th part, p. 455. 94 DISEASES OF THE CEREBRUM AND CEREBELLUM. Oct. 1877. The patient is still in the hospital. Complains now of dix- ziness and disordered vision, which is not dependent upon any structural alteration. The right arm and hand are much more quiet than they have been. There is very little of the tremor which was at h'rst coarse, but rhythmical. She can now execute a variety of acts, but an especially delicate operation is attended with aggravation of the tremor. Causes Any agency which favors a degeneration of cerebral vessels leads to the occurrence of hemorrhage such as I have just described. The list of such causes is therefore a long one. Among the many formidable diseases, leading to that which forms the subject of our remarks, are those of the heart and kidneys. Hypertrophy of the left ventricle, Bright's disease, and local disease of the arteries with deposits of atheromatous mat- ter, or obliteration of vessels by softening, pressure made by tumors, and through other diseases of the brain, may be mentioned as influencing the causation of cerebral hemorrhage. Cerebral hemorrhage is an affection of advanced life, though cases are on record among children. A careful inspection of the records of a great many cases discloses the fact that the majority are between fifty and sixty. With the advance of life and cor- responding impairment of vitality, the arteries become rigid, the heart hy- pertrophied, and the general vascular system undergoes important changes. I have already alluded to the annular and hard character of the arteries ; the arcus senilis, which consists of a small whitish circle which may be seen overspreading the iris, may be mentioned in addition as a suggestive sign. The color of the face is dusky red, and many of the capillaries of the skin covering the cheeks and nose are quite tortuous and dilated, and present minute varicose enlargements. As to inheritance of an apoplectic ten- dency, I fully agree with Hughlings Jackson, that the only heritage trans- mitted from father to son is the liability to arterial degeneration, gout, etc. This exception to the general rule is somewhat conspicuous, for the here- dition of many convulsive and neuralgic, as well as the trophic diseases, is a well-established fact, and has long been recognized as an important etiological factor. Cerebral hemorrhage, as I have stated, is by no means confined exclusively to adult life. Numerous observers have called atten- tion to cases which have occurred among very young children, though, in these instances, injury has generally produced the accident, especially such mechanical causes as convulsions, anremia, etc. And now regarding the predisposing states which favor the rupture of a vessel. An hypertro- phied heart, enlarged by overwork in forcing the overloaded blood which must be formed when the kidneys do not properly act as eliminants, is the first factor of the disease. With this condition of affairs the small vessels must necessarily be subjected to abnormal strain, and consequently under- go such changes as thickening or aneurismal dilatation, or even actual destruction. The arterial changes, of which I will more fully speak when we come to consider the pathology of the disease, are fatty degeneration, aneurismal dilatation, and calcification. These conditions are produced by alcohol, and improper diet, such as continued indulgence in fatty food. A sedentary life, connected with great and protracted intellectual strain, CEREBRAL HEMORRHAGE. 95 as well as such diseases as rheumatism, syphilis, and other chronic mala- dies, enter the field as predisposing causes. Season appears to have some influence in the production of cerebral hemorrhage, the majority of cases occurring in winter. As to exciting causes, their name is Legion. Straining at stool, coition, violent muscular effort of any kind, the indul- gence in stimulants, and in fact any agency which either promotes an ab- normal blood supply to the brain, or prevents its return, will have the effect, should there be disease of the vessels, of producing rupture. I have taken from my case-book data showing the exciting causes in a num- ber of cases, and the time of the attack : Lifting a heavy weight, or other muscular effort . 12 Excitement (alarm of fire) ..... 1 Drawing water ....... 1 Falls 4 Fright ......... 3 Thrown down by husband ..... 1 Head injuries ....... 8 Straining at stool ....... 2 No history of cause 20 52 Time of Attack. At night, in 30 cases; during the day, in 22 cases. The fact that the large proportion of these attacks occur at night, is an interesting one. They were mostly hospital patients, and some were irre- sponsible ; so, of course, their statements are to be taken with allowance. One woman said : " I awoke in a fright, and in attempting to rise found I was unable to do so." It is probable, therefore, that the condition was dependent upon disturbed cerebral circulation connected with nightmare; but in opposition to Hammond's statement that the occurrence of the hem- orrhage during " healthy, undisturbed sleep" is unlikely, I will state that nearly every one of these thirty patients found that they were paralyzed only when they awoke in the morning, and attempted to get out of bed. Exposure to the sun's rays, and the stoppage of any flux that is either normal or pathological, are often sufficient to produce an attack, and as an example of the latter hemorrhoidal bleeding may be mentioned. Heiniplegia may be a result of variola ; and the following case, in which epilepsy and hemiplegia dated from smallpox, possesses much interest. The paralysis was due undoubtedly to an epileptic seizure, during which some vessel was ruptured. M. J. T., 35 years, born in New York ; no occupation ; entered the Epileptic and Paralytic Hospital Feb. 11, 1870. Mother died of con- sumption ; sister had epilepsy. First fits appeared at the age of five years ; came on about three months after an attack of smallpox ; hemiplegia of the right side came on at the same time, she believes, as the epilepsy. Before the convulsions she has cramps in the paralyzed arm and hand, and a feeling of dizziness ; the attacks occur most frequently in the daytime, three or four together, and recur once in three or four weeks. But shortly 96 DISEASES OP THE CEREBRUM AND CEREBELLUM. before her admission she had them nearly every day. Circumference of skull, 20| inches; antero-posterior measurement, 13 inches; transverse, 13 inches; memory good, mind rather weak; speech good, sight good, hearing fair with left ear; cannot hear with right ear, even when the watch is pressed against it. Sensibility to pinching and pi-irking appeal- entirely abolished on the right side from head to foot. Drags right leg in walking ; has but little use of right arm and hand, the muscles of which have a tendency to spasmodic contraction ; temperature somewhat dimin- ished on right side ; appetite fair ; bowels rather costive. Menstruated at *3 years, and has been regular since. Present condition, June 1, 1870 : Memory appears to be very good; the fits have decreased in severity and in number. Had but two attacks last month ; none at night. Has ha'inoptysis sometimes before the attack, and an aura of about a minute's duration ; flexor of muscles of right hand is contracted ; thumb is turned again, so that its inner part touches the under part of the index finger ; lastly, the whole hand is somewhat drawn up, and lies in her lap with the palmar surface up. When directed to put hand up to shoulder, it shakes right and left ; this shaking is very violent, but only so when she makes voluntary movement. It is, however, entirely quiet while in her lap. Has the irregular hemiplegic gait ; protrudes her tongue straight ; eyesight good ; hears perfectly well. There is facial paralysis (peripheral) on the side opposite the hemiplegia, but no ptosis. 1 Morbid Anatomy and Pathology A vessel impaired by dis- ease, and subjected to even the normal blood pressure, will very soon suffer changes in its calibre, insignificant perhaps at first, but afterwards far more serious. But, when the blood pressure is abnormal, and a force is exerted which the resilient character of the vessels enables them to withstand in the healthy state, the weakened portion gives way, and the brain-substance in the neighborhood is subjected to dangerous pressure. The character of the loss of function depends very much upon the import- ance of the vessels and their areas of distribution. The middle cerebral artery is especially liable to rupture, being in direct communication with the left side of the heart; consequently, the corpus striatum, optic thalatnus, and parts supplied by this artery, suffer injury. The other large vessels follow next, and may be affected in various parts of their course. The diagram I present (Fig. 12) illustrates the topography of brain-lesions, and will enable the reader to see how certain hemorrhage may destroy the func- tion of various important nervous tracts, the symptoms being displayed generally on the opposite side of the body, but occasionally on the same. In our future study of the localization of lesions, we are to bear in mind the physiological experiments of Broca and Brown-Sequard, and the later ' As an illustration of a curious cause, Eulcnburg* relates the case of a switch- U'tider who, during a heavy thunder storm, inserted an iron key in the lock of a switch-signal. lie was suddenly deprived of power, and fell to the ground. After an hour or two, when sufficiently revived by the rain, he dragged himself to a neighboring station. He was paralyzed on the left side. * Berliner Klin. Woch., April 26, 1875. CEREBRAL HEMORRHAGE. 97 researches of Hughlings Jackson, Fritsch and Hitzig, Vulpian, Vesseyer, Ferrier, Dupuy, Pierret, Raymond, Putnam, Carvaille and Duret, and others. The pathological course of cerebral hemorrhage is the following : 1. The stage of preparation, during which the arteries undergo the changes Fig. 12. A. Region of articulate speech (probably, also, slightly developed on right side as well). B B. Supra-ventricular region : Paralysis on side opposite lesion. As a rule, not as susceptible to dangerous injury as parts beneath. C. Ventricular region : Lesions apt to be followed by serious motorial and sensorial symptoms. D. Sub-ventricular region : Lesions apt to paoduce paralysis of cranial nerves by extension of pressure. 1. Lesion in central part of hemisphere. 2 2. Cortical lesion, usually affecting special motor centres, or affecting mental functions. 3. Lesion affecting speech-centre. 4. Lesion affecting nucleus caudatus of corpus striatum. 5. Lesion affecting crus. 6. Lesion affecting peduncular expansion. 7. Lesion affecting centre of pons. 8. Lesion affecting lateral half of pons. 9. Lesion affecting medulla. already spoken of. 2. The operation of an exciting cause, the rupture of the vessel, the injury of the nervous substance, and the formation of the clot. 3. Death, absorption, or limitation. Bouchard 1 and Charcot both affirm that cerebral hemorrhage is always dependent upon a peculiar kind of disease of the vessels. This diseased condition consists of a studding over with minute aneurismal dilatations which have been called by them "miliary aneurisms." These arise from a primary degeneration of the outer coat of the vessel, generally secondary sclerosis, and finally atrophy of the muscular coat and dilatation. Of sixty-five cases of cerebral hemorrhage, they found miliary aneurism in every instance. Botli of these authors consider the vascular change to be different from that of atheroma, which begins in the inner coat. These appearances are confined to the brain, and exist when there is no evidence of atheroma to be found in any other part of the body. Notwithstanding that these views are endorsed by such men as Meynert, Bastian, and oth- ers, there are many observers who consider miliary aneurisms to be due only to careless manipulation, or that they are identical with the "hyaline 1 Arc-hives des Phvsiol., 1868. 98 DISEASES OF THE CEREBRUM AND CEREBELLUM. degeneration" of Gull and Sutton which is found in other localities. 1 These miliary aneurisms have been said to be due to " periarteritis," but it cannot be denied that a large proportion of cases of renal and heart disease produce modifications in blood pressure, which would account for the rupture of the vessel without any primary inflammatory condition. Fig. 13. Miliary Aneurisms. 1 have repeatedly seen miliary aneurisms, and must confess that they appeared to depend upon some organic change which extended over a con- siderable space of time. 1 Dr. Barlow* has presented a case which fully demonstrates that cerebral em- bolism may produce a condition of the vessels which leads to the formation of aneu- risms, first causing local arteritis and weakening of the wall of the vessel. In this case (that of a boy aged ten years) there was right and afterwards left hemiplegia, and aortic regurgitation. The autopsy revealed "cortical soften- ing on each side of the lower part of the ascending frontal and the posterior parts of the second and third frontal convolutions. The clue to this condition was found in the middle cerebral arteries. On both sides these vessels were dis- eased at the spot where the fine branches were given off over the island of Reil for the supply of the cortex. Of these branches on both sides, the one supplying Broca's convolution and the one supplying the ascending frontal were also dis- eased. There was no aneurism to be discovered anywhere, but the walls of these vessels presented many small calcified nodules obvious to touch and sight." This calcification was not noticed in any other vessel in the body, and emboli had lodged in the spleen and kidneys. In Goodhart's cases actual aneurism had fol- lowed the embolism, and Dr. Barlow's case demonstrates that there is a primary weakening. Durand-Fardelf found that of 32 cases the arteries were only healthy in 9 cases, while in 21 they were thickened, and in 2 ossified. AmlralJ found that of 32 cases the arteries were apparently healthy in but 4. * Brit. Med. Journal, April 7, 1877, p. 362. \ Trait^, clluique et pratique, des Maladies des Vieillards, Paris, 1854, p. 228. J Clinique Mid., vol. v. CEREBKAL HEMORRHAGE. 99 Zenker differs from Charcot and Bouchard, and considers the internal coat to be that which is first attacked. When miliary aneurism exists, it is generally in conjunction with either gout, cancer, tubercule, leucocythe- mia, or other conditions, when leucocytes may pass into the cerebral ves- sels in large number. In old drunkards and general paralytics this vascular change is not an uncommon one. In regard to atheroma there have been many cases brought forward where this appearance was so constant as to gain recognition as one of the chief factors of the cerebral hemorrhage. An atheromatous artery contains deposits of a firm, semi-fatty nature, between its inner and middle coats. At an advanced stage the deposit is more calcareous and hard, and the artery may be sometimes easily broken in two. Occasionally the deposit between the coats, by distension considera- bly narrows the calibre of the vessel, and in this way forms occlusion at one point while at a weaker one hemorrhage takes place. The veins and capillaries are not so often involved as the arteries. In regard to the seat of cerebral hemorrhages, we find from a table prepared by Gintrac that in 751 cases there was Times. Hemorrhage in the meninges . . . . '. . .172 " " middle lobes . ' . . . . 127 " " pons and peduncle . . . . .76 " " corpora striata . . . . . .72 cerebellum ....... 55 corp. striata and op. thai 48 ventricles (septum and plexus) ... 46 cortex ....... 45 op. thalami ....... 38 post, lobes .... 33 ant. lobes . . . .17 corpus callosum ...... 1 The other 21 were into the medulla and cord. It will be seen then that hemorrhages into the meninges and into the middle lobe of the brain are of most frequent occurrence. It will be well to state that large por- tions of both hemispheres may be destroyed without serious symptoms ; but when we approach the base the danger is increased, and if the third frontal convolution be the seat, we find a very decided and serious result, which is aphasia. The majority of hemorrhages ar^ in or about the optic thalami and the corpora striata, and if they be extensive the ventricles will be filled. If the hemorrhage be great, pressure may be made on the oppo- site side, or the blood may find its way into other localities. In the ante- rior lobes the effusion is generally circumscribed, but from this site it may find escape into the lateral ventricles. In the ganglia and important parts at the base, the hemorrhage is generally small, but is of the most serious character because of the importance of the parts it destroys. This is the case in the corpora striata. In the pons and medulla any consid- erable extravasation is followed by death or serious trouble. The shape of the cavity is variable, but in the gray matter it is circumscribed, and in the white it is irregular and elongated. 100 DISEASES OF THE CEREBRUM AND CEREBELLUM Parrot 1 reports 34 cases of cerebral hemorrhage in new-born children. In these the clot was found at the inferior part of the brain; sometimes on the right side, but more generally on both sides. Should the patient survive the apoplectic attack, and die subsequently of some other disease, the cerebral clot will probably prove to be well organized, hard, and separated from the brain-tissue in the vicinity by a sclerosed mass. The immediate changes are the following: At the end of a few days the serum is absorbed, leaving the solid portion as a gelatinous mass ; finally the clot contracts, becomes yellow, and assumes the appear- ance I have alluded to. It is rare that an old clot is completely absorbed, but it is found encysted and firm, and, perhaps, has produced some soften- ing. It is not uncommon to find more than one clot in a patient who has had several hemorrhages. There may be a cyst filled with thick- ened blood, which is indicative of an effusion of recent occurrence, and there may be others of smaller size, in different stages of resolution. Small aneurismal dilations are also found, while local patches of softening, or cysts filled with clear serum, are not rarely present at the same time. A common form of hemorrhage is the meningeal. Goodhart 2 has written an exhaustive paper upon this subject, in which 49 cases are given, proving most conclusively its connection with diseased kidney and hypertrophied heart. Of these 49 cases, 30 were due to renal disease, and six had uncomplicated heart trouble. When the hemorrhage takes place above the arachnoid, we are assured by Mr. Prescott Hewitt* that the blood very rarely gravitates to the base ; but when the hemorrhage is sub- arachnoid, the blood may find its way below, thus making the condition a most serious one. After death a peri-cortical collection of blood will be found ; which is extensive over the base, and probably produces death by pressure upon the pons and medulla. Diagnosis. Coincident with the occurrence of the hemorrhage, symptoms will be presented which will enable us to localize with some degree of accuracy the position of the clot, its extent, and character. A lesion in or about the corpus striatum will be followed by hemiplegia of the opposite side. The temperature being higher in the paralyzed limbs than in the others; the eyeballs will deviate towards the side of the lesion ; and the tongue, when protruded, will point to the hemiplegic side. The face is paralyzed on the same side as the arm and leg. A lesion in or about the optic thalanms will present the same phenomena, only that the temperature is higher in the paralyzed limb than in the preceding form. A lesion in one cms is followed by very much the same symptoms. If the under and inner part be affected, we find cross paralysis, the face being paralyzed on the side of the lesion, while the extremities are para- lyzed on the other side of the body. Hemianaesthesia is quite marked ; and the third and seventh nerves are paralyzed, so that ptosis and profound 1 Arch, dc Tocologic, 1875. 1 Guy's Hosp. Rep., vol. xxi. p. 181. * Holmes's System of Surgery, 1870. CEREBRAL HEMORRHAGE. 101 .- facial paralysis result. A lesion in one lateral half of the pons is fol- lowed by hemiplegia of the opposite side, profound coma, deviation of the eyes away from the side of the lesion, facial paralysis on the side of the lesion, lowered temperature in the non-paralyzed limbs, paralysis of the muscles of deglutition, and anaesthesia or hyperaesthesia of parts supplied by the fifth nerve. A lesion of the upper half of the lateral region of the pons will be expressed by pretty much all of the symptoms which follow the last mentioned lesion, except that the facial paralysis will be on the side opposite the lesion. A feature of all forms of lesions in the pons is the very decided character of the facial paralysis ; and if there be exten- sion of the lesion, there may be double facial paralysis, with hemiplegia of the body. A lesion in the posterior part of the pons, beside the symp- toms just alluded to, will produce paralysis of the fifth, sixth, and seventh nerves on the side of the lesion ; or, according to Brown-Sequard, it may sometimes produce cross-paralysis. A lesion in the centre of the pons is followed by double paralysis, deep coma, marked contraction of pupils (while in the other forms one pupil may be contracted on the side of the lesion), lowered temperature on both sides, with ultimate rise and but slight loss of sensation. Louville 1 reports a case of hemorrhage into the pons, in which sugar was found in the urine. This he considers to be an ever-present symptom of disease in the lower part of the pons, but never a feature of disease of the upper part. A hemorrhage in the medulla is followed by paralysis of the cranial nerves on both sides, bi- lateral paralysis of the body, and, generally, rapid death. Extensive lesions may produce a combination of these phenomena, and diagnosis may sometimes be an extremely difficult matter. A patient under treat- ment with syphilitic disease of the brain, presents a combination of symp- toms which are extremely interesting in a diagnostic sense. Wm. McG., aged 58 years, when about 21 years of age, had a primary chancre upon the dorsum of the penis, followed some months afterwards by secondary symptoms. After a few years all traces of syphilitic trouble seemed to have disappeared, as he enjoyed extraordinary good health. He has led for the last twelve or fourteen years a very intemperate life, and has regularly " gone upon sprees." Twenty-six months ago, after ah attack of facial neuralgia, which was evidently specific, he became hemi- plegic during one of his drinking bouts, but does not remember any of the circumstances immediately connected with the apoplexy. When he be- came sober he found that the left side was paralyzed, but the loss of power could not have been very great, for he was able to walk in a few- days. About a year ago the right side of the face became anaesthetic, and he began to lose the sense of taste on the left side; at the same time he found it difficult to arrange the food for mastication, and his power of articulation became embarrassed. PRESENT CONDITION Eyes. Pupils of the same size, and not abnor- mal; respond well to light ; no ptosis, nor disturbance of vision ; no retinal change. Face No impairment of buccal muscles, nor of superficial 1 Gazette des HGpitaux, Feb. 8, 1873. 102 DISEASES OF THE CEREBRUM AXD CEREBELLl M. facial muscles, except slight contraction of those of right side when he o(>ens his mouth. When this is done, the orifice is unsymmetrical. Anos- mia marked, taste impaired to slight degree. Warm substances produce an impression on sound side of tongue, but not on the other. Left side of the palate paralyzed, and lower than the other. Left side of tongue atro- phied, presenting the appearance depicted in Fig. 14 ; and when protruded the tip points to the right side, no apparent tactile loss of sensation as de- termined by the sesthesiometer. Saliva is secreted in large quantities, Fig. 14. Multiple Lesion with Tongue Atrophy. and constantly drips from the angles of the mouth when he talks. Sensa- tion of right side of face impaired ; feels points only when separated 3 mm. on other side 1^; some difficulty of speech, especially with the letter r, pronouncing "righteous" "eightehu;" the left leg he drags slightly when lie walks. Six months ago he slept upon his arm when drunk, and thereby added to his other troubles a decubitus paralysis; slight loss of power in both arms. In this case there were evidently two lesions one in the medulla, and the other on the right side of the brain one hemorrhagic, the other of slow growth. AVe are to diagnose the symptoms of cerebral hemorrhage in its different stages from those of the following diseases: Actual attack from urapmia, drunkenness, opium poisoning, tumor, epilepsy, compression or concussion from injury, embolism, and thrombosis. There are certain general ap- pearances which symptomatize the ureemic condition, and can hardly be CEREBRAL HEMORRHAGE. 103 mistaken ; the skin is waxy and cedematous, the eyelids are puffed, and the legs and feet swollen; but, as Bastian suggests, it does not always fol- low, when we find these appearances in an individual over thirty years of age, that the coma is always purely of an uraemic character, and that there may not be a complicating hemorrhage. The urine, when drawn, is found to contain albumen, but this symptom by itself is insufficient to settle the question. Unemic coma is generally of gradual appearance, though Hughlings Jackson calls attention to a form which has a rapid onset, with convulsions ; but, on the whole, such sudden appearance is more suwes- tive of cerebral hemorrhage. It is nearly always preceded by prodromata for several days. The patient is stupid, and inclined to somnolence, and has headache. Bourneville has ascertained that the temperature rapidly sinks when the coma begins, to a point very much lower than it does in cere- bral hemorrhage, and continues depressed during-the condition, while the converse is true in the other affection. Convulsions are much more promi- nent and constant features of unemic coma than they are of cerebral hemorrhage ; and, beside, there is no paralysis. Numerous other indica- tions will serve to make the diagnosis clear in this respect. The coma is not deep, and it is possible to arouse the patient, and there is great hyper- kinesis, there being a tendency to muscular spasm and rigidity which is not unilateral. The character of the respiration differs from that of cere- bral hemorrhage, the stertor being more superficial. From drunkenness the diagnosis is not always so easily made, the two conditions sometimes coexisting, and it may be necessary to delay until the effect of the alcohol has passed away, before we can determine our patient's true condition. The odor of liquor, the circumstances under which he was found, and his imperfect loss of consciousness, are sufficient to excite suspicion. If he vomits, we may chemically test the substances thrown up, or we may ex- amine his urine. Anstie gives a delicate test which may be employed. If even only one drop of the urine of the patient who has taken a toxic dose of alcohol be added to fifteen minims of a solution of one part of bichromate of potash in three hundred parts of strong sulphuric acid, the mixture will turn an emerald green. With a larger quantity this test will be much more certain. The articulation of an intoxicated person when aroused is so peculiar and so interrupted by hiccough that there need be no chance for mistake in this respect. Narcotic poisoning may resemble somewhat the symptoms indicating cerebral hemorrhage. Like alcoholic coma, its advent is gradual, and there are convulsions, while the face is dusky, but the patient may be generally aroused. Much stress has been laid upon the condition of the pupil in opium poisoning as a diagnostic sign ; but, as this symptom is indicative of hemorrhage in the pons, it loses some of its value. Epileptic coma can hardly be mistaken (should it be a stage of the actual epileptic attack) for that of cerebral hemorrhage. In the former there is a history of convulsions ; the stupor lasts but for an hour or two at the most; the temperature is elevated; and there is some- times an escape of bloody froth from the mouth. The previous history of the patient should set all other doubts at rest. Compression or concussion 104 DISEASES OF THE CEREBRUM AND CEREBELLUM. from head injuries may be mistaken for the condition under consideration. In the former there may be a subarachnoid effusion, which may give rise to many of the symptoms. The latter is usually of short duration, so far as symptoms are concerned. The skin is pale, the pupils dilated, and vomiting occurs at some time or other. It is always of decided importance that we should inquire into the nature and receipt of the injury; for, should it follow a fall while the patient is in a safe position, we may suspect that he has had a seizure of some kind, the injury being secondary to the attack. The internal cause of the hemorrhage is always important, whether it be produced by an abscess, tumor, or other intracranial diseased states ; and these tilings are to be taken into account. The antecedent history of the patient, the presence of pain of a localized character, subsequent convulsion, loss of vision, aural disease, and kindred conditions should all be ascertained. Serous apoplexy, as it has been called, when an immense effusion of serum takes place either beneath the investing membrane, or in the ventricles, or throughout the brain substance, is usually of gradual origin, and de- pendent upon the collection of fluid which takes the place of atrophied brain substance or attenuated vessels. Prognosis According to all observers it is an exceedingly difficult matter to make a prognosis with any certainty, especially an early one, and, consequently, it is of the utmost importance that every circum- stance of the case should be taken into account and carefully considered before we give expression to any opinion. Certainty of prediction is made doubtful, by new complications, and fresh dangers that are likely to arise. There are several questions that are to be answered, and the first of these concerns the fatality of the actual attack. The character of the coma, its depth and duration, the appearance of convulsions, abolition of reflex excitability, stertor, involuntary passage of urine and feces are to be regarded as indicative of an early fatal termination. If this condition be connected with unequal pupils, and double hemiplegia, the prognosis is, if anything, more unfavorable. Large hemorrhages into the ventricles, cor- ]Hmi striata, or into the crura or pons are tjien to be feared. The patient presenting these alarming symptoms dies usually in a very short time, say in from a few hours to two or three days, and there may be, perhaps, an aggravation of the symptoms towards the end as the result of fresh hemor- rhage. If he survives the attack, what are the chances for the return of mental power ? or, if not affected, will it subsequently become impaired ? This depends very much upon the occurrence of inflammatory action about the clot, or whether there be ursernic trouble or softening. We may augur well for his chances if these conditions are absent, and if he lives for eight or ten days after the immediate attack. In regard to the speech disturb- ances : if there be simple ataxia, there is no reason to fear ; if, how- ever, any marked forgetfulness of words or genuine aphasia exists, the prognosis is less hopeful. This condition of affairs often exists for years without the slightest improvement taking place. At first the mind is confused and dull, and, unless the hemorrhage is the result of CEREBRAL HEMORRHAGE. 105 softening or other degeneration, there is but little doubt that he will ultimately regain his mental activity. It is, however, well to qualify this statement by saying that in old people the tendency is the other way. Congenital apoplexies, or those occurring in early life, are apt to leave sequelae of the most deplorable description, such as imbecility and kin- dred conditions. The return of muscular power and normal sensation is the most important question to be next considered, for much of the patient's future comfort depends upon the recovery of his lost power. Should the limbs remain paralyzed, or secondary neuritis take place, the consequence will be atrophy and contractures, such as I have described. It is, however, usual for recovery to begin in a few weeks, and in even a shorter time should the hemorrhage be unattended by loss of conscious- ness. The limb first to recover is the lower extremity. He is able after a short time to get out of bed and " hobble" about, or he may retain a certain degree of power from the first should the hemorrhage be slight. He is subsequently able to raise his hand to his head, and ultimately recovers entirely. But this improvement does not always occur, for during a cerebritis, which may subsequently take place, a number of seri- ous muscular distortions of a permanent character may ensue. A case illustrating this is the following : J. C. D., aged 53 ; born in Ireland ; carman. Family history, mother died of old age ; father died of renal disease. The patient in early life was very intemperate, and there are some evidences of syphilitic trouble, there being nodes, bald spots, and enlarged glands ; but he denies any venereal disease. For three months previous to the attack (it occurred three years ago) he suffered from headache, dizziness, and other prodro- mal symptoms ; none very marked, however. He went to bed one night feeling perfectly well, and awoke with " cramps," which affected his right leg ; he called his wife, and attempted to get out of bed, when he found he was paralyzed. There was no speech trouble whatever. He was placed in bed, and remained there for three months, during which time he had violent headache in the occipital region. Present Condition Hemiplegia of right side, sensibility slightly im- paired, and no atrophy of either the arm or leg. When he stands there is slight rigidity of the inner ham-strings. The toes and end of the foot are adducted ; and when he walks, the foot is raised from the ground about one inch ; the knee is rigid, and there is motion only at the hip-joint. The fingers of the right hand are in a condition of extreme flexion, and cannot be extended by ordinary force ; but, when the hand is placed in hot water for some time, the rigidity is partially overcome. The thumb is not in- volved ; but, when the distal phalanx was extended, it could be bent back- wards some distance, and remained in this condition until it was restored by me. The hand is slightly flexed, and the forearm pronated and flexed on the arm, and the arm adducted to the body. No lateral movement is possible. There was an early history of neuritis, which came on a short time after the attack, with decided pain in the shoulder-joint, during which the patient applied blisters and mustard poultices. The dynamometer in- dicates 20, outer circle, with the right hand, and 80 with the left. There is no visible facial paralysis, but the tongue points slightly to the right 106 DISEASES OF THE CEREBRUM AND CEREBELLUM. side. The surface of the paralyzed side is mottled and cold, and the nails are crenated and horny. The facial paralysis is sometimes a grave and permanent condition, and is very serious, especially if there be ptosis. Should the paralysis involve the muscles of the pharynx, the tongue, or the buccal muscles, the prog- nosis is very bad, and these symptoms suggest that the hemorrhage luis invaded the posterior basal parts of the brain, and, perhaps, the medulla. The organs of special sense are affected to a variable extent, and greatly modify the prognosis. If there be involvement of the optic disks, retinal extravasations, or structural changes of the fundus, a grave character is given to the disease ; while such symptoms as ptosis and diplopia, which depend upon paralysis of the third and sixth nerve, sometimes disappear after a time, though such disappearance may very slowly take place. The recurrence of apoplectic attacks is not uncommon, and if there be any spe- cial cachexia, they are to be dreaded. Syphilis and gout, as well as renal disease, are highly conducive to a return of the trouble ; or advanced age is an important predisposing cause of cerebral hemorrhage. When we find a calcareous state of the arteries with cerebral hemorrhage, it is very probable that other fluxions will follow. I remember a case in which a succession of hemorrhages occurred in the person of a middle-aged lady, the third of which proved fatal : N. G. A., aged 57. On the evening of February 3, 1873, 1 was called by Dr. AVm. H. Bennett to see the patient, whom I found in a state of coma. All of the characteristic appearances of a profuse cerebral effusion were mani- fested. The apoplectic seizure had taken place the day before, and she had continued in a comatose state until I saw her with Dr. Bennett. Her surface was cool, her breathing slow and stertorous, her pupils dilated, and corneae insensitive to the touch ; while reflex excitability was entirely abolished, so that tickling of the soles was followed by no withdrawal of either limb. In this state she remained until the 8th of the month, during which time, and in fact until the time of her death, in November of the same year, it was necessary to draw her water nearly every day. At the end of the fifth day there was a slight return of consciousness, but entire inability to speak, the patient making a peculiar short sound when she wished to com- municate with those about her. There was complete paralysis of the right side, but a faradic current readily produced muscular contractions. From this period until September 13th, there was steady improvement, and the family, as well as ourselves, were very hopeful. She recovered consider- able power over the leg and arm, but was unable to get out of bed, although she was lifted from it and placed in an easy chair, where she remained contented for several hours of the day. She was now able to utter two or three words, and seemed to take a lively interest in all that went on about her. On the 13th of September, while lying in bed, she suddenly became comatose, and presented all the symptoms of a fresh hemorrhage. Her temperature, which had before ranged between 98 and 101, now sank to 90; and her condition was so critical that I remained with her during the night of the 14th, when she slightly recovered, regaining her con- sciousness on the 17th ; but there was complete loss of power. The tem- perature now rose to 104, and she was restless and irritable. Her power CEREBRAL HEMORRHAGE. 107 of expression had entirely disappeared, and she remained in this state until the 19th of November, when she died in her last apoplectic attack. This patient, before her last illness, had suffered for some time from albuminuria, but her symptoms had been almost entirely relieved when her first cerebral hemorrhage took place. She was of spare build, her radial arteries were rigid, and the arcus senilis was visible to a limited extent. This tendency to cerebral hemorrhage is sometimes seen in gouty sub- jects. A patient recently sent to me by Dr. William Lockwood, of Nor- walk, Conn., had suffered for years from gouty trouble. Besides the pain her joints presented gouty swellings, with chalky concretions. Within the past five years she has suffered from slight hemiplegia of both sides ; on the right most severely. In this case it is probable that the rupture of a large vessel will some day carry her off. Treatment Our treatment must be, first, preventive, second, for the attack, and third, for the amelioration of the resulting condition. If we have to deal with cachexias of different kinds, appropriate treatment is indicated. Should there be gouty trouble, albuminuria, or syphilis, these are to be met with alkalies (FF. 45, 46), diuretics (FF. 18, 19), and specific remedies (F. 20) such as mercury and the iodides. If there be depraved general health, weak heart action, and general debility, we are to support our patient by quinine, stimulants, and nourishing food. Combinations of digitalis and iron (F. 21) are especially useful when there is low ar- terial tension, and rapid heart action. In speaking of cerebral congestion I alluded to the conditions which might favor an excessive flow of blood to the head, and advocated special forms of treatment. It is not necessary to repeat these indications, but I will simply refer to the value of the bro- mides given in doses of from 20 to 30 grains three times a day if there be any tendency to head fulness, while ergot administered in half-drachm doses two or three times during the 24 hours, and the abstraction of blood from behind the ears, may be resorted to, should there be a suspicion of imme- diate danger. The patient is to be kept perfectly quiet in a cool room, cold applications are to be made to the head, and his bowels should be emptied by some such cathartics as the compound jalap powder, senna, or Rochelle salts. Should we recognize the appearance of any prodromal symptoms, we must immediately inform the patient of the dangerous pos- sibility, and enjoin upon him the necessity of regulating his mode of life, of breaking off bad habits, and using every means in his power to improve cutaneous circulation. The flesh-brush, cold, and sometimes Turkish baths, moderate out-door exercise, and other agents which stimulate the surface capillaries and relieve internal congestion, should be as soon as possible resorted to. The patient's diet should be farinaceous, and the us,e of either strong drink or condiments is to be at once discontinued. He is to sleep in a cool room, and on no account wear tight neck gear. The feet are to be kept warm, and thick woollen stockings should be recom- mended. Violent exertion, especially forms requiring any fixation of the 108 DISEASES OF THE CEREBRUM AND CEREBELLUM. abdominal muscles or straining, are also to be carefully guarded against. Should we be called to find the patient in the actual apoplectic state, another line of treatment must be followed out. If in this condition he is found lying in a comatose state upon the floor, he is to be lifted gently, carried to a bed, and well propped up by pillows so that the head is elevated. The room should be kept cool and well ventilated, and cold applications are to be applied to his head, while his feet may be kept warm by contact with bottles filled with hot water. The room is to be darkened, and his collar and shirt collar band should be cut or ripped off, so that the flow of blood to and from the head shall be unembarrassed. It is essential to keep him perfectly quiet ; so loud talking is to be forbidden, and officious friends kept away. In times gone by, it was customary always to bleed at this stage. I think experience has clearly proven how dan- gerous is such practice, for hemorrhage in the brain is very apt to be started afresh by any such measure. If, however, the pulse be full, strong, and bounding, the patient's face flushed, and his condition one of plethora, the abstraction of a few ounces of blood from behind the ears, with cold douches to the head and mustard plasters to the calves, will do much good. This condition may be so patent to the observer that, perhaps, in rare instances and after careful deliberation, he may decide to abstract ten or twelve ounces from the arm. If we hear that he has been constipated for several days, a drop or two of croton oil or half a grain of elaterium (F. 22) may be given in a wafer, or applied to the tongue if he is unable to swallow ; it is advisable to give the first remedy, however, if the patient is profoundly comatose. Should there be much cardiac excitement, no better medicines can be recommended than tincture of veratrum viride (F. 36), or tincture of aconite ; the former in doses of from 6 to 8 minims till the pulse force is decreased, and the latter in rather large doses, say from 4 to 6 minims at a time, and after an interval of four hours, another dose, if the pulse has not decreased in volume or frequency. The medical attendant should not forget to draw the patient's urine frequently. I have known a neglect of this precaution to be followed by pain and distress which the patient in his helplessness is unable to express ; and I cannot impress too strongly upon the student the necessity of remembering this simple procedure. When consciousness returns we may continue the aconite if it is indicated, and perhaps combine it with small doses (say 10 grains) of the bromide of sodium (F. 1) every two hours. Active medication of any kind, how- ever, is injudicious in the extreme ; so it will not do to give large doses. Should there be a condition of prostration, a tablespoonful or two of rnilk punch may be given every few hours. The subsequent management of the case is sufficiently simple ; continued quiet, a moderate quantity of food easy of digestion, and attention to the functions of the body are the three indications. He should not be allowed to get up to defecate, but the bed-pan may be placed beneath him. It may be found necessary to give an enema, which is better than the administration of purgatives by the mouth, and in this case the patient should not be allowed out of bed, even though he may seem bright and sufficiently strong. Cleanliness CEREBRAL HEMORRHAGE. 109 should be insisted upon, and generally necessitates the faithful care of a responsible nurse; for, if the patient is not carefully washed, the irritation produced by alkaline urine and his loose evacuations may favor the devel- opment of bedsores. As a precautionary measure, the buttocks should be rubbed with salt and whiskey, or, what is still better, tannin and alcohol. Bedsores may occasionally form, and sometimes are unnoticed by the physician if he is not on the alert, until his nose or the nurse remind him of their existence, the patient either being unconscious of such trouble, or unable to inform the physician even if he is aware of their presence. The patient should be immediately put on a water bed, and the slough re- moved by poultices of flax-seed and charcoal which may be sprinkled with iodoform. At the end of the 8th or 9th day, should the tendency be to recovery, and the temperature normal, we are left with an ordinary case of hemiplegia. What is to be done next? If the attack has been a serious one and signalized by marked loss of consciousness, and if the secondary rise of temperature be high, it is not best to begin elec- trical treatment for fully a month or longer. If the muscles respond too quickly to electric stimulus, we are not to use this agent, but to wait for some days or weeks, when we may cautiously employ the faradic cur- rent to the muscles of the affected side. Large sponge-covered electrodes moistened in a salty solution should be employed, so that all the muscles may be subjected to the electric stimulus in turn. Electrization may be direct or indirect, the muscles being made to contract either when both sponges are applied to their bellies, or when one is placed in contact with the muscle and the other is applied over the motor nerve by which it is supplied. In certain cases faradization fails to do any good whatever, and this is especially the case when there is delay in the absorption of the clot or any cerebritis. Two cases illustrating the possible advantages of this form of treatment are the following : Right Hemiplegia; Cure O. S., aged 52, butler, came under my charge October 2d, 1872. He had been deprived of consciousness and power of motion a year before by a cerebral hemorrhage, and, after resuming the duties of his avocation some months afterwards, continued well till three months ago, when a second attack prostrated him ; but, through the good treatment he received at Bellevue Hospital, he partially recovered the power of locomotion. When he came to me for treatment there was complete hemiplegia of the left side. There was no peculiarity in his gait, beyond a very slight dragging. The arm was slightly atro- phied, and the amount of power exerted by a forcible grasp of the dynamo- meter was indicated by 15 of the lesser circle. He could not button his clothes, nor lift his arm above his head. There was no difficulty in speech, except it might be embarrassment in speaking the words containing the letters " b" and "p," when the labial muscles were required. Electric irritability in the arm was slightly exaggerated. After giving him a simple prescription for his constipation, I dismissed him. In three weeks afterward he returned in very much the same condition. I then systematically applied the galvanic current to the head, and the faradic to the limbs. The improvement was marked and immediate. 110 DISEASES OF THE CEREBRUM AND CEREBELLUM. The muscles lost their atrophic state, and became firmer and larger. The patient was able to perform many actions with his hands not possible be- fore this treatment. Faradization to the lips and cheek has effectually overcome the facial paralysis, and he now speaks distinctly. Cerebral Softening; Right Hemiplegia; Slight Improvement. H. Walker, aged 02, Germany, canal-boat captain, presented himself for treat- ment in December with a well-marked right hemiplegia. He had been injured some time before while on the deck of his canal-boat, and then hit upon the head. He was senseless for some days, but recovered, with se- vere cerebral disturbance, which, from his wife's statement, must have been inflammation of the cerebral substance. He left his bed after some weeks, with persistent pain in the head, aphasia, trembling, and a heavy feeling of the lower limbs. His memory and other mental faculties became obscured, and there was an uneasy expression of the eyes. About a year after the receipt of his original in- jury, while working one day in the sun, he had an apoplectic fit. After remaining in bed some time, muscular power and cutaneous sen- sibility slowly came back. He was able to walk with difficulty; his speech was indistinct ; the muscles of both the leg and arm were greatly atrophied ; and I determined to use faradism. The constant use of the very mild current for several weeks brought back, to some degree, the original contour of the paralyzed muscles. He was able to progress with a cane, but his speech remained imperfect. During the treatment he had repeated premonitory signs of a new attack. Faradism was resorted to to prevent atrophy, but its good effects were only temporary, as there is still softening. In connection with this treatment we may give at the same time either iodide of potassium, strychnine, or ergot. Iodide of Potassium Should there be a syphilitic history, I think we may begin at once with this remedy. If there be no such dyscrasia, I do not approve of the remedy at any time. It is administered very often with the idea of producing absorption of the clot, and is recommended by many writers. My limited experience has convinced me that its virtues have been very much overestimated. I have found that in many cases the patient's tendency to recovery was hastened more by rest, good food, and fresh air, than by any other form of medication. It is perhaps of value in old cases. Phosphorus Either in its pure state (FF. 24, 25, 26), or in combina- tion with zinc, it is of great benefit in cases of long standing, especially if there be debility and tardy restoration of power in the paralyzed limb. The phosphide of zinc (F. 27) in doses of one-third of a grain, or dilute phosphoric acid in half-teaspoonful doses, are perhaps better borne than pure phosphorus. Strychnine is entitled to more consideration. If used at the proper time, it is more powerful to do good than any other remedy I know of, ix-rhaps excepting electricity. When the exaggerated electro-muscular irritability subsides, we may give it in doses of ^ of a grain three times a day (F. 29), but before this time its use is attended with danjrer. CEREBRAL HEMORRHAGE. Ill Vance 1 has recommended hypodermic injection of strychnine, but I always hesitate when injecting an irritating substance into the belly of a paralyzed muscle, for I have repeatedly seen abscesses follow the use of even a neutral solution properly injected. Impaired muscular vitality and tardy reparative nutrition do not favor its use. However, Bartholow, Eulenberg, and Echeverria recommend its employment, and have had good results. Perhaps in paralysis of central origin the trouble to which I have alluded is not so much to be feared as when the affection is peri- pheral. Each muscle is to be subjected to injection (F. 30), one being so treated each day. Instead of the plan recommended by these authorities, viz., injections into the substance of the muscle, I prefer local subcutaneous introduction of the solution by the hypodermic syringe. In addition to electric treatment, it is well to resort to massage and passive movement of the contracted members. The patient may be directed to do this himself, and he should be told to rub the paralyzed limb several times daily for at least fifteen minutes at a time. Dr. G. M. Beard has recommended heat in the treatment of paralysis, and his plan is to place the affected limb in a heated earthen drain pipe, well lined with flannel. I can quite agree with him, but have found that alternate heat and cold applied to the sur- face produce more rapid improvement in nutrition of parts which have lost their power. I originally recommended the instrument depicted in Fig 15, which will be found a cleanly and convenient apparatus. One receptacle is filled with hot water, the other with cold. If the contracted limbs Fig. 15. Instrument for applying Heat and Cold. where lately rigidity had taken place are allowed to remain daily for fifteen minutes or half an hour in quite hot water, much benefit will follow; or, should there be neuritis, we may use blisters, or the actual cautery along the course of the nerve trunk. It is of the utmost impor- tance that everything should be done to improve the patient's hygienic surroundings, diet, and habits. He should not remain in-doors, but stay in the open air as much as possible. Food of a nutritious but not of a fatty character, moderate stimulation if needed, and a course of tonics, may constitute our form of treatment during this late stage of the dis- ease. 1 Journal of Psychological Medicine, April, 1870. 112 DISEASES OF THE CEREBRUM AND CEREBELLUM. CEREBELLAR HEMORRHAGE. Very little has been written in regard to effusions of blood into the cerebellum, and the diagnosis of such a condition is attended by many difficulties. An excellent thesis on the above subject, by Dr. Carion, 1 contains the following conclusions in regard to diagnosis of this disease : " The predominating symptom of cerebellar hemorrhage is general enfeeblement of the muscular system. Hemiplegia is relatively rare ; when it exists it is sometimes crossed, sometimes direct. Facial paralysis is exceptional ; it involves the orbicular muscle of the eyes, and occurs on the side of the lesion, and it has for its cause the compression of the seventh pair at its point of emergence. The tongue presents a certain degree of asthenia, shown by a weakness in its movements, without de- viation. Strabismus, like the facial paralysis, is not observed as a symp- tom of cerebellar origin ; it may occur from compression of some one of the motor nerves of the eye. The conjugated deviation of the eyes has been observed ; it always occurs towards the uninjured side as for other parts of the encephalic isthmus. The pupils are sometimes dilated more frequently contracted; they sometimes react under the influence of light, and are insensible. General sensibility is unaltered even when hemipleiria exists ; we barely observe a slight anaesthesia in a few rare cases ; hyperses- thesia is still less frequent. Troubles of special sensibility, principally of sight, have been observed, but they are very rare exceptions. The in- telligence is generally preserved in all its integrity. Vomiting is scarcely ever absent, and it can rightly be deemed one of the more characteristic symptoms of cerebellar hemorrhage." Abstracted in Chicago Journal of N. Disease, vol. ii. p. 621. CEREBRAL ANAEMIA. H3 CHAPTEK III. DISEASES OF THE CEREBRUM AND CEREBELLUM (CONTINUED). CEREBRAL ANJEMIA. Synonyms Syncope, Anemie Cerebrale, Hydrocephaloid. Definition A morbid state characterized by an insufficient cerebral blood-supply, and expressed by impairment of consciousness, pallor, and much muscular enfeeblement. This disease is capable of quite as great modification as cerebral hyperaemia, as it may be what only appears to be a continued physiological condition, or a grave pathological state. Cere- bral anremia may occur : 1, in an acute form (syncope) ; 2, in a chronic form ; 3, in an infantile form (the hydrocephaloid of Marshall Plall) ; and, 4, it is localized or partial, as a result of vascular obstruction. The acute form, which may be only a simple fainting attack, or the result of shock follow- ing severe hemorrhage, is the most familiar variety. It is hardly neces- ssary to describe the alarming and familiar condition that we occasionally meet with after post-partum hemorrhage, or protracted decubitus, when the patient assumes the erect posture. The chronic variety is much less serious in its earlier stages, though, when continued, it is often the forerunner of certain forms of insanity. It is symptomatized by lowered function of the cerebral ganglia, depraved nervous tone, and general intellectual apathy ; for, as normal circulation is necessary for the support of healthy brain action, and as we find that rapidity of thought and emotional activity are proportionate to the increase in the cerebral blood-supply, so must insuffi- cient circulation bring with it an impaired state of intellectual functional activity. This loss of healthy action may be expressed by drowsiness, obscured intelligence, or by irritability and restlessness. The infantile form generally follows some of the continued fevers of early life, and is a disease of childhood. Occurring during the stage of convalescence of the acute form, it is symptomatized by semi-conscious- ness, diarrhoea, great exhaustion, insensitive pupils, pallor, sighing respi- ration, and other symptoms. The last variety, local or partial cerebral anaemia, is that which is usually productive of right hemiplegia, and is due, in the majority of cases, to thrombosis or embolism, and often has a grave termination. It is hardly necessary to allude to Acute Cerebral Anaemia, for it comes within the province of the surgeon rather than within that of the neurologist. Following some grave accident when there is sudden and excessive loss of blood, we will h'nd a corresponding loss of consciousness, and muscular power, sighing, and slow respiration, generally vomiting, and involuntary discharge of feces and urine. 114 DISEASES OF THE CEREBRUM AND CEREBELLUM. The condition is not a lasting one, and provided the hemorrhage has not been too excessive, or the shock too great, there may be a retrograde disappearance of the symptoms, and ultimate recovery. Symptoms A. IN CHRONIC CEREBRAL ANEMIA Subjective Our patient complains of muscular debility, backache, loss of appetite, and somnolence, with great despondency, increasing loss of memory, marked headache, a regularly distributed cutaneous anaesthesia, some- times vomiting, hallucinations of sight and hearing, palpitation, indiges- tion, and constipation. Objective Pallor of the skin, particularly of the face, which is of a dirty white color, while the sclerotics are milky blue, and the pupils widely dilated. The patient's expression is one of anxiety and depression, and if the condition be advanced and of long standing, he will spend hours with downcast eyes and a painful hopelessness, and hebetude stamped upon every feature. Coldness of the hands, heart - murmurs, and a weak, small pulse, are strong evidences of defective circulation of this description. The sphygmograph gives an almost straight tracing, the pulse-beats being weak and small. I have been told very often by these patients that it was with very great difficulty that they could refrain from falling asleep in public places, and one lady was in the habit of becoming so drowsy in the street car on her way to my office that she very often unconsciously passed the street. Women who suffer in this way are subject to fainting attacks, which occur most often during the menstrual period. Among the most aggra- vating symptoms are hallucinations of hearing ; noises such as ringing of bells are heard; and they occasionally have visual hallucinations in con- nection therewith. Delusions are very unusual. Insomnia is some- times a distressing symptom, though during the day, as I have before said, the patient may have great difficulty in keeping awake. It is not un- common for him to complain of a sensation as of falling through the bed ; and one of the prominent elements of his sleeplessness is the continuous roaring in his ears, which is sometimes compared to the sounds heard when a shell or other hollow body is placed over the ear. If the condition has gone on to the state where mental impairment has begun, we will generally find that there is venous stasis, and that the back of the hands is of a livid color, while pressure leaves a white mark which slowly disappears. The lips are pale, thick, and puffed, and the line between the mucous membrane and skin is less sharply defined than in the normal state. The urine is passed in large quantities, is colorless and limpid, and of a low specific gravity. The heart-sounds are weak, and it is not uncommon to find an aortic bellows murmur. There may be amaurosis, and other defects of vision. Digestive derangements are quite common, and vomiting, which is cerebral, is in some cases frequent and obstinate. The individuals presenting these symptoms are poorly nourished. There may be oedema of the legs and ankles, and sometimes albuminuria. Feebleness and muscular want of power, of a light grade, CEREBRAL ANJEMIA ] 15 are often expressed ; and the comfort of a sofa or easy chair is sought by the patient, who seems disinclined to take any exertion whatever. B. IN INFANTILE CEREBRAL AX.EMIA Marshall Hall has called atten- tion to a most interesting form of ansemia, to which I have casually referred, and to which he has given the name " Hydrocephaloid." The disease depends principally upon exudation, and has its origin in early infancy. A case is related by Hall : " The patient, a boy, aged four, became comatose and perfectly blind and deaf. The finger might approach the half-closed eye without induc- ing any movement, but the moment it touched the eyelash, the eyelids would close. A spoon applied to the lips excited their action, and the food it contained was carried into the pharynx and swallowed ; the respi- ration was frequently suspended ; a sigh, and frequent respiration fol- lowed. The cerebral functions had ceased ; the true spinal functions were made." 1 Marshall Hall lays down certain rules from which I may extract the fol- lowing. We should especially be upon our guard not to mistake the stupor or coma into which the state of irritability is apt to subside, for natural sleep, and for an indication of returning health. " The pallor and cold- ness of the cheeks, the half-closed eyelid, and the irregular breathing, will sufficiently distinguish the two cases." He divides the affection into two stages, the first of which is one of irritability, the second, of coma. In the former there is some attempt at reaction, and in both stages there is some resemblance to acute hydrocephalus. " In the first stage the infant becomes irritable, restless, and feverish ; the face is flushed, the surface hot, and the pulse frequent ; there is an undue sensitiveness of the nerves of feeling, and the little patient starts on being touched, or from any sudden noise ; there is sighing, and moan- ing during sleep, and screaming ; the bowels are flatulent and loose, and the evacuations are mucous and disordered. If through an erroneous notion of this affection nourishment and cordials be not given, or if the diarrhoea continue either spontaneously or from the administration of medi- cine, the exhaustion which ensues is very apt to lead to a very different train of symptoms. The countenance becomes pale, the cheeks cool or cold ; the eyelids are half closed, the eyes are unfixed and unattracted by any object placed before them ; the pupils are unmoved on the approach of light ; the breathing, from being quick, becomes irregular, and affected by sighs ; the voice becomes husky, and there is sometimes a husky teaz- ing cough ; and evidently, if the strength of the little patient continues to decline, there is crepitus or rattling in the breathing ; the evacuations are usually green ; the feet are apt to be cold." It is my opinion that this form of disease is very much more common than it is supposed to be, and that many deaths usually reported as maras- mus are evidently of this nature. Of local cerebral anaemia I will speak in another chapter. 1 Op. cit., p. 181. 116 DISEASES OF THE CEREBRUM AND CEREBELLUM. Causes. As causes of cerebral anosmia We may roughly class all agents that interfere with the cerebral blood-supply, and consider them as remote or local. Whether the fault lies in a diseased heart, which is unable to supply the brain with its normal amount of blood, or whether there is some mechanical obstruction through pressure upon the cerebral arteries, the morbid condition is the same. By far the most common cause of this cerebral condition is a general anaemia which may be dependent upon a number of conditions which drain the vessels. Among these may be enumerated uterine hemorrhages of various kinds, hemorrhoidal fluxes, cancers and other diseases attended by hemorrhage, as well as general dis- eases of assimilation which prevent the proper enrichment of the blood. A very slight reduction in the quantity of the blood will be followed usually by indications of the want felt by regions deprived of their nourish- ment ; but when the nervous system suffers this deprivation, the loss is immediately shown. Ilaller has calculated that one-fifth of all the blood in the body is sent to the brain, and with this fact in view, it will not be difficult to realize how any modification of circulation will result in im- mediate changes. Heart disease generally in the form of fatty enlarge- ment, when there is mitral stenosis, or when functional activity is interfered with by emotional or other causes, may have much to do with cerebral anaemia. This cause enters, perhaps, more extensively into the production of chronic cerebral anaemia than any other. Owing to the delicate arrange- ment of the vaso-motor nerves which so beautifully control the supply of cerebral blood, when through emotional or other causes the function is altered, there will be immediate intra- as well as extra-cranial anasmia. We have all seen that sudden emotions not only blanch the face, but as well produce faintness. Various modifications of the functions of the liver may be as- sociated with states of cerebral anaemia through modification of function of this system of nerves. Milner Fothergill has pointed out the association between the nerves of this organ and those which supply the vertebral arte- ries ; and Schrucder Van der Kolk and Laycock have said that those parts of the brain supplied by the vertebral arteries were the seat of the emo- tions. Fothergill reminds us of the fact that we may have functional de- rangement of the liver without affection of the intellect, but with depressed emotional states. There are other forms of abdominal trouble, such as an overloaded rectum and uterine derangement, which coexist with melancholia and depression of spirits, and every practitioner has seen the wonderful elation of spirits which follows a free movement of the bowels after con- tinued torpidity of the liver. The extension of the cerebral vaso-motor and the involvement of other areas of blood-supply may, of course, make the condition a more extensive one, and disturbances of motility and in- tellection naturally ensue. Pressure made upon the carotid or vertebral arteries by various tumors or growths, or sometimes by aneurisms, is a mechanical cause of cerebral ana:mia of decided importance. I assisted at an operation several years ago where the carotid on one side was tied by Drs. Sands and Parker, of this city. In less than twenty-four hours the patient died from extensive CEREBRAL ANAEMIA. U7 anaemia. Embolism is perhaps the simplest example of a cause of this kind. A detached vegetation or clot is washed into the circulation, up through the left carotid and into the middle cerebral artery for instance, cutting off the circulation, and producing extensive cerebral anaemia on the left side, while right hemiplegia and aphasia follow. In thromoosis the artery is narrowed by the gradual deposit of plastic substance until finally its calibre is occluded, and the blood must take some other channel or not reach the part which it normally supplied. Apoplexy, or brain tumors of various kinds, and atheromatous narrowing of cerebral arteries, are also direct causes. In the first two instances pres- sure is made directly upon the brain substance, and in the latter there is a gradual change in the vessels themselves. As a familiar illustration of how cerebral anaemia may be produced by a drain upon the general vascular system, I may allude to the case of a patient whose trouble dated from a series of miscarriages occurring within a very short period. One of these happened when it was impossible to procure medical attendance, and she lost a great quantity of blood. After the last event she never completely recovered, and her present disagreeable and annoying condition remained. She was drowsy, had frontal headache, ringing in the ears ; was constipated, etc. Another pa- tient was subject to attacks of despondency, when life seemed very dis- tasteful and gloomy. Her appearance was characteristic. White skin, cold hands, palpitation, and other symptoms enabled me to diagnose cerebral anaemia, and vomiting and vertigo were confirmatory symptoms. The cause was found to arise from very troublesome hemorrhoids. After cauteriza- tion and removal, she regained her previous health. Certain medicinal agents, as well as tobacco, produce cerebral anaemia. The bromides undoubtedly possess this property, while chloral and chlo- roform, if taken for a long time, as they often are, are likely to provoke an anaemic state of the brain which is distressing in the extreme. I can recall the case of a young lady who confessed that she had been in the habit of putting herself to sleep at night with chloroform, besides inhaling it several times during the day. I have never seen such a typical case of this morbid condition. Her skin was of a hue of waxy whiteness, her pulse small and fluttering, her pupils widely dilated, and her languor and muscular feebleness very profound. Depression and the contemplation of suicide prompted her to confess her bad habit. Tobacco, though only affecting the heart through its interference with pulmonary functions, undoubtedly produces in some individuals a condition of cerebral ana?mia. The clammy, white skin, giddiness, dilated pupils, hurried respiration, and unsteady, weak pulse, and not uncommonly syncope, are, I think, evidences of cerebral anaemia. Certainly the after effects are clearly suggestive of this morbid cerebral condition. That tobacco, in many individuals, in fact the great proportion, possesses stimulating effects, there can be no doubt ; but the variation of effects which follow the administration of opium, for example, when there is some idiosyn- crasy, clearly leads us to infer that its action is sometimes different from 118 DISEASES OF THE CEREBRUM AND CEREBELLUM. that determined by the majority of physiologists. Physostigtna, aconite, and other cardiac sedatives may be mentioned as other anaemiants. Various conditions, when the blood is poisoned, such as lithiasis. are sometimes unsuspected, but nevertheless very important causes of cerebral ana-mia. Morbid Anatomy and Pathology As we might expect, the anaemic brain is white, firm, reduced in bulk, and greatly changed. The vessels are empty, and there are no puncta visible when a cut is made through the white matter. We may find a distension of the perivascular spaces by fluids, and occasionally some thickening of the neuroglia. I have spoken in another chapter of the circumstances which modify the cerebral circulation. It only remains for me to refer to the experi- ments of Kausmall and Tenner, Burrowes, and others, who have devoted a great deal of attention to the experimental study of this subject. The ex- periments of the first two observers were made upon six adults and a number of rabbits. When the carotids of the human subject were compressed, pallor, loss of consciousness, slow respiration, and dilated pupils were produced, which disappeared when the pressure was remitted, and could again be produced at will. Tying of the carotids was followed by convulsions, un- consciousness, and death, when post-mortem examination revealed evi- dences of softening. In the first experiments, when pressure was remitted, there were evi- dences of a secondary cerebral hyperaemia with flushing of the face. Ob- struction of tlie artery on one side may produce loss of motor power on the other, with immediate giddiness, loss of consciousness, syncope, and occasionally vomiting. There may be complete recovery after such an accident, but " it is always imperfect when the obstruction is situated on the further side (from the heart) of the circle of Willis." 1 The obstruc- tion of the minor cerebral arteries is followed by less complete intellectual derangement, by more marked vomiting and giddiness. Should the ante- mia be quickly produced, as it is when severe injuries have been received and the patient literally "bleeds to death," convulsions form a prominent and almost constant symptom. Sighing respiration, and the other phe- nomena I have already named, are also expressed. In cerebral ana-mia there is impairment of functional activity, while in congestion the reverse is the rule. Post-mortem examination shows that the brain in cerebral anaemia is white, condensed, and less bulky, and the vessels are empty. We have already cited the causes of cerebral anaemia, and it now re- mains for us to consider the part they play. Cerebral anaemia depends upon 1. The insufficiency of cerebral blood-supply through actual deficiency. 2. The action of certain agents upon the nerve-filaments themselves. It is hardly necessary to again more than allude to the first of these. In this condition the effect of posture is said to greatly influence the cere- 1 H. Jones, Functional Nervous Disorders, p. 66. CEREBRAL ANEMIA. 119 bral state. The erect position is conducive to an aggravation of the symptoms, while recumbency favors the flow of blood to the brain. This relief follows the supine position when the individual has an ordinary attack of syncope. Abercrombie relates a case which is quoted by Foth- ergill, and which is, I think, a beautiful practical example of this change. The patient, who was greatly reduced by some gastric disease, gradually became deaf, but heard perfectly well when he lay down or stooped forward. As soon as his face became flushed, the improvement in hearing began, and when he raised his head the blush faded away, and he relapsed into his old condition. Abdominal paracentesis is followed by syncope, if the patient is not made to assume the supine position, for during ascites the abdominal veins are so impinged upon that when pressure is remitted they are capa- ble of receiving a very large quantity of blood in fact, so much as to deprive the brain, and produce the anaemia. A quantity of blood gravi- tates directly through the superior and inferior venae cavae, not being thrown over by the right ventricle, but passing down into the abdominal vessels. Insufficiency of cerebral blood may be due to a powerless heart, that organ being unable to lift a requisite amount of blood for the nutrition of the brain. Not only may this be a direct result of a weakened organ, but it may follow strong emotional excitement. This assumption of the recumbent posture is one of the best thera- peutical means in certain cases. Dr. Weir Mitchell has had extraordinary success in the management of certain intractable cases, some of which were directly dependent upon cerebral anosmia. Of the second mode of production, I may allude to the local effect of some blood poisons, and the influence of the emotions. Bearing in mind the important physiological law that section of the sympathetic is followed by vascular dilatation, and that irritation of the proximal end produces contraction, we are enabled to realize many of the pathological processes which occur in the production of cerebral anaemia. Anteriorly the vaso- motor fibres are derived from the superior cervical ganglion, and poste- riorly the fibres come from the inferior cervical ganglion. These fila- ments follow the course of the large cerebral vessels, and in this manner supply every part of the cerebral mass. This close relation with the vascular system explains the prompt action upon the heart of certain exciting emotions, and secondarily the variation in blood-supply. This is the idea held by Fothergill and others, and most ad- mirably explained by that writer in an article in the West Riding Reports. 1 The connection between variation in cell action and the function of the sympathetic fibres is, perhaps, the most interesting part of the subject. Primarily the influence of impoverished blood' affects the integrity of the cerebral nerve-cells, and secondarily the influence of the cerebro-spinal fibres is suspended. I have no doubt that a certain train of symptoms, which is sometimes expressed during general anaemia, is the result of a 1 Art. Cereb. Anaemia, vol. iv. p. 108. 120 DISEASES OF THE CEREBRUM AND CEREBELLUM. temporary locsil hypenemfo, through paresis of the vaso-motor fibres ; and that parts of the brain are congested while others are anaemic. A result of continued emptiness of the vessels is an oedematous condition of the brain, from distension of the peri vascular spaces by the cerebro- npinal fluid. This condition is sometimes so extensive as to receive the name " serous apoplexy/' and profound stupor is the result. In relation to sleep and its connection with cerebral ana-mia, it will be well to say a few words. A great many observers, among whom were Durham, Kausmall, Tenner, and Fleming, strongly held that the brain wsis ana>mic during repose, the anaemia being the cause of sleep. Others have differed with them; but experimental facts seem to favor this view of the case. Not only may anaemia be unattended by sleep, but a condition of unconsciousness closely resembling healthy sleep may be the result of a hyperaemic cerebral state. Opium, alcohol, and various agents which increase the cerebral blood-supply, act in this way ; but the stupor which follows a toxic dose of either agent must not be confounded with natural sleep. Certain curious facts militate strongly against the anaemic idea, or, at least, against the assertion that sleep is directly dependent upon a diminution in the supply of blood to the brain. 1. There are many anaemic individuals who sleep only after taking stimulants. I think all who have seen the good effects of a bottle of ale at bedtime will be disposed to take this view. The sleep produced in no way resembles stupor, and there is no disagreeable sense of fatigue in the morning. 2. My friend, Dr. Janevvay, has called my attention to an experiment he has made. This consists in the administration of a few drops of nitrite of amyl to a sleeping person. Although cerebral congestion follows, the patient does not awake. 3. If mental action is dependent upon activity of the cerebral circula- tion, and sleep upon anaemia, it almost seems that dreams must be incon- sistent with sleep ; while, on the contrary, many individuals enjoy the most vivid and constant dreams, and do not awake till their usual hour. I am more inclined to think that the production of sleep depends upon some change in the function of the nerve-cell, and that this modified form of action is not necessarily dependent upon either anemia or congestion in any particular case, but that, if there be aneemia, it is secondary to the cell- change, whatever that may be. The connection of a torpid condition of the liver with cerebral anaemia will explain the constipation, which is anything but an uncommon accom- paniment of the disease. Intestinal accumulation, as Fothergill says, may " stand to cerebral anaemia in a causal as well as a consequential re- lationship," and he alludes to the experiments of Ludwig and Daziel to illustrate the connection. A finger passed over the intestines produced acceleration of the intracranial circulation. The general symptoms, such as languor, the various modifications of sensation, etc., are directly due to a diminution in nervous supply. Diagnosis Acute general attacks of cerebral anaemia may be con- CEREBRAL ANAEMIA. 121 founded with cerebral congestion, stomachic and auditory vertigo. I have already spoken of the distinction to be made between the disease under discussion and cerebral hypersemia, and it is not necessary to say more. Attacks of stomachic vertigo, or Meniere's disease, are symptomatized as follows : The first is characterized by a feeling of " emptiness of the head," reeling and swimming, general coldness ; " objects whirl around ;" no loss of consciousness, nor marked disposition to sleep. No dependence upon a very full or empty stomach, and the possible existence of gastral- gia. In Meniere's disease there is aural disease, and turning or whirling generally to one side, from left to right, and the condition is not continu- ous. The most important facts to discover are in relation to the cause, whether it be a secondary condition, the result of cardiac trouble, or whether it be simply a result of general anaemia, without any organic disease. Chronic cerebral anaemia presents various phases, and it is almost impossible to go over the long list of general diseases which, like hysteria, it may counterfeit. Prognosis. As cerebral anaemia is nearly always due to some cause which is easy of removal, the prognosis is good. If, however, there be organic heart trouble, the case assumes a different aspect. Old cases are extremely discouraging, particularly when the patients happen to be women. Irritability and hysteria generally enter largely into the complaint, and treatment is sometimes almost useless. If uterine, hemorrhoidal fluxes, and other such drains exist, of course their amelioration is attended by cure. Should the loss of blood be caused by a cancerous uterus or rectum, the prognosis is consequently very bad. Treatment It is of the utmost importance that the practitioner should seek out and remove, if possible, such conditions as diminish the amount of blood in the body, and consequently he must ascertain the exist- ence of hemorrhoids, uterine hemorrhages, either periodical or irregular, and apply appropriate remedies in such cases. Without venturing upon another field, I would call attention to the necessity, in cases where there is menorrhagia, of overcoming this condition as promptly as possible, for special treatment of the nervous condition is of little avail when the woman every month loses a quantity of blood largely in excess of what is made in the interim. Active measures are necessary when there is general anaemia, and for this purpose we must resort to iron, strychnia, phosphorus in some of its forms, cod-liver oil, an abundance of nutritious food, with stimulants such as milk punches, porter, or ale (FF. 8, 9, 10, 24, 29). A word or two is necessary in regard to the diet, and the quantity of alco- hol given to these patients. It is the physician's bad fortune to meet with cases of this kind in which digestive troubles are dependent entirely upon an enfeebled state of the viscera, and we should therefore use great care and not be impatient. A hearty regimen, and too much alcohol, may do mischief instead of good. It is well, therefore, in certain cases, to give the stomach as little work as possible, and at 'the same time to allow it to exert itself 122 DISEASES OF THE CEREBRUM AND CEREBELLUM. in a way that will most benefit its possessor. A very little food, given at short intervals, will be more perfectly digested and assimilated than a large quantity taken at long intervals. I have often given a few table- spoonfuls of cream or beef-juice every hour for days, and have ultimately seen such a marked improvement and an increased capacity for work upon the part of the digestive organs, that the more gross varieties of animal food, as well as alcohol, were after a while borne in large quantities. Should this enfeeblement of the digestive organs exist, we may give either pan- creatine emulsion, or strychnia and muriatic acid (FF. 31, 33, 34). Ex- tract of malt is sometimes very well borne, and hastens the improvement. This may be given in combination with cod-liver oil (F. 32). One of the most useful forms of treatment to which I have already alluded the " rest treatment" of \Veir Mitchell is of marked service in old cases, especially if the subjects happen to be women. Dr. Mit- chell has treated many cases which are almost identical with those that generally come under the head of chronic cerebral anaemia. He says : ' These cases vary, of course, endlessly ; but their essence is a state of reduced nutrition, which no mere tonic will cure, while they are afoot and Jiving on their capital. The main symptoms are the state of painful tire, the low temperature, the great or less anaemia, the quick pulse, the excess of white blood." lie calls attention to the necessity for perfect quiet, and at the same time daily massage and faradization of all the muscles. His treatment is expressed in his own words thus : " The amount of feeding, of massage, and of faradic-muscle exercise which each case will bear and prosper under, is a matter to be told early in the case by watching the pulse, the temperature, and the appetite. In these cases the pulse is always rapid. If it fall, if the temperature rise, above all, if there be the least gain in flesh, I know that I am on the right path, and am not moving on it too fast ; but if these symptoms be reversed, and if the patient ceases to be hopeful and looks weary, then I lessen the passive exercise, and wait a little ; but, above all, I listen to what, my masseur or masseuse tells me of the ease with which the limbs flush or the readiness with which the muscles grow firm under the kneading fingers, for in this matter I get to have a very shrewd judgment. As to the rectal feeding, which I rarely omit. I say little, as it is well understood. It should always include cod- liver oil. There is only this to be borne in mind: most medical men feed by the bowel when they cannot by the mouth. I like to use both ends at once." This treatment seems to be the very best in cases of long standing ; but it is well to see first what fresh air, tonics, and abundant nitrogenous food will do for our patient, while she pursues her ordinary life. I have lately modified Mitchell's treatment, and have placed my patient in a darkened room. This condition, which is attended by excitement and irritability of the organs of special sense, is much benefited by abso- lute quiet, and, therefore, darkness and rest are most agreeable and useful forms of treatment. STOMACHIC VERTIGO. 123 STOMACHIC VERTIGO. Synonyms Vertigo a stomacho laeso (Lat.) ; Vertige stomacal (Fr.) ; Gastric vertigo. Definition. A condition of giddiness, hallucination, nausea, head- ache, etc., without loss of consciousness, and probably dependent upon a reflex excitation of the cerebral vessels from some visceral irritation. Symptoms. The condition, which is a very common one, is pro- duced, in most cases, directly after a hearty meal, or else when the stomach is entirely empty. A sense of gastric fulness at first, while head- ache, with buzzing in the ears, palpitation, and giddiness of a few mo- ments' duration, follow. Should there be hallucinations, the patient is not worried by them, but realizes their unsubstantial character. Trous- seau 1 insists upon the fact that the hallucinations of this condition differ from those attendant upon cerebral hypenemia from the fact that in this form they do not occur when the head is lowered, which is the case in cerebral hyperoemia. Causation Stomachic vertigo is more a condition of middle life and old age than one of youth. Young women occasionally suffer, but this is the exception. Certain forms of indigestible food may directly provoke the attack, or it may follow violent exercise after a hastily eaten meal. In one case of which I know, a gentleman ran for over a mile to catch a morning train. He had arisen but a few moments before, and had hurri- edly eaten his breakfast. He fell to the ground, but did not lose con- sciousness. The disorder often occurs when the individual has been eating irregularly; and business men or others who take but little exercise and eat hurriedly are very often the sufferers. Handfield Jones 2 considers taenia to be a frequent cause of vertigo, and such has been my own experience. Treatment Trousseau, who has written most fully upon the sub- ject, recommends that the patient be directed to drink every morning a glassful of quassia infusion made by maceration of the shavings in water, or to use the goblet of quassia wood in which the water is allowed to re- main until it has become bitter. After each meal one of these powders should be taken : R. Sodae bicarb., Magnesias calc., aa gr. xv. Greta? praep. 3ss. M. Divid. in chart, no. iij. Sig. One after each meal. Strychnia, pepsine, and sometimes bismuth (FF. 30,31, 28) are excel- lent remedies, and should be given, while attention is to be paid to the patient's general habits. 1 Clinical Medicine, Am. edition, vol. ii. p. 358. 2 Functional Nervous Disorders, p. 444. 124 DISEASES OF THE CEREBRUM AND CEREBELLUM. AUDITORY VERTIGO. Synonyms Labyrinthine vertigo ; MeV.ere's disease. Definition A morbid cerebral condition expressed by vertigo and rotatory movements, unattended by loss of consciousness, and dependent upon disease of the labyrinth, or other parts of the central auditory appa- ratus. To Mdn'ere 1 belongs the credit of having first accurately described this disease, though Triquet 2 gives the credit of its discovery to Saissy, of Lyons, who observed a nervous condition connected with diseases of the inner ear. Trousseau 3 says that Saissy did not mention vertigo as a symptom of the condition to which he called attention. It is enough to say that, prior to 1861, the form then known only as stomachic vertigo was always supposed to arise from digestive troubles, and the existence of a distinct variety, with aural disease, was not appreciated. Symptoms Generally there are some indications of otitis, whether they be simple inflammation denoted by pain, or a discharge of bloody pus, or even perforation of the tympanum. In many cases the disease may be preceded by a chill, and this should be always looked upon as a serious indication. The patient is suddenly seized with vertigo, and at the same time experiences a feeling of nausea and buzzing in the cars, which may be double, or confined to one side. This vertiginous condi- tion calls to mind a sensation experienced when one is twirled in a swing. A boyish prank is to twist the ropes of a swing while the unhappy victim is seated therein; then to suddenly release the board, which revolves with great rapidity as the ropes unwind. This description of the symptom was given me by a patient who suffered from nausea at the same time with vertigo. The vertigo is attended by a loss of equilibrium. The patient sways or reels, and there is an impulse to turn from the left to right when the left ear is affected, and vice versa when the other is the seat of the disease. Ferrier 4 describes a sensation usually experienced. He (the patient) feels "as if he were suddenly lifted from the ground and pitched forward and to the right side." There is also a tendency, when walking, to keep close to the side of the wall or house which corresponds to the affected ear. Deafness is generally present, but this is, of course, the result of the destructive aural disease. 6 Recovery is not always to be 1 Bulletin de 1' Academic de M6rl., xxvi. p. 241. 2 LeQons cliniques sur les Maladies de 1'Oreille, p. 113, Paris, 1863. 3 Loc. fit., p. 363. 4 Labyrinthine Vertigo, W. R. Reports, vol. v. p. 34. 5 Crum-Brown is of the opinion that, in addition to the other senses, the indi- vidual possesses one of rotation, by which we are able to determine the axis about which rotation of the head takes place ; the direction of rotation, and its rate. In explaining some experiments performed by him, he says: " In ordi- nary circumstances we do not wholly depend upon this sense for such information. Sight, hearing, touch, and muscular sense assist us in determining the direction AUDITORY VERTIGO. 125 expected, but a great many cases improve under appropriate treatment presently to be described. John B., aged 47, iron railing manufacturer. Nearly eighteen months ago, he became troubled by noises in the left ear, which he compared to the " singing of canary birds," and afterwards this subjective noise changed its character, and he described it as a continuous roaring like the escape of steam from a boiler. To. this sound he has since become par- tially accustomed. He has never had earache, but nine years ago there was a discharge from the left ear, but there have since been no other symp- toms. He has suffered for a long time from post-pharyngeal catarrh, and there is now a catarrh of both Eustachian tubes. When a young man he had secondary syphilitic symptoms, but denies having had any primary sore. Sixteen months ago, during hot weather, he was seized in the street with dizziness and reeling, and was obliged to grasp a lamp-post for sup- port. There was no loss of consciousness, and he realized fully his con- dition of helplessness. He said that he felt as if he was being " twirled " from right to left, but did not fall. This attack occurred before dinner (about 11 A. M.), and his stomach was neither filled nor completely empty, for he had eaten his breakfast at 8 A. M. He was perfectly well otherwise, and the only disordered function was that of the lower bowels, for he was constipated. He has had these attacks very frequently. For the six months following the first attack of vertigo they occurred about once a month, but since then they had been of daily recurrence. Present State. The patient's digestive, organs are in good condition, and his appetite is fair. He is ordinarily of constipated habit, but it re- quires but slight medication to overcome this. He is of medium height, weighs 1 43 pounds, and seems a well-nourished man. His face is some- what suffused when he becomes excited, but he is ordinarily pale. His eyes convey an anxious expression, but the pupils are normal. His hair is scanty and gray, but not removed in patches, nor suggestive of any pre- vious syphilitic trouble. He has occasional headache, and still complains of the " roaring" noise on the left side. Hears the tick of a watch only six inches from left ear, and indistinctly at any distance within this limit. AVatch tick heard at five inches from right ear, but more perfectly. Dr. C. S. Bull examined his eyes, and the following is his report : and amount of our motions of rotation, as well as of those of translation ; but if we purposely deprive ourselves of such aid, we find that we can still determine with considerable accuracy the axis, the direction, and the rate of rotation. The experiments that I have made with the view of determining this point were con- ducted as follows : A stool was placed on the centre of a table capable of rotating smoothly about a vertical axis; upon this the experimenter sat, his eyes being closed and bandaged ; an assistant then turned the table as smoothly as possible through an angle of the sense and extent of which the experimenter had not been informed. It was found that, with moderate speed, and when not more than one or two complete turns were made at once, the experimenter could form a tolerably accurate judgment of the angle through which he had been turned. By placing the head in various positions, it was possible to make the vertical axis coincide with any straight line in the head. It was found that the accuracy of the sense was not the same for each position of the axis in the head ; and, fur- ther, that the minimum perceptible angular rate of rotation varied also with the position of the axis. It was also found that considerable differences of accuracy exist in different individuals." 126 DISEASES OF THE CEREBRUM AND CEREBELLUM. 20 " Examination of J. B. V ... -; with convex 32 spherical V H . Fundus perfectly normal." 30 His attacks occur nearly every day, and seem to have no relation with the condition of digestion. These " reeling fits " may take place at any time of the day, last for five or six minutes, and usually are not so sudden as to prevent him from taking hold of the nearest lamp-post or railing. In a recent vertiginous seizure he was taken just as he was about to get into a street car, and would have fallen had the conductor not dragged him upon the step. He tells me that he has asked his wife to " turn him the other way " when the attack occurs, and usually this has the effect of abating it. I placed him upon large doses of quinine at first, which have decidedly influenced the frequency and character of the ver- tigo, so that he often passes a week at a time without any seizure. Bro- mide of potassium had been prescribed for him before his visit by another physician, but he tells me that this drug increased the dizziness. The phenomena of these attacks are the following : He suddenly feels light headache ; objects swim about him from right to left while he seems to be rotated the other way, and during this period he separates his feet and braces himself. The outlines of the houses, trees, and sidewalks are blurred and distorted, and after a few minutes they suddenly assume their proper relations, and the attack passes off, and he has subsequent headache. Causes The disease being directly due to aural inflammation, and the causes of this condition, whether they be exposure, the extension of other inflammatory processes, or the injudicious use of douches and injec- tion, are only secondarily productive of the neurosis. Pathology The experiments of Flourens and Goltz' have been the basis for our pathological study of Me*niere's disease. Brown-Se'quard* and Flourens demonstrated that when the membranous canals of the labyrinth were divided, various disturbances of equilibrium followed. "Walter and Lincke 3 and others have divided the horizontal canals and produced oscillation of the eyeballs, swaying of the head from one side to the other; and have seen the animal spin round like a top. Division of the posterior vertical canal causes the animal to topple over backwards, and the head is moved backwards and forwards. When the superior ver- tical canals were cut across, the animal pitched forward. It may be seen that a diseased condition, not limited to any particular spot, may produce a combination of these symptoms. Brown-Sequard, in speaking of the relation of rotatory movements to auditory irritation, calls attention to these familiar illustrations: " 1st. Any one who has received an injection of cold water in the ear 1 PHuger's Archiv i'Ur Physiologic, 1870, and Recherchcs sur les Propr. et les Functions du Systferae Nerveux, 2d ed. 2 Central Nervous System, Philadelphia, 1860, and Experimental Researches, 1853. 3 Wagner's Handworterbuch der Physiol., vol. vi., 1853, p. 420 et seq. AUDITORY VERTIGO, 127 may know that it produces a kind of vertigo, and that it is difficult to walk straight for some time after this irritation. 2d. A sudden noise makes the whole body jump, particularly in old people, or in persons attacked with anaemia, chlorosis, epilepsy, chorea, hysteria, hydrophobia, and in certain cases of poisoning ; in a word, in all circumstances in which the control of the will over reflex actions is lost or diminished. 3d. A T ertigo and various convulsive movements in cases of irritation of the acoustic nerve have been observed in adults and children. Rotatory movements have taken place in cases of suppurative inflammation of the ear, and twice imme- diately after an injection of nitrate of silver." Ferrier, 1 who has written most clearly upon this disease, goes very deeply into the subject. In the normal state it is necessary for tactile, visual, and auditory impressions to be unembarrassed, so that the power of equilibriation may be preserved ; but it is of absolute importance that the labyrinthine functions should be perfect. It seems to regulate the state of equilibrium of the individual, and to preside over coordination. The mechanism of the labyrinthine canals is admirably described by Crum-Brown. 2 The sense of rotation, as suggested by him, must, like other special senses, have a special peri- pheral organ, a brain centre, and a connecting sensory nerve. All experi- menters agree that the labyrinth is a special peripheral organ, and the auditory nerve is that which conveys the peripheral irritation to the centre. " The bony canals are filled with liquid, in which float loose connective tissue, and the membranous canals with the contained endolymph. Rota- tion of the head about an axis at right angles to the plane of a canal will then produce, on account of the inertia of the liquid, etc., motion of the contents relatively to the walls of the canal ; and this may be expected to irritate the terminations of the nerves in the ampulla. If the rotation be continued at a uniform rate, fluid friction of the endolymph against the membranous canal, and of the perilymph against the membranous canal, and the periosteum will gradually diminish this relative motion, which will at last cease. We should therefore expect, as we have seen to be the case, that continued uniform rotation should be perceived less and less .strongly, and that the sensation should at last die away altogether. The time required for this equalization of the motion of the canal and its con- tents will depend upon the rate of rotation and upon the dimensions of the canal and the amount of attachment of the membranous canal to the periosteum. These latter conditions are not the same in the three canals, and therefore we ought to find, as we do, that the rate at which the sense of rotation dies away is not the same for different positions of the head. Again, if the uniform rotation is stopped, the contents of the canal will continue to move on, thus causing an apparent rotation in a direction the reverse of that of the original rotation, and this also will die away owing to friction." The irritation of the auditory nerves which occurs, is at- tended by anaemia of certain parts of the brain, which accounts for the 1 Ferrier on the Functions of the Brain, New York, 187(3. 2 Journal of Anatomy and Phys., May, 1874. 128 DISEASES OF THE CEREBRUM AND CEREBELLUM. reeling, dizziness, nausea, and other symptoms with which we are already familiar. Diagnosis. (lowers, 1 in a paper before the British Medical Associa- tion, pointed out the liability of its confusion with gastric trouble. He calls attention to the fact that violent and repeated vertiginous attacks, the sense of movement or actual turning, tinnitus aurium, and deafness, are more suggestive of the auditory origin than of gastric vertigo. Gowers' cases were connected with affections of smell and taste, and at the same time in one there was a gastric ulcer. He made his diagnosis by the de- tection of loss of function of the right ear and by one-sided falling. It is often necessary to differentiate from petit mat, from apoplectic warnings, and from general cerebral anaemia. In the first there is rarely vertigo, but there is loss of consciousness of temporary duration, and there is some convulsive movement, though sometimes so slight as to be unrecognized. The presence of aural disease is enough to throw out of the question the other condition I have named. Treatment. Large doses of quinine have been of service in these cases, and CharcotV experience with this agent is extremely gratifying. He recommends the energetic use of revulsives in vertigo, the cautery being applied over the mastoid bone three or four times a week. He gave sixty centigramme doses of quinine in one case for a period of two months with happy results, and a short time after the commencement the vertiginous attacks ceased. It is necessary to give the drug in large doses, and at the same time the aural disease should not be neglected. In the case of " J. B." I combined infusion of digitalis with the quinine, and obtained very good results. He was also directed to turn in an opposite direction to that caused by the disease. Subsequent expe- rience has convinced me that strychnine is perhaps better than quinine, and I have been highly successful in relieving a case of much greater vio- lence in which increasing doses of the drug were administered. In this connection it will be well to call attention to attacks of malarial vertigo of a periodic character which are sometimes encountered, and which re- semble auditory vertigo: quinine or arsenic is of course indicated. 1 Br. Med. Journal, Aug. 26, 187G. 2 Lc'Qons sur les Maladies dti Syst. Nerv. No. 4, p. 321. INTRACRANIAL THROMBOSIS 129 CHAPTER IY. OCCLUSION OF INTRACRANIAL VESSELS. THROMBOSIS EMBOLISM. THE deprivation of an area of greater or less extent of its blood-supply constitutes a condition which has been called by some writers " Local cerebral anosmia," and it may take place through the existence of either of the above vascular states. Though very closely allied, these two forms of mechanical obstruction may be defined : in one case, as the local for- mation of deposits, or morbid changes favoring obliteration of bloodves- sels ; and in the other, as the lodgment of clots, or organized tissues which have been brought from a distance. Their chief interest lies in the fact, that it is often difficult for us to distinguish the subsequent symptoms from those indicating an effusion of blood from a ruptured vessel ; that speech troubles are prominent ; and that the prognosis is nearly always unfavorable. Thrombosis and embolism, though usually followed by many of the same symptoms, and confounded with each other by some of the medical writers by whom they were first described, differ greatly in their manner of occurrence and pathology. The first, as we shall hereafter see, is of slow development, and is not so serious in its results as embolism, while the latter condition is much more grave in all its features. INTRACRANIAL THROMBOSIS. Any local vascular change from the normal state which favors the depo- sition of fibrine in an intracranial vessel, whether it be an artery, a vein, or sinus, produces the condition which is known as thrombosis. As a con- sequence, the calibre of the vessel is narrowed, and circulation of blood is impeded therein ; clots form, and either from actual obstruction of direct supply or by pressure, a region of greater or less extent becomes anaemic. Though the arteries are more frequently the seat of such an alteration, the veins and large sinuses and the capillaries may be plugged up by clots which are of local origin. The condition, however, last mentioned is for- tunately a very rare one, but when it is met with it is a most dangerous and alarming morbid state. THROMBOSIS OF THE CEREBRAL ARTERIES. Symptoms It is a disease of slow development, and may affect several arteries simultaneously, or but one. For weeks, or even months 9 130 OCCLUSION OF INTRACRANIAL VESSELS. before, distressing and important evidences appear, and the patient may present unmistakable expression of the cerebral change, such as headache, which is generally localized, confusion of ideas, and awkwardness of speech, these disturbances being, usually, varieties of aphasia. As the disease advances this trouble becomes much more pronounced, and in place of there being simply a difficulty in expressing a clearly origi- nated idea, there may be a condition of amnesia. Clumsiness of speech, and want of delicacy in articulation are followed by an actual failure in remembering words. Memory is also defective in other things, and our patient begins to become stupid and listless. The next indication of this advance may be the appearance of paralysis, which is sometimes slight or incomplete, only involving the muscles of the face or eyeballs, or there may be hemiplegia. Should the thrombus be seated in a large artery, or softening occur, a complete and lasting hemiplegia may be produced. There is rarely loss of consciousness at any time, and in very few of the cases that recover, is there anything at all like the paralysis following cerebral hemorrhage. Recovery is generally to be looked for, provided the vessel be not an important one; and, though like its first cousin, embolism, it may be one of the causes of softening, such a termination is not always to be feared. Aphasia, which is insisted upon by most writers as a pathog- nomonic sign, is occasionally absent. In one case reported, though the left middle cerebral was affected, there was no aphasia at any time. 1 The following case is one that came under my observation, and is of interest because of the seat of the thrombus, and the interesting character of the morbid appearances. L. C., aged 22 years, seamstress; admitted into hospital October 9, 1876. History from friend who accompanied her. The patient had been feeling unwell for about two months, having had pains in her head and back, loss of appetite, insomnia, and other troubles. About a week ago the friend went up to her room to assist her to dress for breakfast. When the patient stepped out of bed she fell upon the floor, and then first noticed that she was completely paralyzed on the right side. The friend knew nothing of the patient's antecedents. Her husband, who was seen subse- quently, stated that he had left her because she drank ; and that after the separation she went to New York and became a prostitute. Two years ago he saw her, and at that time she had marks of syphilis on her face, and her hair was falling out. She went to Ward's Island for treatment. She conversed with him intelligibly, but said she was suffering from "general debility." She had headache, pain in the back, etc., and was at this time leading a very irregular life; sitting up during the greater part of the night, and sleeping only a portion of the day. The following history was taken by Dr. Naylor, resident physician in hospital: Oct. 10. Complete hemiplegia of the right side, limbs lax, and muscles flabby; impossible to excite reflex movements by tickling; right pupil 1 St. George's Hospital Reports, vol. i.. 1866, vol. vi. p. 322. THROMBOSIS OF CEREBRAL ARTERIES. 131 irregular, and smaller than the left ; tongue drawn to left side when pro- truded, and when she laughs the right side of the face is drawn up. Con- trol over the sphincters good; temperature 101 ; patient aphasic. When asked, " How long have you been sick?" replied, "Since Benny;" this answer was given to many questions asked. " What do you hold in your hand?" (it was a piece of bread.) "Tobacco." Seemed puzzled, but when reminded of its true nature she brightened up and appeared to realize her mistake. 13th, In about the same condition. Muscles of the right arm and leg do not respond to the currents. When asked how old she was, replied, " So and so." " What did you work at ?" " So and so." " What street did you live in?" Appears puzzled. "Was it sixteenth? seventeenth? eighteenth?" "Yes." "How long has it been since you last saw your mother?" " You long so, John." Expression intelligent, and she seems to understand all that is said to her. Does not hear so well on left side, with right ear perfectly. 17th. Appeared to be suffering great pain. When asked to locate the pain, she did not attempt to do so. She has passed no urine since yester- day morning. Has a hard and swollen erythematous spot on the outside of each knee, and two similar enlargements on each leg below. There is a hardened red spot over the fourth cervical vertebra. All of these parts are painful to pressure. . 18th. Right hand somewhat swollen. 6P.M. Is drowsy this evening. Appears to suffer pain, and places left hand upon abdomen. One pint of straw-colored urine containing no abnormal constituents was drawn by the catheter. 19th. Still dull and drowsy. Said nothing to-day but " yes," " no," and " well ;" passed her urine in bed ; stupid and dull all day. Carotid on right side pulsates very distinctly. 21st. Somewhat brighter to-day ; bowels regular. 22d. Relapse to stupid condition ; passed urine in bed ; became choked while eating some beef at dinner. 23d. Seems to take no interest in anything that is said to her. 24th. Two furuncles (one surrounded by a red areola) have appeared on the right buttock. 25th. Still absolute loss of power and sensation on right side, and con- tinued drowsiness. 2ftth. Involuntary discharges of feces and urine. 27th. She brightens up after receiving nourishment, but cries and seems distressed. 2Qth, 2 P. M. Nurse called the house physician, seeing that she appeared to have stopped breathing. Her eyes were turned upwards and her lips blue, and her pulse was very weak and feeble. Ordered stimulants. Nov. 1. Made no attempt to speak, but answered "yes" or " no" cor- rectly to any questions asked. 2d. Feverish and restless; temperature 101; discharges from the bowels have stopped. 6th. Complains, of pain in her thigh and legs ; cries a great deal ; refuses food, and appears to be very much run down. 8th. Right pupil approaching more nearly the size of the left ; appetite still good ; bowels regular. Cannot write her name with the left hand, but makes a disorderly scrawl. Asked her to repeat several words; pro 132 OCCLUSION OF INTRACRANIAL VESSELS. nounced " eggs" very distinctly ; for " cross," she said " cork." 7 P. M. Quite feverish and restless ; temperature 102. 13th. Has still fever; temperature 102. Ordered quinine and cold sponging. She cries, and appears very sensitive when moved. 14th. Slept well last night. 7P.M. Temperature 100. Several inguinal glands on the right side are somewhat enlarged and painful on pressure. 2'2d. Complains of great pain at the attachment of the adductors to femur. The month of December was passed without anything occurring of spe- cial note. The patient grew much more feeble ; there was no improve- ment in the paralysis, and she became reduced to a shadow. The tem- perature continued elevated, and she was restless and delirious at times. Of course the burden of her delirium consisted of two or three words, which were repeated over and over. Jan. 8, 1877. Dr. Naylor was called to see the patient at 4 o'clock P. M. He then noticed some fibrillary contraction about the right angle of the mouth, with an occasional spasm of the upper lip, when it would be drawn up with the wing of the nostril. Eyes closed, pupils more con tracted than usual, face Hushed and head hot ; temperature in axilla 101^. When left foot was pricked she turned it up ; pulse too rapid to count ; heart's action tumultuous. Tr. digitalis, gtts. xv. 5 o'clock P. M. Spasm of lip still continues ; lies on her back with eyes closed, and gives no evidence of pain when any part of the body is pricked ; pulse in same state. 6 o'clock P. M. Breathing heavily ; eyelids closed and eyes turned upward ; pupils do not contract to light, but lids contract slightly when conjunctiva is touched; reflex irritability very much impaired; pulse 100; temperature 102. 7 o'clock P. M. Spasm of mouth has ceased ; respi- ration very slow and feeble ; pulse 80 ; temperature 102. lOo'clock P. M. Mucous rales heard over whole chest. 12 o'clock A. M. Patient remains unconscious. 2 o'clock A. M. Patient still breathes slowly and feebly ; small amount of frothy mucus comes out of her mouth ; patient remained in this condition until death, 10 A. M., 9th instant. Autopsy Head : dura mater normal ; sinuses empty ; moderate effu- sion into arachnoid cavity ; pia mater intensely congested ; left middle cerebral artery about ^ incli from its origin occupied by a firm thrombus ; beyond this the artery was thin, ribbon-like, scarcely perceptible, and finally lost ; membranes readily detached from the brain, leaving the sulci gaping widely over the under surface of anterior lobe, left side about third frontal convolution and island of Reil. In detaching the mem- branes portions of brain-substance were removed with them, leaving an almost pultaceous mass exposed; indeed the whole of under surface of an- terior lobe was much softened, but this was most marked near the lateral border ; under surface of middle lobe slightly softened ; superior and lateral aspect of anterior and middle lobes from fissure of Rolando forwards was in a very softened condition, breaking down under the least pressure, of a pale yellowish-gray color, in marked contrast with other parts of the brain, which on section showed very numerous puncta vasculosa, and were of the normal color. Thalamus opticus somewhat softer than that of the right side ; corpus striatum much softened and of a yellowish color. Thorax : lungs oedematous, and poured out an abundance of mucus on section. Heart : insufficiency of mitral valve ; no vegetations noticed ; left ventricle entirely filled by a firm white clot entangled in chordae tendinse and projecting into aorta ; abdomen, kidneys, liver, and spleen much congested. THROMBOSIS OF CEREBRAL ARTERIES. 133 Causes Men are more often subject to arterial thrombosis than women or children, though we find the great number of cases of thrombosis of the sinuses to be among women, and this is perhaps due to the tendency of this sex to chlorosis. Gintrac considers very young children to be subject to venous throm- bosis. Of 37 cases seen by him, 14 were among infants ; but arterial throm- bosis is a condition peculiar to advanced life, and instances before middle age are not at all common unless they be of a specific nature. The ex- citing causes are numerous, but it may be assumed in nearly every instance that the blood is in a state of hyperinosis as a consequence of acute disease, such as rheumatism or pneumonia. Excessive heat is very often a cause. Dickinson 1 gives four cases, in two of which heat was the cause, in one other intemperance, and in the fourth violent vomiting. In many of these patients there is old heart disease with some enfeebled action of that organ. The basilar artery, which receives its blood from the vertebral arteries, may be the seat of a clot at its remote end when heart force is preternaturally weak, but this is a rare form of the disease. I have already spoken of peripheral phlegmatous troubles, and it is only necessary to call attention to the danger which may arise from carbuncle. The puerperal state favors the formation of thrombi, and just as phleg- masia alba dolens is brought about, so may the thrombosis of the cerebral arteries be produced. The graver variety of intracranial thrombosis may be produced by internal or external cause. Lancereaux collected 39 cases, 30 of which were connected with caries of some of the cranial bones, and 24 with otitis. In one-half of these cases there were multiple abscesses of the brain. In conclusion I would allude to the possibility of traumatic origin, a variety of blood-states, and pressure from intracranial tumors, exostoses, and thickened meninges. Morbid Anatomy and Pathology Von Dusch, Parnum, 2 Grissole, 3 Zahn, and a host of observers have devoted themselves to the study of this subject, and since the original observations of Kirkes 4 were published in 1852, which were devoted to the pathology of thrombosis as well as embolism, a great deal has been written. Parnum and Burro wes 5 ' O both experimented by injecting substances into the circulation, and Bur- rowes probably relates the earliest case of recognized thrombosis. Zahn gives the following concise description of the pathological process which attends the production of a thrombus. " The intensity and the dura- tion of the injury, together with the previous condition of the individual, determine the durability of the clot. The process of formation is the fol- lowing. Colorless blood-corpuscles adhere to a part of the intima denuded 1 Loc. cit. 2 Virchow's Archiv, xxv. 3-6, pp. 308-338, 433, 530, 1862. 3 Pathol. Intern., p. 247. 4 Med. Chir. Trans, 1852. 5 Med. Gaz., vol. xvi. 1834-5. 134 OCCLUSION OF INTRACRANIAL VESSELS. by an injury of its endothelium. They accumulate there, form a ring- like obstruction, and gradually the clot obstructs the vessel altogether. It' the injury be slight, and the nutrition of the individual unimpaired, the current of blood soon breaks through the blood-clot and carries along the flakes of the colorless blood-corpuscles. The normal condition is soon restored. If the injury of the vessel be more severe, and the surrounding tissue already in a state of irritation, the thrombus, whilst forming in the same way as described, is firmer and larger. The obstruction is more complete, and lasts for twenty-four hours and more ; after that period the thrombus begins to disintegrate into granular fibrine, the outlines of the blood-corpuscles composing the thrombus cease to be visible, and thus an uninterrupted circulation is re-established." 1 In more serious trouble the detached clots may be the nuclei of larger ones in the sinuses if the con- dition of the arterial walls be such as to favor more extended formation of thrombi so that the vessels become entirely occluded. The consequence of arterial occlusion is the formation of an extended clot which blocks up the vessel more fully, and consequent ischaemia of distal parts. Through the agency of outside vessels collateral circulation is generally established in a short space of time. If, however, the anato- mical site be such as to interfere with this provision of nature, softening or tardy degeneration will ensue. This softening, when it follows, is ex- pressed by a series of changes, which occur about as follows : Red soft- ening in from 24 to 48 hours, while the yellow change does not take place until after 14 days. But of this condition of affairs I will speak in a sub- sequent chapter. The carotid arteries and their termination are more often affected, and basilar vertebrals, anterior cerebral, and posterior com- municating come next, in the order I have given them. The pathological processes in the second form of intracranial thrombosis, viz., that affect- ing the sinuses and veins, are much more gross. Either through sluggish circulation of the blood on the part of a weak heart, pressure upon a sinus, or unusual density of the blood, coagulation occurs, the arterial flow is in- terfered with, a part of the brain is deprived of blood, and serum is effused. If the disease be due to outside causes, there may be an extension of in- flammatory action from without in the manner I have described. By an extension of thrombosis, a form of meningitis resembling tubercular men- ingitis may be produced. Several of these cases have been seen by Scuch." An artery which is the seat of a thrombus presents these appearances : The inner coat is rough and perhaps corrugated ; the artery as a whole may be hard and discolored, with diminution in calibre and a deposition of recent or ancient date, in which latter case it will be pale and tough, while atheroma is not uncommonly present. Fox* has observed that the part of the clot adherent to the inner coat of the vessel is much more dense than that nearest the centre. When the capillaries are implicated, they 1 Virchow's Archiv, Band Ixii., Heft 1, Nov. 1874. 2 Verhandlung dur Wurz., p. Mod. Geselschaft, viii. 179. 8 Path. Anat. of the Nervous Centres, p. 32. THROMBOSIS OF SINUSES AND VEINS. 135 are generally found to be hard and calcareous. In thrombosis of the large sinuses or veins, the morbid appearances are much more striking. The thrombi are large, and, if old, of a gray color, and it is not rare to find pus, effusions of serum into neighboring parts, and perhaps some menin- gitis. Von Dusch has collected 57 cases, which are given by Fox. 1 In 32 the thrombosis resulted from gangrenous, erysipelatous, and other in- flammations of the body (chiefly of head). In 4 foreign bodies were found. In 15 it appears to have resulted from asthenic circulation. In G cases nothing positive could be ascertained. Diagnosis There are very few conditions with which that under consideration may be confounded. When we remember that in throm- bosis the development of symptoms is gradual, the loss of speech incom- plete, and primary ; and in cerebral hemorrhage the onset is sudden, the aphasia is secondary to a loss of consciousness, and the paralysis more marked, the diagnosis from this disease is not so difficult. Doubts may arise in our minds when we are to decide whether or not the case before us is one of thrombosis or uncomplicated softening. Thrombosis is rarely attended by marked elevation of temperature, while the opposite is to be observed in cerebritis, which presents as symptoms trembling and per- haps muscular rigidity. The psychical symptoms are also more strongly marked. The more serious form can be diagnosed by the coexistence of other conditions which may favor its origin. Treatment The chief indication seems to be : The improvement of the condition which influenced the production of the thrombus. If arterial tension be at all weak, we may combine digitalis and iron (F. 21), give tonics (FF. 40, 43, 8, 9, 10, 32), and improve the patient's general condition by good food and stimulants. Nature will arrange the process of collateral blood-supply, and we may aid her by enforcing rest and quiet. THROMBOSIS OF SINUSES AND VEINS. When a large sinus or vein is involved, the resulting symptoms are much more complex and difficult to diagnose. Lancereaux, 2 who has written quite extensively about this form of dis- ease, has divided it into two grades, in regard to the variety of morbid action. One of these is inflammatory, the other is non-inflammatory. The first form is dependent upon the extension of some inflammatory pro- cess, usually from the ear, while the other is attended by coagulation of the blood in sluggish circulation. 'Von Dusch 3 does not agree with him, but Tonnele, quoted by Grisolle, 4 makes the same varieties as Lancereaux. 1 Loo. fit., p. 35. 2 Lancereaux, De la Thrombose, etc., Paris, 1862. 3 Zeits. fur Ration. Med., B. vii., 1859, p. 11. 4 Op. cit., tome ii. p. 240. 136 OCCLUSION OF INTRACRANIAL VESSELS. The seats of this pathological condition are the longitudinal, lateral, basal sinuses, and the large veins communicating therewith. Bastian* alludes particularly to the longitudinal sinus as the most common seat, and describes the tendency to plugging up of the cerebral veins on both sides. As I have said, the symptoms are very obscure, but in every case we may consider them to be the indication of pressure. Headache, delirium, coma, convulsions, ocular troubles, and generally death in a very short space of time mark the course of the disease. Mr. Tuckwell 8 reports a case which is a representative of the anaemic form. It is as follows : Eliza C., et. 16, was admitted to Radcliffe Infirmary on the 20th day of April, 1871. She ceased working a month before on account of palpi- tations, shortness of breath, weakness, irregularity of the menses, etc. Two weeks before admission she began to suffer from violent headache. She never had fits. A condition of decided chlorosis was diaj:nos< empty, as were others which were higher up. No arterial occlusion was found. The patient had died suddenly in convulsions with coma. Causes Blows upon the head, injuries of various kinds, extension of otitis, intemperance, and the causes I have already enumerated, may be mentioned. There seems to be no special dependence upon age or sex, though it may be said that most of the cases occur during adult life. What I have already said, and the excellent cases of Tuckwell, which have been presented, render it unnecessary to say more about the morbid anatomy, pathology, or diagnosis. In regard to the prognosis, there can be no question. It is about as bad as it can well be. As to treatment, the most we can do is to build up our patient, and reduce the danger of external disease by favoring a free escape of pus if the original disease be otitis, and there be an accumulation. We may employ local cold and derivatives, but even these do little good after the disease is recognized. EMBOLISM OF THE CEREBRAL VESSELS. The cerebral arteries and capillaries are alike subject to this form of mechanical obstruction, but the former are perhaps the most common seat 138 OCCLUSION OF INTRACRANIAL VESSELS. of the lodgment of fibrinous plugs. The little bodies which are forced into the vessels are always from some other part of the system, and are not formed in the vessel, as is the case in thrombosis. Embolism also differs from thrombosis in the fact that the latter is slowly developed, and attended by gradual narrowing of the vessel ; while the condition under consideration is a sudden accident, and may occur in a perfectly healthy vessel: the converse is the rule in thrombosis. Symptoms. .Unless there is previous acute endocarditis, there will seldom be any warning, the patient being suddenly stricken down as the little plug is violently forced into some vessel of the brain. There may even be no loss of consciousness, though this is the exception. Uncon- sciousness invariably occurs when a large embolon plugs up some such artery as the middle cerebral ; but if the embolon be small, and the artery occluded is one concerned to a very limited extent in the vascular supply of the cerebrum, the unconsciousness may be but transitory, and psychical symptoms of slight moment will constitute the sole indications of confused mental activity. The eyes are sensitive to light, the pulse is small and rapid, and there is usually pallor. There are no indications of pressure, no stertor, no tumultuous respiration, nor full pulse, and the pupils are either dilated or irregularly contracted. If the heart be auscultated, various murmurs or friction-sounds will in many cases be heard. Mitral murmurs are perhaps the most common. Paralysis taking the form of complete or incomplete hemiplegia is the result of such sudden arterial occlusion. Special facial muscles may be those affected, or various modifications of sensation, such as anaesthesia or hyperaesthesia, may be detected, but rigidity or contractures are rarely present unless there is secondary disorganiza- tion, and they are never seen during the early stages. Vertigo is a dis- agreeable and common symptom, and is sometimes attended by cerebral vomiting. Of course aphasia is an almost invariable consequence of em- bolism, as the middle cerebral artery is so commonly occluded. This aphasia is of variable extent, and is ataxic or amnesic, but generally the latter. On the other hand, the patient may be simply stupid and taciturn, refusing to answer, or he may be troubled with a light form of clumsiness or slowness of speech. The headache, which is subsequent to the loss of consciousness, is coincident ordinarily with the re-establishment of col- lateral circulation, and if further changes occur there may be intense head- pain, delirium, mania, or symptoms indicative of softening. The duration of this stage varies greatly. I have seen examples where the symptoms were trifling and transitory, such as headache, awkward speech, and paralysis of one arm rapidly disappearing. Other cases are correspondingly serious. Mr. Shaw 1 reports a case which proved fatal in twenty-four hours, and others have detailed examples in which death ensued in from thirty- six to forty-eight hours. 1 Trans, of Path. Soc. of London, vol. iv. EMBOLISM OF THE CEREBRAL VESSELS. 139 It is very common to find, at the same time, symptoms indicative of embolism of other organs. The spleen, lungs, and organs which receive a large supply of blood, or are in the direct line of arterial supply, are apt to be involved as well as the brain. It rarely happens that two or more cerebral arteries are simultaneously plugged. In such cases the symptoms are complicated. One case is recorded in which both middle cerebral arteries were occluded, and the following case reported by Sokolowski 1 is an example of coexisting splenic and cerebral embolism : The patient was a servant, married, aged 23, who had always menstru- ated regularly, except when she was pregnant second year before, and then gave birth to a healthy child. Her health had been ordinarily good. Four days before her admittance to the hospital she had suffered from alternate chills and heat, with headache and constipation. On admis- sion her pulse was 100 ; temperature, 102.6. Heart friction sound at apex, but nowhere else. Passed 53 oz. urine in 24 hours ; sp. gr. 1025. October 13th. She suddenly became paralyzed on the right side, lost all power of speech, and only moaned and cried in a frightened manner. The third day after, acute idiopathic endocarditis was diagnosed. The right ventricle was found to be greatly enlarged. Temp. 101.2 ; pulse, 100. After paralysis she lost hearing in the right ear ; pupils were normal ; left side of mouth was drawn up. Anaesthesia of paralyzed parts. Urine and feces passed unconsciously. Spleen tender and enlarged. An additional diagnosis was now made. Embolism of left middle cerebral artery, and embolism of splenic artery. The loss of speech was peculiar. She was unable to articulate at all, though there was sufficient evidence of mental activity and originating power, so she communicated with her friends by signs. The paralysis had begun to disappear in the right leg below the knee, and she could move her foot slightly. The temperature on the first day was 102.2 ; pulse, 90. In the evening, 104.8 ; pulse, 100. On the second day, Oct. 14, there was much improvement. The morning tem- perature was 102.8, and the evening 103.8. loth. All paralysis and alalia have vanished. She is, however, ex- tremely weak. During the next two or three days a diarrhoea, loss of appetite, and considerable increase of tenderness over the spleen appeared. 28^. 35 oz. of urine were passed, which contained albumen, hyaline casts, and urates in abundance. November Wth. She has grown gradually worse, is no longer able to answer questions, but repeats words and sentences over and over. There is marked loss of memory. The fever has greatly increased, the evening temperature being 105.2 ; pulse 120, and quite thready. There are evi- dences of bronchitis and pulmonary difficulty. Urine greatly decreased in quantity, and albumen increased ; tongue quite dry. '20th. She died. There was extensive hypostatic pneumonia; con- sciousness remained to end. Autopsy Arteries at base healthy, except middle cerebral on left This contained a semi-transparent embolism of cartilaginous consistency. Right side of brain healthy, though pale. The left side in the same con- dition, except at the island of Reil, and gray matter of lenticular nucleus, Deutsche Med. Woch., Dec. 15, 1875. 140 OCCLUSION OF INTBACRANIAL VESSELS. which were small, hard, and yellow, and showed evidences of softening and subsequent cicatrization. The heart was enlarged, and yellow spots were found beneath the endocardium. The edges of the mitral valves were thickened and covered with coagula. The spleen enlarged, " blocked," and the splenic artery occluded. Cases have been reported where embolism followed, or was connected with, chorea, and this connection has been made use of in the explanation of the pathology of the latter disease. One of these cases, seen by Murchi- son, 1 is worthy of mention. The patient, a boy 14 years old, had suffered from chorea when seven years old, from which he recovered. Two weeks before h<- died, irregular choreic movements appeared, connected with a bellows murmur at the left apex. When seen, June 12th, the pulse was 120 ; temperature. 102. There was a pericardial friction sound, but no pain in joints or other symptoms of rheumatism or endocarditis. June 28. Sudden unconsciousness, head drawn to right side, extreme rigidity, twitching on right side. Pulse, 145. Pupils normal and equal, but subsequently contracted ; no paralysis. Died June 29. Vegetations on mitral valves, spleen containing emboli. Left vertebral and left in- ternal carotid arteries blocked by pale, firm, and easily detached coagula; left hemisphere considerably softened. Examination revealed no small embolf in capillaries. A case of my own, showing an accident which may occur in the course of certain acute diseases, seems to me to be of sufficient interest to present, as it may call attention to a cause of death which is probably sometimes overlooked. Mr. N., set. 35, a stout, full-blooded man of good habits and no vices, took to his bed on the 25th of June, 1874. He had contracted a " bad cold" at the theatre, and the next day was seized with pain in the left side, was chilly and uncomfortable, and when I saw him on the evening of the same day, he had a violent headache. His skin was hot, and his pulse hard and rapid. The thermometer indi- cated a temperature of 101 ; pulse, 122. At the base of the left lung crepitant rales were heard. Flaxseed poultices were applied, and quinine and other remedies administered. For the next four or five days the lungs underwent consolidation, and nearly all of the physical signs con- nected with the different stages of pneumonia were observed. The most marked of these was a high temj>erature, which ranged between 103 and 105 for six days. Resolution was slow, and but a few sputa were brought up, but the temjx'rature had fallen to some extent. I was sent for in haste on the evening of the fourteenth day, an hour after my ordinary visit, to find that the patient had suddenly, while taking his beef-tea, fallen back unconscious, and had remained so ever since. This was about half an hour before my being sent for. His pupils were widely dilated, and his corneae when touched were sen- sitive ; his legs and arms were extended. His temperature was not high, and his breathing had not changed very much from what it was when I saw him earlier in the day. 1 London Path. Soc. Trans., vol. xxii. EMBOLISM OF THE CEREBRAL VESSELS. 141 After an hour and a half he made some movements which showed slight voluntary control, and vomited, turning his head slightly to do so. He uttered no sounds except low moans. Towards morning his breathing be- came more troubled, and he rolled in the bed. At about nine o'clock in the morning of the next day he seemed to recognize those about him, and made signs which were not understood, when he knit his brows and seemed perplexed. He refused food, but permitted an enema of beef-tea to be injected, but this was not retained. It was then found that he was hemiplegic on the right side. Later in the day he passed his urine in bed. 16th day. Did not sleep last night. The temperature 104; pulse, 130, full and hard. After my visit this morning he became comatose. 3 P. M., died. Autopsy 20 hours after death Lungs : right, rather more pinkish than normal ; some spots of induration at base. Left, solidified through- out most of its substance ; when cut, bloody serum exuded. Heart some- what enlarged. Mitral valves were covered by stringy clots. The right ventricle contained a large fresh clot. Kidneys : right, normal ; left, somewhat smaller than it should be ; contained a small cyst beneath the capsule. Head : On opening the cranial cavity, the vessels of the dura mater were filled with dark blood. The longitudinal sinus contained a quantity of thick, clotted blood, which was almost black. The left hemi- sphere was redematous, except at a point beneath the lateral ventricle, where there was a circumscribed patch of a pinkish hue, which seemed to be well defined. The left middle cerebral artery, at a point just before it gives off its branches, was found to be swollen and hard, and when cut open a small, rather firm clot was found. Behind this there was a long, stringy clot of more recent date. About the vessel the brain was cedema- tous. Another patch of red softening was found in the same hemisphere somewhat more posteriorly. No other large arteries were affected, but when microscopically examined, I found considerable occlusion of many small capillaries, and great disorganization of the nerve elements. I have seen several other cases of this kind occurring during acute dis- eases attended by a hyperinosed condition of the blood. Causes Endocarditis is, above all other causes combined, the most important and common in the production of embolism. At the Patholo- gical Institute of Berlin 1 there were 300 cases of embolism of all kinds associated with endocarditis during the years included in the period be- ginning 1868, and ending 1871. Twenty per cent, of these cases were of brain embolism. Of a large number of cases reported in the London Pa- thological Societies' Transactions, nearly all of them were of this nature ; and out of fifteen cases I have seen, twelve were connected with disease of the heart, and generally with deposits upon the mitral valves. Croup, the puerperal state, phlebitis, and other conditions where there is any tendency to the formation of clots, or the detachment of tissue which finds its way into the circulating apparatus, may all produce em- bolism. Numerous accidents which happen through carelessness, or perhaps 1 Edinburgh Med. Journ., July, 1873. 142 OCCLUSION OF INTRACRANIAL VESSELS. unavoidable injury during surgical manipulation, may, by the introduction of a blood-clot or foreign substance into the circulation, produce an occlu- sion of some cerebral or other vessel. This accident has occurred \vln-ii pressure has been made upon large aneurisms, and is one of the arguments against the intravenous injection of substances which coagulate the blood, such as ergot, persulphate of iron, hair, or other organic substances. Dr. Barker 1 has given two cases of embolism following the parturient state, and Thomas has seen one or more cases of this kind. As to age, I have found that more young people have had cerebral em- bolism than persons of advanced life. An examination of twelve cases reported by different observers gives the relative frequency as follows: Between 10 and 20 years . . 2 Between 40 and 50 years . . 2 44 20 " 30 ' " . . 4 " 50 " 60 ' ' 4 . . 1 44 30 " 40 " . .3 Of these, 3 were males, and 9 were females. Of my own cases, seven were between twenty and thirty ; five between thirty and forty ; and three between forty and sixty. Eight were women, and the others men. It seems, therefore, that the period between the twentieth and thirtieth years is that in which the disease is most common, and that women are most subject to the disease. According to the observations of medical writers in general, mitral disease is more often an affection of youth or early life than of advanced years; so it seems probable that people who have not reached middle life should be more subject to embolism. Diagnosis The important distinction is to be made when we suspect the cause to be one of cerebral hemorrhage. Next in order come throm- bosis, cerebral congestion, meningeal hemorrhage, and cerebral tumor. Gelpke* has given the following table, on one side of which are detailed the features of cerebral embolism; on the other, those of cerebral hemor- rhage : CEREBRAL EMBOMSM. CEREBRAL HEMORRHAGE. Youth of patient. Advanced age, atheroma. Sudden onset without prodromata. Prodromata generally present. Previous articular rheumatism, val- Hypertrophy of left ventricle, vular sounds. Previous disease, which might lead to formation of clots. The altnck. The attack. Extensive muscular paralysis ; amnc- Symptoms of cerebral pressure; ataxic sic aphasia. aphasia; involvement of the intelligence. Very rapid; or quite imperceptible Disappearance of the residual dis- disappearance of the residual disorder. order after a moderate time. .Retention of early mental power. Reaction stage. Puerperal Diseases, p. 270. Archiv der Heilkunde, xvi., Aug. 1875, p. 485. EMBOLISM OF THE CEREBRAL VESSELS. 143 Janeway 1 relates an admirable case to illustrate the obstacles some- times encountered in making a diagnosis. As it will be seen in his case, there were many circumstances of a puzzling character which made the diagnosis exceedingly difficult. A young woman, while at work, fell to the floor unconscious, in what appeared to be a " fainting fit." There were some convulsive movements limited to the left side of the body. When admitted to Bellevue Hospital on the following day, there were irregular contraction of the pupils, coma, and high temperature. A loud systolic murmur was heard all over the chest. She remained unconscious for two days, and on the third day died. Her breathing previous to death was stertorous, her limbs flaccid, and reflex action diminished. The pupils were dilated. Her urine con- tained a small amount of albumen, but not enough, in the absence of oedema and other symptoms, to suggest nephritic trouble; besides, the quantity of urine passed was sufficient. The question of thrombosis was excluded by the absence of premonitory symptoms. Congestive chill, by the paralysis and meningeal hemorrhage, was suggested, but excluded when the absence of rigidity was taken into account. Janeway considered the lesion to be hemorrhage, and I will give his own description of the autopsy and its result. " The post-mortem examination revealed the following: Skull, normal. Brain and membranes: On opening the dura mater on the right side, a clot of blood, a little over half an inch thick, three inches long, and two inches wide, escaped from the arachnoid sac. This clot was in the main black, moderately soft, but provided with a bufly coat at one portion. It had produced a corresponding depression of the brain, over which it was situated, and in its centre was an opening about an inch long and a half inch wide, leading from a recent excavation in the middle lobe of the brain, through the torn pia mater and so-called arachnoid, into the sac of the latter. This excavation reached from the convex surface nearly to the corpus and optic thalamus at posterior extremity. The opening was situated a little nearer to the longitudinal fissure than would correspond to the middle of the convex surface. The excavation was about two inches wide and contained clotted blood, of which some had escaped in removing brain. The brain-tissue surrounding this was soft, slightly blood-stained, and where it formed the boundaries of the space, numerous black points were present, corresponding to clots of blood, closing numerous small torn vessels. The brain-tissue of the posterior lobe, espe- cially on its outer surface, was softer than natural. The posterior ex- tremity of the optic thalamus of the right side, over a small area, presented an ecchymotic softened state. " In the clotted blood and disintegrated brain-tissue found at the mouth of the excavation, a small branch of the posterior cerebral was found torn across, presenting a widened extremity at the point of rupture, surrounded by thickened and firm tissue, and in the interior of this a firm reddish- gray clot, uniform in its structure and of older date than any others. I failed on careful examination to find the other extremity of the torn ves- sel, but from the condition of the portion found doubt not that it would 1 Am. Psychological Journal, Nov. 1876. 144 OCCLUSION OF INTBACRANIAL VESSELS. have proved of similar shape to the other, and that together they would have constituted a cylindrical dilatation of this artery. " The left (opposite) hemisphere showed the convolutions flattened and so closely pressed together laterally as to nearly obliterate th<- appearance of sulci. The arachnoid was dry, and there was no sub-arachnoid fluid present. The brain on this side appeared anaemic, and on cutting the dura mater pressed out. " The lateral ventricles were of normal appearance. The anterior lobe of right side was normal. Pons, cerebellum, etc., were normal. The arteries at the base were carefully examined, being followed to their smaller ramifications without finding any emboli. " The lungs were slightly oedematous. "Heart: The left ventricle was slightly hypertrophied. On the auri- cular aspect of the mitral valve, and on the ventricular of the aortic, con- dylomatous excrescences were present, narrowing both orifices ; but the largest mass passed obliquely across the heart from the leaf of aortic valves nearest the septum to the anterior leaf of mitral valves, and above thi>. between it and the other leaflet of aortic valves, a slight dilatation of the heart-wall existed. " Small infarctions were present in the spleen and the kidney, and the latter showed at some points interstitial nephritis, around glomeruli, with atrophy of these ; but the disease was not advanced. The mesentery pre- sented two small aneurismal dilatations of little arteries, and at these points emboli were present : one was of the size of the head of a pin ; the other, of a pea. " In this case it seems exceedingly probable that the primary lesion of the artery, which finally ruptured, was embolism, and that this obstruction caused, secondarily, a dilatation of the artery at this point, and that, owing to the heat, 1 such an obstruction of the circulation in the brain oc- curred as to cause the rupture of the vessel described. This is rendered still more probable by finding two small arteries in the mesentery with aneurismal dilatation, and containing emboli. " A point of interest in this case is the absence of serious symptoms of cardiac disease, though there was so marked a lesion. It did not seem as if any regurgitation had occurred at the aortic orifice, simply obstruc- tion. The left ventricle contained such a firmly adherent clot that the hydrostatic test was of no avail. " It also furnishes another to the already long list of cases in which a heart-murmur is heard sudden paralysis occurs the patient moderately young, and yet the lesion is hemorrhage, and not embolism. I have met with several of these exceptions." From thrombosis there will be no difficulty in making a diagnosis when we remember the slow origin of the former. The "apoplectic form" of cerebral congestion sometimes resembles the condition presented by the patient; however, the former history, the suft'used face, contracted pupils, and rapid subsidence of symptoms, will put us on our guard. 1 The weather was excessively warm at this time, and the patient was at first supposed by those around her to be suffering from the effects of the heat. EMBOLISM OF THE CEREBRAL VESSELS. 145 Morbid Anatomy and Pathology Burrowes and Kirkes were- the first English writers and Virchow the earliest Continental writer to de- scribe these conditions. Prevost and Cotard have since related interesting experiments. They injected tobacco seed into the carotids of dogs, and afterwards watched the changes that followed. One of these do-s was killed thirty-nine days after the seed had been introduced, when they found the middle cerebral artery obstructed, and induration about the fissure of Sylvius. The pathological processes which follow such mechanical obstruction have been sufficiently noticed in a preceding article, so it will be enough to call attention to the fact that the consequence of such an accident will be softening of the parts deprived of their nourishment, unless the collat- eral circulation be established at an early date, or the embolon is broken down and removed, which is a very unlikely circumstance. Kirkes 1 calls attention to the distribution of emboli in the following words: "The parts of the vascular system, within which these transmitted masses of fibrine may be found, will of course depend in a great measure upon whether they proceed from the right or left side of the heart. Then, if they have been detached from either the aortic or mitral valves, they will pass into the blood propelled by the left ventricle into the aorta and its subdivisions, and may be arrested in any of the systemic arteries or their modifications in the various organs, especially those which, like the brain, spleen, and kidneys, receive large supplies of blood directly from the left side of the heart. If, on the other hand, the fibrinous masses are derived from the pulmonary artery and its subdivisions within, the lungs will necessarily become the primary if not the exclusive seat of their sub- sequent deposition." In regard to the side of the brain where the deposit occurs, I think we may say that the left side and the middle cerebral artery are the most com- mon site, though many cases reported by Shaw, Glynne, Murchison, and others prove that the right artery may be affected as well. An interesting example, which is almost unique, is the following case of embolism of the right posterior cerebral artery, The history was read by Broadbent before the London Clinical Society : 2 " The patient, a young man aged 19, had suffered three years previously from acute rheumatism. Ten days before his admission, he suddenly be- came blind, and had great pain in the head. Five days later, vision hav- ing returned, he lost the use of his left limbs, while the right arm and leg were continually in motion ; and, unless restrained, he rolled over and over towards the left, falling out of bed and bruising himself severely. The left hemiplegia and uncontrollable movements of the right limbs con- tinued when he was admitted; the hemiplegia not being absolute, but accompanied by slight rigidity and very considerable impairment of sensa- tion. The patient took no notice of persons or objects, but answered ques- tions, and put out the tongue on being urged. His pulse was variable, 1 Royal Med. Clin. Trans., vol. xxxv. p. 281, 1852. 8 Abstracted from Lancet, Monthly Abstract, April, 1876, p. 576. 10 146 OCCLUSION OF INTRACRANIAL VESSELS. 120 to 100 or more. Temperature in the right axilla, 99.2; in the left, 100.6. A loud mitral systolic murmur was present. The bowels were confined, and, when opened, the feces and urine were passed in bed. A dose of three grains of calomel was given, and two grains of carbonate of ammonia with two drachms of infusion of digitalis every two hour-. Chloral also was given at night. He was ordered a diet of milk and beef- tea, with four ounces of brandy. There was gradual improvement; and, three days after his admission, an ophthalmoscopic observation, previously attempted in vain, was obtained, and the disks were found to present the appearances of marked ischaemia. The pulse was now 108, soft, short, and strikingly dicrotous. A day later the pulse was 88, and more full. The temperature was still nearly a degree higher in the left (100) than in the right (99.2) axilla. Slight paralysis of the left external rectus of the eye was observed. At the end of a fortnight's stay in hospital, the right limbs were quiet, and there was considerable return of power and sensation in the left side. His speech was rather slow, but there was no obvious impairment of the intellect. Notwithstanding this, however, he not only passed his feces in bed, but threw them about and bedaubed himself and the bedclothes without any regard to decency. The optic ischaemia was marked, but vision was good. The temperature of the right axilla was 99.3? ; of the left, 100. At the end of three weeks he passed his excretions naturally. After five weeks he was up and about, eating well; but pale, and still complaining a little of headache. Impairment of power and of sensation in the left limbs was still perceptible. The optic neuritis was subsiding. Distant vision was good, but small print was not easily read. A systolic mitral murmur was heard. The temperature was still ne\i-r below 99; usually 100; it was now equal on the two sides. But for this elevation of temperature, the patient would have been allowed to leave the hospital. Soon afterwards, however, there were symptoms of splenic embolism, and later of ulcerative endocarditis ; and he died from this four months after admission. On post-mortem examination, with ulcerative endocarditis and numerous recent embolisms, there was found softening of the occipital lobe of the right hemisphere from the posterior cornu of the ventricle downwards, and the branch of the post-cerebral artery entering the calcarine fissure was occluded and lost in adhesions. It was considered probable by Dr. Broadbent that originally the posterior cerebral artery itself had been blocked up, and not only this branch. The interesting points in the case, on which comments were made, were the temporary blindness, the agitation of the right limbs and rolling tendency, the usual association of loss of sensation and of double optic ischemia with embolism of a cerebral artery, and the remarkable indifference to decency persisting when the intellect was apparently good." Fat globules may sometimes plug up the small capillaries, producing wide areas of softening. The morbid appearances indicative of cerebral embolism are of interest and worthy of the closest study, not only because the brain is the point which suffers the most seriously, but because generally the heart, spleen, lungs, bloodvessels, and other organs may be involved as well. On-the valves of the heart, either mitral or aortic, may be found excrescences, induration or recent clots, and the arteries themselves may exhibit patches of atheroma. In the brain we will probably find one or more of the arteries I have EMBOLISM OF THE CEREBRAL VESSELS. 147 spoken of to be swollen, hard, and filled by one of these little masses of fibrine. They have been compared to grains of wheat, and resemble them very closely. Generally the embolon is separated from a second plug which has followed clotting of the arrested blood. Emboli are never attached to the walls of the vessels. Several arteries may, perhaps, be found obstructed in the same way. " Sometimes all on one side ; at other times some arteries of one side of the brain, and some of the other,'" so says Fox. Softened masses are generally found on examination, and are usually the cause of death. The parts behind the occlusion are subjected to the full force of blood which is arrested, and not sent to the parts it should supply, and local hypersemia is a result. The resulting softening is generally con- fined to the left hemisphere at its base, for reasons I have before stated, and the frontal convolutions, corpus striatum, and adjacent parts are found to be either red or yellow, softened or indurated. (Edema of the brain is not an uncommon appearance, such oedema being seen in the parts deprived of blood. The perivascular spaces being enlarged, it is but natural that their fluid should rush in to fill up the in- creased space left by the bloodless arteries. Prognosis The outlook for the patient is generally a very gloomy one if the accident be at all grave, and the artery be one of importance. The severity of the symptoms, the existence of emboli in other organs, the element of severe pain, high temperature, and gradual development of symptoms indicative of softening are of unfavorable import, and give affairs a very dark look ; therefore it is never well to make too hasty a prognosis. Treatment Rest, abstinence from stimulants, and agents which will diminish the arterial tension are the only remedial means to adopt besides the ordinary indications which appeal to the common sense and discretion of the medical man. Afterwards, resulting conditions, such as paralysis or softening, are to be treated. 1 Op. cit., p. 32. 148 DISEASES OF THE CEREBRUM AND CEREBELLUM. CHAPTER Y. DISEASES OF THE CEREBRUM AND CEREBELLUM (CONTINUED). CEREBRAL SOFTENING. Synonyms Ramollissement (rouge, blanc, jaune). Encephalitis aigue, chronique (Fr.). Mollities cerebri, Encephalitis, Softening of tin- Brain (chronic, acute), Inflammation of the Brain. Definition A disease of the brain of an acute or chronic character, attended by destruction of nervous substance, and of an acute inflammatory nature, with purulent formation ; or of a chronic non-inflammatory charac- ter, with less rapid disorganization of nerve-tissue ; but in either case pro- ductive of a mollification of the nervous substance. So much confusion has arisen from an incorrect appreciation of the morbid anatomy and its connection with pathology, that it is a difficult matter to attempt the reconciliation of the many widely differing views of the legion of writers. "Inflammation of the brain" is the term which lias led to all this confusion ; and I have been bold enough to base my classi- fication rather upon the character of tissue-changes than upon the arbitrary law that softening of the brain is the only result of inflammation. Sclero- sis, as we know, is undoubtedly the result of a low grade of inflammation, but in this case the tissue-changes are quite different. Considering that the word " softening " means a mollification, and that it may result not only from purulent inflammation, but from low nutritive changes, I shall divide the subject as follows : 1. Acute Softening, ( Diffiised Cerebritis. (Inflammatory), Meningo-Cerebritis. Purulent Cerebritis. 2. Chronic Softening, < Primary Softening. (Non-inflammatory), < Secondary Softening. 1. Under the first head we may place the variety described by Elam, 1 which is a quite rare affection in its uncomplicated form, that is, when -it involves the brain substance en masse; and meningo-cerebritis, which is by far more common. In a third variety the acute disease is characterized by purulent collections, and perhaps by the ultimate formation of abscesses 2. Chronic softening in its primary form we will consider to be depend- ent upon general disease, intellectual prostration, and like causes ; while " secondary softening" may be used to express the form which follows vascular lesions, such as embolism, thrombosis, or cerebral hemorrhage. 1 Cerebria, and other Diseases of the Brain, London, 1872. / ACUTE SOFTENING. ACUTE SOFTENING. In the first form it may be either cortical, diffused, or combined with meningitis. Symptoms Cerebritis of either kind is preceded in nearly every instance by symptoms of functional disorder, such as cerebral congestion or cerebral anaemia, but these are not sufficient in themselves to arouse the suspicion of the observer as to the serious character of the disease which is to follow. The later prodromata of cerebritis, however, cannot be mis- taken, and finally the developed disease presents most pronounced symp- toms, which, if they do not always enable us to locate the brain lesion, are sufficient to assure us that some violent inflammatory process is under -weigh in the cerebral mass. The patient may for some months suffer greatly from headache of a diffused character, accompanied by burning sensations, and a sense of pressure behind the eyeballs. These headaches are quite intense, and are aggravated by exposure to heat, concentration of the mental powers, and alcoholic indulgence. His memory becomes gradually enfeebled, so that at first dates and names are forgotten, and afterwards faces, locations, and even information which may have been imparted to him a short time previously. Some slight clumsiness of speech may be indicative of the near approach of grave symptoms, but this clumsiness is not aphasic till later. Irritability of temper, restless- ness, and incapacity for mental application are attendant evidences of the smouldering fire which afterwards is to make itself known by still more decided symptoms. Among these may be enumerated nystagmus, stra- bismus, and diplopia, as ocular troubles ; contractures of the limbs, tremors of individual muscles or groups of muscles, a twitching of the limbs, or other motor troubles, and hyperaesthesia, followed by anaesthesia, and other disorders of sensation; these last sometimes being peculiarly prominent. Next we find that there may be an apoplectic attack or convulsions of an epileptiform character, which mark the violent stages of the disease. Should there be, as a result of the morbid process, cerebral hemorrhage, it will be found that the paralyzed limbs become markedly contracted, and that rigidity is a striking feature. According to Jaccoud, the contractures may be bilateral, though the rule is the other way, the limbs of but one side being rigidly flexed. 1 He has seen one case where the left arm and leg were the seat of contractures, and where the face was contracted and strongly drawn towards the left side, suggesting a right facial palsy, but the appreciable rigidity of the facial muscles of the left side left no doubt as to the origin of the deviation. The paralyzed mem- bers are generally those that are the seat of convulsive movements in the first place. The convulsions may be general, and assume an epileptiform character, and may be accompanied by vomiting. The patient's mental condition meanwhile undergoes a great change. Delusions, which somewhat 1 Trait6 de Path. Interne, vol. i., art. Enceph. algue. 150 DISEASES OF THE CEREBRUM AND CEREBELLUM. resemble those of general paralysis of the insane, are present ; the exaltation delirante of the French, which is by some considered to be an early symptom. This has not been my experience, and I am convinced that in the cases where it has been noticed as an early expression of the affection, the disease was probably general paralysis, and not cerebritis. Memory is abolished, and finally dementia remains, which, should the patient live for some time, is expressed by all the other signs, drivelling of saliva, inane smile, hebetude, and total imbecility, while there may be aphasia of the amnesic or ataxic variety. The muscles concerned in articulation and deglutition are in- volved, and the patient may narrowly escape being choked by the masses of food which " go down the wrong way " or accumulate in his mouth. Constipation or retention of urine is not an uncommon accompaniment, and the urine is charged with urates, is dark-colored, and rapidly under- goes decomposition. The temperature and pulse are both changed, t In- latter becoming accelerated and irregular, and the heart-sounds sharp and " precipitative." A tremulous character of the pulse has been noticed by several observers ; but I agree with Hammond that there is nothing dis- tinctive about this. The temperature may rise to 110 F., and generally attains its highest point at the end of the first four days. Coma precedes a fatal ending in the acute form at the end of a few days, and death occurs generally after seven or eight days by asphyxia. Should the patient sur- vive, there is a remission of the symptoms, and the formation generally of an abscess. Cerebritis does not always begin in the same way, and, as I have already stated, is not invariably symptomatized by all the forms of disordered functions I have enumerated. There may be no premonitory symptoms should the disease follow otitis or injury, but in the insidious form, which has been so admirably described by Klam and Reynolds, the appearance of prodromata is gradual and progressive. In certain cases the paralysis is an early symptom, in others the defects of articulation and deglutition are more prominent ; in other cases psychical disturbances are decided, while in still others coma or convulsions are the striking features. The predominance of these different symptoms depends very much upon the region which suffers the most from the violence of inflammatory action. It must be borne in mind that the disorder is attended from the first by febrile disturbances, and that all the symptoms are those indicative of a hypenvsthetic state of the cerebrum. Should the patient survive the im- mediate violence of the attack, he may recover to some degree. The tem- jKTature and pulse are lowered ; the active evidence of the central disease subsides, but it is not common for any amelioration of the paralysis to take place. The headache may become more localized and less intense, or may subside altogether, and it mfvy only reappear when the patient is fatigued. lie may remain in this condition for several years. In one case that came under my observation I accidentally found a large abscess about the size of a horse chestnut in the white matter of the anterior lobe of the right hemisphere. The individual had died of phthisis, and during life com- plained of no symptoms which would direct suspicion to the brain lesion. He had had a febrile attack six years before, which was probably the time ACUTE SOFTENING. 151 at which the abscess was formed. In many cases cerebral abscess follows disease of the temporal bone, and in the majority of instances it is not essentially necessary that there should be complicating general meningitis, though such is often the case. A very interesting history was presented by Dr. Elliot 1 to the New York Pathological Society. A man aged 50, of intemperate habits, for the last twenty years subject to constant headache, fourteen years ago had an attack of acute mania, lasting two weeks, and ten years ago a similar attack. For the last four months vision has been failing, and there was an inclination to talk con- tinually, either to himself or the attendants. One month before death he was seized with general convulsions. A week later there was spasm of the left leg, attended with intense pain, alternating for three days with pain in the lumbar region, and imperfect paraplegia, terminating in paralysis of the left leg; this, however, passed off in twenty-four hours. One week before death there was convulsive action of the right side, with severe pain for two hours, succeeded by right hemiplegia. After thirty-six hours, motion was regained in the arm, but not in the leg. Dur- ing the last month of life there was constant vomiting. Autopsy There was found near the centre of the upper surface of the right middle cerebral lobe a thickening of the arachnoid, and beneath this an abscess of the size of an English walnut, with smooth walls. The brain-substance surrounding the abscess was condensed and gray, and around this again red and soft. In the centre of the right middle cerebral lobe, in the anterior and inferior part of the right posterior cerebral lobe, in the centre of the left middle lobe, and in the inferior part of the left middle lobe, were similar abscesses. The left lateral ventricle was filled with pus coming from the abscess in the left middle lobe ; the pus in all the abscesses was green and fetid. No lesions were found in the other organs. Causes. Exposure to the sun's rays, alcoholism, inflammatory disease of the bones of the head or face, meningitis, brain tumors, traumatism, and syphilis, as well as several of the zymotic fevers and rheumatism, are all predisposing and exciting causes of cerebritis. The simple form may be idiopathic, but that which results in the production of abscesses is more often due to traumatism, caries of adjacent bones, or syphilis. Jaccoud has found that the proportion of patients in regard to sex was in favor of the males, nine men being affected to every four women, and that the dis- ease was developed between puberty and the forty-fifth year. Cerebral abscess or traumatic cerebritis may be produced, of course, at any age by injuries or the extension of other diseases. I have seen one case in which cerebritis followed otitis in a child ten years old. Lead poisoning should not be forgotten as a rare cause. Morbid Anatomy and Pathology Cerebritis may either in- volve the cortex cerebri or some central parts, such as the corpora striata or optic thalami, or more rarely may affect the entire brain, but it prefers the gray matter, which is so richly supplied by bloodvessels. The brain may be found to be the seat of many softened parts, as "foyers" of purulent 1 Trans. N. Y. Path. Soc., vol. i. p. C. 152 DISEASS OF THE CEREBRUM AND CEREBELLUM. accumulation, serous exudation from the vessels, infiltrating the surround- ing brain-tissue, or there may be ruptured vessels, and an escape of thi-ir contents. The brain-tissue may be stained by the hematine, and occa- sionally present the appearance .of simple non-inflammatory softening. The microscope enables us to see a multiplicity of changes granular degeneration, leucocytes, broken-down nerve-elements, rarely neuroglia- thickening, and still more rarely amyloid bodies. I know of no more in- teresting field for the study of morbid microscopical anatomy than a brain of this kind, for nearly every appearance or grade of diseased structure may be found. The vascular lesions are capillary hemorrhage, miliary aneu- rism, etc. Suppuration takes place in several ways. The brain-sub- stance may be generally infiltrated, so that it presents a yellow color throughout its extent, or there may be a localized infiltration or an en- cysted collection of pus. About the latter will be found a sclerosis of the brain-tissue, and about this a serous infiltration. Jaccoud has found that abscesses are more often to be observed in the white substance, in which conclusion he is supported by the observations of many writers. Lebert, 1 in fifty-eight cases, found the abscess to be located twenty-three times in the left hemisphere, eighteen in the right, twice in the corpora striata, twelve times in the cerebellum, twice in the pituitary body, and once in the spinal cord. I have already presented cases which will enable the reader to appreciate the origin and size of such collections of purulent matter, and the evidences of diseased bone, fracture, etc., that are to be discerned in cases of traumatism or disease. In certain pynemic condi- tions, such as erysipelas, abscesses may be found in other parts of the body as well, notably in the liver and lungs. In rare forms a rapid ne- crobiosis or " death" of tissues takes place, which is almost analogous with gangrene in other parts of the body, and large masses of brain-tissue are destroyed very rapidly. 2 1 Virchow's Archiv, x. 1866. * Of fifteen cases of cerebral softening of the acute form, Camleil* found in one fibrine in the sinuses of the dura mater ; in one, this membrane was bathed in purulent liquid, and it was also perforated at one point; in five there were recent spots of encephalitis on the right and left sides, in six on the left only, in three on the right only ; in three there were cellular cicatrices in the right lobe of the brain, in one in the left lobe ; in two the right hemisphere of the cerebellum was the seat of an acute inflammatory spot ; in four the principal recent inflammatory spots were still in a state of red hepatixation ; in seven they were in a state of softening, with disintegration of the nervous substance ; in four they were in a state of disintegration of the nervous substance, with a mixture of a liquid that resembled pus ; in four the spots of acute local encephalitis without clot were studied microscopically. Of these, in one they were still in the state of red hepati/ation ; the diseased regions were reddened by the widening of the capilla- ries, and by the presence of extravasated globules of blood ; the cerebral fibres were not yet disintegrated ; already small granular cells had begun to be formed in the inflamed parts. In three the nervous substance of the diseased seats was disintegrated, and more or less reduced to fragments ; it was soaked in plasma, * Quoted by Fox. I ACUTE SOFTENING. 153 Diagnosis. Cerebral hemorrhage, meningitis, cerebral tumor, embo- lism, and thrombosis are all conditions from which it is proper we should distinguish acute cerebritis and cerebral abscess. Some of the symptoms of general paralysis of the insane may possibly mislead the observer. From cerebral hemorrhage we are to distinguish cerebritis by the rapid amendment of symptoms in the former, while in the latter there is progressive evidence of advancing structural changes. Fever is not connected with cerebral hemorrhage, unless there be secon- dary inflammation of the brain-substance. The headache is not suggestive of cerebral hemorrhage, nor is the delirium or vomiting; and, after all, the only symptom which deserves attention is the paralysis. It is impor- tant to bear in mind that rigidity and contracture take place before pa- ralysis, while we know that the converse is the rule in cerebral hemorrhage. Should hemiplegia follow a number of the other symptoms, we may consider that the hemorrhage is secondary to the cerebritis, and that some vessel has been cut across. It is almost impossible to distinguish uncomplicated cerebritis from meningo-cerebritis. The pain is perhaps more marked in the latter, and the convulsions are bilateral. In uncomplicated cerebritis there is not nearly so much fever as in the meningeal form or in simple meningitis. Typhoid fever may simulate cerebritis, and vice versa, Attacks of the latter begin with headache, vertigo, movements of the eyes, insomnia, delirium, nose-bleed, and diarrhoea, with high evening tem- perature. The absence of tympanites, and gurgling in the left iliac fossa, and the appearance of paralysis and visual disorders, are quite sufficient landmarks to prevent the diagnostician from losing his way. When there is suspicion of otitis or traumatism, it is exceedingly difficult to make a diagnosis from thrombosis of the cerebral sinuses, and it is fortunate that no value is to be attached to such a diagnosis, as far as therapeutical indi- cations are concerned. Prognosis There is very little hope for the patient, and should he survive the acute attack he is usually left paralytic and demented. If there be a purulent accumulation, which becomes encysted, the chances of recovery are very little better, and it only becomes a question of time when the patient will die. If there be such a cerebral abscess, subsequent symptoms very much like those connected with other brain tumors will be probably developed ; but, in numerous cases cited by various authors, a cerebral abscess has existed unsuspected for years. Treatment Acute cerebritis in either form must be met with ab- straction of blood, cold effusions to the head, agents which lower vascular tension, counter-irritants, and mercury in some one of its forms. The ice-bag, or the apparatus already alluded to for the application of cold water, may be used, and leeches are to be applied to the arms or behind the ears. Jaccoud and most of the clinical teachers recommend purgation, mixed with a considerable number of great cells collected together, and molecular granules ; sometimes in the preparation there were seen rare globules of pus scat- tered. The vessels and their principal branches were constantly very apparent. 154 DISEASES OF THE CEREBRUM AND CEREBELLUM. which may be obtained by the use of the compound jalap powder, followed by calomel carried almost to the point of salivation. This seems to me to be rather energetic treatment ; and I think that the purgative alone, with just sufficient calomel afterward to insure a continued free action of the bowels, is preferable. For the purpose of diminishing vascular tension, either fjirtar emetic (F. 35), aconite, or veratrum viride (F. 36) may be used. Should the cerebritis be found to depend upon syphilis or lead, the iodide of potas- sium may be employed as the most serviceable remedy. Blood-letting is admissible in serious cases, and is recommended by nearly all of the older writers. The head may be shaved and blistered, or cauterized ; but I .mi convinced that sub-occipital vesication is in every way as good, and the infliction of this punishment is not warranted. If there be any otitis, it is well to promote otorrhcea ; or, if there be a collection of pus beneath a depressed and fractured bone, it may be liberated by a free incision. CHRONIC SOFTENING. Definition A disease of the brain of a very serious character, gene- rally of a secondary nature, and dependent upon impaired nutrition of the brain-substance through occlusion of the cerebral vessel, and symptom- atized by a numerous variety of mental, sensorial, and motorial symptoms. Much confusion has resulted from the use of a variety of terms, such as " red softening," " white softening," " inflammation of the brain," and other names which tend to mislead the student. For our purpose it will do to consider white and red softening as different stages of the same con- dition, which may result from a variety of causes ; and inflammation of the brain more as the condition which I have just described than that of which I propose to speak, viz., the variety spoken of by Reynolds and others as ." non-inflammatory softening." Symptoms The symptoms of softening of the brain may follow a cerebral hemorrhage, embolism, or thrombosis, or perhaps be connected with symptoms of cerebral tumor ; or, again, cerebritis may leave behind it a chronic condition expressed by the symptoms I am about to detail. The early troubles of the primary form are those of intelligence ; the patient becomes silly, loses his memory of events which have recently transpired, is unable to concentrate his attention, and becomes restless and irritable, quarrelling with his immediate friends, and getting quite excited towards night. His speech may become affected, and he sits by himself for hours during the day, and mutters constantly a mass of disconnected rubbish. This condition of stupidity increases ; he may become drowsy and complain of headache, with feelings of head-pressure ; he may tell us that his limbs feel heavy, and complain of muscular pain, from which he suffers in the attempt to make any movement. As to other sensory dis- turbance, hy|>era?sthesia is much more common than anaesthesia ; though cutaneous areas, in which sensation is impaired, are by no means rare. Motorial troubles are of later appearance, commencing with gradual loss CHRONIC SOFTENING. 155 of power of an irregular character, which may affect either the arms or legs in the beginning, but finally becomes general. This paralysis is not always constant, there being a greater loss of power at times than at others. The first indication of the motorial trouble may appear either in the exe- cution of some ordinary act, which will be performed very clumsily ; or in locomotion, when the patient will stumble or fall to the ground, as there may be a sudden giving way at the knee. When he walks he scarcely lifts his feet from the ground, but drags them after him in a helpless manner. With the paralysis there may be a certain amount of rigidity, or tonic spasms, affecting the muscles, so that there are occasionally spastic contractions, which last for some little time. Epileptiform convulsions may occur during the disease, as well as attacks of mania, which are quite vio- lent. When the softening is secondary, and follows an attack of embolism, thrombosis, or cerebral hemorrhage, the initial symptoms make their ap- pearance in from one to two weeks after the occurrence of the hemiplegia. The troubles of intelligence are those which first attract our attention, and are generally connected with high temperature and severe headache. The patient may become delirious ; he indulges in delusions, and grows ab- normally sensitive ; or, on the other hand, he is drowsy, stupid, and melancholic ; and after this may follow paralytic contractures, clonic spasms, convulsions resembling epilepsy, or fibrillary contractions ; and he may finally become comatose. It is not uncommon for the patient to in- voluntarily pass his feces and urine. With the formation of cysts or ab- scesses, which constitute a late result of cerebral softening, convulsions of an epileptoid character may make their appearance ; or, should the con- dition be acute, and result from otitis, as is the case in cerebritis, these, as well as other symptoms, may be among the first to develop. Affections of speech are quite symptomatic of softening, because in so many of the cases the middle cerebral artery is that obstructed or destroyed. The hemiplegia, which may occur, is unattended by any loss of consciousness, and electro-muscular contractility is generally perfect or even exaggerated. The following may be presented as an illustrative case : J. A., aged 45. The patient was brought to me by his wife during the summer of 1872. Four years before, while actively engaged in business which demanded the most devoted attention, and required a great deal of intellectual labor, he began to suffer from headaches limited to the frontal region. These were so severe that while engaged in his office he was obliged to bind a wet towel about his head. He suffered very greatly from insomnia, and found it impossible to sleep unless he took large doses of opium. He very often awoke in the night, and went upon the house- top or out into the street, wandering about the city until morning. He became very moody, treated his wife with indifference, and scolded his children without cause. He could not talk for five minutes at a time without rising and pacing furiously about the room, while he seemed to be annoyed by the slightest noises about the house. The trickling of water from the pipe over the water-closet tank, which was next to his bedroom, so annoyed him that, in a fit of impatience and ungovernable irritability, he wanted to send for the plumber in the middle ot tin' night. His wife persuaded him to consult a homoeopathic physician, by 156 DISEASES OF THE CEREBRUM AND CEREBELLUM. whom he was treated for nearly a year, and at the end of that time went abroad. He had meanwhile grown much worse, his mentiil state was much more aggravated, and his headaches, though not so severe, were still constantly present. He complained of formication of the soles of the feet, and his walk was markedly affected, both feet being scarcely lifted from the ground, and he dragged one after the other when lie walked. He lost rapidly in flesh, and though the sea-voyage did him some good, he relapsed into his previous state after he reached Europe. While in Switzerland he had an epileptiform attack, and after recovery found that his right side was paralyzed. His speech was affected, and from what I can learn he must have been aphasic. The paralysis improved in a short time, and, strange to say, his mental condition also underwent a change for the better. After a few months he returned to New York, when I saw him. He was then in an almost helpless condition, and needed the a^i-tance of a cane and his nurse's arm to make any progress. He was bent over. and his chin was depressed, so that it almost touched the chest. The mouth was open, and the lower lip drooped slightly ; while from the cor- ners of the mouth there was an escape of saliva which trickled down over his chin. His face bore a very vacant look, and when he attempted to speak it was clouded by an anxious and discontented expression, which arose probably from the vexation he felt at being unable to speak. Pho- nation was not affected, but word formation seemed entirely lost, so that his attempts to speak consisted in the production of disorderly noises, the tongue being used extensively, the lips not participating. He could not protrude his tongue when told to do so. His right pupil was larger than the left. His right side was partially hemiplegic, and his wife stated that the loss of power was greater at times than at others. The right fore- arm was slightly flexed upon the arm, and the fingers seemed rigid. His control over the bladder was partially lost, and very often he would void his urine while upon the street, orlvt night. There is a history of trem- bling which affects the right arm and leg. This occurs during quiescence, and seems to have no connection with voluntary movements. His appe- tite is voracious, but there appears to be some difficulty in swallowing, so that it is found necessary to cut up his food. About two weeks ago he had a slight epileptoid attack. During warm days he seems disposed to sleep a great deal ; but when excited by the presence of disagreeable people, or thwarted or crossed, he becomes extremely violent, and even dangerous. I saw him but once, and I believe he was afterwards sent to an asylum. Causes First and foremost are primary forms of disease, which either produce occlusion of an artery, or irritation from a blood-clot or tumor. Vascular degeneration, which may result from general disease, or renal trouble, acts as a predisposing cause in the development of cerebral soften- ing. Intellectual fatigue, sexual excitement, alcoholic intoxication, head injuries, and local disease act as exciting causes. Exposure to cold has been given as a cause of cerebral softening, and exposure to the direct rays of the sun may induce the condition. Bamberger 1 has observed it as a consequence of typhus and acute articular rheumatism ; and Jaccoud" con- 1 Beobachtungen und Bcrnerkungen liber Hirnkrankheiten (Wlirzburg Ver- handlungen, 185C). 2 Pathologic Interne, torn. i. p. 177. CHRONIC SOFTENING. 15f aiders that it may be produced by syphilis in two different ways, either by a gummy tumor, which gives rise to irritation of the tissue in the neigh- borhood, or by infiltration. Cerebral softening is more common among people of advanced life as an idiopathic affection, and unless it follows embolism injuries, or like causes, is quite rare in early life, Andral having found only 39 cases out of 153 in persons under 40. Jaccoud is of the opinion, which others hold, that males are more commonly affected than females. Season has nothing to do with its development. 1 Morbid Anatomy and Pathology There has been great dif- ference of opinion in regard to the pathology of brain softening. Those who described it in the early part of the century considered it to be an in- flammatory affection, while Rostan, 1 who reported many cases, recognized a non-inflammatory form which he had met with among old people with rigid arteries. As Russell Reynolds 2 very properly observes, " much con- fusion has arisen from a tendency to misinterpret morbid anatomical ap- pearances, without paying sufficient attention to their mode of origin." Cruveilhier 3 considered two forms, one of which was apoplectic, or " apo- plexie capillaire." which he did not consider inflammatory : and, later, Andral 4 announced his disbelief in the necessarily inflammatory origin of the disease, and considered it due to occluded arteries and insufficient nutrition. Among the powerful advocates of the inflammation theory are Durand-Fardel 5 and Gluge, 6 while upon the other side may be mentioned such additional names as Kirkes, 7 Laborde, 8 Hughlings Jackson, 9 and many others. It may be said, I think, that softening of the brain is nearly always of an inflammatory character when it follows head injury and dis- eases of the cranial bone, while the majority of cases, which are secondary to occlusion of vessels, are dependent upon general disease of a non-inflam- matory nature. If the disease be primary, Jaccoud considers that the lesion will be of the first form, that is, at a single point ; but that when the softening follows typhus fever, puerperal, and other general diseases, the foyers will be mul- tiple. If the softening results from embolism or thrombosis, or, in fact, from any other condition producing obstruction of the circulation, there will first be a congestion with exudation of serum, hyperaemia of the vessels, and perhaps capillary hemorrhage, which is attended by coloration of the parts in the neighborhood, so that they become of a bright pink or red color, and are limited by other regions, which are anaemic and blanched, and a condition which has been called " red softening" exists. If this morbid process takes place in the grp-y matter, the hemorrhagic spot will be of a much darker color, and much more sharply circumscribed. The 1 Recherches siir le Ramollissement du Cerveau, 1820. - System of Medicine, vol. ii. p. 461. 3 Etude de la M6d., etc., 1821. 4 Precis d'Anatomie Path., 1829. 5 TraitS du Ramollissement, 1843. 6 Comptes Rendus, 1837. ' Op. cit., vol. xxxv. p. 821. 8 Le Ram. et la Cong, du Cerveau, Paris, 1859. 9 Op. cit. 158 DISEASES OF THE CEREBRUM AND CEREBELLUM. next change takes place within a week or two, when the color of the becomes much more pale, ami the exudation granular; fatty degeneration takes place, the softened spot becomes extended, the neuroglia-cells, ncrvc- h'bres, and nerve-cells become disintegrated, the axis cylinders disappear. Fig. 1C. DIAGRAMMATIC. TISSUE CHAXGES IN SoFTEXiso. A. Vessel. B, B, C. Nerve-tubes. D. Gluge's corpuscles. E. Swollen nerve-tube. and the bloodvessels alone may be distinguished, and even they are greatly disorganized. At this stage the softened spot becomes much paler, is creamy in consistence, and contains stringy flakes of a fibrinous nature. It is extremely rare for resolution to take place even in the earliest stage. A form of softening, alluded to by Jaccoud, Durand-Fardel, and others, consists in the formation of yellow plates, chiefly in the convolutions (plaques jaunes) which are the result of a partial metamorphosis of the softened patches. There may be also a retrograde change, as is witnessed in the formation of cysts, which are filled by a chalky fluid containing fat globules. There is always present a variety of cells known as Gluge's globules, which are composed of collections of small granular bodies, some- times surrounded by a cell wall, and these are produced by the degenera- tion of neurojrlia-cells, the debris of which are aggregated as masses of fatty granules. These little bodies, which rarely exceed 5 J V of an inch in diameter, have been found by Reynolds, Turck, and Bouchard in the cord, where their form of origin is the same. The various colors may be seen in the brain at the same time, patches of red, brown, yellow, or white denoting different stages of the morbid process. The lighter shades generally indicate advanced stages, such being the opinion of Durand-Fardel. Charcot and various observers have found forms of white softening in old people ; and others, among them Cotard, Pre" vost, Bastian. and Reynolds, have seen cases of the same kind. It is extremely doubtful whether the condition of degeneration was not CHRONIC SOFTENING. 159 preceded by some exudation of blood-elements, and, if it was not, whether the condition had not been confounded with sclerosis. Softened patches may be in the second stage removed by allowing a stream of water to fall upon the cut surface, and when the disorganized tissue is washed away a depression is left. If the cut be made through a brain which presents the appearance of red softening, the affected patch will be found to stand slightly above the normal tissue, and this is probably due to a hypersemia of the capillaries of the part. This fulness of the capillaries is undoubtedly due to collateral circulation of blood through the vessels contiguous to that obliterated, the normal functions being increased through double duty imposed upon them. This is the view held by Weber, 1 as well as by Prdvost and Cotard. 2 If the yellow appearance of the softened patches be not due to altered coloring matter of the blood such as we find in the early stages, it may be found later in connection with gelatinous circumscribed masses scattered through the brain or about old clots or tumors. The parts most liable to this change are the corpora striata, optic thalami, white substance of the hemispheres, and sometimes the cerebellum ; or there may be multiple foyers scattered through different parts of the brain. Durand-Fardel 3 has collected sixty-two cases from the writings of other authors, in which the locality of the softening was the following : Convolutions and white substance . .- . . . .22 Convolutions alone ......... 6 White substance alone . . . . . . . .5 Corpus striatum and optic thalamus ...... 6 Corpus striatum alone . . . . . . .11 Optic thalamus alone ......... 4 Pons Varolii . . . . . . . . .3 Cms cerebri . , . . . . . . . .1 Corpus callosum ......... 1 Walls of the ventricles (septum) ...... 1 Fornix ........... 1 Cerebellum ............ 1 Diagnosis In an excellent lecture delivered by Hughlings Jackson, 4 he says : " I do not see how the diagnosis that there is actual softening of the brain is in any case to be possibly arrived at, tinless the patient has certain local paralytic symptoms, as hemipleyia, or some other symptoms imply- ing a local cerebral lesion, such as affection of speech; or, again, unless there be signs of cerebral tumor (severe headache, urgent vomiting, and double optic neuritis) or evidence of injury to the head. For, so far as I know, cerebral softening is always local ; I know nothing of general or universal softening of the brain. To be warranted in diagnosing soften- 1 Handbuch der Allgem. und Spec. Chirur., 1865. 2 Gaz. Med. de Paris, Mai 19, 1866, p. 336. 3 Op. cit. 4 London Lancet, Sept. 4, 1875 160 DISEASES OF THE CEREBRUM AND CEREBELLUM. ing, you must have symptoms which point to local disease. I do not say that local cerebral softening cannot exist without localizing symptoms. I only say that in their absence you are not warranted in diagnosing its existence." This remark is made in connection with the lecturer's disbe- lief in various forms of functional disease which are so often improperly called "softening," and in which a few functional symptoms which disap- pear under appropriate treatment are vested by the careless or unscrupu- lous practitioner with an importance they do not deserve. These symptoms are those which follow depraved states dependent upon venereal excesses, fright, and other causes which lower the tone of the nervous system. Jackson's warning is a pertinent one. If we have hemiplegia, some renal or cardiac disease, and valvular de- posits, with murmurs, our suspicions of softening generally turn out to be well founded. The history of the antecedent attack, should it be throm- bosis, embolism, or cerebral hemorrhage, has much to do with the making of a correct diagnosis. As I have said, hemiplegia, unattended by loss of consciousness at the outset, is a diagnostic point in favor of softening, and suggests embolism, and if the train of symptoms given on a previous pain- is afterwards expressed, there can be little doubt as to the nature of the disease. A point insisted upon by Jackson is that the general mental symptoms of softening are either expressed before the softening, or follow it. He denies that general mental symptoms (wandering, delusions, etc.) are directly caused by the softening, but that special mental symptoms (affection of speech) are. The general mental symptoms follow a few hours or days after the local softening. The "preceding mental symp- toms " are irritability and altered disposition. Chronic meningitis may resemble cerebral softening, but in the former the pain is more diffused, and the motorial phenomena (spasms, etc.) are more pronounced. Softening with tumor niay be made out from the addi- tional presence of optic neuritis, choked disk, and Vomiting. Some forms of progressive meningitis, such as pachymeningitis with cerebral h;ematoma (vide the case detailed in the chapter upon pachymeningitis), may closely simulate cerebral softening, and very often the diagnosis is exceedingly ditlicult, or may be impossible. The symptoms of hemorrhage from rup- ture of a meningeal vessel, such as occurs in the course of these chronic varieties of meningitis, may closely counterfeit the apoplectic attack which occurs so often in cerebral softening. Prognosis. Cerebral softening is one of the most unfavorable con- ditions with which we are acquainted. Death follows the establishment of the morbid condition sooner or later in nearly all cases occurring in adult life. An occasional case of recovery may be encountered in a young subject, but this is exceptional. Of 109 cases of both forms of cerebritis collected by Aitkin, 1 he found that the duration of life in cases of this disease was the following, which also proves that there are more cases of the acute than the chronic form of the disease. 1 The Science and Practice of Medicine, vol. ii. p. 304. APHASIA. 161 1 died in 12 hours. 2 died in 12 days. 1 died in 35 days. 1 " " 15 " 3 " " 13 " 1 " " 36 " 1 " " 24 " 3 " " 15 " 1 " " 47 " 1 " " 32 " 1 " " 16 " 1 " " 49 " 5 " " 2 days. 2 " " 17 " 1 " " 60 " 9 " " 3 " 4 " " 18- " 1 " " 65 " 5 " " 4 " 5 " " 20 " 1 " " 68 " 4 " " 5 " 3 " " 21 " 1 " " 190 " 7 " " 6 " 1 " " 22 " 1 " " 220 " 8 " " 7 " 1 " " 23 " 1 " " 5 months. 8 " " 8 " 1 " " 25 " 2 " " 6 " 3 " " 9 " 1 " " 29 " 1 " " 1 year. 5 " " 10 " 4 " " 30 " 2 " " 3 years. 4 " " 11 " The greater number of these patients died, it will be seen, before the twelfth day. The experience of other observers is slightly different from this, as many persons with secondary softening have been found to live for years after the commencement of the softening. These cases being all fatal we have to remember as well that there are many instances in which the abscess becomes encysted, or the non-inflammatory softening circumscribed. Treatment Our efforts should be to improve, as rapidly and fully as possible, the patient's general condition. For this purpose we must not only prescribe for him a hearty hydrocarbonaceous diet, but we are to insist upon cold bathing, out-door exercise, and moderate stimulation. As medicaments, I am positive that there is no better remedy than phos- phorus, which may be given in combination with cod-liver oil, or in solu- tion in absolute alcohol (FF. 37, 24, 25, 26). The bromides may be given in combination with lupulin (F. 38), if there be headache or de- lirium; or cannabis indica, as recommended by Reynolds (F. 39). If the bowels be sluggish, a free use of the saline cathartics is of great bene- fit; and to relieve the head symptoms, leeching may do much good. In the chronic form tonics are indicated, and for this purpose I prefer the ammonio-citrate of iron (F. 40). I am not in favor of strychnine, and should hesitate to use it if the case were at all acute. ASEMASIA 1 (APHASIA). Synonyms Aphemia, Alalia, Laloplegia, Paralalie, Agraphia. Definition We may define asynesis, or aphasia (which is derived 1 It has occurred to me that the word "aphasia," as at present used, has too restricted a meaning to express the various forms of trouble of this nature, which not only consist of speech defects, but loss of gesticulating power, singing, read- ing, writing, and other functions by which the individual is enabled to put him- self in communication with his fellows. I would, therefore, suggest "asemasia" as a substitute for "aphasia." The word is derived from d and u^cwVw (an inability to indicate by signs or language)- "ll 162 DISEASES OF THE CEREBRUM AND CEREBELLUM. from the Greek o, priv., and $derhaps is unconscious of his mistake. He may be unable to read, but may show by signs that he knows what such and such a picture may be. The jx>wer of gesticulation may be, and often is, lost. He may make attempts to describe the figure of some object, but cannot do so. Trousseau related the case of a person who was told to imitate the playing of a clarionet, but when lie attempted to do so beat instead an imaginary tambourine. He is sometimes able to count figures which are before him, or piece* of money put in his hand, but if he has no such reminders, and is simply told to count, he may be able to count up to a certain number, and say ten, and does so in a peculiarly automatic way. After this, when some thought is required to make combinations, the effort is unsuccessful. APHASIA. 167 For the purpose of making himself understood it is necessary that an individual should be familiar with signs (visual and auditory), which have been received either upon the retina or tympanum, and reflected upon certain ideational and receptive centres, where they are retained and serve as models for expressions the individual may wish to make in the future. The mental process which attends the formation of language or the communicating faculty becomes so intricate and automatic that insensibly the process of comparison and centre stimulation goes on without the knowledge of the person, and words and signs are made upon the ground- work of impressions previously received for guidance and formation. It is only when disease affects the particular centre that the harmony is lost, and the patient, though possessing the ear and eye as mentors, is unable to coordinate the mental factors of intelligible communication. The fa- cility for connecting ideas with sounds or signs, which is a normal faculty, is thus spoken of by Ogle : " This faculty of converting ideas into symbols is quite distinct from that of converting symbols into ideas. The one may be acquired or lost independently of the other. Thus, a child learns to interpret the language of others before it can itself speak. Adults, as a rule, follow the same order in learning a new or foreign language. Most of us, moreover, know what it is to have the pictured map of some familiar object in our minds, yet to be perfectly unable to call up its name." This defect depends not upon the apparatus for the receipt of impressions, nor upon the apparatus for communication, but upon a loss of function in what has been called the "central organ of articulate speech; and both the ina- bility to remember words and connect them with ideas, and the inability to compel the organ of articulation to form words, depend upon some change at this point. The loss of power to express ideas is symptomatized by aphasia, agraphia, or other defects in the communicating faculty. If there be amnesia, the central disturbance (whatever it is) is the same, and the variation of lost means for expression depends on the manner of separation of organs from mental control. There seems to be little doubt as to the seat of this centre, and as to the circumstances under which it is impaired. The collected cases of different authors mainly go to show that the left side of the brain is the seat of a lesion in its anterior part, and that the third frontal convolution is the one most constantly involved. I have already casually referred to Broca's investigations, and will now present his description, which has been modified by Bateman, 1 of its anato- mical seat. " The anterior lobes of the brain comprehend all that part of the hemisphere situated above the fissure of Sylvius, which separates it from the temporo-sphenoidal lobe and in front of the furrow of Rolando (R. R.) which separates it from the parietal lobe The direction of this furrow is almost transverse ; setting out from the median line, it con- tinues almost in a direct line, and after describing some flexuosities ter- minates below and outside of the fissure of Sylvius, which it meets almost at a right angle behind the posterior border of the lobe of the insula. 1 Journal of Mental Science. 168 DISEASES OF THE CEREBRUM AND CEREBELLUM. " The anterior lobe of the brain is composed of two divisions, the one inferior, or orbital, formed by the several convolutions called orbital, which lie on the roof of the orbit, and of which I shall not have to speak ; the other, superior, situated under the outer wall of the frontal bone, and unl< T Fijr. 19. the most anterior portion of the parietal. This superior division is com- posed of four fundamental convolutions called, properly speaking, the fron- tal convolutions; one is posterior, the others are anterior. The posterior, F F, slightly tortuous from the anterior boundary of the furrow of Rolando. It is therefore almost transverse, and ascends from without, inwards, from the fissure of Sylvius to the great median fissure, which receives the falx cerebri of the brain. This is why it (F F) is described indifferently under the name frontal, posterior, transverse, or ascending convolution. The other three convolutions of the suj>erior division are very tortuous and very complicated, and some practice is needed to distinguish them in all their length without confounding the fundamental furrows which separate them with the secondary furrows which separate the second order folds, and which vary in different individuals according to the degree of complication ; that is to say, according to the degree of development of the fundamental con- volutions. These three fundamental convolutions, 1,2, 3, are antero-pos- terior, and, running side by side, extend from before backward over the whole length of the frontal lobe. They commence on a level with the sujM-rciliary arch, whence they are reflected, to be continuous with convo- lutions of the inferior division, and terminate behind in the frontal trans- veree convolution, F, F, which all the three enter. They are called first (1), second (2), and third (3), frontal convolutions. They may also be called internal (1), middle (2), and external (3) ; but the ordinary names have prevailed. The first (1) runs along the great fissure of the brain ; it presents, constantly, in the human species an anterio-posterior furrow more or less complete, which divides it into two folds of a second order; it APHASIA. 169 has, therefore, been divided into two convolutions, but comparative anatomy shows that these two folds form only a single fundamental convolution. The second (2) i'rontal convolution presents nothing peculiar ; not so with the third (3), which is more external. The latter presents a superior or internal border, adjoining the tortuous border of the middle convolution (2), and an inferior or exterior border, the relations of which differ accord- ing as they are examined before or behind. In its anterior half this bor- der is in contact with the external border of the most external orbital con- volution. In its posterior half, on the contrary, it is free and separated from the temporal sphenoidal lobe by the fissure of Sylvius, S, S, of which it forms the superior border. It is in consequence of this latter relation that the third frontal convolution is sometimes called the superior margi- nal convolution. " Let me add, that the inferior border of the fissure of Sylvius (S, S) is formed by the superior convolution of the temporo-sphenoidal lobe, which is therefore called the inferior marginal convolution T, T. It is an antero- posterior fold, thin, and almost rectilinear, which is separated from the temporo-sphenoidal convolution T 2, T 2, by a furrow parallel to the fis- sure of Sylvius. This furrow is described under the name of the parallel fissure (with reference to the fissure of Sylvius, S, S). Lastly, when the two marginal convolutions, superior, 3, 3, 3, and inferior, T, T, are drawn away from the fissure of Sylvius, S, S, there appears an enlarged and slightly prominent eminence, I, from the summit of which five small sim- ple convolutions, or rather five straight folds, radiate in a fan-like manner. It is the lobe of the insula which covers the extra-ventricular nucleus of the corpus striatum, and which, arising from the bottom of the fissure of Sylvius, S, S, is found to be structurally continuous by its cortical layer with the deepest or most deeply seated part of the two marginal convolu- tions, 3, 3, 3, and T, T, and by its medullary layer with the extra-ven- tricular layer of the corpus striatum. The result of these structural rela- tions is, that a lesion which propagates itself continuously from the frontal lobe to the temporo-sphenoidal lobe, or, vice versa, will pass almost necessarily by the lobe of the insula, and that from thence it will most probably extend to the extra-- ventricular nucleus of the corpus striatum, since the proper substance of the insula I, which separates the nucleus from the surface of the brain, forms only a very thin layer." Not only may a lesion of the speech-centre itself produce aphasia, but in numerous instances (some of which have been referred to by Jackson) it may follow the destruction of adjacent parts, as a consequence of some such accident as the plugging up of the middle cerebral artery. As a consequence of such a pathological condition, a large area of brain sub- stance will be destroyed, so that impaired mental function as well as nphasia takes place. An important subject in this connection is the side of the brain which is affected. Though exceptional cases have been reported in which the right cerebral hemisphere has been the seat of the lesion, the rule is the other way. In some instances, even, no lesion whatever has been found ; 170 DISEASES OF THE CEREBRUM AND CEREBELLUM. or, on the other hand, the left anterior convolutions have been the seat of morbid change, and no loss of speech has been occasioned. Simpson 1 has related one case where marked destruction of the left anterior lobe VMS observed, and yet no aphasia existed. This man, aged 65, who had been epileptic for ten years, having as many as three or four attacks a month. died. The white and gray matter of the left hemisphere were markedly atrophied, and there was a cavity in the left posterior frontal convolution 1| inches longitudinally, and l transversely. The following case is interesting, as it shows that almost complete aphasia may exist without any disease of the island of Reil : M. A. B., aged thirty-five years, married. Family and previous per- sonal history good, but it is possible to trace syphilis. The patient had an aj)oplectic a'ttack in August, 1859, with loss of consciousness, which lasted for two hours ; on recovery it was found that she was unable to speak, but there was slight improvement after a few months. Present condition, July 17, 1874: The patient is a medium-sized woman of seemingly good condition, with the exception of her nervous trouble. There is slight paralysis of the left side ; can move left arm well, but slowly, and walks with a shuffling gait. Tactile sensibility, and sensibility to differences in temperature, are decidedly impaired on the left side, on which side there is an appreciable amount of analgesia. She protrudes her tongue in a straight line, but feebly. No loss of taste or smell. Her mental condition is be- low the average. This first part of her history I have taken from the records of the Epileptic and Paralytic Hospital, and I also find that for some months she has been suffering from symptoms of phthisis. When I saw her on August 10, 1875, the patient was in advanced phthisis; her nervous condition was the following : Paralysis of the left side ; her left hand lies in her lap, the thumb being contracted and flexed ; the flexor tendons of the hand are rigidly contracted, so that at the wrists they stand out like tense cords. There is very little atrophy oT the left upper ex- tremity, but there is a certain stiffness about the elbow-joints of this side. Tin- left lower extremity seems to be nearly as strong as its fellow. Motion at the hip- and knee-joints is limited. She can raise her foot from the ground when sitting, but when she walks it is in a shambling manner, dragging her left foot, or scarcely lifting it from the ground. There is some para- lysis of the left side of the face, and it is impossible for her to protrude her tongue. Sensibility seems to be very slightly affected in the paralyzed side. She is almost completely aphasic, her repertoire of words being con- fined to " yes" and " no," the former being repeated several times in answer to any questions she may be asked. When she is asked her name, she is unable to tell it. " Is it Jane?" she shakes her head and smiles. " N it Ann?" another shake of the head, and an attempt to speak, the only result Ix-ing the production of an unintelligible noise. '' Is it Mary?" when she brightens up and says, " Yes, yes, yes ; Ma " prolonged, and she generally gives it up in disgust. She cannot write, but makes a disorderly scrawl ; although we learn from her friends that in health she wrote well. She gesticulates a great deal, and endeavors to attract the attention of those in the ward, and evidently appreciates everything that goes on about her. Her pupils are easily dilated, but she does not see Mod. Times and Gazette, Doc. 21, 1867. APHASIA. 171 with the right eye, and on examination I find atrophy of the optic disk. During the winter and spring of 1875-76, she seemed to suffer much from her pulmonary trouble. There was oedema of the lower extremities, which increased so that the anasarca became general, but she was somewhat relieved by digitalis and iron ; diarrhoea supervened, and she finally died on the second day of June, 1876. Autopsy The dura mater was considerably thickened, and presented the appearance of old pachymeningitis. There was no lesion to be dis- covered in either third frontal convolution, but an old clot was found in the right caudate nucleus. This clot was about half an inch in diameter, and was surrounded by some dense tissue. Cortical lesions were present on both sides of the brain, but of superficial extent, and confined chiefly to the parietal convolutions ; these consisted of softened patches in advanced stages of degeneration. The cerebral arteries contained patches of a yel- lowish or atheromatous nature. The spinal cord was not examined. Both lungs were Ibund to be tubercular, and in the middle lobe of the right there was a large cavity. I was unable to find any tubercular deposit whatever in the brain or its meninges. The left frontal convolutions were examined, but no disease whatever was found. Hemingway reports the following interesting case of left-sided paralysis with aphasia. 1 Jane R., aged 30, widow ; occupation seamstress ; education fair, can read and write. Entered hospital October 30, 1873. Family history good ; says she always was a healthy woman tiH present illness. Admits having had a sore on genitals five years ago. Cicatrices are at present visible on forehead, which are probably a result of tubercular syphilides; says they came there five years ago. Her left eye shows the result of an old ophthalmia, which, it was supposed, was of gonorrhceal origin. ' For two years past has had slight palpitations on exertion. Always used her right hand in her occupation. Four months ago, one night when she was going to bed she became suddenly speechless ; there was no paralysis whatever. Next morning, on attempting to arise, found her left arm, leg, and side of face paralyzed ; also, with loss of sensation in those parts. Loss of speech was complete ; and hearing, which before this was excel- lent, was now lost in left ear. Her tongue was only affected in sensation ; she was not able to appreciate sweet substances placed on the tongue ; sense of smell also lost. About one month after this attack, i. e., three months ago, improvement began in speech, face, and lower extremity, and has continued since then. Upper extremity began to improve one month ago. Sphincters have not been affected. Is a medium-sized woman, pretty well nourished ; mental faculties good, with exception of loss of memory, constituting well-marked amnesic aphasia. Is unable to recol- lect many words, names of objects, as hat, key, handkerchief, pencil, etc. ; though she can readily repeat them on being told, she forgets them imme- diately afterwards. Is unable to read continuously, omitting words, and giving up from inability to fix attention. On attempting to write the letters of the alphabet, the result was A B C D S G H I ; but when the letters were separately told her, she wrote them down easily. Partial paralysis remains on left side of face ; cannot close eyelids tightly. Sen- sation is lost to a great extent in left side of face, and in left nostril. Does 1 Medical Record, March 4, 1876. 172 DISEASES OF THE CEREBRUM AND CEREBELLUM. not wince on the application of aqua ammonia to left nostril, nor when the conjunctiva or same side is touched with an irritant. Hearing poor on left side. Taste is impaired anteriorly and posteriorly on left side of tongue. Dynamometer, ! * ,' ' I outer circle. ( right, 80, ) ^Esthesiometer is valueless, on account of loss of sensation of reaction to pain. Does not wince on pinching arm, but does on palm of hand and tips of fingers. Perception delayed; takes about three seconds. Can raise arm to level of shoulder, a little stiffly. Can flex and extend fore- arm and fingers, but slowly. Heart sounds normal. Walks without elasticity. Sensation in leg as in arm. Reflex action lessened. Electro- muscular contractility good. The accumulation of reported cases, however, in which the lesion was on the led side, leaves no doubt in regard to this question. Jackson and Ramskill report 40 cases of right hemiplegia with aphasia, and but one of left hemiplegia. Ogle 1 reports 25 cases all with the lesion in the left hemisphere, though there were morbid changes in some of these in other parts. In not one of these where the lesion was on the left side was there undisturbed speech. Magnan 1 reported thirty-one cases of aphasia, and in all but four was there right-sided hemiplegia. Trousseau, in 18G8, had collected all the cases he could find, the number being over r O one hundred, and in all but ten there was right-sided paralysis. Seguin 8 has collected 4(i cases from the records of the New York Hospital, and in all but three there was right hemiplegia. Hammond has collected 243 cases of right hemiplegia with aphasia, and but 17 of left. Thus it is settled, I thiuk, that the left side of the brain is that which contains the apeech -centre. The question as to the relative frequency of right and left hemiplcgiu naturally arises, and from the inspect ion of a large number of cases it will be seen that there is a very slight preponderance of the former. Browne, 4 from Baillargor's tables, says that " in aphasia, right is to left hemiplegia sus l.> is to 1." By the following table it will be seen that there is very slight prepon- derance of right -sided paralysis, and the comparison between the infre- quenc.y of aphasia with left hemiplegia, and the slight difference between the relative frequency of occurrence of both forms, is inconsiderable. Casoe of hemiplegia. K. L. i- rl .... 75 43 S2 Aiulrnl .... 136 73 63 Baillarger HO 58 52 821 174 147 1 St. Cieo. Hosp. Reports, vol. ii. * Bull, de I'Acad&niede Medecine. s Quarterly .Journal of Psychological Medicine, 18G1, xxx. 663. 4 W. Riding Reports, vol. ii. p. 284. APHASIA. 173 As to the exact site, Seguin tabulates 545 cases, in all of which but 31 the lesion was in the left anterior lobe. Why the left side is the seat, especially when embolism or thrombosis is the cause, has already been explained by the fact that the left middle cerebral artery is that which is in the most direct line from the heart. The next link in the chain, which is the question of valvular disease, and its connection with loss of speech, has been pointed out by H. Jackson, who has found that valvular disease was nearly always associated with hemiplegia, and connected with loss of speech. He has seen more than 50 of these cases. In my own experience, and my records show 8 cases of right hemiple- gia with aphasia in which I made autopsies, there were other lesions, but always some trouble in the course of the middle cerebral artery. I therefore agree fully with the majority of observers, that loss of speech depends, except in rare instances, upon lesions in the left hemisphere, but that it may also follow a lesion in the other hemisphere. Both Brown- Sequard and Van der Kolk have advanced theories the first, that articulate speech is a reflex process ; and the latter, that it is seated in the olivary bodies. This last view was held by Willis, Solly, and others. Laycock is of opinion that these organs are " subservient to the emotions through the muscles of the face and tongue by language, and emotional cries and sounds." And he says : " It is by no means improbable, however, that the emotional movements of the hands, as well as of the tongue and face, are likewise under their direction. They are, therefore, to be considered as regulative ganglia to the motor centres of the facial, hypoglossal, and limb nerves in the medulla oblongata belonging to the substrata of the sensory tract." Dr. Herbert Major, 1 in a very complete article upon the microscopical anatomy of the island of Reil, sums up his conclusions as follows : " 1. The cortical layers of the insula agree in number, order, and general arrangement with those of the vertex, but the cells of the third layer are in the insula generally smaller than at the vertex. The vessels and neu- roglia present no peculiarity. " 2. The various gyri forming the insula present a similar structure. " 3. No difference of structure can be detected in the right as compared with the left insula. " 4. The method of union of the white matter with the cortex is in the insula similar to that observed in other lobes." The departure from the healthy state is seen in enlarged vessels, a shrunken appearance of the cells of the first layer and a diminution in their number, together with even a change in the cell-contents, the nuclei being broken down and agglomerated at the centre. The cells of the second and third layers have lost their processes, and the protoplasm contains granular debris, while the other cells of the lowermost layers suffer the same changes as well as transposition. 1 West Riding Reports, vol. vi. 1. 174 DISEASES OF THE CEREBRUM AND CEREBELLUM. Aphasia may be dependent upon any form of brain disease which pro- duccs disorganization of, or pressure upon, the third frontal convolution or piirtn immediately adjacent. 1 Among the common diseases which lead to the structural changes are central hemorrhage, thrombosis or embolism. tumor, or sclerosis, as well as certain forms of meningitis. Age appears to play but a small part in the production of this condition, except so fat- as it influences cerebral hemorrhage, embolism, or the other diseases just mentioned. Very few examples of aphasia in very young persons have been reported, for vascular neuroses are quite unusual among children, and right hemi- plegia, with a lesion in this particular part of the brain, is of rare occur- rence. A case was reported by Eulenburg which was quite unique.* The patient was eight years old ; two years before he had had scarlet fever, and six weeks after the development of the disease there were convulsions and coma, followed by right hemiplegia with aphasia. The paralysis almost subsided in two weeks. He speaks but two words, viz. : " Ach," which he always uses for " nein," and " Ja," with which he answers all other questions. The fact that dropsy and albuminuria had existed induced the author to infer the presence of softening of the central organ of speech. That disease of the island of Reil is not always the cause of aphasia is proved, 1 think, by the fact that aphasia has existed with dis- ease of other parts of the brain while the speech-centre was in a normal condition; and tumors have been found involving the corpora striata, and other parts of the motor tract, but not affecting the integrity of the third frontal convolution. Aphasia of a temporary character may depend upon functional conditions, such as cerebral congeal ion, indigestion, or as the result of fright or other emotional forms of excitement, or may be connected with epilepsy or hys- teria, Kiseh* re|Hirts three cases of transitory aphasia due undoubtedly to cerebral congestion. One of these was a very stout woman who, having drank a very large quantity of carbonic acid water, fell to the floor after being dizzy, but did not lose consciousness. This seizure was followed by headache, and later by complete aphasia. She subsequently recovered. Two rases of aphasia of a similar character are reported by Bcrger. * Habershon* presents an example of aphasia which was caused by fright. A much more rare variety of the disease is that which is connected with 1 Among fifteen cases reported by Sander* there were two in which the origi- nal lesion was found in tin- left parietal lobe, iu some of the bundles of fibres radiating from the corpus striatuin. * Hvrlin Mcd. Geselbchaft, July, 18G9. 3 Berliner Klin. NYochciischrift, 1869,433. 4 \Yicn. Mt-d. \Y<>rli. , 1HG9, 102. * l.t null >u Lancet. 1S70, vol. ii. 402. * Archiv fur Psychiatric, ii. 38. APHASIA. 175 epilepsy. Three such cases were published by Allbutt. 1 One of these patients fell, striking on his left temple ; some time afterwards epilep- tiform attacks appeared with paralysis of the right arm and leg. The second case was that of a woman aged fifty, who had had epileptic con- vulsions of a bilateral character for two years. After the attack she was somewhat aphasic, and "had a mental vision of the words," but was unable to speak them. This condition of affairs lasted for two hours. The third patient was a man, thirty years of age ; there was no loss of consciousness, but attacks of hypergesthesia in the right arm and hand, followed by blindness, lasted for twenty minutes or longer, and was succeeded by speechlessness lasting two hours. Diagnosis In making the distinction between aphasia and other difficulties of speech, we are apt to be misled by defects in articulation, dependent upon incoordination or paralysis of the tongue, or by certain mental irregularities, or sometimes by congenital mutism. 2 We are to bear in mind the fact, that there may be transitory aphasia, but that organic disease of the speech-centre is generally of permanent duration ; and that there are but very few exceptions to this rule. The speech defects which are of a local character are symptomatized by the patient's inability to 1 Med. Times and Gazette, 1869, vol. i. p. 491. 2 Dr. Browne,* of the West Riding Asylum, recently examined 29 cases of morbid affections of language, or all in the existing population of the Crichton Institution at Dumfries; 14 of these were females, and 15 males. Of these, which he arranged in three classes, he found among the women : " 1 . Intermittent mutism 5, in one connected with the catamenia. 2. Constant mutism, 7 : of these one had been a public singer ; 1 when roused could with difficulty articulate, having facial paralysis; 1 could not walk in consequence of spinal deformity; 1 was an idiot laboring under phthisis ; 1 uttered cries when suffering pain, o. One was reduced to monosyllabic utterances. 4. One manifested inces- santly, day and night, irresistible loquacity. Among the males: "Intermittent mutism, 1. 2. Constant mutism, 5: in J the mutism is of twenty years' duration ; in 1 it is accompanied by tremor of the limbs ; in a third, who attempted to cut his throat, there is unintelligible mutter- ing in soliloquy. 3. One was reduced to monosyllabic utterances. 4. Two manifested constant loquacity : in one, an idiot, there is congenital left hemiplegia ; in the other, who is healthy, the loquacity is so great and rapid that the words run into each other so that he seems to speak in long sentences. 5. Two pre- sent symptoms of general paralysis ; the articulation is indistinct or unintelligible, (i. In one case there appeared to be the omission of the first syllable of every word, followed by alternate mutism and loquacity. 7. In one, an idiot, language is limited to a few words, and these are exclusively oaths, with congenital right hemiplegia, and club-foot. 8. Two idiots emit nothing but acute inarticulate cries ; one roars like a wild beast." There was no paralysis in these cases except of the face in two general paralytics, and of the lower extremities in two idiots, the paralysis in these latter cases being congenital. * Op. fit. p. 297. 176 DISEASES OF THE CEREBRUM AND CEREBELLUM. speak at all, though he may fully convince us of his ability to form words and appreciate their meaning ; and, moreover, he can always, should there not be paralysis of the hand or forearm, write any word that he may wish to speak. This is not the case in aphasia. In lighter forms of tongue paralysis there is no trouble about the selection of words, but simply a clumsiness in pronunciation, and in many of these forms evidences of local muscular weakness, in connection with the speaking apparatus, draw attention to the real nature of the trouble. A disease presenting these local defects is a so-called glosso-pharyngeal paralysis. The same condition of affairs is met with in general paralysis of the insane, but with this, as well as other troubles of the same kind, there are various other symptoms which accompany the speech defect, such as mental impairment, with peculiar delusions and muscular trembling. Hysteria sometimes gives rise to a very curious speech derangement, which, in its strictest sense, can hardly be called aphasia. The patient occasionally introduces obscene and profane words in place of others more conventional. A form of speech trouble described by Window 1 and Komberg* is expressed by mimicry of individuals, who speak to the patient or who talk within earshot. He closely imitates the tones of their voices and mannerisms, and repeats the word.* addressed to him, besides mimicking their gestures and attitudes. These phenomena are occasionally seen among the insane. Romberg luis called this morbid state echo/alia. I have at present a case under obser- vation who is an example of this kind, only his infirmity does not exist to so marked a degree as in the cases of the two observers above mentioned. My patient is an idiot, and possesses but very little mental power. He can point to his mouth, places his hand upon his abdomen when hungry, and can call attention to his bodily needs by equally simple gestures, but beyond this he is more an automaton than a living being. When asked a question, for instance, "How are you?" he repeats the two last words, "Are you?" and "Why don't you answer?" he replies, "Don't you answer?" He invariably repeats the last two or three words of any ques- tion that may be put to him, so that his answers are but echoes of the questions. In the early speech disturbances of left hemiplegia, or organic diseases of the brain, the patient's attempts to articulate will result in a clumsy and mispronounced word ; while in aphasia his articulation, be it ever so lim- ited, is rarely imperfect, his " yes" or " no" being fairly pronounced, or, if he has improved so far as to be able to pronounce but a part of a word, he will do this distinctly, while jmrhaps the other syllables will either be not pronounced at all, or in such a way as to be utterly unintelligible. There are generally with aphasia great impatience and embarrassment, mimicry, and gesticulation, which are evidences of mortification arising from the knowledge of his failing, and his gestures take the place of words. In agraphia the handwriting or results of attempts at writing must be 1 Obscure Diseases of the Brain and Mind, Am. ed., p. 343. 1 A Manual of the Nervous Diseases of Man, Syd. Trans., vol. ii. p. 431. APHASIA. 177 compared with specimens, such as would be made by patients who are insane, ataxic, or paralyzed, and it is necessary for us to carefully note the omission of words, or combination of syllables which bear no relation to one another, as well as the character of the patient's composition. If he be insane, he will not admit any absurdities to which he may give expres- sion, but with the aphasic the case is different, for he always evinces his chagrin when he finds that he has written the wrong word, and endeavors to correct his mistakes. There are cases spoken of by Bacon 1 and others, in which the only evidence of the patient's insanity is his writing, but even here the defect is more in the expression of a disordered mental state than in an impairment of the communicating faculty. The handwriting of the general paralytic sometimes closely resembles that of the aphasic patient, but in the first, with time there is progressive impair- ment, while in the other, if anything, there is improvement. The medico-legal questions which may arise in regard to the responsi- bility of aphasia are worthy of consideration. The aphasic of course may suffer an intellectual impairment, which lasts a shorftime after the attack. This is not necessarily accompanied by a loss of judgment. It is more a condition of mental sluggishness, and it will not do to say that the indi- vidual is incompetent. The aphasic makes intelligent efforts to communi- cate, even though he may not be able to do so. He gesticulates, and tries to explain himself, and the expression even of his eyes tells of everything but intellectual unsoundness. Additional evidence of softening in dementia throws an entirely different light upon the matter, but even then it must be remembered that aphasia is not necessarily associated with such states. A case of interest is reported by M. Lucas Championnieres : 2 " The ques- tion was raised in this particular instance a propos of a case in which the patient, in spite of an enfeebled intelligence, had become capable of writing with the other hand. He could not, however, write if left to himself, and could only recopy w r hat was written and set before him, and the expert physicians vainly tried to make him recopy a power of attorney or a will, while he willingly wrote any ordinary phrase or document which did not bind him to anything. This man, then, knew perfectly what he was doing, and the Societe de Medecine Legale concluded that he possessed still thorough intelligence and free will to be able to continue to enjoy his civil rights, the intellectual debility which he had suffered not appearing to be sufficient to justify what the French laws call an ' interdiction.' ' The society recommended that he should be taken care of by a " council," so that he should be guaranteed protection against danger that might arise in the condition of his affairs. We must bear in mind the existence of heart trouble should it exist, or vegetations and other indications of extraneous disease which might lead to the causation of thrombosis or embolism. 1 On the Writing of the Insane, p. 12. 2 Journal de Me>l. et de Chir. Prat., abst. Br. Med. Journ., Sept. 15, 1877. 12 178 DISEASES OF THE CEREBRUM AND CEREBELLUM. Prognosis The view we are to take of our patient's condition is to b governed entirely by the question whether there is or not a primary organic disease, its imjKjrtance and the character of the aphasia. 1 In the light forms, such as result from fright and cerebral congestion, or those connected with hysteria, the prognosis is exceedingly good, and the same is the case when it is the result of protracted fever. Legroux (op. cit. p. GO) sj>eaks of an aphasia of quite temporary duration, which is occasionally of gouty origin, or connected with diabetes or albuminuria. The prognosis of the condition itself is quite good, but a serious indication of grave cere- bral trouble. Aphasia with paralysis is always significant of deep trouble. Such an aphasia, when it occurs with hemiplegia, may persist perhaps during the individual's lifetime, and after every vestige of the hemiplegia has disappeared. If there be softening, or previous acute cerebral dis- ease, or if there IK? evidence of arterial degeneration, or valvular deposits, the ease assumes a hopeless aspect, and may be nearly always pronounced incurable. Aphasia as the result of traumatism is occasionally relieved by surgical interference. ' Treatment Our first indication is to improve, if possible, the or- ganic dise;ise, and sometimes we are able to better the patient's condition to a great degre e. Should there be hemiplegia, contractures, or other evi- dences suggestive of degeneration of the cerebral tissue, we will find our- selves jKiwerless to help our patient materially. It is only when aphasia exists as an isolated symptom that very active measures are followed by some show of success. In such a case local blood-letting, purgation, and the use of ergot, and the bromides, may completely relieve the condition ; and even when the disease is established, and the destruction of the speech centre has been limited, there is a possibility of improving the patient's partially lost faculty. Systematic education, and the training of the left hand, and the development of the right side of the brain, may result in an increase in the patient's facility of communicating. In rare cases, viz., those of traumatic origin, it may do well to use the trephine. Broca, un- der the heading, " La Topographic Cranio-C^rebrale,"* described experi- ments made by him to determine the relation of the cranial bones with underlying parts; and Turner 8 has made additional observations, and given rules for determining this relation. Figure 20 is taken from Tur- 'ner's article, and 1 have slightly modified it so that the point where the trephine may \w used is indicated. This instrument may be also em- ployed in aphasic patients at parts where the depressions of bone have resulted from head injury. Fig. 2O "Diagram showing the relations of the convolutions to the skull. K. The fissure of Rolando, which separates the frontal from the ' In one ease report^ by Bateman, the patient recovered almost entirely, and he rould pronounce every word distinctly, with the exception of those containing the IftU-r P. 1 Revue d' Anthropologie, tome v. No. 2, 1876. 3 Journal of Anatomy and Physiology, vola. xii., xiv., 1873, 1874. CEREBRAL SCLEROSIS. 179 parietal lobe. PO. The parieto-occipital fissure between the parietal and occipital lobes. S. The fissure of Sylvius, which separates the temporo- sphenoidal from the frontal and parietal lobes. SF, MF, IF. The supero-, mid-, and infero-frontal subdivisions of the frontal area of the skull ; External indication of Island of Reil. (After Turner.) the letters are placed on the superior middle and inferior frontal convolu- tion. SAP. The supero-antero-parietal area of the skull. IAP. The infero-antero-parietal area of the skull. IPP. The infero-postero-parietal area of the skull ; the letters are placed on the mid-temporo-sphenoidal convolution. O. The occipital area of the skull ; the letter is placed on the mid-occipital convolution. Sq. The squamoso-temporal region of the skull; the letters are placed on the mid-temporo-sphenoidal convolution. AS. The ali-sphenoid region of the skull; the letters are placed on the tip of the supero-temporo-sphenoidal convolution.'' The circle indicates the point at which the trephine is to be applied. CEREBRAL SCLEROSIS. Synonyms Sclerencephalia ; atrophia cerebri. Tabes cerebri. Atro- phy of the brain. Definition An induration of the nervous substance consisting in increase of connective tissue, and atrophy and destruction of the nervous 180 DISEASES OF THE CEREKRUM AND CEREBELLUM. elements, constitutes the condition known generally as sclerosis. The French writers have applied the terms " Sclerose en plaques dissemine'e," "rubane*"," " jie'riphe'riques," and " diffus" to the disease; adopting iln->c names in regard to the character, site, and form of the lesion. Such ex- pressions, while making the nomenclature more exact, imply delicate dis- tinctions which are not always to be made, and do very well only when applied to appearances witnessed .after death, but are not so valuable when making a diagnosis before death. I prefer to use the terms " dif- fused sclerosis" of the brain, " cerebro-spinal sclerosis," and " spinal sclerosis." Even this nomenclature is open to objection, for it is very rare for sclerosis of any kind to be confined to either the brain or cord, though such involvement of the organ not originally affected may be of late n her left side, the head drawn down to the same side ; and it was agitated by coarse tremors, which ceased when she slept. Her right arm and forearm were drawn to her chest, and likewise agitated by almost constant tremors. Her left arm was also adducted, and the forearm semi- flexed ; while the fingers were extended. Tremors of the same character agitated this member. The thighs and legs were drawn up, but did not seem to be quite so rigid as the arms, and there was great atrophy of all four extremities. She passed her excreta unconsciously, and a bedsore had formed upon the left buttock. Voluntary power was absent almost entirely, and I do not remember having seen her change her position in bed from the time I first saw her until her death. Sensibility to pain was very much lost, and reflex excitability was nil. Perhaps some of this want of sensibility was due to the horny condition of the plantar skin. She had a great many general convulsions, attended by turgescence of the mirface vessels, and nystagmus. She continued in this condition during the year, improving slightly during this time in regard to the number and violence of convulsions, but gradually growing weaker. Dec. 26, 1876, 1.30 P. M. Being fed with stewed meat she had three convulsions in rapid succession, while her mouth was filled with food. Attendant states that she first became cyanotic, but her teeth were so clenched that the nurse was unable to extract the food. As soon as the *|asins relaxed, she thrust her fingers in the mouth of the patient, and re- moved a piece of meat, but the patient was dead. Autopsy IK hours after death No food found in larynx or fauces. Membrane of brain congested and thickened ; the gray matter of all the convolutions was of the consistency of the white of a hard-boiled egg. I afterwards can-fully examined the brain, and found patches of advanced Bcleroeed tissue over the cortex, and throughout the gray and white matter of other parts of the hemispheres. The induration was so general that the brain seemed, as u whole, quite hard and tough. The arteries were throughout, and the calibre of the vessels was quite reduced. This patient presents evidences of cerebral sclerosis, which were evidently of very early origin. The patient is at present in the Epi- leptic and Paralytic Hospital. Her early history is somewhat meagre. She gives a history of epilepsy, and has attacks several times a week. Her CEREBRAL SCLEROSIS. 188 mind is very feeble, and she has attempted suicide several times. The atrophy is one-sided, and there is probably atrophy of the left side of the brain. The following history and table of measurements were furnished by my predecessor, Dr. Janeway : E. B., aged 19 years ; state, single. Admitted to hospital May 1, 1868. Examination Head : no facial paralysis or deviation of tongue ; no atrophy of tongue ; pupils normal, no strabismus ; hearing good, as is also common sensibility. Right upper extremity : shoulder-joint is freely movable ; elbow cannot be fully extended ; hand flexed and extremely pronated ; muscles of hand to a certain degree rigid ; fingers flexed, thumb not rigid ; marked atrophy of entire arm ; skin of fingers soft and sodden, but no other changes of nutrition. Measurements Middle sternal notch to coracoid process : right side, 4|- inches ; left side, 4| inches. Edge of acromion to external condyle : right side, 10 inches ; left side, 10^ inches. External condyle to styloid process of ulna : right side, 7^ inches ; left side, 8^ inches. Apex of acromion to styloid process : right side, 1\ inches ; left side, 8 inches. 1st metacarpal bone (index finger) : right side, 50 mm. ; left side, 55 mm. Metacarpal bone (little finger) : right side, 47 mm. ; left side, 50 mm. Metacarpal (thumb) : right side, 40 mm. ; left side, 43 mm. ; right index, 65 mm. ; left index, 70 mm. Little finger : right side, 53 mm. ; left side, 60 mm. Thenar eminence, thickness of: right, 31 mm.; left, 35mm. Hypo- thenar eminence, thickness of: right, 20 mm.; left, 24 mm. Vertebral prominence to edge of acromion : right side, 6^ inches ; left side, 7|- inches. Inner edge scapula to supra-spinal notch, to deltoid : right side, 12f inches; left side, 14f inches. Length inner border sca- pula : right, 5^ inches ; left, Q\ inches. Semi-circumference thorax (4th rib): right, 13^ inches; left, 14^ inches. Sensibility of right hand normal in every respect. Dynamometer : first trial in left hand, 18 ; second trial, 10. Hardly any power of right hand, but reflex movements are readily excited in it. Circumference : right arm, 8-| inches ; right forearm, 8^ inches ; left arm, 9^ inches ; left fore- arm, 9f inches. Lower extremities : left, length of fibula, 1 3 inches ; right, length of fibula, 13^ inches; right calf, ll inches; left calf, 12f inches. Lower edge patella to lower edge external malleolus : right, 13 inches ; left, 13| inches. Anterior edge inner malleolus to end of great metatarsal : right, 4^ inches ; left, 4^ inches. Circumference over heads of metatarsal bones : on right side, 1\ inches ; on left side, 1\ inches. Anterior sup. spinous process to lower malleolus : right, 28 inches ; left, 28| inches. Supra- sternal notch to lower edge of external malleolus : right, 45j inches ; left, 48| inches. Sensibility of legs good in all respects. Difference of malleoli as she lies in bed, ^ inch. Causes So little is known in regard to the circumstances favoring the development of this disease, that beyond the mention of certain facts of age and sex nothing more can be said in connection with etiology. Women seem to be more affected than males, and we may consider that it is usually a condition that begins in infancy and progresses slowly, or is arrested ; or, on the other hand, it may begin in advanced life, and pro- 184 DISEASES OF THE CEREBRUM AND CEREBELLUM. gress moro rapidly. In one case which I have seen, syphilis had probably something to do with its development. Morbid Anatomy. Those authors who have made autopsies have found a condition of density of the white matter, the same being shrunken and more firm at the centre of the hemisphere than at the periphery. When a microscopical examination is made, the brain-tissues are found to show ap|>earances which are highly characteristic. The connective tissue will be found to be proliferated, and to present a fibrillated appearance. Corpora amylacea are often present, and we usually find granular deposits in the blastema. The new tubes are quite changed in character, and are .shrunken and attenuated. The axis cylinder may have disappeared, and its place may be filled by a granular substance. The nerve-cells are greatly altered, their prolongations being torn off, and their contents granular. Oil-globules are often found scattered over the field, and sometimes col- lected about the bloodvessels. These vessels are generally much increased in size, and their walls are thickened, and covered by a granular deposit. If the gray matter be the part affected, we shall find an unusual develop- ment in the bloodvessels. I have s|K)ken of the involvement of the cranial nerves. It is not un- eoinmon to find at the roots of this nerve a sclerosed point which has involved the nuclei. Diagnosis Diffused sclerosis, in its incipiency, maybe mistaken for cerebral softening, but though the two diseases seem very much alike, the absence of severe pain, and variations of temperature in the latter, as well as subsequent progress of the disease, will enable us to decide; it must be borne in mind, however, that in the great number of cases diffused sclerosis begins in very early life. The congenital non-development which we sometimes see will be recognized by the absence of tremors. Prognosis and Treatment The former is excessively bad, and even temporary relief, I think, is out of the question in the great majority of cases. I have never seen a case cured ; and if there is any disease of the nervous system that is utterly beyond the reach of drugs, I am con- vinced that it is this. The actual cautery has been used, but, as far as I can learn, without benefit. Hammond recommends chloride of barium, and claims to have improved the condition of the patient. BRAIN TUMORS. ] 85 CHAPTER VI. DISEASES OF THE CEREBRUM AND CEREBELLUM (CONTINUED). BRAIN TUMORS. WHEN the brain chances to be the .seat of a morbid growth, whether vascular, parasitic, homologous, or heterologous, we may be apprised of the existence of such a new formation by a train of symptoms which have no very constant character; or the tumor may involve a large part of the brain without giving rise to any indications of its presence during the life of the patient. There is no regularity as to the grouping or appearance of symptoms, although the very valuable researches of Hughlings Jackson have enabled us to define the position of the morbid intracranial growths with much greater certainty than heretofore. Symptoms We may group the prominent symptoms under the following heads: 1. Convulsions. 2. Vomiting and vertigo. 3. Headache and cutaneous hypenesthesia or anaesthesia. 4. Hemiplegia. 5. Paralysis of cranial nerves. 6. Ocular symptoms. 7. Psychical disturbances. Convulsions The appearance of convulsions as the only indication of brain tumors has frequently led the observer to make a diagnosis of epi- lepsy. However, when it is taken into account that there is, at the most, but transitory loss of consciousness and even this is very rare during the epileptiform attack, such a mistake is hardly possible. The convul- sions may be general or local, and in this place it is proper to refer to the connection between certain cortical lesions produced by brain tu- mors, and consequent convulsions beginning in members which are sup- posed to have motor centres. Among sixteen cases collected by Hughlings Jackson there were several in which the convulsive seizure began in the thumb of one hand, and finally became general. Cortical lesions were found in the third frontal convolution. In another the epileptiform seizure began in the right cheek, and still another is reported where the right arm was the point of seizure, with subsequent paralysis ; and after death a tumor was found in the uppermost frontal convolution on the op- posite side. Upon the authority of Bastian 1 and Reynolds, " it may be 1 Op. cit., p. 493. 186 DISEASES OF THE CEREBRUM AND CEREBELLUM. .-t:it'-'l that convulsions are most common when the disease is situated in the interior lobes of the brain or in the cerebellum, and least frequently when the anterior lobes are affected." Ilughlings Jackson considers that psychical disturbances are likewise connected with destruction or injury of the posterior lobes. When the growth is syphilitic, the presence of much headache before the convulsion is the rule. Convulsions may be the first symptoms of tumor, and when they occur in advanced life there is always occasion for suspicion. Several writers have agreed that convulsions and other symptoms are the result of irritation of parts adjacent to the tumor, and that they may vary in ap- |M'aranee and severity in proj>ortion to the local disturbance created by the growth ; for this reason convulsions may appear in the most irregu- lar manner. Pain is one of the earliest and most persistent symptoms. It is nearly always localized, and is very intense, especially if the me- ningcs be affected in any way, when it may be combined with muscular twitehings. It is rare for it to subside for an extended period, and then reappear; and in such cases it is highly probable that the growth has either expanded in some other direction, or that the tissues have become accustomed to its presence in the manner suggested by Niemeyer. Pain aggravated at night is highly suggestive of a syphilitic tumor. Photophobia is sometimes a symptom, and intolerance of noise is a de- cided feature, while vertigo is produced by very slight irritation, and it has In-en found in tumors which injure the corpora quadrigemina that this occurs when the patient closes his eyes. Such was noticed to be the case in an example reported by Dr. Duffin. This patient, a man aged twenty- five, presented the following symptoms : A dragging of the muscles at tin- back of the neck, so that the head was pulled downwards and backwards, unsteady walk, vertigo when eyes were closed, vomiting, frequently slow and irregular circulation, obscured intelligence, double optic neuritis, de- fective sight, and finally coma. A gliomatous tumor was found which had destroyed the pineal gland, and extended into the optic thalamus. Reel- ing is commonly associated with vertigo, and is generally symptomatic, of a growth in the substance of the cerebellum. Symptoms of minor importance are cutaneous aiwsthesia or hypertesthesia, with tingling or formication of the hands or feet. Such anaesthesia may affect the tract supplied by the fifth nerve, while deep cerebral pain may coexist. This combination is almost pathognomonic, and should be looked upon with suspicion. Hemiplegia is not an uncommon symptom, and may be sudden when produced by the rupture of a vessel; or of gradual origin, as the result of pressure made upon important parts of the motor tract by a tumor of slow growth. It is generally a late symptom, and may begin by paralysis of one member, and afterwards of the other of the same side. By far the most interesting paralyses are those of the cranial nerves, because of their value as diagnostic signs ; and not only may the optic nerve be affected, but the auditory motor oculi, and even the fifth, may suffer an alteration of func- tion. BRAIN TUMORS. 187 Jackson and others are of the opinion that those muscles concerned more in the execution of direct voluntary movements are often affected in a greater degree than those which perform automatic movements almost exclusively. Paralysis of both external recti muscles occurred in one of Jackson's cases, and is, perhaps, one of the most significant indications of the pre- sence of a gummata. Lateral deviation of the eyes from the side of the lesion is also a form of cranial nerve paralysis which is by no means a rare symptom. In a case reported by AfanaschifF, 1 where a tumor was found in the right crus, there was dilatation of the pupil and ptosis. Par- tial paralysis of the face, showing involvement of the seventh, and actual deafness, are not rare consequences of injury sustained by the seventh nerve. 2 When the fifth nerve is affected, as in one of Broadbent's cases, there is generally marked anaesthesia of the region supplied by this nerve, with difficult mastication, deglutition, and articulation. The most im- portant changes, however, are seen at the fundus oculi, and by some optic neuritis is considered to be a positive sign of brain tumor. Russel, 3 in the description of a very instructive example, details an examination of the fundus. This may be considered a typical case, although the retinal appearances were in an advanced stage. He found " loss of vision com- plete, neuro-retinitis of both eyes. Right disk comparatively invisible, even its position not clearly distinguishable. Position of left disk indi- cated by short portion of retinal vessels, which were visible near their point of convergence. Region around the disk in each eye occupied by large irregular patches of hemorrhage, some recent, others undergoing absorption. Only very small portions of retinal vessels are here and there A'isible." Complete atrophy of the optic disk is generally to be observed in cases where the retinitis has existed for some time. Htighlings Jackson calls especial attention to the fact that loss of vision is not inseparable from optic neuritis, though complete blindness often does occur. He has seen cases in which there was double optic neuritis, though the patients were able to read the smallest type.* A very important appearance observed at the fundus, and known as " choked disk" or " congestion papilla," is often produced by brain tumors. In fact, when not a peripheral condition, it is almost always, according to Swanzy, 5 connected with intracranial tumors, hydrocephalus, or menin- gitis ; but when it is produced by these morbid conditions it is usually binocular. " Choked disk" may be caused by a tumor in any part of the brain, whether it be in the cerebellum or cerebrum, and it is not necessary 1 Wien. Med. Woch., 1870, No. 9. 2 H. Jackson does not believe that tumors of the cerebrum or cerebellum pro- duce deafness, unless the auditory nerves be pressed upon. 3 Med. Times and Gazette, July 26, 1873. 4 Royal London Ophthalmic Hospital Reports, vol. iv., 1865. 6 Signs of Congestive Papilla or Clicked Disk in Intracranial Disease. H. R . Swanzy, M.B., F.R.C.S., Dublin Journ. of Med. Science, June, 1874. 188 DI8EA8E8 OF THE CEREBRUM AND CEREBELLUM. that the optic nerve shall be implicated either at its origin or in its course. Another fact is of im|x>rtance, viz., that the size of the tumor has nothing to do with the production of the condition, and a small tumor may pro- duce choked disk as well as a large one. The appearance of choked disk ig, in substance, the following. The disk may be seen to be prominent, Fig. 21. Choked Diik. (After Leibrcich.) the fibres are swollen, and the papillary region is sometimes of a dark red- dish-gray, much change of color being due to passive effusion and old hemorrhage. The disk may, in other cases, be of a bright color. There may be some evidences of retinal extravasation, which are not found at any great distance from the edge of the disk, and Albutt 1 says not more thai, a distance of the radius from the edge. The margin of the disk is concealed by infiltration and by vascularity. which give it a "mossy" ap|M*arance. The central radiating appearance resembles very much a scintillating body, while the retinal veins are distended and tortuous, are <|iiite serpentine in their course, and they may even be varicose. I cannot agree with Albutt. who considers the recognition of any prom- inence of the disk a ditKcult matter, and I think that this is the opinion of the majority of ophthalmologists. Sjieech is generally involved at some time or other, and psychical trou- bles of all kinds, but more frequently the asthenic forms, make their appearance. There is often a condition of hebetude and stupidity which is supposed to symptomati/c a tumor in the posterior lobes, or there may be mental decay 06 a most grave character. Delusions, loss of memory, change of temper, suicidal tendencies, and various perversions of intelli- gence may occur in any case. 1 The Ophthalmoscope, etc., 1871, p. 55. BRAIN TUMORS. 189 A feature of cerebellar tumor, which I find was also observed by Caton, was the assumption by the patient of the erect position as a means of relief from the nausea and desire to vomit. This author, 1 in reporting a case of cerebellar tumor, alludes to the inability of his patient to regulate his visual coordination ; and this seems perfectly reasonable when we consider the paralysis of the muscles of the eyeball, and the diplopia, amblyopia, and other disturbances of visual regulation. The case of Miss F. is in some ways instructive, although it lacks completeness, as it does not contain the report of an autopsy, the patient being still alive (Oct. 16, 1877) : Miss F., aged 37, U. S., school teacher; was sent to me by Dr. Richard F. Derby, in July, 1876. Seven months ago her present trouble began with weakness of vision, for which she consulted Dr. Derby, of Boston, who adopted Dyerization as a means of treatment. In Novem- ber, 1876, she began to complain of severe localized headache on the left side of the head. This symptom was constant for three months, and to- wards the end of this period a gradual hyperaesthesia of the entire left side developed itself, which is now present. It is more decided for three or four days at a time, when there is a lull. There is also strabismus, which attends the paroxysms of acute head pain, which once in a while recur. In December, 1876, there was some vomiting, which did not have any connection with the fulness or emptiness of the stomach. There is no loss of motor power in the upper extremity of either side, but the left leg and foot are rather weak, and there is some awkwardness in progression, the toe dragging slightly. Slight impairment of electro-muscular contractility of muscles of leg and thigh. Dynamometer on left side, 9 ; on right, 12, Slight ptosis of left eye, occasional diplopia, Dr. Derby's record of the examination of her eyes : " Neuro-retinitis o. u., with great reduction of vision o. s. ; moderate reduction o. d." The patient hears subjective rushing sounds on left side. Is slightly hysteri- cal, and suffers from menstrual irregularities. She gives no history of any traumatism, no blow or fall, nor previous illness. Her mother and father are living, but of decided nervous temperament ; paternal aunt and some of mother's connections are insane. Maternal grandmother and her brother died of phthisis. The patient has had night-sweats, and some pulmonary symptoms. There is no specific history. Upon a previous visit she stated that there was great formication in the sole of the right foot. She afterwards went to her home in Vermont, when I lost sight of her, but have subsequently heard of the advance of her symptoms. Morbid Anatomy Without attempting any classification, I will briefly allude to those forms of intra-cranial growth most often met with. Probably that which is most common is Tubercle, Among young children tubercle is found sometimes in masses of considerable size; and, according to Wilks, the cerebellum is its most familiar seat. It is found as a cheesy accumulation of dirty green color, and very rarely has the gray- ish appearance of the deposit been found in other parts of the body. These 1 London Lancet, Oct. 31, 1875. 190 DISEASES OF THE CEREBRUM AND CEREBELLUM. musses are rather dry, and decidedly non-vascular, and if a collection has been arrested in its growth will be found to be encysted, and may be readily removed. If of progressive growth, the limits of the deposit are blended with the surrounding brain-substance, and of a consistency like cold, white glue. Tuberculous masses are rarely single, but generally invade several regions in the same brain, so that it is impossible to give any very satisfactory table which will throw light upon the question of distribution. 1 Fox, in speaking of Jaccoud's observation, says : " I much prefer Jac- coud's account of these tubercles. They occupy the white and the gray substance equally, and present themselves under the form of small isolated circumscribed masses, varying in number from one to twenty, and seldom exceeding the latter. Their volume is in inverse ratio to their number. Pretty often they are the size of a cherry, at other times they scarcely exceed the size of a grain of wheat. As to the colossal masses which attain to the magnitude of a hen's egg, they result from the confluence and fusion of several spots originally distinct." 1 They are sometimes separated from the nervous substance by a sheath of connective tissue and bloodvessels. In this connective tissue, which is well filled with vessels, according to Virchow, 3 the new granules are formed, and are impacted with the central mass, and become cheesy. When the process stops, the growth is found to be surrounded by a tough fibrous coat, which is sometimes very hard, and even calcified in old cases. Ogle 4 has re|K>rted a case where the tuberculous mass had broken down, so that it was soft and pultaceous. In the younger subjects tubercle is generally found in other parts of the body. Cancerous growths in the brain, which seem to affect those of ad- vanced age, take much the same form that they do in other parts of the lK)dy. Encephaloid and scirrhus are the commoner forms, though melano- mutn are occasionally found. The investing membranes may all be the seat of cancer, but notably the pia mater and the bony walls of the cranium are its starting-points. ' (Jrasset* has clarified bruin tumor*: 1. Those of the embryonic tissue (tissu embryonnairc). These arc the Sarcomata a. Soft sarcoma ; b. Sarcoma nevro- i/lii/ne (^lionia) : r. Sarcoma rt'i//i'>/jVAj'/ue (or psammoma). He considers that tlic terms glioma and psammoma an-, improperly used ; that the first term sugjjfsts more tlu> consistence rather than the character of the tumor. 2. Those of the connectirt tissue, which are a. Myxoma ; b. Fibroma; c. Lipoma ; d. Carci- noma; f. Melanoma. 3. Those of the cartilaginous tissue, Chondroma. 4. Those of the osseous tissue, Osteoma. 5. Tho.su of the epithelial tissue, Papil- loiiui. 6. Those of the nervous tissue. Neuroma. 7. Tubercle. 8. Syphilitic Tumors. 0. Parasitic tumors (Hydatids), Aneurism. 10. Abscesses. * Fox, op. rit., p. l. r )l. s Cellular Pathology, p. 523. 4 Articles in Br. and For. Mcd.-Chir. Review, 1864 and 1865. * Maladies du Systeme Nerveux, Paris and Montpellier, 1878, p. 302. BRAIN TUMORS. 191 In this case the cancerous mass grows inwards, where it meets less resistance, while cancer of the brain itself grows outwards. Cancerous masses are occasionally very large, and in one of Russel's cases (to which allusion has already been made) the cancerous mass, which occupied the right parietal region, weighed six ounces and a half. These tumors pre- sent the same characteristics which they possess in other regions. The encephaloid variety is very vascular ; the scirrhus not so much so, and is quite hard. The carcinomatous growth presents the usual appearance of Fie. 22. Fig. 23. Tubercular Deposit about Vessel. Sarcoma. cells contained in the alveoli of a fibrous network or stroma. It may ex- ist alone as an intracranial growth, or coexist with cancer of other organs. Fiosition. In the following April a loss of steadi- ness of the lower limbs was noticed. He reeled, and a sudden fright would cause him to full. He no longer went alone on the street ; when he did so, he reeled, staggered, and felt conscious that he was the object of His face became congested, and his nose very red, although i habits were very good. lie went to the seashore, but nevertheless rew worse, and derived no benefit from the change. About this time lopia troubled him, and he tried various devices to correct this visionary ifficulty, such as shutting one eye and looking across his nose with the er, but without relief. In August, violent headache developed itself, and vomiting was frequent. He could not look up or throw his head back BRAIN TUMORS. 195 without dizziness and pain. Cathartics and local blisters did no permanent good, nor did the bromides. May, 1875. The patient presents the same symptoms. He is very much troubled by headache, which is paroxysmal. He staggers wildly, and his vision is not improved. On the day before his death he went to see some friends, and on his return complained of a terebrating pain in the back of his head. He went to bed, and slept, under the influence of chloral hydrate. When his wife awoke in the morning, she found him dead. He had evidently died without any convulsions, or she would have been aroused. The night before his death there was some mania, and he shouted words of the different languages he spoke German, French, Italian in a confusing jargon. At no time was there impairment of speech or deglutition ; there were never ptosis, deafness, loss of smell or taste. Paralysis was never observed, nor were there convulsions of any kind. Autopsy eight (?) hours after death. The scalp was cut through, and the exposed surfaces were almost black with blood. On removing the bone the meninges were found hyperaemic to a marked degree, the spaces were engorged beneath the arachnoid, and in the ventricles was a large amount of yellowish fluid, the former being puffed out by the serum under the surface Nothing unusual was noticed in the hemispheres beyond the hyperasmia before alluded to, and careful slicing of the basal ganglia revealed nothing of importance. The texture of the nervous sub- stance was normal. At the base of the brain a very different state of affairs was found to exist. From before backwards there were evidences of acute inflammatory action, the left side more particularly being the seat of softening. The right crus of the optic commissure was very much dis- organized. There was a well-organized membrane, very pink and net-like, which extended over the inferior surface, one band binding down the left root of the optic commissure. Beneath the lining membrane of the fourth ventricle, at a point beneath the lower and anterior part of the cerebellum, was an effusion, with soft- ening of this organ. This membrane was bellied out, and had evidently produced death by direct pressure upon the calamus scriptorius. At a point corresponding to the middle of the lower vermiform process of the cerebellum was a small hard tumor, about two centimetres in length, one and a half in breadth, and the same in thickness, which, when cut, disclosed a red jelly-like centre, and a hard fibrous exterior, resembling, somewhat, a syphilitic growth. The line of demarcation between the healthy tissue and the circumference of the tumor was very well marked. Beneath the microscope Dr. E. G. Janeway and I found it to be a glioma of the firmer kind, there being a fibrous structure containing the charac- teristic cells. After hardening pieces of the cerebellum and the medulla oblongata, I examined them microscopically. The evidences of disorganization of the nervous elements at the nuclei of the vagus were apparent. The nerve- cells were deprived of their processes, and the nerve-tubes were broken. The sections of the cerebellum were made contiguous to the tumor, and here I found considerable thickening of the neuroglia and disappearance of nerve-tissue, while the vessels were very much increased in size. Amyloid bodies, connective tissue cells and vessels are found to compose these tumors, which may sometimes attain a diameter of several inches. The peri-vascular spaces are filled with adventitious matter, and the calibre 196 DISEASES OF THE CEREBRUM AND CEREBELLUM. of the vessels is very much reduced. These growths may undergo fatty degeneration or absorption. The hard varieties, I think, predominate, ami they are very easy to recognize. Papillomata, both of the vessel and meninges, are not uncommon. Alyjromata, which Jaccoud describes as having their source of origin from the spheno-occipital suture, are quite rare, as are Lipomata. The former are usually of large size, have a gelatinous appearance, and at times are cloudy. The latter consist of large cells filled with fat, and are transparent and shining. Sarcomata may be met with as soft masses, which contain " fusiform bodies, nuclei, and vessels," or else round cells closely packed. They are lobulated, and, when cut, present a pinkish-gra^y and softened surface, and sometimes contain central fluid. The soft sarcoma, according to Grasset, is found among young children in the deeper parts of the brain, and remains dormant for some time, not giving rise to any symptoms, the cells being usually round (" globo-cellulaire"). With fatty degeneration the tumor may undergo a change, so that it resembles the yellow plates in cerebral softening. It usually has a surrounding vascular network, and is easily separated from the brain-substance. Fibrous tumors are quite rare, but are sometimes met with. Lebert has seen, in one case, seventeen small fibrous tumors upon the ependyma of the lateral ventricle, varying from the size of a pea to that of a small cherry-stone. These tumors are of a white color and globular shape, and they are separated from the healthy brain-tissue by a space in which the vessels are enlarged. They are easily enucleated, and quite hard and dense. 1 Aneurisms. One of the most interesting and important forms of intra- cranial growths are those of a vascular character. I have taken occasion to refer to the smaller aneurisms described by Bouchard and Charcot, the so- called miliary aneurisms, which are of minute size ; but large aneurisms, arising from such arteries as the middle, anterior and posterior cerebral, bosilar, and communicating arteries, may be even an inch in diameter. These, with miliary aneurisms of small size, are generally found to coexist in the brain. Gougenheim 1 has found that aneurism of the basilar artery was much more common than any other form, and that of sixty-eight cases seventeen were of this artery. It is rare, however, that the disease can be diagnosed during life, and but two or three cases have been reported where their presence was recognized by symptoms, and afterwards verified by an autopsy. One of these cases was reported by Coe, s another by Holmes,* and a third by Humble.' An interesting case of cerebellar aneurism is reported by Bristowe : J. B., a lighterman, let. 5G, was admitted on the 2Gth of October, 1858, 1 Annt. Path., vol. ii. p. 71. 2 Gougenhcim, Dub. Journ. of Med. Sci., Nov. 1870. 1 Association Med. Journal, Nov. 1855. 4 System of Surgery. 4 Lancet, Oct. 2, 1875. BRAIN TUMORS. 197 for an attack of acute rheumatism (gout ?). No distinct account of the previous duration of his illness was obtained. Five days after admission he complained of severe epigastric pain, and had some vomiting. Shortly afterwards he became comatose, and continued so until his death, which took place on the 2d of November. Post-mortem Examination. There was a considerable amount of serum both on the surface and in the ventricles of the brain ; and much athero- matous and earthy deposit in the arteries at the base, and their branches. In the right corpus striatum was a small apoplectic cyst, but in other respects the brain-substance appeared healthy. In the substance of the right hemisphere of the cerebellum was accidentally discovered an aneu- rism about twice as large as a grain of wheat ; it was irregularly fusiform ; Fig. 28. Cerebellar Aneurism. (Bristowe.) its parietes were thickened and hardened with atheromatous and earthy deposit, and it gave off several partly ossified branches, each about half a line in diameter. Its anterior extremity was continuous with a thin walled healthy vessel, having between one-third and one-half the calibre of the aneurism itself, and found to be a branch of the right superior cere- bellar artery. Gouty indications were found at different points. Occasional intracranial growths are the psammomata which are found as sandy little bodies scattered over the dura mater, and have a calcare- ous formation, feel gritty when rubbed beneath the fingers, and may be crumbled. Examined microscopically with a low power they may be found to consist of small, compact, round bodies, imbedded usually in the dura mater. Cholesteatoma, or pearly tumors, which are composed chiefly of choles- terine, stearine, and degenerated epithelium contained in an investing membrane, are occasionally present in the brain. The latter growths are 1 Trans, of Path. Soc. of London, vol. x. p. 4. 198 DISEASES OF THE CEREBRUM AND CEREBELLUM. generally found attached to the meninges or cranial bones, and are nearly always superficial. The literature of intracranial bony growths contains much that is inte- resting. One case reported by Vulpian in the Archives de Physiologic was remarkable for the slow development of an exostosis from the temporal bone, which completely penetrated the Gasserian ganglia on the right side. Beyond neuralgia of a severe character, no other symptoms were ex- pressed. I have seen many of these bony growths, some of them even several inches in length, which had existed for years without any mischief being produced. In slow growths there seems to be an accommodation of the brain so that the pressure is rarely injurious, and it is generally not till the exostosis attains some size, and atrophy or softening takes place, that bad symptoms make their appearance. A case which was under the care of Dr. Janeway at the Epileptic Hospital is one of the most remarkable of which I have ever heard, and I ap|>end his very valuable record of the post-mortem examination. A. T., aged 42 years ; widow ; domestic. Admitted to Hospital De- cember 31, 1K72. Patient says that fourteen months ago, as she was crossing the Jersey City ferry, she fell down, and heard the people say that some one had had a fit. When she came to, she found that she herself had had a convulsion. During the attack she was perfectly con- scious of all that passed about her, and, on arising and attempting to tie her bonnet strings, she found that she could not do so on account of what she says was numbness of the hands or arms. April 21), 1874. For the past five days she has been very dizzy, and has had headache, and pain in the left side under the breast. IWth. Is in bed. Says " her back feels as if it was breaking in two." May 1. Is quite weak. Can move her left leg somewhat, but not her left arm ; her emotions are easily excited ; pulse weak : temperature, '2d. Pulse good ; temperature, 101. 3M. Still pain at base of skull. Temperature, 101 1. \'2th. Temperature, 100J. 12 M. Temperature, 99 ; headache not so severe. BRAIN TUMORS. 199 Jane '2. Xo headache ; cries when spoken to. dth. Headache not severe ; pain in her back ; has passed urine and feces in bed for four weeks past. M/i. Temperature, 100. Wth. Lies with head turned to left. Complains of pain when position of head is changed. Headache is relieved by bromide of ammonium. 19^. Complains of no pain. There appears complete muscular relaxa- tion. Cannot speak without crying. 20th. Patient is rapidly failing. Temperature, 103|; pulse, too rapid to count ; respiration very quick ; conjunctiva insensible ; pupils respond slowly to light. 21 st. This morning about the same ; can swallow wine. P. M. Patient sank gradually, and died at 4.30 P. M. Post-mortem 18 hours after death Heart, liver, lungs, spleen, and kidneys normal. An abscess found in right Fallopian tube containing about 3ij of pus. Rigor mortis not well marked. Skull On removing skullcap, an outgrowth of bone is noticeable on the right side, near the central line, just posterior to the groove for the middle meningeal artery. The growth is nearly two inches long, and one inch wide ; raised about of an inch from internal surface. The dura mater was pretty firmly attached at this place, and little pieces were left attached to the exostosis. There is another bony projection (small) just back of the middle meningeal artery, at the inferior angle of the parietal bone. Otherwise interior of skull appears normal. The lowest first (1st) is situated just anterior to the fissure of Sylvius, f inch below posteriorly, and | inch from above downwards. Elevation, yths of an inch. This has produced a corresponding depression and flattening of the commence- ment of the lower end of the transverse convolution of the anterior lobe. Two smaller ones are situated one just ^ of an inch above it, the other 1 inch above, and about anteriorly. They are nearly half an inch apart, the posterior being the longer, and about T ^th of an inch in diameter. Elevation, T 7 ^ inch. Around the first large tumor three small ones exist ; the second small one is about one-third the size of the first. A bridge of new formation connects this with the two already described. At the point of the large exostosis, a number of tumors spring forth from under surface of the dura mater, close to one another, averaging 1^ inch in diameter. One of these tumors is quite large, and is sunk in a depression in the brain ; the depth is f of an inch, and it is an inch long and broad. The brain-tissue around this is in a state of pulpy softening. The diameter of the softened part of brain is two inches, and nearly reaches the longitudinal fissure, extending two inches downwards to within two inches of anterior border of the brain. The falx throughout its extent is the site of new formations, some project- ing on the right, others on the left ; one very large one in front, which is l inch in length, and has an elevation of || ths of an inch ; and another which dips into a depression in the anterior lobe of left side. The pia mater covering both hemispheres is markedly congested. Tumors are firm, white, and yield only a thin serous fluid on scraping. Diagnosis It is a difficult matter, when we consider the great variety and irregularity in the appearance of symptoms, to make always a correct diagnosis. This branch of neurology is undoubtedly the most puzzling, and I am inclined to differ from those persons who consider it 200 DISEASES OF THE CEREBRUM AND CEREBELLUM. ]>ossiblc to determine in the majority of cases the exact location of a cere- bral growth. The fact that brain-tumors are very often multiple, and that secondary lesions are produced, is enough to cool the ardor of the most enthusiastic diagnostician. It is possible, however, to sometimes make a verv close diagnosis. Localized pain and convulsions, with optic neuritis, cranial palsies, and vomiting, suggest very strongly the probability of tumor In speaking of the character of the paralysis, its gradual appearance, and its limited Held, I have said enough to demonstrate that, generally, there is no reason why we should confuse this symptom with the paralysis of softening, although softening may sometimes be secondarily produced by the growth, and then there is much more difficulty in deciding on the nature of the trouble. It behooves us to make, if possible, a diagnosis of the nature of the tumor, and sometimes a very slight circumstance will suggest the real cha- racter of the growth. The localization of cerebral tumors has received very extended conside- ration during the past few years. In the many cases collected by Jack- son we are enabled to make a much closer diagnosis than before his excel- lent investigations were presented. Ogle's large number of cases are more of interest in the light, of morbid anatomy, and as they are several hun- dred in number almost every variety of formation is to be found. Quite recently an excellent article by Petrina, of Prague, 1 has appeared. His directions for localization are so complete that I think it wise to present them, especially as they are based upon a number of cases. I. Tumors of the Convexity Clonic spasms limited to single groups of muscles on the side of the body opposite to that of the tumor ; no loss of consciousness ; incomplete hemiplegia, constant headache, decided ver- tigo, nervous irritability ; amblyopia and disturbances of hearing ; circum- scrilwd affection of sensibility. The localization of circumscribed motorial disorders is not definite, and can be only limited at present to the region of the anterior and posterior central convolutions. II. Tumors of the Anterior Lobes Frontal headache; the intellectual sphere being involved (?, A. McL. H.) there will be often psychical disturb- ances, with chorea ; paresis or hemiplegia (the former more frequently) ; no disorders of sensibility ; general convulsions with loss of consciousness is rare, except when there is deep pressure ; visual disturbance and deaf- ness, with anosmia. 1 1. Tumors of Parietal Lobes Hemiplegia on opposite side preceded frequently by apoplectic attacks; aphasia very frequent when tumor is large enough to compress the third frontal convolution ; general convul- sions with large tumors ; disorder of special sense, except vision, quite rare ; impairment of cutaneous sensibility common ; frontal headache. IV. Tumors of the Occipital Lobes But one of Petrina's cases pre- sented opposite sided paralysis with paralysis of the third nerve on the 1 Viertcljahrsschrift fuer die prakt. Heilkunde, cxxxiii. 1. 2. BRAIN TUMORS. 201 same side ; disorders of intelligence ; convulsions, involvement of organs of special sense, cutaneous derangements of sensibility are mentioned by Rosentlial and others as pathognomonic : but are not observed by Petrina. V. Tumors of the Motor Ganglia Hemiplegia on opposite side, with loss of consciousness and frequent convulsions ; profound cutaneous anaes- thesia when the internal capsule is destroyed ; sometimes aphasia ; corpus striatum ; complete hemiplegia with loss of consciousness and convulsions ; psychic disorders and irritative motor phenomena, such as tremor and cho- roid movements ; disorders of organs of special sense are rare, with the exception of amblyopia. VI. Tumors of Optic Thalamus Extensive motorial symptoms are not constant, and general convulsions or disorders of sensibility are rare. "According as the tumor affects more the bundles of fibres going to the optic tracts or those branching out from the cerebral peduncle, we have sometimes predominating paralytic phenomena in the optic nerve, altera- tions of the pupil and disturbances of the innervation of the ocular mus- cles (nystagmus, exophthalmos) ; sometimes, again, there are the most remarkable vaso-motor anomalies of circulation (striking alterations of temperature, and cyanosis, or circumscribed redness), as the chief morbid symptoms. Pronounced disorders of speech (retarded speech) and of the intelligence are symptomatic only of quite extensive tumors in the thala- mus ; decided paralytic phenomena are likewise characteristic of simulta neous destruction of the peduncular fibres, or of one of the motor gan- glia." VII. Tumors in or about the Pituitary Body Somnolence, mental weakness, or apathy ; slowness of speech. Amblyopia and amaurosis are common, as well as disorders of other organs of special sense. Rosenthal demonstrated that diabetes is an important complication of tumor in this region. VIII. Tumors of the Peduncles of the Cerebrum Vaso-motor disor- ders and anomalies of temperature ; early paralysis of the third nerve on the same side, as tremor, occasional vesical paralysis ; opposite hemiplegia with sensory disorders ; intelligence unimpaired ; optic nerve often in- volved ; involuntary movements of limbs on side opposite to tumor. IX. Tumors of the Crus Cerebelli Intense headache and vertigo, in- voluntary lateral decubitus, rotation of body, one-sided deviation of axis of vision, reeling gait, and tendency to fall ; commonly disturbances ot organs of special sense. ( Vide Caton's Case, A. McL. H.) X. Tumors of Cerebellum Headache quite intense, and limited to sub-occipital region, vertigo, reeling gait, disorders of coordination ; paresis of opposite side of body ; convergent strabismus, diminished elec- tro-muscular contractility on sound side of head. XI. Tumors of Pons Cross hemiplegia ; ocular paralysis (convergent strabismus), lingual paralysis ; cutaneous anaesthesia, double or single, dys- phagia ; disorders of special senses ; facial nerve involved ; crossed sen- 202 DISEASES OF THE CEREBRUM AND CEREBELLUM. gory troubles ; vaso-motor disturbances ; vertigo ; increased electro-mus- cular contractility of parts supplied by the seventh nerve to galvanic cur- rent, but not to faradic current. Greisinger has written quite fully upon the diagnosis of the character of the growth. He considered that convulsion with psychical disturbance, but no paralysis, pointed to the presence of cysticerci, because these para- sites infest the uppermost layers of the cortex cerebri. In one of Jackson's 1 cases (No. 13) the signs of an old iritis enabled him to make a diagnosis of a gumma. Other marks of syphilitic disor- der may be taken into account. Nodes, old scars, eruptions of a tertiary character, and alopecia, as well as numerous unmistakable symptoms, such as rheumatism, night-sweats, etc., are confirming points in diagnosis. Aneurism, which is rare in early life, may be suggested by vertigo and subjective noises heard by the patient. In the case reported by Humble a diagnosis was made by the stethoscope. Cancerous tumors are very dif- ficult to diagnose, the age of the patient being our only guide, and we are left absolutely in the dark in regard to gliomatous and other non-diathetic tumors, although some of the German writers suggest that a history of in- jury generally precedes the first named. Tubercle may be suspected after a careful inquiry in regard to the patient's antecedents, and the recog- nition of the physical signs of deposit in the lungs. Parasitic tumors are generally attended by mental decay, and Hammond' states that epilepti- forin attacks are the first symptoms of such trouble. Prognosis Cancerous tumors prove fatal in from two or three months to a year, while syphilitic tumors are occasionally retarded in growth, and the patient may ultimately recover under energetic treatment, though when left alone they rapidly increase in size. I do not agree with Ham- mond in regard to the chance of spontaneous cure in aneurismal tumors, and feel disposed to consider any cases of sudden recovery as anomalous. The progress of non-diathetic growths is very slow, and the patient may live for many years, and finally die of some other disease. Gliomatous tumors are perhaps less formidable than are others, but after all more depends upon the site of the growth than its size and character. Death is preceded in most instances by coma. Holmes says in this connection : " "We know nothing at present of the diagnosis of intracranial aneurism, so that no treatment can as yet be di- rected gpecially to it. And, looking at the very free intercommunication of the four large trunks which nourish the brain, it seems unlikely that surgical measures directed to any one of them would procure the consoli- dation of an aneurism situated on one of its main branches." Treatment It has been my practice in every case to place the patient upon an anti-syphilitic course of treatment. The iodide, in in- ereasing doses, until a very large quantity is taken during the day, will 1 Medical Times and Gazette, August 1, 1874. 2 Diseases of the Nervous System, p. 301. BRAIN TUMORS. 203 sometimes effect a cure. I have given mercury also, but cannot speak so favorably of its virtues. If the pain is excessive, I use the ice-bag, as recommended by Jackson, and find that it gives great relief. Hypodermic injections are very useful, and hyoscyamus (F. 71) and belladonna (F. 70) also do good. Galvanism I believe to be useless. Ligature of the carotid has been employed by Coe for aneurismal tumors, and although it was successful in the case he reports, I am inclined to think it is not only a dangerous but an uncertain measure. 204 DISEASES OF THE SPINAL MENINOES. CHAPTER YIT. DISEASES OF THE SPINAL MENINGES. SPINAL MENINGITIS. ACUTE PACHYMEMXGITIS. THE investing membranes of the spine may be the seat of chronic or acute inflammation, together or singly, though there is generally a certain amount of coexisting myelitis, and consequently the meningitis is not an uncomplicated condition. In exceptional cases, however, the dura mater may be affected, and the resulting affection is known as Spinal Pachy* meningitis ; or the pia mater and arachnoid in other cases are the seat of such inflammation ; or the three membranes may be together involved. INFLAMMATION OF THE SPINAL DURA MATER, OR SPINAL PACHYMENINGITIS. Michaud 1 has given the name external p achy meningitis to the form which results from pressure made by diseased vertebrae, and coexisting with Pott's disease, while other varieties have been described as internal hemorrhagic pachymeningitis (Meyer 1 ) and cervical hypertrophic pachy- meningitis (Clmrcot 1 ). The form described by Meyer is almost identical with that which involves the cerebral dura mater, and in which there are thickening and encysted clots. As the name indicates, the form described by Charcot is confined chiefly to the cervical portion of the spinal dura mater. ACUTE AND CHRONIC SPINAL MENINGITIS. Symptoms This disorder, which commonly involves all three mem- branes, is generally ushered in by a chill, followed by elevation of tem- jR-nittire; a hard, full pulse; and excruciating pain. This pain is increased by any movement the patient may make. He tries to relieve his suffering by changing his |>osition and by keeping quiet, so that muscular rigidity, which is semi-voluntary, is often mistaken for a tetanic spasm. Pain darting along the spinal nerves adds all the more to his misery, and his legs are forcibly drawn up. Hypenesthesia of the surface is generally present, and reflex excitability is nearly always exaggerated in the earlier stages. The head is sometimes drawn backwards by contraction of the 1 Sur la MSningiU', etc. Thfese, Paris, 1871. 2 Di-fl Paohymeningitide, etc. Bonna>, 1861. 8 Lwjons sur les Fonctions du Sys. Nerveux, fas. 1, part 2, p. 243, etc. SPINAL MENINGITIS. 205 post-cervical muscles, and the appearance is presented which is so well marked in cerebro-spinal meningitis. Should the meningitis be general, or extend upwards, the intercostal and phrenic nerves are finally involved, and asphyxia and death result. The tendency in many cases is towards chronicity, and very often there are secondary affections of the cord from pressure. The bladder and rectum frequently suffer to such a degree that involuntary discharges of urine and feces result, but the former sometimes escapes the involvement. Should the disease become chronic, it exists in a modified form, the pain being less severe, and the contractions of the limbs more marked. The skin is cold and hyperaesthetic, and reflex exci- tability is present to an extraordinary degree, the slightest prick of a pin being sufficient to cause violent retraction of the limbs. The muscular power is greatly reduced, so that the individual may be unable to take any exercise. The bladder trouble is much more marked than in the acute variety, and the patient may find it necessary to empty his bladder every few minutes. Obstinate constipation, distension of the bowels by wind, and gastric disturbances, are accompaniments. If the cord is involved, there may be presented symptoms of meningo-myelitis, and then paralysis of motion and sensation becomes marked, and the muscles undergo atrophic changes. The case of Mr. J. E. is instructive. He is a great sportsman, and up to four or five years ago was often exposed during his hunting excur- sions. Four years ago, during one of these, he lay for several hours in a "battery," shooting ducks. The weather was cold, and he was directly exposed to a drizzling rain. On the same night he was seized with a chill, which lasted for nearly an hour, and, supposing he had "caught cold," he drank altogether nearly a tumblerful of whiskey. Dur- ing the night he became feverish, complained of pain in the back, vomited, and was delirious throughout the next day and the two following. His pain was excruciating, and the slightest jar of the bed caused him intense agony. At the end of fourteen days he was moved upon a mattress to the nearest boat, and from thence to the railroad, and was carried to his home by easy stages. For a month or so after, he was confined to his bed, the pain gradually becoming less intense, and his strength returned by degrees. He presented himself to me with the history I have just detailed. For the past year he has had spinal pain, which he refers to the last dorsal and upper lumbar vertebras. It is constant and worse at night, and increased by pressure. There is gastrodynia, and pains down the back of the thighs, which seem to increase after exercise. He com- plains of loss of power in the legs, and cannot walk more than a block or two without being greatly fatigued, and at night his legs are jerked up during sleep. For the past year he has had great distress and discomfort, as he cannot hold his water, and is obliged to empty the bladder every few minutes. His bowels are so constipated that he finds it necessary to use an injection every night. Examination revealed pain upon pressure over the two lower dorsal vertebra?, analgesia and anaesthesia of the cuta- neous surface of the posterior region of thigh. The glutei muscles, as well as the adductors of the thigh, were much reduced in size, and did not contract as powerfully as did those in the neighborhood when subjected to electrical stimulus. His abdomen was tympanitic and greatly distended. 206 DISEASES OF THE SPINAL MEN1NGES. He had become desj>ondent during the post year, and neglected his busi- ness. In addition to the pain, loss of power, and the other symptoms I have enumerated, there has been a sense of abdominal constriction at the level of the painful point. Damp weather aggravates the pain, and he has periods of improvement, when he goes to Florida or some other warm region. SPINAL I'AOHYMENINGITIS. Symptoms The forms of pachymeningitis cannot be during life separated as a rule. There may be no acute stage whatever, but a gradual appearance of symptoms indicative of slowly developed pressure upon the cord. The form described by Charcot 1 runs its course in five or six years, and the cervical enlargement of the cord is the part which suf- fers the most. Pressure is made upon the cord itself, and upon the nerve- trunks, so that partial or total loss of function ensues. There is a painful stage, the premiere &riode of Charcot, which lasts several months, the pain being intense at the back of the neck and in the upper extremities. With these pains there is rigidity of the upper extremities, and the head is drawn backwards and downwards in the manner I have before described. There are in addition formication and disagreeable sensations in the upper extremities, and some paresis, which ultimately increases, so that the in- dividual retains but little power. Charcot lias observed eruptions of bullse and pemphigus as evidences of lowered vitality. After this period there I'-f<>rtnlly of Hand in Tprvical Parhymoningiti* (Charcot). is atrophy of the paralyzed muscles, particularly those innervated by the ulnar and median nerves, while those which are supplied by the radial escape the atrophic change, and deformity often results which somewhat resembles the main en r/rfjfe of progressive muscular atrophy. The pre- 1 ()).. c-it. SPINAL PACHYMENINGITIS. 207 ceding cut from Charcot represents the appearance of the hand in this condition. Contractions of the paralyzed muscles ultimately follow the paresis, and the skin becomes decidedly anaesthetic, so much so that a pin may be in- serted without any expression of suffering from the patient. It is very rare for the lower extremities to be implicated, and the medulla seems to escape the effects of the disease, consequently troubles of deglutition or respiration are rare. The hemorrhagic or internal form of pachymenin- gitis runs a most irregular course, but the complicating spinal affections are apt to be much more marked than in the last-mentioned variety. The indications of internal pachymeningitis are throbbing pain in the back, sudden paralysis, and the other symptoms to which I have alluded. The disease is connected with hemorrhages, and consequently there are at inter- vals accessions of fresh symptoms. The large number of cases which were known as " syphilitic para- plegia" some years ago include many examples of chronic syphilitic pachymeningitis, which were then recognized as the result only of myelitis. The progress of the disease is much more slow than in other forms, and the patient lasts a very long time, and is sometimes quite cured by appro- priate antisyphilitic remedies. The acute zymotic fevers are not rarely followed by pachymeningitis, the following case being an interesting example of this occasional sequel of typhoid fever : Two years ago Capt. S. recovered from an attack of typhoid, and with convalescence he gradually lost power in the right hand, right leg, left leg, and left hand, in the order I have named them (this is his statement). Preceding these conditions there were shooting pains running down the spine and around the body. He was paraplegic two months afterwards. During this time reflex movements were easily provoked. " When my feet came in contact with the foot of the bed, if the cold wood touched them they would fly up." He evidently had the contractions which are so clearly symptomatic of meningitis, and there was some constipation, but no bladder trouble except atony. His neck "felt stiff," and he was occa- sionally dizzy. The loss of power in legs has gradually returned. Present condition The patient walks fairly, with no apparent impedi- ments. The skin is slightly hypera>sthetic ; no atrophy of any muscles ; has good muscular strength ; there is slight tenderness produced by pres- sure over the vertebra?, between the scapulae ; muscular tension at back of neck, and some pain with movement ; slight distension of abdomen by flatus (he says this is a constant symptom) ; bladder and bowels in excel- lent condition ; some very trivial effort required to urinate ; no headache, but dizziness caused by looking upwards ; no loss of power in hands or arms ; no constricting band ; patient can stand with eyes closed. Co- ordination of delicate muscular acts unimpaired ; there are no twitchings at night left. I suggested the propriety of giving iodide of potassium in addition to ergot, which he had taken before. I also recommended the actual cautery. Causes According to Grisolle, 1 spinal meningitis is much more common among men than women, and three-quarters of the patients are Op. oit., vol. i. p. 436. 208 DISEASES OF THE SPINAL MENJNQES. men ; and Calmiel considers it to be of much more frequent origin before the thirtieth year than afterwards. Cold and intemperance favor its ap- |>earance, but, in the great majority of cases, it is of spontaneous origin, and lias occurred in epidemics, at least so say the earlier French writers. 1 In 1837 an epidemic appeared at London, Versailles, Avignon, Metz, and Strasburg, and there were no atmospheric causes nor any influences dis- covered which could account for its appearance. It is probable, however, that the form of meningitis was cerebro-spinal, with the history of which we are now familiar. Alcoholic over-indulgence, syphilis, and injury, or vertebral disease, will account for the affection in some cases. Like locomotor ataxia it very often occurs among seafaring men who have fallen overboard, or have been obliged to stay aloft in damp, cold weather. Pott's disease has generally been supposed to have little to do with the etiology of the disease, but my own experience and that of professional friends who have had much to do witli this class of cases, convince me to the contrary. In a case of this kind where I was enabled to make an autopsy, I found great thickening of the spinal dura, with fibrinous de- posits beneath that membrane and the bone, as well as some involvement of the nervous substance proper, which consisted in atrophy. Frac- tures of the spine, sometimes unrecognized, are attended by so much injury of these membranes as to give rise to symptoms which may be either supposed to be due to myelitis or simple concussion, but which are undoubtedly occasioned by an unrecognized fracture. Such a case has been reported by Mr. Hutchinson, in which the individual jumped from a height, alighting on his feet. Morbid Anatomy and Pathology The simple forms of spinal meningitis, that is to say the acute forms, present all the appearance of violent inflammatory action which we witness in cerebral meningitis: injection of the pia mater, serous or purulent effusions, together with infiltration of adjacent cellular tissues, more posteriorly than anteriorly, and perhaps some evidence of myelitis, but ordinarily the cord is healthy if the disease be uncomplicated. The region affected is more apt to be at tin; upper part of the cord, but there may be inflammation of the me- ninges covering the dorsal or lumbar portions as well. It may be circum- scriled, as the result of pressure from displaced vertebrae, or fracture, and this limitation is more characteristic of pachymeningitis. The different membranes may be adherent to each other, and connected with the cellu- lar tissue in the vertebral canal. New growths beneath the dura mater are not common, but may be found sometimes between this membrane and the bones. In cervical pachymeningitis there is great thickening, ami in old cases the nervous matter is compressed to such a degree that it is atrophied, and may be found to be hardly two-thirds its normal size. A lamellar arrangement of the dura mater exists, which is like that seen within the cranium, and the other membranes may be quite undistinguishable from 1 See articles in Meinoires de 1' Academic Nationale de Med., t. x., Revue Me licale, and Gaz. M6dicale, 1842. SPINAL PACHYMEN1NGITIS. 209 the dura mater, and consequently the cord will be found encircled by an almost homogeneous, tough, and thickened envelope. In the hemorrhagic form, there may be discovered encysted blood-clots which resemble those found in the cranial hemorrhagic pachymeningitis. The nerve-trunks within the vertebral canal will be found to be covered by the same dense tissue, and the peripheral portions of the nerves are often atrophied. Syphilitic inflammatory changes, alluded to by Buzzard, 1 are sometimes present, with gummatous growths in the nerves proceeding from the cord. The following case illustrates the morbid anatomy of meningo-myelitis of a quite extensive character : Idiot; Chronic Spinal Meningitis; Myelitis; Lobular Pneumonia; Circumscribed Acute Interstitial Nephritis ; Chronic Cystitis D. A., aet. 26, admitted June 22, 1877. No previous history of the patient could be obtained, except that she had been an inmate of the almshouse for three years previous to admission, where she was confined to bed entirely. On admission patient was very much emaciated ; legs and thighs flexed. She was unable to talk, but almost continually screeched, especially at night. Two days before her death she had a slight diarrhoea. On morning of June 28 had elevated temperature, rapid pulse, and cough. Chest could not be satisfactorily examined, as she would not keep quiet. Moist rales were heard over entire chest. Patient became worse during the day, and died at 4 o'clock A. M., June 29, 1877. Autopsy twelve hours after death, made by Dr. Maxwell, the Curator Rigor mortis present; body small, and very much emaciated; thighs flexed and adducted, and the legs upon the thighs, and contractured. Feet o?dematous. Bed-sore over sacrum and nates. Fingers and thumbs are flexed ; the cranium small ; round, low forehead ; hair dark ; complexion brunette ; eyes brown. Head Bones : calvarium circular ; antero-posterior diameter six inches ; deep Pacchionian depression on right side. Dura mater and sinuses nor- mal. A little over three ounces of fluid in subarachnoid space. Pia mater over the convexity meshes is markedly elevated by oedema, and is opaque in latter situation ; it is also abnormally adherent over convexity, and in Sylvian fissure. Weight of brain and cerebellum 22 ozs. Exter- nally shows nothing except that the sulci are wide. Lateral A-entricles- are moderately dilated. Ependymae appear normal. Cerebellum weighed 1^ oz. Brain -substance of cerebrum and cerebellum, gross appearances normal. Spinal Cord Adhesion in cervical region, between dura mater and wall of spinal canal, so firm as to require section for its removal; also another point in dorsal region. Adhesions between opposed surfaces of arachnoid in cervical region quite firm and general on the posterior sur- face ; on anterior surface scattered filaments. On posterior surface of dorsal region a few filamentous adhesions. Dura mater in cervical region is appreciably thickened, especially the upper two inches. Pia mater cor- responding with these adhesions has brownish appearance, and is thick- ened. Veins of cord are filled. Nearly all dorsal portion of the cord is soft to the feel. Throughout cervical region the posterior and right lateral columns are to the feel firm and normal ; have bluish-gray color, with 1 Syphilitic Nervous Affections, p. 70. 14 210 DISEASES OF THE SPINAL MENINQES. yellowish streaks. The dorsal portion of the whole cord markedly soft- ened. Lumbar region and cauda equina, to gross appearances, slum- nothing marked. Dura mater surrounding vertebral foramina is thick- ened and adherent to sheaths of up|>er four or five inches of cervical nerves. Posterior long fissure of cord of the dorsal region obliterated by firm adhesions of pia mater. TTiorax Lungs softened ; on right side adherent. Pericardium nor- mal. Heart weighs 4 oz. ; walls, in color and firmness, normal. Cavities contained partially decolorized clots. The mitral valve is the seat of chronic endocarditis. Chronic endocarditis at commencement of aorta. Kight lung patches of fibrinous exudation on pulmonary pleura (re- cent) ; lower lobe posteriorly. Lobular pneumonias scattered throughout, showing red and gray hepatization. On opposite lung only few lobular pneumonias in upper lobe; in lower lobe, plentiful. Both lungs markedly cedematous ; small amount of mucus in bronchi. Peritoneal Cavity. Stomach displaced ; pylorus drawn downward to left, dilated. Peritoneum normal. Liver weighs 27 oz. ; parenchyma pale, otherwise normal. There are bands of adhesion between sides of gall-bladder; hepatic flexure of colon and duodenum. Spleen weighs l oz. ; apparently normal. Kidneys: each weighs l oz. Left kidney was deformed. Capsules of both strip normal. Surface of left shows several large depressed cica- trices. One prominent spot, yellowish, of circumscribed interstitial nephritis. Cicatrices, probably due to old circumscribed interstitial ne- phritis, seen from surface. Right kidney of normal shape; surface pale and smooth. Four nodules of acute interstitial nephritis becoming puru- lent are seen from surface. Pelvis shows mild catarrhal inflammation. Bladder is the seat of intense cystitis. Uterus and appendages found in a state of retroversion ; size corresponds with that of other organs. Ovaries are large in proportion to size of uterus. Cysts in cortical portion, but no corpora lutea or cicatrices found. Stomach and intestines normal. Prognosis The patient's chances are sometimes good, even in the chronic form. Charcot 1 has cured one case of cervical pachymeningitis, and doubtless others have been equally successful. In the great number of cases, however, a fatal termination is the rule. In the acute form death may occur in six days, but Tourdes and Chauffard have observed cases in which this termination did not take place till the fortieth or fiftieth day. In acute purulent meningitis the pus may make its way out, pointing ex- ternally, or forming an abscess in the muscular tissue of the back. Cham- pion has seen a case of this kind in which the purulent contents of the vertebral canal found passage through at the third lumbar vertebra, and formed an abscess in the spinal muscles. This, however, is exceptional. When the disease results from Pott's disease, or some other vertebral affection, it is perhaps possible, by mechanical treatment, to improve or cure the patient ; and syphilitic forms, of course, are generally amenable 1 Op. eit. SPINAL PACHYMEMNG1TIS. 211 to treatment. Death may occur from exhaustion, and is preceded by the formation of bed-sores, and evidences of a typhoid state. Diagnosis It is necessary to diagnose spinal meningitis of the acute form from myelitis, 1 especially as these are the only two acute spinal mala- dies beginning with fever. The pain is much more severe in meningitis, and is aggravated by movement. The contractures and cramps are cha- racteristic of meningitis, and are not connected with uncomplicated mye- litis. Hypenesthesia, and exaggerated reflex irritability, and the lighter grade of the paresis (there rarely being paraplegia, and, if there is, it is quite late), are suggestive indications of meningitis, which should prevent any mistake. The chronic forms are of slow development, and all the symptoms increase progressively after their appearance, the paralysis being gradual and connected with contractures of the affected limbs. The para- lysis may not be bilateral, as is usually the case in syphilitic meningitis, and there is rarely any extension of the disease to a higher or lower level. In meningitis there are none of the atrophic tissue changes of the myelitis, but the chronic form may so closely resemble chronic myelitis as greatly to puzzle the diagnostician. The anaesthesia that belongs to myelitis, how- ever, is rarely present in meningitis ; and, if it should be, is a late and slight symptom. Tetanus may possibly be mistaken for meningitis, but such an error in diagnosis should be rare, the spasms of the former being much more general ; and, besides, the temperature variations are entirely different, as the thermometric rise in tetanus is unattended by any increase in the volume of the pulse ; while in acute meningitis the temperature and pulse are those of an inflammatory disease. Treatment The acute disease must be met with energetic treat- ment. Local, abstraction of blood by leeches or wet cups is the first indi- cation. Rollet 2 has used the cautery even in the last stages, applying it from the nucha to the sacrum, and with good effect. Chauffard 3 has given opium in large doses in the early stages. I prefer, however, suppositories of opium or belladonna, which seem always to relieve the pain, and are attended by the additional advantage of not deranging the stomach. Blisters applied on either side of the vertebral column, iodide of potassium, and mercurials (the former in large doses, even to the amount of a drachm thrice daily, beginning, however, with a minimum dose), are excellent remedies. In chronic meningitis I have repeatedly witnessed the benefi- cial effects of ergot, and the notes of the case I present will enable the reader to appreciate its immediate and powerful action in a very obstinate example. B. TV., female, aged 24 years, single, domestic ; admitted to hospital July, 1875. July 6. The accession of her trouble began about eight months ago, 1 By the use of this term I mean not only general myelitis, but those localized forms known as adult and infantile spinal paralysis. 2 Memoires de 1'Acad. Xat. de ]\led., xx. 3 Rev. Med., 1842. 212 DISEASES OF THE SPINAL MENINQES. when severe pain in the lumbar region made its appearance. This was very intense, and seemed aggravated by the supine position. About ten days after this api>eared, the abdomen became tender, and there w-n- darting pains which extended about the body, radiating from the spine ; this abdominal tenderness continued for two weeks, and then disappeared. She was able, at the end of a month, to " go up stairs, and to move about the house." A few weeks afterwards she noticed a loss of power in the right leg and thigh, and next in the left ; and, a month later, she found it impossible to get out of bed in the morning. She said that her legs wen- hypera-sthetic, and spoke of feelings of " pins and needles" in the soles of both feet. She says that she thought her trouble arose from a cold that she had caught when working in a damp place. All this time her pain was quite intense, and there has been no improvement. She has great difficulty in micturition, and is constipated. 2DM. Painted iodine on either side of the spine, and gave her gr. v potass, iodid. t. i. d. Aug. 17. Her abdomen has been distended by gas for the last two weeks. Pancreatine Jss t. i. d., and low diet. '24th. This treatment has not diminished the size of abdomen. Ordered milk, rice, and beef-tea. ,'iOM. Lumbar pain very severe. She can hardly move at all, and is obliged to use crutches. Injections of tr. assafoctida. Charcoal and water fail to relieve the flatus. The abdominal distension is quite distressing. 31 st. To-day another injection of the same kind did no good. Insom- nia and great suffering, as the lumbar pain is severe ; prefers her bed, and lies on the left side. Chloral hydrate; potass, iodide. Increased con- vulsive movements of legs. Oct. 9. At times she has localized pain over insteps of both feet, and pain on outer aspect of right knee. For the last five days slight numb- ness as far tip as her knees. Legs have "jerked" less for the last fort- night ; can move well in bed ; very slight power to move right knee ; frequent desire to urinate ; tympanites ; some colic, pain less in lumbar region. Pulse 12(5, small and irritable; temperature 101^. Blisters every other night on either side of the spinous processes. '24th. Abdominal pain lessened ; can move legs more freely ; numbness less. Jan. 20, 187<>. Acidi nitrorauriat dil. has relieved constipation, which has been a constant symptom. Felt. 7. 5 SS - fl- ext - ergot t. i. d. 1 { Mh. Ergot has had wonderful effect. Patient left her bed yesterday, and walked to the front door of hospital (about f>0 feet) and back without fatigue. She steadied herself by taking hold of the bedsteads. Has dis- carded her crutches. L>:.M. Walks well. March If). Goes out of hospital. April 1 . Discharged recovered. This patient was seen six months after- wards, and she had had no relapse. Ergot has acted equally well in other cases which I have treated, and I am of the opinion that it is more valuable than any other remedy in both the acute and chronic varieties of spinal meningitis. The actual cautery applied even- other day should be faithfully used, and in addition we may employ setons at the nucha or lower down. Cod-liver oil and generous SPINAL TUMORS. 213 diet are to be prescribed, and every measure is to be adopted that will in any way build up the patient. Should we find vertebral disease, a suita- ble brace, or the plaster-jacket should be provided. SPINAL TUMORS. The growth of tumors in the spinal canal or cord is of far less frequent occurrence than in the cranial cavity and brain, but when tumors choose this locality their presence is to be much more easily diagnosed. The forms of spinal growths are just as numerous as those of the superior part of the cerebro-spinal axis. They may be of any of the varieties I have named in speaking of cerebral tumors, but the kinds usually met with are the following : Syphilomata. Fibromata, attached to the meninges, or in the substance of the cord. Tuberculous (rare). Myxomata. Sarcomata. Parasitic growths are more rarely found, and the other forms which have been spoken of in our consideration of brain-tumors are equally uncom- mon. Exostoses give rise to many obscure, but none the less interesting, symptoms, while sarcomata are occasionally to be found attached to the inner surface of the dura mater or other meninges. Spinal tumors are of slow growth, and of course the appearance of symp- toms is consequently gradual and insidious. Symptoms. The first indications are expressions of irritation, and as a result there will be localized pain, and various disturbances of motility dependent upon the aberration of that part of the cord which is the seat of the tumor. Our knowledge of physiology of the cord will enable us to appreciate that disturbances in various parts will be followed by symptoms of pain, 1 hyperkinesis, akinesis, or muscular contractures expressive of in- volvement of the posterior, anterior, or lateral columns, but there is usually no such possible localization, as the growth generally impinges upon large tracts and works wholesale mischief. Compression is followed by still more pronounced symptoms than those attendant upon simple irritation. And there may be complete paralysis and atrophy, with muscular contrac- tures of the members either of the upper or lower extremities. Should the tumor be situated high up in the cord, the muscles at the back of the neck may be the seat of contractures, and those of the face and neck may even suffer; if the tumor be seated lower down, the bladder and rectum may also become involved, as in some other forms of spinal disease. Among the early symptoms may be mentioned the constricting band which is connected with neuralgic pains that shoot down the legs. These 1 Reynolds considers that pain in the back is more intense with carcinoma than with tubercular or other growths. 214 r DISEASES OF THE SPINAL MENINQE8. indicate irritation of the posterior columns and nerve-roots. Should the anterior column and nerve-roots be subjected to the irritating presence of a tumor, the consequence of such trouble will be convulsive local spasm- and increased reflex excitability. Vomiting, dizziness, and pupillary dila- tation are mentioned by Jaccoud as evidences of tumor situated in the cervical region, while nystagmus and strabismus are also occasional ex- pressions of a growth so located. The paralysis which follows increased pressure is not always equal, one limb being more feeble than another ; or there may be hyperkinesis on one side, and paresis on the other. Unilateral irregular troubles, both of motility and sensibility, are the rule. There may be anaesthesia and analgesia on the side opposite the lesion, while the paralysis maybe the striking symptom on the side of the tumor. This may be explained by the diagram of Radclitfe, which I have slightly Fig. 30. MS S >f modified. Supposing that Fig. 30 represents a segment of gray matter, we will consider that S S' represent sensory fibres of a nerve-root, and M M motor fibres. The sensory fibres decussate, S going to one side of the body, while S' goes to the other. M and M' both leave the cord on op|K)site sides. A tumor, pressing upon either lateral half of the cord, such as " I." may simply paralyze motion on the same side, while sensa- tion remains unaffected, and l>oth sensation and motion are intact on the other. If deeper pressure is made, supposing " II " to represent the tumor, not only would motion be paralyzed on this side, but sensation on the other. If a, tumor such as u III" should impinge at the decussation of the sensory conductor, we might expect total abolition of sensation on SPINAL TUMORS. 215 both sides, while there would be no paralysis of motion. A tumor such as " IV" would paralyze sensation on both sides, and motion on one. Reflex excitability is ordinarily increased in the limbs below the lesion, but it is stated that, when the inferior part of the lumbar region or the cauda equina are destroyed, reflex excitability is abolished after a period of six days, and that then the muscles begin to atrophy. Jaccoud 1 says : " There is here a new application of the law I have endeavored to make clear. As long as cerebral influence only is deficient in the inferior mem- bers, the reflex and electric motility and nutrition of muscles are intact, but when the spinal influence is in default these properties are abolished." A case which during life seemed to refute this assertion is the follow- ing, but after death an additional tumor was found higher up, which might have suspended cerebral influence, and still have left a portion of the cord capable of giving rise to reflex movements when irritated ; but in some respects the case still renders what Jaccoud has said somewhat doubtful, as the question arises whether the larger tumor did not antedate the smaller, and whether the original paraplegia did not take place before the growth of the smaller tumor destroyed the cord. The patient entered the Epileptic and Paralytic Hospital September 18, 1872, and was examined by Dr. Janeway, Dr. Seguin, Dr. Mason, and myself, and the very thorough autopsy was made by Dr. Maxwell. P. K., aged 30 years ; occupation, painter ; habits, intemperate. Inva- sion of the disease, five years ago. Relations to other diseases, disease of the spine. Seat of paralysis, lower extremities. Control of sphincters, very poor. Voluntary movements, imperfect. Sensibility, good. Speech, good. Hearing, good. Patient denies venereal disease, and no indications of it are found on examination. He states that ten years ago, after an attack of smallpox, he noticed a pain in the lumbar region, slight and irregular in occurrence, Accompanying this pain he has had frequent and uncontrollable desire to go to " stool," and to make water, but could not do either to his satis- faction. This all continued for about five years, when he noticed that he was gradually losing control over his lower extremities, and in five months was completely paralyzed. Says the left lower extremity remained unaffected the longest, and in a short time this also became as weak as the right. Has no control over bowels, and has but little control over the bladder. Physical examination reveals a slight degree of right lateral curvature, and a marked prominence in lumbar region, and tenderness on pressure at a point corresponding to fifth lumbar vertebra. These signs seem to point to lumbar abscess, as there is slight fluctuation, and the cachexia of patient is decidedly indica- tive. Both lower extremities are much atrophied, soft, and flabby. Patient very anemic. Prescribed iron and quinine. October 9. Patient since examined by Dr. Seguin, who says the ab- scess is over a point corresponding to upper third of sacrum, instead of last lumbar vertebra, as was first supposed. 1 Op. cit., p. 352. 216 DISEASES OF THE SPINAL MENINGE8. Uth. At the age of thirteen was struck in the small of the kirk with a stick. No phthisis. At beginning of trouble he had seviv pains in tlorsum of feet, with swelling and short lancinating pains. Pains in back part of the thighs, in loins, and about the sides of pelvis. No incontinence of feces. Curvature began about a year later than the commencement of paralysis. When limbs were extended, they were agitated by clonic spasms, and increased pain in feet. As paraly>is increased pain diminished, although diminution was not noticed until after eon tract ure. In last two years no material change has taken place. Pain at irregular intervals, and occasional spasms in legs at night. Has had from the first a feeling of coldness, but never any numbness. Volun- tary movements at hip-joint quite free. Knees flexible at an acute angle. Extension and flexion possible in both knee-joints to such an extent as to bring legs at right angles to thighs. Xo sign of voluntary movement below knee-joints. Passive movements free at hip-joints for extension, which is considerably restrained at knee-joints. Flexion free, extension beyond right angle hindered by tension of flexor muscles of thigh. More free at ankle-joints and toes ; the thighs are somewhat wasted, but not truly atrophied. Left measures 37-^ centimetres ; right, 32 centimetres. The legs show extreme atrophy, most marked on right side. Left rait' measures 23 centimetres; right, 21^ centimetres. The feet are not oedematous. The integument over lower half of tibia is apparently hyper- trophied, feels elastic, does not pit on pressure ; the appearance as to sight is like that of oul the etiology of spinal or other tumors. Spinal growths am rarely found, except in adult life. Morbid Anatomy and Pathology. Syphilitic deposits are found in the spinal substance between the meninges and about the nerve-roots. The exudation resembles that found in the brain and other organs. The site of these deposits is chiefly about the circumference of the cord, and is rarely central. Tubercular deposits may affect the entire cord and its covering, but have been met with in the majority of instances in the gray matter. Jaccoud says that they are nearly always found in the gray mut- ter of the lumbar enlargement. Tubercles may be found coexisting in the cord and brain. Myxoma are found in the cord much more often than in the brain, and are attended by separation of the nerve-fibres and great mechanical destruction. Cancerous growths may and usually do spring from the vertebra;, and are of a fungoid character. Secondary degenera- tions are to be found in certain cases, as well as aneurisms, organized clots, cysts, and other evidences of previous disease. Diagnosis. It is not an easy matter to distinguish the symptoms which attend spinal tumor from those of some of the other spinal diseases. "We should bear in mind, however, that the indications are slowly ex- pressed ; that the paralysis is irregular ; that one group of muscles may be affected at first, and then others ; that the degree of lost power is not the same on both sides of the body ; and, also, that perverted sensation is not the same over the two sides ; that, usually, there are contractures of the limbs which need not be preceded by atrophy ; and, finally, that pain is a symptom which is very constant. Prognosis I have never witnessed a recovery from spinal tumor unless the character of the growth was syphilitic, and doubt very much whether a cure has ever been effected. It is impossible to limit the dura- tion of disease which depends so much upon the character of the morbid growth. Patients may last for eight or ten years ; or, on the other hand, they may live a very short time, should the tumor be cancerous. Death usually occurs by pneumonia, uraemia, or some debilitating disease. Treatment If syphilis be suspected, we are to give very large doses of the iodide of |K>tassium ; or, we may administer the biniodide of mercury in combination with this salt. In other states, supportive treat- ment or counter-irritation offers a feeble hope of relief. SPINAL HEMORRHAGE. MKNIX(;EAL; CRXTKAL. Synonyms lla-matorrhachis ; htematemyllie (Ollivier). Spinal apoplexy. tender this head we may consider the effusion of blood into the spaces between or under the meninges of the cord, and the effusion of blood into the substance of the cord itself. SPINAL HEMORRHAGE. ' 219 Symptoms. Very often the first intimation of the rupture is a sudden loss of power, and consequent inability of the individual to stand. It may, on the other hand, be of gradual development, the symptoms appearing in groups, one after the other. The resulting paralysis is generally complete, and the patient loses both motor power and sensibility, as well as control over the bladder and bowels, accompanied by a number of slowly-developed symptoms, with diminution of reflex excitability, although the latter may be exaggerated in some cases should the hemorrhage be small and between the meninges. The abolition of muscular power may vary in proportion to the gravity of the hemorrhage, and if it be small the patient may ulti- mately recover, and eventually present no indications of his loss of power. I have never seen a fatal termination before the end of several days, and doubt if such could be the case unless the hemorrhage should occur at a very high point, involving a number of the intercostal nerve-roots ; but even this is improbable, although Hammond takes an opposite view. Ot course much depends upon the site of the ruptured vessel. If the upper part of the cord or the medulla be affected, then an immediate and fatal termination is a natural result. Meningeal hemorrhage is characterized by more pronoun.ced symptoms of muscular rigidity, or by convulsions, which may be of a tetanic character. If the hemorrhage has taken place above the fourth or fifth dorsal vertebra, it is common to find obstinate pria- pism and intestinal disturbances, giving rise to flatus, these resulting from paralysis of the splanchnics; if it be extensive, there may be para- lysis of motion and sensation from pressure exerted upon the cord, and pain and spinal tenderness are also quite marked symptoms, and in un- complicated cases there is cutaneous hyperaesthesia. There is commonly no loss of consciousness in either variety, but when the effusion takes place in the medulla there may be conditions akin to epilepsy. In this case, however, effusion would be very small, and the region affected would be near the circumference. Causes Spinal hemorrhage is usually the result of a traumatism, but may proceed from various debilitating diseases and some of the zymotici, smallpox playing occasionally a part in the etiology. Alcoholism, and other conditions in which the cord is congested, may predispose; or the hemor- rhage may result from the rupture of an aneurism in the vertebral canal, such as occurred in Laennec's case. It very rarely takes place as a secondary accident in tetanus, so that it can be recognized before death ; but at the post-mortem examination such pathological evidences may be occasionally observed. Traumatisms undoubtedly most frequently produce this condi- tion ; and falls, blows upon the back, or concussion following a fall upon the feet, enter into the etiology. It may occur in the course of myelitis, but again it may happen without any trace of inflammatory trouble to be discovered after death ; and, in some instances, there is no history of in- jury. Such a case undoubtedly resulted from sudden congestion at the menstrual period, and is reported by Goldammer 1 : 1 Virchow's Archiv, Jan. 1876, and Abstract Medical News. 220 DISEASES OF THE SPINAL MENINGES. " The patient, a girl of about sixteen years, was suddenly attacked with u severe pain in her back between her shoulders, which soon passed over to her right, and after a while to her left arm. She also noticed a pain in the pit of her stomach, and found somewhat later that she could not move her right leg. Having been sent to the hospital, the examining physician found complete paraplegia, complete anaesthesia up to the mamilhv, and paralysis of the bladder, while the reflex action of the lower extremities was still intact ; her temperature was normal, pulse 80 ; did not show any brain symptoms, but complained of pain in both arms. A few days after- wards the abdominal and dorsal muscles proved to be paralyzed, and per- cussion of the spinous processes of the dorsal vertebra? caused her pain. The pulse was DC ; her bowels moved only when drastics were given her. A slimy discharge from her vagina was noticed. The case was considered as hemorrhage into the spinal cord below its cervical enlargement. The treatment consisted in local depletion, in the methodical use of the oint- ment of mercury, and in the Use of drastics. The patient, having im- proved in general very little, died from decubitus about a year after the attack. The most noteworthy observations made on autopsy are the following : About one inch below the cervical enlargement of the spinal cord there seemed to be a compressure. A cross section through this part showed that its original diameter was reduced very much, and that the right lateral column and the adjacent parts of the anterior and posterior columns, as well as the gray substance between, were occupied by a rusty brown substance of callous consistence. The microscopic ex- amination of this proved that it was formed of connective tissiie inclosing tatty matter, crystals of tuematoidine and a granulated brownish pigment; the vessels in this part had undergone fatty degeneration, their walls were thickened, and contained brown pigment ; no nervous elements could be found in this substance ; its entire length was about one-tenth of an inch. The adjacent parts of the medulla were not degenerated by softening; only a few rusty stripes and a yellowish color were noticed on their examina- tion ; the whole remaining cord was found to be intact. As no symptom speaks for myelitis as a causal element in this disease, it could only be caused by an effusion of blood into the substance of the cord : the latter probably had been provoked by suppression of the menses, for the heart iind the vessels, especially those of the spinal marrow, were intact, and no injury had occurred to the patient, It is true that she stated she never had had her catamenia nor noticed any molimina, in spite of her age and bodily development. There were, also, no signs of menstruation noticed during her sickness. But there was revealed by autopsy the presence of a corpus liiteum of the size of a pea, and certainly of a longer standing; and a slimy excretion from her vagina was observed a few days after the attack. These facts favor strongly the above-mentioned suggestion." Morbid Anatomy Central : hemorrhage takes place into the upper part of the cord more often than in any other locality, but the lumbar and dorsal segments may also be its seat. The gray matter is naturally more frequently the seat of hemorrhage than the white, and when preceded by myelitis or injury it will be generally more extensive than in the latter. If the hemorrhage be profuse, we will find that the cord is enlarged at the point where the escape of blood has taken place, and that it has a doughy feel. Hemorrhage into the meninges may be sometimes associated with SPINAL HEMORRHAGE. 221 an intracranial condition, the blood escaping from a cerebral vessel, flood- ing the ventricles, and passing down into the spinal cavity. Various meningeal diseases may terminate in this way, as well as spinal congestion and tetanus, and occasionally spinal tumors and vertebral disease give rise to such an effusion of blood. Old cysts have been found in the cord in some cases, but their existence is comparatively rare, and when met with they present the same appearance as is seen in the brain, though of course they are much smaller. In meningeal hemorrhage, the coverings of the cord are red and suffused, and perhaps opalescent and thickened, and there is possibly some meningitis with sero-purulent collection ; the effused blood may be found as a semi -organized clot, and presents, according to the time of existence, changes of color of varying depth. Occasionally the condition which favors the development of spinal apoplexy may lead to cerebral accidents of the same character, and evidences of such trouble may be found to coexist. Diagnosis The symptoms must be distinguished from paraplegia due to myelitis, and from those of cerebral hemorrhage, which may, as Brown- Sequard has lately shown, be produced. In the former there are primary symptoms which I will discuss in speaking of myelitis, and in the latter there is usually some affection of consciousness, and some disturbance of speech. This latter variety of disease (cerebral paraplegia) is so anoma- lous, however, as to have but little weight as a condition to be excluded. The subsequent effects of such a hemorrhage, paralysis, contractures, etc., may be confounded with several chronic conditions. Among these are spinal tumors, adult spinal paralysis, and ataxia. The first is connected with decided hyperkinesis, is of gradual development, and is accompanied by slowly appearing symptoms. Antero-spinal paralysis or adult spinal paralysis is ushered in by fever and unattended by any loss of sensation or incontinence, and the atrophy is rapid. Locomotor ataxia is symptom- atized by increased electric contractility, by no paralysis, and by disturb- ance of coordination. Prognosis If the hemorrhage takes place in the meninges or in the lower pat of the cord, the prognosis is perhaps better than if its seat is in the cervical or dorsal segments. In the first instance the patient may live some time or ultimately recover, but in the latter the probability of sudden or early death is almost certain. Grisolle 1 says : " Spinal hem- orrhage runs a rapid course. A single patient has survived forty days ; the majority, however, succumb at the end of several days, by suspension of respiration. Among others death is hastened or produced by the devel- opment of bedsores. Nevertheless, spinal hemorrhage is not necessarily a fatal condition." He refers to a case observed by Cruveilhier, and states that this is the only cure of which he has known. Erichsen, 2 however, 1 Grisolle, Path. Interne, vol. i. p. 659. 2 On Concussion of the Spine, etc. 222 DISEASES OF THE SPINAL MENINOE8. has reported recoveries which have taken place in cases which were of traumatic orijrin; so the prognosis is |>erhaps not so bud, after ;ill. Treatment The early treatment of spinal hemorrhage should con- sist of cold applications to the spine, perfect quiet, and rest. Subsequently ergot and belladonna will be of great benefit. Blistering and leeches to the painful point in the back are next in order, and later on the actual cautery is the most serviceable external agent. SPINAL HYPER^MIA 223 CHAPTER Will'. DISEASES OF THE SPINAL CORD. SPINAL HYPERjEMIA. (A) SPINAL CONGESTION ; (B) SUBACUTE SPINAL HYPERvEMIA. Two varieties of spinal hypertemia exist: one of sudden origin, and of a sthenic character, which I prefer to call Spinal Congestion; the other of slow progress as compared to the first, and characterized by accumula- tion rather than congestion, which I will speak of as Subacute Spinal Jfypercemia. SPINAL CONGESTION. This first variety, which has been excellently described by Badclife, 1 is not so common as the latter, or at least such has been my experience. It is apparently a serious condition, and may somewhat puzzle the incautious observer who may mistake it for some one of the organic diseases; but it has certain distinct features which do not belong to the organic neuroses, and I think there should be no difficulty in making a diagnosis. Symptoms The following may be the symptoms of an attack of Spinal Congestion. The patient probably attracts the notice of his friends by telling them that he cannot get out of bed, that " he feels as if he were a lump of lead," or that his " legs and arms are made of wood." He can- hot move, and complains repeatedly of his utter weakness ; he sighs, and may complain that the room is close, and ask to have a window opened; he is able to appreciate any warm substances that may be applied to the surface, and very acutely feels pinching or the prick of a pin. The legs, he says, seem very cold, and he requires extra covering ; he has backache and pains, which run down the back of the thighs, but pressure does not aggravate the pain in the back, which is only relieved by lying upon the side or belly. His mind is clear, but he is restless, suffers for want of sleep, and is extremely uncomfortable. The functions of the bowels are perhaps interfered with, there being constipation; but there is never incontinence of urine or feces. The patient becomes paralyzed, and such paralysis is rather sudden, and may take place during the night, or perhaps more gradually after the appearance of pain and the other symp- toms just mentioned. Reflex action is abolished, and electro-muscular contractility is increased. 1 Article in Reynokls's System of Medicine, vol. ii. 224 DISEASES OF THE SPINAL CORD. Kadclitfe calls attention to the wasting of the muscles, but I have never seen more than the general atrophy which would occur from disease of the lower extremities, for the patient may sometimes lie in bed for months before he regains the lost power. The duration of the attack rarely exceeds six weeks, but there is a possibility of a second attack. Tlic paralysis is generally paraplegic, though it may be irregular in its onset, one leg or arm being affected before the other, and in some cases it i> general. The spinal pain seems to be increased by warmth, and tin- patient will feel the ice-bag to be very grateful after lying upon his back for a long time on a warm bed. These pains are as a rule unaffected by movement, which is not the case in meningitis. I have never seen bed- sores as a feature of the disease, and for this reason no suspicion of mye- litis should arise. SfBACUTE SPINAL HYPER^MIA. Symptoms The expressions of this condition are very slowly mani- fested, and are very often mistaken for those of the opposite condition nnuMnia of the cord. Tingling and heaviness of the limbs may distress the patient, and render him disinclined to take exercise or remain stand- ing for any length of time, and much of his want of energy may be mis- taken for laziness. These symptoms are especially disagreeable towards night in those who have walked much during the day, and there is an uneasy, tired feeling, which is only relieved by change of position ; and the patient seeks in vain for a comfortable place to rest his weary limbs, and only finds it when he lies upon his bed or sofa. There may be cutaneous anaesthesia, and occasionally hypenesthesia, but these sensory troubles are by no means common. There may also be the "constricting band," which is so usually suggestive of inflammation, and there are vague undefined pains in the thighs, legs, and back, which are extremely dis- tressing. The temperature is lowered, and there may be the same op- pressed breathing which is such a marked feature of the acute variety. Decided paresis is rare, and, if it should take place, it is nearly always para- plegifonn, and not general, as it may occasionally be in the acute variety. Should this be the case, we will find the same impaired condition of reflex excitability and normal electro-muscular contractility which characterizes the more active variety of spinal hypera-mia. The tendency of the disease is to disappear under proper treatment, and in its worst forms is neither a grave nor lasting trouble, and should not be looked upon with alarm. Causes Women seem to be more subject to the first form than men, and this is probably owing to irregularities of the menstrual condi- tion. Uterine conditions, symptomatized by dysmenorrluca or amenor- rh(i-a, may be, and often are, its sole causes. Among men, the long con- tinuance of the erect position seems to favor the gravitation of blood, and hypostatic hypenemia of the spine is thereby induced. A few years ago I satisfied myself that the maintenance of the erect posture for a long-con- tinued period resulted in a great deal of mischief. My investigations SPINAL HYPERAEMIA. 225 were much among car-drivers, who were compelled to stand upon the platform of the city railroad cars for a period of from fourteen to sixteen hours daily. Spinal congestion, varicose veins, and other vascular changes were common and serious results ; and the spinal troubles were only relieved by a long rest. Venery, alcoholic intemperance, and malaria are often causes of spinal hypenvmia; and suppression of any bloody discharge, such as the menses, or that from haemorrhoids, will be apt to be followed by more or less spinal hyperaemia. Among the more serious causes of spinal hyperaemia may be mentioned the fevers. The spinal congestions which usher in some of the exanthemata are symptomatized by back pains, etc., and do not properly come under this head for discussion ; but there are conditions which play a most important part in the etiology of spinal congestion. The malarial cachexia very frequently induces a condition of spinal hyperaemia which misleads the observer, and the true cause may be lost sight of under the periodic character of the painful exacerbations. This we should take into account if there be any suspicion of malarial poison- ing. I have seen many cases of very decided subacute spinal hyperaemia which followed intermittent fever. The disease had become masked to some degree, so that no chill was complained of; but the individual suf- fered more at some parts of the day than at others, and, in one case of this kind, there was some loss of powder, which was increased daily at a certain hour, and never seemed to disappear entirely. Morbid Anatomy and Pathology. "What I have said in speak- ing of cerebral hyperaemia may be referred to in explanation of the ap- pearances met with in spinal congestion. The gray matter will be found to be quite dark, and the vessels are usually enlarged. The w r hite matter is often of a pinkish hue, and there may be areas of hyperaemia which are localized ; or the suffusion may be general. Microscopically examined, the cord will be found to have undergone very slight changes, and they may consist only in increased vascularity, enlargement of capillaries, and per- haps some exudation beneath the vascular sheaths. The vessels of the me- ninges are engorged, and there are to be observed small ecchymosed spots, or occasionally an effusion of serum. The symptoms of the disease result from pressure upon, and irritation of, the nervous elements; and the vio- lence will depend upon the site of the most decided hyperaemia. The gray substance, when subject to pressure from distended vessels, gives rise to the pain in the back, and cutaneous hyperaesthesia, as well as the spas- modic movements which symptomatize the aggravated forms. Spinal hyperaemia is directly induced by blood defects and disease of other organs, and it is favored by the anatomical structure of the parts con- cerned. The tortuous course of the veins, and the absence of valves, are, according to Jaccoud, among the latter. The stasis of blood in their inte- rior, which follows forced respiration, such as must be caused by violent exertion, or by disease of the thoracic and abdominal organs which to some degree arrests the return of venous blood from the cord, favors hyperaemia. 15 226 DISEASES OF THE SPINAL CORD. Diagnosis Spinal meningitis, myelitis, and spinal irritation are the diseases with which it may be confounded. 1st. The spinal pains of meningitis are increased, as has been shown, hy movement, which is not the case in spinal congestion, and there is a muscular rigidity in the first-mentioned disease which does not exist in this. 2d. Myelitis differs from spinal congestion for the reason that complete unrest hesia, wasting, loss of electric contractility and sensibility, reflex- excitability, incontinence of urine and feces, and bedsores, belong to the former. 3d. Spinal irritation (antemia?). The spinal tenderness is increased by pressure in anarnia, and there is no cutaneous tingling. There are troubles of other organs, and generally a variable amount of hysteria. Hammond alludes to the fact that urinary troubles, when they ex^t. antedate the spinal anirmia, while in spinal congestion they are secondary. Prognosis. The chances for recovery are very good, provided active measures are at once taken to reduce the fulness of the spinal vessels. If the condition becomes a chronic one, even then much may be done to im- prove the abnormal state of the circulation. In many cases, however, it precedes myelitis, particularly when it takes the slow course which I have described as subacute spinal hyperrcmia, or it may lead to atrophy ; but this tissue-change is more directly induced by spinal anaemia. Treatment The local application of cups, counter-irritants, and old may all be practised; and, in addition, we may use either hydrobromie acid (FF. (>, 7), the bromides, or ergot, in full doses; or belladonna (F. 70), till some of the toxic effects are produced. It is never well to prescribe alcohol, strychnine, or iron in these cases, or any other agents which in- crease central irritability, and I have witnessed disastrous effects from their use. The Turkish bath is, I think, one of the best adjuvants to these forms of treatment. As a local application to the spine, I have directed the patient to procure a strip of adhesive plaster, which should extend from the lower cervical vertebra to the sacrum. This is to be warmed and dusted with red pepper, and then applied to the back. It is a very excellent form of counter-irritant, and may be worn for some time. The cups may be wet or dry, according to the severity of the case, although I prefer the former. Should there l>e any pronounced symptoms, these are to be used two or three times a week. It must be borne in mind that general treatment, such as the re-establishment of fluxes which have been interrupted, and the regulation of the functions of the excretory organs, is to !M undertaken as early as possible ; for, like cerebral hypenemia, the con- dition is nearly always one that is secondary. As an immediate remedy, e gm\v< small, fluttering, and the voice very weak, and ultimately the patient dies. his mind remaining clear to the end. If, however, the structural altera- tion progresses upward, it is very probable that the mode of death will be asphyxia. As exceptional instances, cases have been recorded in which there was myelitis of the upper part of the cord, with complete paralysis of the upper extremities, while the lower limbs, the bladder, and rectum were not affected, and other equally rare forms are occasionally noted. When the dorsal (>ortion of the cord is the seat of inflammatory action, the re- spiratory symptoms are immediate, and the breathing becomes embarrassed at once. The prominent symptoms of this interesting neurosis may be recapitu- lated as 1. Paraplegia of sudden or gradual origin, attended by anaesthesia and analgesia, but usually preceded by dysresthesia of various kinds, or actual hypenrsthesia. It may be accompanied in the beginning, accord- ing to Kadclifte, 1 who has observed this symptom in severe cases, by "un- controllable restlessness." Paraplegia is nearly always the form of lost power, though in rare cases there is hemiplegia. There may be, in excep- tional cases, variations in sensibility, the symptoms of aiuesthesia being absent when the anterior columns are alone partially affected. Again, in other cases one leg may be paralyzed and the other anaesthetic. Tin- onset of the paraplegia may be very sudden, and the disease prove rapidly fatal. Jsiccoud" has seen one case in which the paraplegia developed in thirty-six hours from the commencement of the disease. Eighteen hours afterwards, the autopsy revealed a purulent meningo-myelitis of the. entire lumbar and part of the dorsal segments of the cord. The extent of the paraplegia is of course governed by the seat and course of the myelitis. If the lumbar portion of the cord be destroyed, the lower extremities, and the muscles of the abdomen and sphincters will be paralyzed; if the myelitis extends so that the dorsal portion and the cilio-spinal centre are involved, the arms are paralyzed, and pupillary changes with irregularity of cardiac functions are produced. When the lesion is still higher, and the cervical jxu-tion of the cord is involved, there may be, in addition to all these forms of paralysis, various difficulties in swallowing, speech, and respira- tion, and the patient dies from asphyxia. Op. cit., p. 315. * Path. Interne, vol. i. p. 314. ACUTE MYELITIS. 235 2. Reflex excitability is generally abolished entirely, or impaired to a great extent. Occasional exaggeration is seen in the earliest stages, or when the myelitis involves limited regions, especially the lumbar segment. Jaccoud says : ! " Durant la periode d'exageration (hyperkinesie reflexe) le segment lombaire soustrait a 1'influence du cerveau manifest-ait son action propre avec la puissance accrue qu'elle tirait de son isolement ; durant la periode d'abolition (akinesie reflexe) cette action propre ou spinale est aneantie parceque les elements qui en sont doue'-; sont detruits." 3. Electric contractility and sensibility are abolished or greatly lowered. The only exception to this rule is when the reflex excitability is increased. 4. Muscular atrophy as a result of severance of spinal innervation sometimes follows. This may take place in from four to six weeks. The atrophy is general, and is of course attended by absence of electro-mus- cular contractility and by coldness of the surface. 5. Bedsores and other evidences of defective cutaneous innervation are present. The skin becomes swollen, or there may be at first great dryness and redness, or oedema at the points subjected to pressure. A hard, red bullous nodule may form, and subsequently break down, and sometimes large patches of tissue are rapidly destroyed. 6. The sphincters are paralyzed, the urine is intensely alkaline, the walls of the bladder being paralyzed, and as a consequence a certain amount of urine remains in that organ in a decomposed state, and rapidly induces an alkaline reaction in that which may collect before it is dis- charged. Though Brown-Sequard is inclined to consider that this con- dition of affairs is pathognomonic of disease of the dorsal region, and I infer holds that it is essentially a nervous symptom, I am compelled to believe that it is only an intra-vesical change, and occurs in this disease just as it may in various local troubles, such as cystitis, prostatitis, or other affections in which the expulsive force of the organ is affected, perhaps the walls being thickened as a result of local trouble. Kadcliffe alludes to a reflex spasm of the sphincter ani which occasionally occurs in this dis- ease, but this symptom is so exceptional as to need but passing comment. The paralysis of this muscle is ordinarily so complete as to be followed by the almost constant escape of softened feces and watery discharges. 7. Increase of temperature and pulse calls for no special mention. Occurring with paralysis of the lower extremities and no loss of conscious- ness they can symptomatize but two acute spinal affections, myelitis and meningitis. The spasmodic movements of the latter disease, however, are not observed in myelitis, so that it possesses at least some diagnostic im- portance. The temperature varies from the normal standard to 104 or 105, and the pulse may reach 160. 8. The constricting band sensation, which is more marked in myelitis than any other form of spinal disease, is generally likened by the patient to that which might result if a tight cord were tied about the body. It is usually located at the waist, and sometimes when it is not complained of 1 Op. cit., vol. i. p. 315. 236 DISEASES OF THE SPINAL CORD. may be developed by a sharp blow on the back, or by the application of an electrode to the spine. CHRONIC MYELITIS. Symptoms The disease sometimes takes a more slow course. The paralvlic symptoms are much less sudden in their onset, and occur one after another, so that the extension of the inflammation may be sometimes traced. For some time, perhaps for several months, there may be di-i>rd<-r< of sensation, such as tingling spinal pain, and the "constricting band." The perception of pain in the affected limbs, though not entirely abolished, is greatly influenced. Charcot, 1 Romberg, 8 and Cruveilhier 3 have called attention to the curious mistakes sometimes made by patients in locating painful sensations. Pain following the pinching of one leg is referred to the other, and the painful impression may take several seconds to reach the sensorium. In one of Romberg*8 patients pressure upon the toe was referred to the hip. Cruveilhier's experiments demonstrated that an interval of from fifteen to thirty seconds elapsed sometimes before any sensation was excited, and that the impression had to be made several times before it was perceived. Electric contractility is perhaps increased, and reflex excitability is very much exaggerated, and may be followed by very violent movements. Thus, when a warm bottle is sometimes applied to the feet, though the temperature is not so high as to cause discomfort to a healthy person who touches it, the patient's legs will be violently drawn up ; this always sug- gests a meningeal complication. Dysaesthesise are referred to, and pains in the joints and bones, especially aggravated by humidity of the atmosphere, are s|K>ken of by the patient. The paralysis of motion is much less exten- sive than it is in the acute form and in the beginning; and spasms of the muscles of the lower extremity are very violent. Subsequently, however, they disapjwar as the loss of power becomes more complete, and at this time there are lowered temperature and electric irritability instead of the primary exaggerated condition. The bladder and rectum are subsequently affected, and various degrees of deranged function may be noticed. One of my patients is obliged to pass his water every ten or fifteen minutes, and his bowels are so constipated as to require an injection every day. . The individual generally loses his power for sexual gratification if the disease is at all advanced, though in the beginning there may be a marked disposition to erection. Atrophy takes place if the anterior horns be affected. Causes The common causes of myelitis are injury, syphilis, acute diseases, exj>osure, and extension of meningeal disease. Falls and blows ujMHi the back are the origin of the majority of cas.es, but I consider syphilis to have a very great deal to do with even these, when often it is 1 Op. oh. 1 Manual of the Nervous Diseases of Man, Syd. Trans., vol. i. p. 267, et seq, * Anatomic Pathologique, livre xxxviii. p. 9. CHRONIC MYELITIS. 237 not suspected. Meningeal thickening or acute meningitis undoubtedly plays an important part as a mechanical cause ; and in many cases reported, disease of the vertebrae has been found to produce the myelitis. Venereal excesses, onanism, and continued dissipation are direct causes which should not be overlooked. Morbid Anatomy and Pathology When the vertebral canal is opened, the investing membranes slit up, and the cord exposed, it will be found to be greatly changed in color and consistency at certain parts. It may be diffluent and of a pinkish color. Scattered throughout the softened portion collections of blood may sometimes be found, and these arc more often in the greatly altered gray substance, from which the dis- a-c seems to have started. At other points there may be found evidences of slight vascular changes, such as occur in the red stage of cerebral soften- ing. There may be adhesions of the meninges to the cortex or collections of pus between them. In the more slow form of degeneration (chronic myelitis) the process may not be so widespread, limited areas being only affected. As a result of either form there may be an atrophic condition of the cord, or an actual hardness which we shall presently~speak of in our consideration of sclerosis. The microscopical appearances are the follow- ing : the vessels are enlarged, varicose, or broken, and are surrounded by effused ha?matine; the nerve-tubes are swollen, irregular, and disrupted, and the axis cylinders substituted by oil-globules or granular debris ; and the nerve-cells may have been broken down and become simple granu- lar masses of a round or ovoid shape (Gluge's corpuscles). Fat globules may be found scattered here and there if the cord of an advanced case is examined ; and the connective tissue may be found to be thickened and increased in density. Pus-corpuscles may also be seen. Jaccoud 1 speaks of two kinds of myelitis mySKtt en foyer and my&ite central. In the first form the meninges will be found to be injected and adherent to the nervous substance, and the nodules or patches may be several centimetres in length or smaller. These foyers are quite distinctly separated from each other by healthy tissue, and when one is removed the nidus in which it has formed is seen to be in quite normal condition. The anterior columns and anterior nerve-roots are often found to be involved ; and the latter are the seat of " petites nodosites exuberante"s." When the dis- ease assumes a chronic form, these softened patches may become encysted as in cerebral softening. The central form, as its name implies, begins in the gray matter, and generally extends longitudinally. Diagnosis It is necessary to exclude spinal meningitis, locomotor ataxia, spinal tumors, and spinal congestion. Spinal Meningitis What I have already said in a previous article renders further consideration unnecessary. Locomotor Ataxia There is no paralysis of motion in this disease, but rather an increased muscular activity, which is expressed by the vio- lent manner in which the patient throws out his foot ; while in chronic 1 Path. Interne, ed. 2me, vol. i. p 310. 238 DISEASES OF THE SPINAL CORD. myelitis he drags one foot after another. The neuralgic pains in the ex- tremities are absent in myelitis; while in locomotor ataxia they are marked symptoms. In myelitis there are none of the paralyses of cranial nerves so commonly found with sclerosis of the posterior columns. Spinal Tumors The presence of a spinal tumor may sometimes pro- duce pressure upon the cord, and give rise to some of the symptoms. The slow development of the growth is, however, attended by corresponding slowly appearing symptoms, and the paralysis is not complete. The chance for doubt as to the condition arises when secondary myelitis results from such a tumor. Spinal Congestion These serious symptoms of myelitis are never pro- duced by anything but a degenerative process, and there are rarely bed- sores, alkaline urine, or the profound disturbances of sensation or motion which characterize myelitis. Prognosis In every case much depends upon the nature of the cause, and the extent of the cord involved. If there be a traumatism, ot course this gives the disease a serious character, and death may occur in a few days. If the myelitis result from pressure from diseased and dis- placed vertebnv, the result, though more distant, is equally bad. Very few cases recover entirely from chronic myelitis, and in those that do, the lesion must either be due to syphilis, or be very limited. Treatment Counter-irritation, cold, and ergot are useful in the early stages of the acute disease. The former may be produced by the actual cautery, but care should be taken not to burn extensively, as the tissues are too ready to slough. Ice-bags may be used, and the patient should be laid on a water-bed, and kept as clean as possible ; the thighs and nates being washed occasionally with salt and water, or with hot and cold water alternately. The iodide of potassium, with belladonna, should be given internally (F. 74). Should the case be one of slow development, I prefer the use of ergot in half-drachm doses thrice daily; or we may use the bromides (F. 44). The sesquichloride of iron (F. 7">) seems to have enjoyed deserved popularity in England, and it is preferred by Radcliffe to the iodide of potassium. In one case I obtained very excellent results with the tincture of the chloride of iron. Phosphorus and cod-liver oil, those valuable builders of healthy nervous tissue, may be employed here with every hope that they will do good. In chronic myelitis they are especially service- able, and, later on, small and frequent doses of strychnine are, in addition, useful. There are forms of auxiliary treatment which not only increase the comfort of the patient, but go far towards ameliorating his disease. One of these is the assumption, if possible, of a position which shall favor the determination of the blood /row the spine. Brown-Sdquard has re- commended that the patient should lie upon his side or belly, with his legs somewhat lower than the rest of the body. I have found that wash- ing out the bladder with a dilute solution of carbolic or nitric acid, or chlorate of potash, prevents the disposition to cystitis which there very ANTERO-SPINAL PARALYSIS OF INFANCY. 239 often is in myelitis. Warmth of the limbs, established by wrapping them in cotton batting, with a covering of oil-silk, or the new India-rubber tissue-paper, prevents contractions, and stimulates the cutaneous circula- tion ; while application of the faradic current, and the employment of mas- sage, help the patient to a great extent. The electric brush should be used faithfully every day, and it is better that the physician should make lii> own electrical application, than trust it to a nurse or attendant. ANTERO-SPINAL PARALYSIS OF INFANCY. Synonyms Paralysie essentielle de 1'enfance (Rilliet and Barthez) ; Infantile Paralysis (Radcliffe, Yolkman, and others); Paralysie atro- phique de 1'enfance, Organic Infantile Paralysis (Hammond) ; Infantile Spinal Paralysis (Seguin) ; Spinale Kinderlahmung (Heine). Definition. This form of paralysis may be described as a condition usually characterized by a primary febrile stage, a secondary paralysis generally of the lower extremities, and a tertiary atrophy. The paralysis is incomplete, as sensibility is never lost. Symptoms The disease is marked by a febrile onset of greater or less severity, attended by restlessness, malaise, and pains in the joints or back, and there may be rigors; or in some instances the loss of motor power is preceded by one or more paroxysms of convulsions. This febrile state is by many mothers mistaken for "teething," "worms," or other un- important childish troubles, and it is not till the development of paralysis that any alarm is created. This symptom appears within two or three days from the beginning of the fever, and may take place at night. The onlv condition of disturbed sensibility is one of hypertesthesia, which, however, is not a constant symptom. Sinkler 1 has collected a number of cases in which he has noted the form of invasion of the disease. He found that the paralysis took place suddenly, that is, with prodromata in but 6 of 108 cases, while Mrs. Jacobi 2 noted this form of invasion in 12 of 163 cases that she had col- lected. The modes of onset are the following : 1 . The child, while playing, suddenly drops palsied. 2. The child may be paralyzed at night. 3. Fever, but no convulsions ; rapid loss of power. 4. Convulsions, followed by sudden paralysis. (Sinkler reports but one case of this kind, and but two in which convulsions folloiced the paralysis.) 5. The paralysis preceded by one of the exanthemata, or by whooping- cough. 1 Clinical Lecture, Med. and Surrtrage, Heft 1, 1870. 2 Produced by attempts to restore disturbed equilibrium. ANTERO-SPINAL PARALYSIS OF INFANCY. 241 lysis ; the primary attack being hemiplegia, and the secondary para- plegia : CASE I Robert B. (a seventh-month child) was sent to me by Dr. H. G. Piffard, of this city. During September, 1876, he became feverish, and, after two days, during which he was confined to bed, he had a general convulsion. Before his fever he had eaten a great quantity of cherries, and his mother supposed his illness to be due to this cause. The mother stated that the convulsion lasted three and a half hours. He became para- lyzed two days afterwards, the right arm and leg being affected ; but two days after this he could use even these limbs. A few days subse- quently lie went out to play, but came back feeling out of sorts ; and, after u few hours' fever, another spasm took place. Within the next thirty -six hours both legs were paralyzed, so that he could not stand. Towards the first of November he regained some power, and can now stand when hold- ing a chair. Present Condition He is a puny boy, about five years old, and is badly nourished. He has no voluntary power over lower extremities, but can move the arms perfectly. The legs are both very much reduced in size, and the muscles are flabby and atrophied. The peronei, solei, and ante- rior tibial muscles are reduced in size, and have lost their electric con- tractility. He perceives pinches, and changes of temperature, and the " wire-brush" produces much pain. The skin is cold, mottled, and dry, and here and there is dotted with patches of scurfy eruption. CASE II Annetta F., aged 10 years. About three years ago she be- came quite ill after a sleigh ride, and it was supposed that she had " caught cold." Her feverish symptoms were quite decided, and she was slightly delirious. After several days she seemed to improve slightly, but on awaking one morning it was found that she was paralyzed and unable to rise ; and she complained of intense backache and tingling of the limbs, which, however, were of very short duration. About two months after this she began to recover the use of her arms, but the legs were more fully paralyzed ; and it was several months before she began to move her toes, and finally make feeble movements of a more extended character. The muscular contractions of the flexors were performed more easily than movements requiring extension ; and, after a time, she attempted to walk, but at first this act was impossible. During the next year she was obliged to use crutches, and needed the assistance of her nurse. When I saw her, there was talipes equinus varus of the left foot, while the right seemed to be but little affected. Flexion was possible, but extension of the leg or foot was beyond her power. There was some relaxation of the ligaments of the knee-joint, so that when I made extension I caused the tibia to form an obtuse angle with the femur, so that there was some anterior curvature. Her gait was peculiar, and she swung the left leg, bringing it down with a jerk. The skin covering the left leg was dusky and mottled, and seemed in close contact with the tissue beneath ; and the surface-temperature was several degrees below that of the other side. No rectal trouble. CASE III A girl sent to me by Dr. Lockwood, of Xorwalk, had pre- sented, among other symptoms, mitral disorder, fever, general paralysis, residual paralysis, paraplegia, and paralysis and atrophy of the right deltoid, which cannot be made to contract when subjected to either current. Right leg more affected than the left. CASE IV A girl 10 years of age. At the second year after a fall she became feverish, was delirious, and took to her bed. There was general 16 242 DISEASES OF THE SPINAL CORD. paralysis of the right leg and thigh ; but after three months there was im- provement, except of the leg, which remained paralyzed. There are now a pronounced talipes varus, complete atrophy ot the anterior muscles, ami utter loss of electro-muscular contractility. She has used various forms of orthopa-dic apparatus without relief. CASK V. Frank N. C., 4 years old, a stout, rugged boy, enjoyed good health until January, 1H77, when he contracted scarlet fever, with albiimiiiuria as a result. From this he recovered, but in August he again fell sick with what was pronounced to be rheumatic fever. There were high temperature, some diarrhoea, which lasted for a number of days, pain- ful joints, and loss of power in both lower extremities. The power re- turned in the right leg, so that by the middle of September (three weeks from the invasion of the fever) lie had control of that member. The left remains powerless, and there has been slow atrophy. The extensors of the leg and foot are now powerless, and there is decided atrophy of thcM- and the posterior tibial, adductors of the thigh and anterior muscles. The knee-joints are quite weak, and there are projections on the inner side of both knees. He is knock-kneed, no eversion or inversion of feet, but there is slight talipes of the left foot. CASE VI Mamie AV., 6 years and 1 month old, always was a nervous, excitable child. Has had several convulsions in her life of an epileptic character, without any after-effects, or apparent coexisting disease. In July last she had whooping-cough. On September 4th she was taken with colic, malaise, and convulsions, during which the body became rigid, and she frothed at the mouth. These convulsions appeared at 5 P. M., and lasted until midnight. She was unconscious all the time. At 7 P. M. the corner of the mouth became drawn up by spasms. She had fever dur- ing the following day and for a number of days. Did not make any attempts to move for a number of days, and for twelve days she could not speak. She was found to be generally paralyzed, and after a short time the arms recovered their strength, but the legs began to lose their size and shape, and became smaller than they were before. Her mental condi- tion is defective (five weeks after attack). And, though there is no impairment of bladder or rectum, she does not call attention to her wants, but defecates and urinates in her clothing. Power of upper extremities good. The legs are cold and mottled ; there is slight talipes on both sides; and great wasting of the flexors of the feet, especially of the right. Faint contractions are excited by the strongest faradic currents, but she can move her toes very feebly, but not flex the foot. She has control over the thighs. I?oth feet are slightly everted. There is redness of the skin covering the right knee, but no pain; no pain in back; slight impairment of sensation, but reflex irritability not embarrassed, as was demonstrated by pinching; pupils moderately dilated. The muscles of the leg are more often affected than those of any other part. In nearly every instance the tibiaJis anticus is paralyzed, and in 18 of the 23 examples I have noticed this muscle was affected. The peroneus ter- tnis, lonrjus; ertensores longi dif/itornm, proprius pollicis; and the Jieroreg longi digitorum, and longus pollicis, are usually affected. The deltoid is paralyzed more rarely, and of the cases I have enumerated there were but two in which this muscle was affected. The muscles of the up- per extremities are seldom involved in comparison with those of the leg, and those that are usually paralyzed are the flexors of the hand. Though ANTERO-SPINAL PAKALYSIS OP INFANCY. 243 the muscles of the trunk may be sometimes involved in the early paralysis, it is extremely rare that we find any residual paralysis of any of them. Causes The etiology of the affection is anything but clear. Expo- sure and bad or insufficient food are supposed to account for it, just as they do for many other diseases of the same class. It is a significant fact that more of these patients belong to the lower walks of life than to the higher, and that the children of the destitute poor who come of drunken parents, and are " knocked about" and half-fed, are those who are generally the victims of the disease. As to age, Sinkler has found that 84 of 108 cases were between the ages of six months and three years, and that half of this num- ber were males. Duchenne 1 holds that two-thirds of the cases begin before the second year, which view I am disposed to take. Warm weather seems to favor the development of the disease, and in nearly two-thirds of Sink- ler's cases the disease began in the months between May and October. Cases have been reported in which the exanthemata have preceded the paralysis, and varicella, measles, and scarlatina may be mentioned among these; but it is probable that in the majority of such cases sclerosis not limited to the anterior columns has been the central condition. Morbid Anatomy and Pathology We are indebted to Charcot 2 and Jotiroy, Duchenne, 3 Echeverria,* and others for reports of autopsies and microscopical examinations, and as the result of their investigations the following appearances may be looked for. In the early stages of the disease there is probably a condition of sub- acute myelitis, with softening and destruction of nerve-elements, etc. This is confined exclusively to the anterior horns. Some of the nerve-cells of this portion of the cord are sometimes filled with granular pigment deposits, while others are disorganized and broken up. The nerve-tubes of the anterior roots will be found shrunken, the myeline absent, but the axis cylinder is nearly always intact. In other cases of longer standing there are evidences of atrophy of the anterior horns, perhaps amyloid degeneration, and sometimes sclerosis. The nerve-cells are found in an atrophic condition, or absent altogether. The white matter of the anterior and lateral columns is not rarely the seat of such degeneration, and proliferation of the connective tissue is sometimes found. In 25 cases, collected by Seguin, 5 the constancy of the lesion is very clearly shown. The anterior horns together were affected in . . .11 cases. The right anterior horn alone was affected in . . . * . 1 case. The left " ** ... 4 cases. Both affected in 6 " Sclerosis of antero-lateral columns (chiefly) and other white matter . . 13 " Tubercules and blood-clots . . . . . 2 " Meningitis and meningeal congestion . . . ' ^ . . 2 " 1 De 1' Electrisation localise, 3d ed., Paris, 1872, p. 417. 2 Arcliiv. de Phys., tome iii. 1870. 3 Ibid., tome iv. 1870. 4 Reflex Paralysis, etc., p. 29, ISTew York, 18G6. 5 Spinal Paralysis, etc., pp. 12-13. 244 DISEASES OF THE SPINAL CORD. Dumaschino 1 and Roger, Cornell,* Clarke, 8 Charcot, 4 and Joffroy have udded many histories to those given to the profession by the early writers, and it is now well settled that the anterior horns and lateral columns are the seats of the central lesion. Rosenthal 5 considers that the primary cause is dilatation and thickening of the vessels, and does not believe that the morbid process begins by degeneration of the nerve-cells. Notwithstanding the appearance of well- defined lesions in nearly every case, there are occasional examples of the disease where no central changes are to be found. Ke"tli 6 reports one of these in which extensive muscular alterations were visible, but not the slightest indication of central disease. Elischer 7 examined the muscl -, which were seen to be the seat of both fatty and colloid degeneration. The sareolemma and nerves were not altered. In the striated muscles, instead of the single normal cell-nucleus, there were seen three or four granular cell-nuclei, which seemed to be at the same time enlarged, and contained two or three, or even more nucleoli. The contractile material was diminished, so that it did not fill out the sheath, but drew away from it. This atrophy was so great that at the upper and under part of the spindle-shaped cell-nucleus of the sheath there was hardly to be found a breadth of .002 millimetre of cross-striped contractile muscular substance. Ke"tli thinks that these changes in the muscle without central disease point to the peripheral nature of the affection, in which opinion he has but few followers. Lesions of peripheral nerves have been found by various observers. Rinecker 8 reports an autopsy, made by Forster, in which these nerves were found to be thin, shrunken, and greatly degenerated. The bones and muscles present appearances which are perhaps more inte- resting than those of the cord. The muscular fibres are at first found to be reduced in size, and subse- quently the transverse striae gradually disappear, while the longitudinal fibres become more marked. There is a marked increase in the connective tissue, and next a fatty degeneration, the oil-globules taking the place of the normal muscular tissue, and finally nothing remains but the connective tissue and fat, which latter disappears, leaving the sarcolemma bound together by connective tissue. The accompanying cuts, from Duchenne, show the changes that take place. The bloodvessels running to the atrophied muscles are often of smaller size than they should be, and sometimes are the subject of atheromatous degeneration. The bones also undergo atrophic changes, becoming friable and thin, 1 Gnz. M6d. de Paris. 1H71. * Ibid., 1864, p. 290. 3 Mfd.-Chir. Trans., vol. ii. 1869, p. 249. 4 Op. cit. 6 Quoted by Fox, op. fit., p. 290. 6 H'i'l. 7 11,1,1. Jsihrs. ftlr Kinderlu'ilkundc, 1871, 5 Heft 1. ANTERO-SPINAL PARALYSIS OF INFANCY. Fig. 31. 245 a. Normal fibre. A. Represents the normal fibres with well-marked transverse striae. B. The transverse striae are not quite so distinct, but the longitudinal fibres are well marked. Firtance, and it is advisable to begin an energetic course of bromides and ergot, with the actual cautery, before the atrophic condition commences. After this the central disease is very difficult to manage. Heine recom- mended strychine (FF. , 1), 10, 32, 40, 42), which, in young children, may be given in doses of -, ^ O th of a grain, and afterwards increased. Cod- liver oil and sea-air, good food, and tonics are of as much importance as anything else. AN hen we come to the treatment of the paralyzed muscles, we may try electricity, massage, hypodermic injections of strychnine, and the applica- tion of heat and cold. If the faradic current be found to be incapable of producing contractions of the paralyzed muscles, we must make use of the 1 Ullsburger's Prize Essay, Am. Journ. ot'Obstet., 1870-71. ANTERO-SPINAL PARALYSIS OF ADULTS. 247 galvanic current. From ten 'to thirty 1 cells of any good galvanic battery should be employed, and the electrodes must be covered with sponge or cloth. When the positive electrode is placed in the groin (if the legs are paralyzed), and the negative over the muscle or muscles paralyzed, a con- traction may be seen ; if such does not take place, the current may be slowly intermitted by proper apparatus, or by simply removing the sponge from the surface and reapplying it again. If the current be too strong, or if the application be too protracted, we may be disappointed, for the small amount of electric irritability that exists may be quenched before an ap- preciable contraction is perceived. It is therefore better to use a current of low tension. If we are gratified by the appearance of a contraction, we should produce two or three more and then stop for the day. By increas- ing the muscular stimulation little by little each day, we may finally create powerful contractions with a minimum current, and after a short time we may substitute the faradic current. It is of great importance that muscular relaxation should be produced during the use of electricity. I may repeat what I have already said, and add that a tired muscle naturally responds less perfectly to electric stimulation than one which is unimpaired. If massage is used, it is well to knead and rub each muscle every day. Should electricity fail to relieve the contracted condition of the limbs, which may be present, we may avail ourselves of the knife. Tenotomy is often of service, but it should not be prematurely resorted to, but left as a last resource when all other remedies fail. Volckman speaks in glowing terms of the use of Junot's boot, which, with the rubber muscle of Sayre, and the plaster bandage, is a useful form of treatment in these ancient cases. The paralyzed limb is placed in the boot and the air exhausted, so that a determination of blood to the part shall be induced. ANTERO-SPINAL PARALYSIS OF ADULTS. Synonyms Acute anterior spinal paralysis. Subacute general ante- rior spinal paralysis (Duchenne). Spinal paralysis of adults (Meyer. Charcot, Gombault). Myelitis of the anterior horns (Dujardin-Beau- metz, Seguin). Acute spinal paralysis of adults (Petitfils). Anterior poliomyelitis (Erb, Eisenlohr). Acxite anterior poliomyelitis (Kussmaul). Definition A myelitis of the anterior horns of the spinal cord, either symptomatized by an acute invasion attended by fever, and followed by sudden paralysis, or by the gradual appearance of the paralysis which be- comes complete and next partially disappears, leaving certain muscles affected ; unattended by loss of sensation, or vesical and anal trouble. Symptoms I am indebted to the little memoir of Dr. E. C. Seguin for assistance in the preparation of this article, and for the report of a 1 It will rarely be found necessary to use this number, and it is advisable to begin with the weakest current that will provoke contractions. 248 DISEASES OF THE SPINAL CORD. Fig. 35. case which afterwards fell under my observation when I followed him :is visiting physician to the Epileptic and Paralytic Hospital. Duchemic 1 first called attention to this form of paralysis as early as lHf)3, and recognized its identity with infantile paralysis. In 18f>3 Charcot* was struck- with the similitude between the two diseases, and in 1872 73 and later years Gombault, 8 Dujardin-Beau- metz, 4 Petitfils, 6 and Bernhardt 6 have presented cases, and decided the fact that infantile paralysis had an analogue in adult life. Gombault brought forward the first case with an autopsy confirming the theory enunciated by Duchenne. In this coun- try Hammond 7 has written quite fully, and later the admirable little works of Seguin epitomize all that has already been brought forward. The first case seen by Seguin 8 has since fallen under my observa- tion, and from his published notes I copy her his- tory. Female, unmarried, aged twenty years. Admit- ted to the Epileptic and Paralytic Hospital, Black- well's Island, service of Dr. E. C. Seguin, Novem- ber, 1H71. Patient presents a paralyzed and ex- tremely atrophied left leg, and gives the following imperfect history : The trouble began nine months ago, suddenly during sleep, with painful contrac- tions : she then gradually(?) lost power in the left leg : no other limb affected. The patient cannot state how long a time elapsed between the first symptom and the discovery of palsy. She adds that, on the day before the attack, her left leg felt quite cold and a little numb ; and that her menses were suppressed. No cause is apparent no hereditary influence, no injury. Examination : Left foot is drawn up in moderate pes eqmnns, with inward inclination. No voluntary movements below the knee. The patient's answers to the festhesiometer test are unreliable ; sensibility to painful impressions is somewhat impaired, that to temperature preserved ; tickling is felt equally on both feet. Pressure shows tenderness over the lumbar vertebra; ; no spontaneous pain. The right calf measures 2(5.0 c. in circumference, the left 23.7 c. There is absolute loss of electro-mus- cular contractility in all the muscles of left leg. The left leg is very cold, and its circulation feeble. I frequently called the attention of the resident Antero-spinal Paralysis. (Seguin.) 1 Do 1* Electrisation localises, Paris, 1X72, p. 437 et seq. 1 Tapers of Petitttls. 1 Arcliiv. de Physiol. Norm, et Path., 1873, pp. 80-87. 4 DC la my&litp aiglie, Paris, 1H7'2. 8 Consideration sur 1'atropliie aiglie des cellules mortrices, Paris, 1873. ' Arch. fUr Psych, mid Nervenkrank., 1874. 7 Diseases of Nervous System, N. York, 1877, p. 470 et seq. 8 Spinal Paralysis, N. York, 1874, and Anterior Myelitis, 1877. ANTERO-SPINAL PARALYSIS OP ADULTS. 249 staff and of friends to this remarkable case as one of the same kind as that which, occurring in the early years of life, we call infantile spinal palsy. The subsequent history need not be reported. No treatment did any good ; the girl remained in the hospital without any active symptom, and went away October 3, 1873, carrying this wasted left leg. She was em- ployed as a help in the wards of the Convalescent Hospital on Hart's Island, and was there much exposed to cold. The second attack, of which patient gives a good account, came on late in 'December, 1873. Had pains "like rheumatism" in right leg; there was a feeling of pins and needles in the limb, this numbness extending above the knee. She is positive that on the fourth day the right leg was completely paralyzed. No symptoms in left leg. No bedsore, and no affection of bladder or rectum. Re-admitted to the Epileptic and Para- lytic Hospital, March 3, 1874, with atrophy and palsy of both legs ; no acute symptoms. During the spring and summer this patient rather gradually lost strength in the thighs, in the right most. She also exhibited a variety of interest- ing visceral disturbances, consisting of amenorrhoea, lasting two and three months; the menses then appearing with much pain, the blood "abundant and in clots ; there were also pains in the back and lower abdomen. On many days in this period the urine had to be drawn off with the catheter, and it often was bloody, exhibiting a heavy mucous deposit, and contain- ing albumen. The microscope showed only leucocytes and a variety of epithelial cells there being probably both pyelitis and cystitis. Since the middle of September has not required the catheter, and, with excep- tion of palsy, has been better. Re-examined October 25, 1874. Patient, when she first came in this year, walked ill with a crutch and stick ; is now able to walk with two sticks (result of education). Cannot stand or walk without help. The patient is a stout and healthy girl, exhibiting nothing abnormal above the hips. Both lower extremities are extensively palsied and much wasted. The left leg (first attacked in 1871) shows no voluntary movement below the knee, with exception of slight separation of the toes. As the patient lies on the bed she is able to raise the extended limb as a whole ; but the strength at knee-joint is small. The thigh is thin and flabby ; the leg is the seat of extreme atrophy, and looks just like the same part in cases of infantile spinal palsy, there being apparently only connective tissue and fat around the bones, the skin being bluish and very cold to the touch. The right lower extremity (paralyzed in 1873) is in a very similar though less extreme state. All voluntary movements are possible with the foot, though they are feebly performed. The limb, as a whole, cannot be raised from the bed, and flexion at knee-joint is weak. The quadriceps exten- sor femoris is wholly paralyzed ; the flexors of the thigh upon the body act feebly ; the adductors fairly. Both feet lie extended and adducted ; toes flexed. The right leg is, like the left, extremely wasted, bluish, and quite cold. Sensibility to contact, pain, and temperature are preserved in both limbs. Tickling is felt, but produces no reflex movement in the palsied parts. The electro-muscular reaction of the atrophied muscles of both limbs is lost (both currents). At present, urine is passed normally. The patient's arms, shoulders, and chest are large and rounded, standing in remarkable contrast to the dwindled legs. There have been no bedsores and no spinal epilepsy. 250 DISEASES OF THE SPINAL CORD. Circumference of right thigh (lower third) . . . 31.5 c. " left " " " ... 30.5 " right calf 24.0 left " 21.5 " forearms 25.0 On a healthy girl (non-palsied) of same proportions as the patient the following measurements are obtained : Circumference of right calf ...... 35. Oc. " left " 34.5 " forearms . . . . . .24.0 The patient having been in bed some time, well covered up, has a ther- mometer held between the great and second toes of each foot for three minutes, with results: Right side, 84.25 Fahr. ; left side, 86 Fahr. In March, 1876, the patient came under my charge, when I found that her condition was somewhat aggravated. She manages to go about with the aid of crutches, but has utter loss of power below the knees. .The tac- tile sensibility is much lowered, and tickling can be borne without any reflex movement being produced, and she has lost control to a great ex- tent over the bladder and rectum. Another case reported by Lincoln is well worth presenting as illus- trative of this form of disease beginning without fever. A tall, stout man, 1 49 years of age and of previous good health, noticed one morning, without any previous symptoms, a feeling in his legs as if they had fallen asleep. The feeling came on again and again through the day, and he began to be a little weak in the legs. In the afternoon, when trying to step upon the platform of a street car, he failed, and had to be helped in. On arriving home, he was able (with assistance) to walk up stairs to his bedroom, and went to bed, where he remained. When seen by Dr. L., two days later, he felt well, no giddiness, muscles of face and eyeballs under perfect control, pupils normal in size and con- tracted well, speech natural, vision and hearing without defect. The bladder and rectum performed their functions normally. The senses of touch, pain, and temperature were normal in the hands, and nearly so in the feet. Heflex contractions could scarcely be obtained from the soles. There were no abnormal sensations. Pulse, 80 ; temperature, 98. No albumen in the urine. The muscles of the neck and limbs, except below the knees, were gene- rally in a condition of semi-paralysis. He lay on his back almost help- less ; could not raise his head from the pillow without some help, and could not raise his knees from the bed by flexing the thighs. The grasp of his hand was very feeble indeed. There was no paralysis of any mus- cle. Below the knees he seemed to have more strength. The weakness was much more marked on the left than on the right. Treatment consisted at first in mix vornica and cinchona, and subse- quently tincture of iron with strychnia, and Horstbrd's acid phosphates of lime and magnesia. On the fifth day of the attack, treatment by the induced electric current was begun, when it was found that some at least of the muscles had lost part of their susceptibility to this stimulus. The 1 Boston Medical and Surgical Journal, March 25, 1876. ANTERO-SPINAL PARALYSIS OP ADULTS. 251 loss went on increasing until the twenty-first day, when the galvanic cur- rent was substituted, a descending current being applied to the spine, and interrupted currents to the muscles, three times a week ; the faradic cur- rent was also continued for a few weeks. The hot-air bath to profuse perspiration was used just before the appli- cation of the currents, together with regulated gymnastic exercises. The paralysis of the muscles was gradually relieved under this treatment to a very considerable degree. The patient's improvement was very gradual, and it was six months before he was able to ride out. He finally was en- abled to attend to his business pretty much as before the attack. Other cases begin much more slowly, and several of this kind are re- ported by Duchenne, but the origin of the disease is nearly always sudden. There may be pain and dysaesthetic symptoms, or no warning at all, the patient awaking in the morning and finding himself paralyzed, as was the case with Seguin's patient. Like the infantile form, there may be an acute attack of fever, which may last for several days, during which there is usually delirium or rigors. The paralysis appears during this time, and may be general, so that the upper and lower limbs are affected and the loss of power is complete. The functions of the bladder and sphincter ani ore always normally performed until other parts of the cord are affected, and there is neither incontinence of urine nor involuntary evacuations. At the end of a few weeks there is a commencing improvement, some of the muscles regaining their lost power and contracting quickly under electric stimulus, while atrophy of those already paralyzed begins to take place. The skin over the paralyzed limbs is quite cold and blue, and there is diminution of temperature and faradic excitability, while ulti- mately it is impossible to provoke any response, and the limbs become deformed and twisted. Atrophy of deeper parts follows, and the bones become reduced in size, while the articular ends appear large in contrast with the attenuated size of their shafts. Sensibility is rarely disordered, though exceptional cases of anaesthesia or hypergesthesia are met with, but after the inflammation has involved the posterior columns the phenomena of general myelitis are presented. Dysaesthesiae are common, and the patients complain of subjective cold, various pains, and the waist-constrict- ing band. The muscles of the face, neck, chest, and abdomen are rarely affected, but the extremities remain deprived of pain after there has been a considerable retrocession of the original complete paralysis. The atro- phy is rapid, and differs from that of progressive muscular atrophy in the fact that whole groups are affected at a time, while the peculiarity of pro- gressive muscular atrophy is that muscles are irregularly affected. There are never bedsores. Erb 1 alludes to a light variety of spinal paralysis, which has been de- scribed by Kennedy, Fry, and others. To this variety has been given the name " temporary spinal paralysis." The paralysis is characterized by its brief duration, and may involve a limited group of muscles or seve- ral groups. It would seem, therefore, that there are two varieties : the 1 Ai'chiv fur Psychiatric, Band v., Heft 3. 252 DISEASES OP THE SPINAL CORD. temjxirary and permanent ; but Seguin and others have made the classifi- cation nettle, stibacttte, and chronic, which is based rather upon the variety of myelitis than the paralysis. Duchenne applies the term sub- acute to the former, which begins without fever, attacks the lower ex- tremities first, and, extending upwards, involves the muscles of respiration and deglutition. Causes The same unsatisfactory history of exposure, fatigue, and jKM-ipheral irritation is connected with the history of this as well as other spinal diseases. In four of Seguin's cases surface exposure to cold is said to have produced the attack, and in three other cases " refrigeration" is named, while in others dysentery, measles, and other acute diseases were at the origin of the trouble. As regards age and sex, I can do no better than refer to the tables of Seguin. All of the patients whose histories he collected were of middle age. " The greatest age at the time of seizure was 62 years, the least 18 years." Among 17 cases reported by various observers, there were 13 men and 4 women. Morbid Anatomy and Pathology But very little light has been thrown upon the morbid anatomy of the cord, which accounts for this form of paralysis. Chalret 1 and Gombault* have reported two cases. The appearances found may be briefly enumerated as these: The horizon- tal fibres which pass from the anterior horns to form the anterior spinal nerve-roots were diminished in size, and the large ganglion-cells of the anterior roots were atrophied, having undergone yellow pigmentation. Some of the nerve-cells which had not undergone this form of degeneration were also reduced in size. This information is very meagre, though these two cases illustrate the pathological anatomy of the disease. Charcot and the majority of observers believe that the situation of the lesion is always in the anterior horns. The only matter of dispute seems to be whether or not there is primary degeneration of the cells, or an acute interstitial mye- litis and secondary injury of the nerve-cells. This latter view is held by Krb, 3 and, I think, is being generally adopted. The muscles were found to be in a state of fatty granulation, which is the case in the infantile variety. In some respects the disease resembles progressive muscular atrophy and bulbar paralysis, the lesion being atrophy of the motor and trophic cells, but it is probable that the trophic cells are primarily affected in these latter diseases. Diagnosis Antero-spinal paralysis is likely to be sometimes mis- taken lor progressive muscular atrophy. If we bear in mind its sudden or almost sudden and complete origin ; the absence as a rule of fibrillary tremors (only two eases which presented these symptoms having been re- Ijortwl); that the paralysis precedes the atrophy, and retrocedes after the first general attack; that electric irritability is primarily lost ; and that the atrophy involves the muscles of one or more (usually two) limbs, there 1 Thfese (K- Paris, 1872. 1 Arclu'v. dc Physiol., Norm, et Path., tome v. 1873. 3 Op. cit. ANTERO-SPINAL PAEALTSIS OP ADULTS. 253 need be no error made in diagnosis. Anaesthesia, incontinence, and pa- ralysis of the sphincter ani prevent it from being confounded with general myelitis, these symptoms belonging to the latter in addition to the loss of power and atrophy. Spinal congestion may sometimes give rise to some of the symptoms, and Cartwig 1 presented a case which he called " inter- mittent," somewhat resembling the lighter form of true antero-spinal paralysis. A sugar-baker, aged 23, who was exposed to great heat and sudden changes of temperature while very lightly clothed, had suffered in his eighteenth year for four or five weeks from an attack of tertian ague, from which he recovered. One day he perceived a numbness in his legs, which rapidly attacked his arms also, and finally led to complete paralysis of the muscles of the neck. Speech, deglutition, and respiration were somewhat impeded; the muscles of the eye were unaffected, as were also the alvine and urinary excretions, and sensation. After twenty-four hours there was a remission of the symptoms; first the neck began to become movable, then the fingers, arms, body, and finally the legs. All this took place in half an hour, and was followed by an increase of perspiration. During the next twenty -four hours the patient remained free from paralysis, but was dull; after which, the above-described symptoms returned. The brain was always free ; the cervical portion, especially the upper, was not always equally affected ; the movements of the neck were often free ; and difficulty in deglutition and respiration, inequality of the pupils, and myo- sis, were frequently present. The phrenic nerve was always unaffected. When there was not complete paralysis, the affected limbs were generally stiff, and there was contraction of the predominating groups of muscles ; when complete paralysis was present, the muscles were soft and flabby. Electro-muscular irritability was almost completely absent during the pa- ralysis, and the violence of the muscles varied. Under the use of quinine, the patient's condition was on several occasions quickly improved, but he was not cured. He was under observation for more than six months. The author believes that the case was one of masked intermittent, and that the phenomena were due to hypersemia of the cord and occasional increase of serous exudation. In spinal congestion there are no deformities, no atrophy, and nearly always vesical trouble and constipation. Acute ascending paralysis has been described by the French writers, and resembles very closely certain forms of the disease under consideration. In one remarkable case of this kind reported by Desjerine, 8 no morbid ap- pearances were found after death. A man entered the hospital suffering from undefined pain in the lower limbs, and two days after became para- plegic without any loss of sensibility. The paralysis rapidly ascended, and, after four days, he died; no trace of disease after paralysis of the respiratory muscles could be found except dilated vessels. Seguin considers that this involvement of the respiratory muscles is a diagnostic sign. 1 Centralblatt f. d. Med. Wiss., June 15, 1870. 2 Archives de Physiol., etc., June, 1876. 254 DISEASES OF THE SPINAL CORD. Prognosis Antero-spinal paralysis is not a disease which is rapidly fatal, and many cases recover within a short time after the beginning of the attack. I am not disposed to think that the lesion is an ascending one; but rather that, if it progresses at all, it involves the posterior parts of the cord in the majority of cases, and does not spread longitudinally. This is probably the condition of affairs in the case of S. W. Should the paralyzed muscles become atrophied to such an extent that deformities result, I think that there is very little hope for the patient. If, however. the muscles can be made to respond to the galvanic current, we should never be discouraged. Of the cases reported by Duchenne, Meyer, Hammond, Bernhardt, Se- guin, and others, I find that of 1C cases there were but 2 deaths. In one case there was improvement in six months, in another in four, and in others two, three, eleven, and twelve. In two cases the patients were cured, and in several there was progressive unfavorable advancement. Treatment. In electricity we possess a remedy of the greatest value. I have already called attention to its use in the infantile form of the dis- ease, so there is no need for going into details. It is well to use both the galvanic and faradic currents, and in the acute form of the trouble we should begin with counter-irritation of the spine as early as possible, and for this purpose may employ blisters or the actual cautery. Ergot and belladonna in rather full doses should be employed in con- junction therewith (F. 7G). Seguin recommends leeching and dry i-ups. which are both excellent. Should the pain be severe, we may use morphine by means of the hypo- dermic syringe ; or spinal galvanization. The after-treatment should be with the galvanic current. Hammond has benefited some of his patients by the use of the iodide of potassium and ergot, but it is probable that ergot possesses the most value. PROGRESSIVE MUSCULAR ATROPHY. 255 CHAPTER X. DISEASES OF THE SPINAL CORD (COXTIXCEB). PROGRESSIVE MUSCULAR ATROPHY. Synonyms Wasting palsy ; Cruveilhier's paralysis ; Progressive mnskelatrophie ; Progressive muskell'ahmung. Definition This is an essentially progressive atrophy of certain groups of muscles. It is not preceded by any paralysis, but followed by loss of power, and terminates usually by involvement of the respiratory nerve-centres. Cooke, 1 in 179$, directed attention to a condition he called "anomalous hemiplegia," which was clearly progressive muscular atrophy, and his was probably the first recorded case. Bell, 2 Abercrombie, 3 and Darwell 4 each published cases which were undoubtedly of this kind; and, in 1836, Mayo 5 related two cases. It was not, however, till 1849, when Duchenne de Boulogne 6 presented a memoir to the Institute of France, entitled i 'Atrophie musculaire avec transformation graisseuse," that the pre- sent disease was recognized. In 1853, Cruveilhier 7 described some cases in which the atrophy was general, all the voluntary muscles being affected. In 18501856, Aran, 8 Duchenne, 9 and Eisenmann 10 brought forward additional facts, and the latter agreed with Cruveilhier that the "nerves or nervous centres are at fault anterior to the muscles, and that the atrophy of the latter is a secondary process." Since that time we are in- debted to Roberts 11 for the most clear and instructive article that has yet been written. Symptoms. The appearance and progress of the disease are most gradual. The affected individual may first notice a slight weakness in one of the upper extremities, and if he be a tailor, as was one of my pa- tients, he finds difficulty in handling his shears. Perhaps the first indica- tion of trouble which suggests to the patient the commencement of the 1 Cooke on Palsy, p. 31, 1822. 2 The Nervous System of the Human Body, London, 1830. 3 On the Brain and Spinal Cord, p. 419, Edin., 1828. 4 Loud. Med. Gaz., vol. vii. p. 201. 5 Outlines of Human Pathology, p. 117, London, 1836. 6 ^Jemoires de 1'Acad. des Sciences, 1849. 7 Archives Gen. de Med., May, 1853. 8 Ibid.. Sept. 1850. 9 De 1' Electrisation localise, Paris, 1850. 10 Canstatt's Jahresbericht, 1859. 11 An Essav on Wasting Palsv, London, 1858. 256 DISEASES OF THE SPINAL CORD. disease, is when the act of writing is attempted. According to Roberts, the disease begins, in two-thirds of the cases, in the upper extremities, and the muscles of the hands are the first to suffer loss of function. Yn-y often several muscles are affected together, and they soon become agitated by what are known as Jibrillttry contractions, or, as they have been called, vermicular contractions. The subcutaneous contraction of muscular fila- ments suggests the appearance of worms crawling beneath the skin, and there is sometimes a species of muscular shivering. These fibrillary contractions may be excited by sharply striking the muscles with a ruler or the hand, and they sometimes follow the passage of the galvanic cur- rent through the nerve-trunk. As I have said, the hand may be affected first, and there may be extensive wasting here before other parts are attacked. The muscles of the palm of the hands, when atrophied, give to that member a most unsightly appearance. The bones stand out in strong relief, and the thenar and hypotlienar eminences are flattened, and the flexor tendons are prominent, and increase the deformity. With this there is contraction of the flexors, and the hand resembles more the claw Fig. 36. Main en Griffe." (Roberts.) (Fig. 30) of an animal than anything else, so that it has been called "le main en griffe." The back of the hand also presents a most skeleton-like aspect, the extensors, the interossei muscles, and sometimes the adductive of the thumb having l>een reduced in size. The forearm and arm are next to follow, and rapidly lose their normal conformation. The deltoid and serrati muscles may be involved, while those of the arm proper may occasionally be passed over. The head of the humerus and angle of the scapula are quite distinct, and this bone may be drawn out of place by the healthy muscles, this being the rule when the serratus magnus is the seat of atrophy. The angle cf the scapula is drawn upwards and inwards, and stands out from the trunk. It is rare to find symmetrical atrophy, and in the majority of cases I have seen there has been a great difference in the invasion of muscles on the two sides. The right upper extremity appears to be the favorite seat of the atrophy, while the lower extremities are quite rarely affected, and in the proportion of 1 to 12 to the upper ex- tremities. The muscles of the face and head are sometimes the seat of atrophy, but this is unusual, though muscles may occasionally be so ex- tremely wasted that there is no appearance of intelligence whatever. The eyes, of course, being unaffected are the only agents of expression. There PROGRESSIVE MUSCULAR ATROPHY. 257 may be atrophy of the tongue and buccal muscles, with disturbances of speech and drooling of saliva, and in such cases death usually follows in a very short time. Sometimes the muscles of the neck do not escape the extension of the disease, and the chin falls forwards and downwards. The last muscles involved are generally those concerned in respiration ; and not only are the intercostals the subjects of such a change, but the diaphragm is finally paralyzed, so that the action of the lungs is interfered with, and ultimately the patient is literally asphyxiated. Subsequent to atrophy, a loss of power takes place. The affected muscles preserve for a long time their electro-contractility ; but this is finally lost as they decrease in size, and loss of power increases till finally the patient becomes helpless. Tactile sensibility is, however, rarely blunted. One of the earliest symp- toms of progressive muscular atrophy is the presence of dull pains in the affected limbs, and this has led very frequently to a mistake in diagnosis, the condition being often considered rheumatic. In one case sent to me by Dr. E. G. Loring, I found that the atrophied muscles were the deltoid, serratus magnus, and biceps, but none of the lower muscles of the forearm were attacked. The man had consulted another physician, who considered the case one of chronic rheumatism, and prescribed liniments and alkalies. The patient was an upholsterer, and had been obliged to use his right arm to a great extent, especially in hammering on cornices, and putting up decorations which were above his head. He had had violent pain in the shoulder for some months, and subsequently the atrophy began in the del- toids. When I saw him the head of the humerus was prominent, and there were fibrillary contractions in some of the muscles of the back. The progress of the disease is marked by the occurrence of well-marked inter- missions, and a year or two may often pass without any extension, while at the end of that time a fresh start is taken, and two or more of these sta- tionary periods are not uncommon in the course of the malady. The ordinary tendency of the affection is however progressive; and although, as I have said, the disease may pursue the most eccentric course, attack- ing groups of muscles here and there, it will involve ultimately a very great number, and finally those supplied by the lower cranial nerves, unless it be checked by proper treatment. I may illustrate the symptomatology of progressive muscular atrophy by a case which ran a somewhat irregular course by attacking the muscles of the lower extremities : J. F. H., 31 years old; U. S. ; engineer. Twenty-one months ago the patient, after exposure, developed what he says was articular rheumatism, which chiefly affected the legs. On recovery he noticed that the right leg " began to grow smaller at the calf," and that afterwards his left thigh became smaller. His pains continued at intervals, and were increased by damp weather. Present Condition The muscles of the anterior part of legs and thighs are much wasted, the adductors of thighs and the recti femoris on both sides being notably so. The knees seem very large, and the condyles of the femur are felt to be superficial and covered tightly by the skin. There IT 258 DISEASES OF THE SPINAL CORD. is no loss of sensation, and electric irritability appears to be very generally preserved, except in the recti femoris. The glutei muscles have sufti-n-.l to some extent on both sides. He has sevei'e pain at night, which runs down the legs, and " seems to be deep." There is impaired motor power, and he finds that walking is difficult. He does not experience any urinary trouble, and his bowels are not constipated. There is no loss of coordi- nating power, no constricting band, no history of any kind of acute mye- litis. The muscles on the outer side of the thigh are the seat of fibrillary contractions, which occur sometimes when he makes a voluntary effort. There was at this time no atrophy of any of the muscles of the upper extremities, but when I saw him some months subsequently there was commencing atrophy of the muscles of the right hand. In the paralyzed Fig. 37. Atrophy of Left Shoulder. muscles the temperature is much lowered, and this is a constant feature ot the disease. Jaccoud 1 and others have called attention to a temperature lhange, which they call " refroidissement variable," in which there are times when the temperature may fall several degrees, and this eeems to be the result of a paroxysmal ischemia of the tissues. The papillary condition s an interesting feature of the disease, the dilators sometimes being para- lyzed, so that the pupils are widely or unequally dilated. Causes These may be enumerated as heredity, which is found to iter conspicuously into the etiology of progressive muscular atrophy, exposure, the over-use of particular groups of muscles, injury of the spi- d cord, and sometimes syphilis and the zymotic diseases. As to the litary influence which favors its development Friedrich* reports several 1 Op. cit., p. 326. 8 Ueber Muskelatrophie, etc. Berlin, 1873. PROGRESSIVE MUSCULAR ATROPHY. 259 cases, and Hammond 1 others, which go to show that this disease more than all others commonly appears in several generations of the same family. I have seen one case where it could be traced for three generations back, and in another, which I will presently detail, there were uncles and aunts affected. Eichert, 2 in a very valuable article, gives the family history of one case. In a genealogical table he traced the disease back six genera- tions, and representatives of these generations are still living. Seven cases are related by him. In two of the cases the parents have escaped, while the children have suffered. It is unnecessary to pursue this matter further, but I am firmly convinced that there is no other disease, except perhaps it may be phthisis pulmonalis, which is transmitted so frequently as this terrible malady. Exposure to damp, neglect to change wet cloth- ing, and like imprudences, are exciting causes in many cases. Neuralgic pains are very prominent in such cases, and the onset of the disease is rather precipitate. Mechanics of all kinds, who are in the habit of using some muscles much more than others, are frequently the victims of the disease, and the muscles which have been over-used are affected before the others. The case of a ballet-dancer is reported by Hammond in which the sural muscles were affected, and I have seen the same limited atrophy in a cigar-maker and in a compositor, who used certain groups of muscles almost constantly. Roberts has dwelt upon the connection between injury of the spinal cord and the disease under consideration ; and Valentiner, 3 Bergmann,* and Thudicum have all called attention to the appearance of the disease some time after the receipt of an injury. Roberts reports a case in which atrophy of the ball of the right thumb, and subsequent com- plication of the respiratory muscles, and death followed a slight injury received six months before. The other cases are none the less interesting, and go to prove the importance of recognizing such causes. As to age and sex it has been found that progressive muscular atrophy is not confined to any period of life, but the bulk of cases occur after puberty. Of 88 cases reported by Roberts, 1 was only 2 years old and another 69. Of the 28 cases I have seen, the atrophy began in 2 between the 5th and 10th years ; in 5 between the 10th and loth ; in 18 between the 20th and the 30th; and in 3 after the 30th. Of these, 23 were men, and but 5 women. This seems to be the rule, and Roberts states that six men are affected to every woman, and he considers this due to the exposure and external violence to which males are subjected. Morbid Anatomy and Pathology The disputed point in regard to the pathology seems to be whether it is a primary peripheral condition, or whether it is a central affection in which the trophic cells are affected. The advocates of the first theory call attention to the fact that muscular atrophy occurs independent of any loss of the muscular function, and believe it to be purely a local degeneration. The authorities I have spoken 1 Op. cit., p. 526. 2 Berliner Klin. Wochenschrift, Oct. 20, 1874. 2 Frag. Yiert., 1855. 4 Petersburg Met! . Zeitsch., 1864. 260 DISEASES OF THE SPINAL CORD. of, in alluding to the early history of the disease, all believed in this intra- muscular origin, but lately there have been so many proofs of its central origin brought forward, that the former theory has been abandoned. This difference of opinion seems to exist in regard to the form of central lesion. The majority of observers are agreed that there is an affection of tin- anterior horns ; and that the change is one that affects the trophic cells of Duchenne and Westphall, and the fibres which connect with sym- pathetic ganglia. To Loekhart Clarke, 1 who has so often decided questions regarding the pathology of nervous disease, belongs the credit of having discovered the central origin of this disease. He has found atrophy of the anterior gray horns, and since his original observations many other observers have come forward to endorse his views. Von Recklinghausen and Dumenil 3 disagree, however, with this view, and the microscopical examination made by the former was unattended with any discovery of morbid ap- pearances. Jaccoud has collected six cases in which fatty degeneration of the sym- pathetic had taken place, and one of them was observed by Jaccoud himself. Not only was there fibre-fatty degeneration of the sympathetic nerve, but there was atrophy of the anterior roots. The view held by Jaccoud is that the trophic filaments of the sympathetic which pre- side over nutrition do not perform their duty, and that the affection of a mixed nerve, which contains motor, sensor, and trophic filaments, at a point where they are intimately mixed, must result in a perversion of all their functions, but if the separate filaments be attacked at a point before they become blended, there may be independent loss of function of either one.' Charcot* and Gombault have described the following interesting post- mortem appearances witnessed in a recent case : " No change in hemisphere, cerebellum, pons, or medulla oblongata in these nerves. The gray substance of the cervical and dorsal medulla spinalis was greatly altered from the lower portion of the cervical enlarge- ment down, gradually decreasing downwards and outwards. The nerve- cells and nerve-fibres of the anterior gray cornua had disappeared ; the capillary vessels were greatly developed; the parietes of the smaller and 1 Brit, and For. Mcd.-Chir. Review, vol. xxx., 1862. 2 (Jaz. Hclxlom., 1867. 8 The localization of well-defined lesions in this disease is sometimes made be- fort: death and verified afterwards. Prevost and Cotard (Archives de Physiol., Sept. 1 874) present such a ease. There was atrophy of the right thenar eminence, with atrophy of the right anterior root of the eighth pair of cervical nerves, slightly marked atrophy of the right anterior root of the seventh cervical nerves, and atrophy of the gray matter of the anterior horn at this level of about an inch in extent. 4 Archiv. dc Physiol., 1875, No. 5, abst. Phil. Med. Times. PROGRESSIVE MUSCULAR ATROPHY. 261 larger vessels were thickened. The lumbar portion of the cord and the lateral columns were normal. In the cervical and dorsal region, the por- tions of the cord near the merging external roots were sclerosed ; the change being proportionate to the intensity of that which had taken place in the gray cornua. The few ganglion-cells present were very much diminished in size, without processes, more rich in pigment than normal, but still containing nuclei and nucleoli. The anterior roots of the cervical region were atrophic ; empty sheaths, frequently containing large nuclei, appeared in place of the normal fibrillar contents. The posterior roots seemed normal. "As to the peripheral nerves, one phrenic and several intercostal nerves were examined ; more than two-thirds of the nerve-tubules (in hardened sections) were wanting, by a process similar, as it would appear, to that induced by an external wound. The muscles about the shoulder and the upper extremities were for the most part atrophic ; there seemed to be a peculiar atrophy of the primitive fasciculi, without any marked alteration in the fibrils, and without any excessive development of the interfibrillar fatty tissue." Lockhart Clarke 1 has discovered marked changes in the gray matter. There was a granular deposit about the vessels, and corpora amylacea about the central canal. Lesions of the anterior nerve-roots were found, and in the cervical region there seemed to be more distinct appearances than at any other point, where it will be remembered there may be found sympathetic as well as motor and sensor fibres. The muscles present distinct evidences of fatty degeneration and fatty substitution. They appear to the naked eye as wasted bands which con- tain lines of fat. The appearance of healthy muscles of good contour in juxtaposition with others which have undergone atrophy is very peculiar, and it is difficult to realize that the disease can involve such isolated tracts. The muscles of the lower extremities may have undergone general fatty degeneration. A specimen prepared by my friend Dr. Weiss, of the Medical Department of the N. Y. University, shows very beautifully this condition of affairs. Fatty substitution has gone on to such an extent that there is no appearance of muscular fibre to be seen, but every muscle exists as a distinct band of adipose tissue. Atrophied muscles have been examined by Meryon, 2 Galliet, 3 and others, and their descriptions of ap- pearances agree very closely. The muscular structure suffers a complete change, the striae disappearing and the sarcolemma undergoing a granular change. Fox 4 divides the secondary changes into the fatty degeneration which takes place inside of the sarcolemma, and as an interstitial deposit. These he calls the parenchymatous and the interstitial. Sometimes, as observed by Robin, the atrophy may take place as a fibrous degeneration, or species of muscular sclerosis. Some muscles appear as fibrous cords of a white color, while others may be found which have undergone the fatty degeneration just described. 1 Mod. Chir. Trans., 1851, 1856. 2 Ibid., 1866. 3 Archiv. Gen., vol. i., 5me s6rie, 1853, p. 584. 4 Op. cit., p. 266, etseq. 262 DISEASES OF THE SPINAL CORD. An instructive case in which very striking appearances were presented was observed by my friend, Dr. Janeway, whose observations are recorded below : M. G., aged 02 years, widow ; admitted to hospital December 16th, 1873. Right hand : the muscles of ball of thumb are very much atro- phied, and she is unable to move it ; there is also slight rigidity of the joints of the thumb. Dorsal interossei are very much wasted ; there is slight power of flexion and extension of fingers, especially little fingers, and there is also a slight movement at the wrist. Sensibility good, except in index finger, and here it is decidedly dimin- ished. She can raise her arm to her head and place it in any position. Hands seem cold. Left hand is not so much affected ; the muscles of ball of thumb are partiallv wasted. The abductor opponens and outer head of flexor brc\ is are almost gone ; the inner head of flexor brevis and abductor partially, and capable of acting to a slight extent. Has slight power of ;il>- and ad- duction of fingers, especially the little finger, most on the ulnar side, and decreasing toward the radial ; has slight power of extension over fingers, none over thumb, but flexion power is more marked. Has no power of extension, but considerable of flexion at the wrist. Dynamometer L. II. 28. Sensibility normal ; hands cold. The mus cles that are capable of acting respond to the induced current very well. July 9. Complains of dizziness and nausea. 17M. Dizziness still. Her hands are in same condition. She expe- riences some difficulty in walking, and moves with her body " sloping over." She cannot use her hands, and when she attempts to do any- thing, they drop, and she cannot raise them. The muscles that remain unaffected respond well to electricity. She still vomits at times after eating. August 3. Is quite weak ; has chilly sensations. .4th. Had a severe fever last night; temp. 104; passed feces in bed, and did not know it ; to-day temp, is almost normal ; is quite apathetic. itth. Has chilly sensations; complains of no pain ; arms and jaws trem- ble ; temp. 102. 2 P. M. Temp. 102. ftth. She is very much worse ; mucous rales heard all over chest ; respi- ration accelerated ; temp, high ; pulse very feeble ; pupils normal ; bowels moved once to-day ; swallows with great difficulty. 2 P. M. She sank gradually, and died at 12.45 P. M. Post-mortem, held tirrnty-seven hours after death Rigor mortis mode- ratelv well marked. Nearly all the muscles of the hands are atrophied, especially the dorsal interossei and the propria muscles of the thumb ; the change is nearly symmetrical in both hands. The forearms are extremely wasted, !>oth on the flexor and extensor surfaces. There is no marked wasting in the arms, the shoulders are well rounded ; both pectoral regions appear waited ; there is no marked wasting in the lower extremities, un- less it be in the adductor region of both thighs. Incisions made into the pectoral muscles show well-colored fibres also in the deltoid, biceps, and triceps. The extensors of the forearms are of whitish-yellow color, being nearly as pale as the skin. PROGRESSIVE MUSCULAR ATROPHY. 263 The flexors of right hand are very much wasted, but not so much as the extensors. The flexors of the left side are small, but seem in good condition. The muscles of the right thenar eminence show extreme degeneration. In left thenar eminence the inner head of flexor brevis and adductor are red and large ; the external is white, as on the other side. The adductors of thighs are small, but well-colored. The quadriceps extensor femoris is of good color. The anterior tibial muscles are of good color. Heart : Valves are normal, muscular substance soft and yellowish-gray. The diaphragm is not atrophied. Brain : Convolutions and corpora striata appear normal. There is some atheroma of the carotid and basilar arteries. The substance of the cord and brain is quite soft. The viscera are normal, except the kidneys, and these are granular ; their pyramids are small, and they contain small cysts. Diagnosis. Progressive muscular atrophy may be mistaken for seve- ral conditions of a paralytic nature, among these lead paralysis, antero- lateral sclerosis, and partial paralysis from traumatism. For an illustration of the first of these I do not think I can do better than mention a case in which there appeared to be lead paralysis, but which subsequently turned out to be progressive muscular atrophy. Several months ago Mr. N., a Cuban gentleman, came to me with a letter from his medical adviser, Dr. Findlay, of Havana. The doctor's history of the patient is as follows : " Mr. N., about eighteen months ago, began to experience a tremor in the fingers and wrist of the right hand, together with muscular debility, which caused some inconvenience in writ- ing, and in carrying food to his mouth, as well as in other movements of the hand. Having on a single occasion submitted to local faradization of the arm (some ten months ago), the tremor was much subdued, and, as was thought, the fingers and wrist were strengthened. It was not, however, until four months ago that the patient returned to put himself under a regular course of treatment. " Condition of the patient in July, 1876 General health good; no signs of cachexia ; no antecedents of specific taint ; no lead poisoning. Suffered on two or three occasions, at some years' interval, rheumatic pains and neuralgia in the arm and shoulder of the left side, but never in the right side, which is the one now affected. The outer appearance of the right arm showed but little muscular atrophy ; the tremor was inconsiderable ; the patient could close the hand tightly, but not well grasp larger objects, such as a tumbler, owing to incapacity to maintain the first phalanx of the third, fourth, and fifth fingers extended. The wrist was inclined to drop forwards (in flexion) and outwards. " On inspection it was found that the common extensor of the fingers was considerably weakened, most so in the portion attached to the ring- finger, the weakness being manifested both to voluntary and to electrical contractility. The same condition existed also, though a little less, in the extensor of the little finger, and in the radial extensors. The contractility was not totally absent, but would vary in degree without apparent cause. The disease continued to progress (notwithstanding treatment), the por- 264 DISEASES OF THE SPINAL CORD. tions of the common extensors losing all excitability to my small Gaiffe's battery, and the extensors of the thumb being also implicated. " The left arm was now examined, and although the patient did not notice any weakness in the hand, some deficiency of electric contractility was observed in the common extensor, especially in the extensor of the ring-linger. The constant current was now used for six weeks without much benefit. The extensor carpi ulnaris is now becoming also affect rd. The patient, however, finds that he can write and perform various acts with the right hand better than before. Within the last week he com- plains of some pain along the back of the left forearm when he has been holding an object in the air, and feels an inclination to relax his grasp." The Doctor also gave a history of hereditary trouble, which was probably in one case (the patient's uncle) progressive muscular atrophy. I can-fully examined the patient, and found that the right arm was that most affected. Motor power The power of extension of the muscles of the right fore- arm was lost completely, and on the left side the power of extension of the two middle fingers was to some degree impaired. Flexion was perfect. Atrophy. The following muscles were more or less affected and reduced in size. Hight forearm: Extensor communis digitorum; extensor minimi digiti ; extensor carpi radialis ; extensor longus pollicis ; extensor carpi ulnaris ; extensor communis of the left. Sensation Slightly impaired on the right side. The teeth of the a?sthesiometer were separated by a space of about ten centimetres before two points could be -appreciated. This loss was not so great on the under surface of the forearm. There was no history of recent pain either con- stant or neuralgic, nor were there any dyszesthetic sensations. No fibrillary contractions were observed. There was a slight tremor in the right hand when voluntary movements were made. Electric con- tractility to a very slight degree was observed in the extensor communis digitorum when a strong faradic current was applied. The galvanic cur- rent also seemed to have some influence upon the weakened muscles. The fingers were covered by small flakes of skin, and the nails were crenated, irregular, and evidently badly nourished. This trophic defect disappeared under the use of the galvanic current. Diagnosis In the order I name them I proceeded to dispose of lead paresis, amyotrophic sclerosis, cerebral paralysis, traumatic paralysis, and progressive muscular atrophy. That it might be lead paresis seemed reasonable at first, because of the loss of electric contractility, the seat of the paralysis, etc. ; but when I bore in mind that the trouble was one-sided at first, that there was a subsequent invasion of the muscles of the other arm, that sensibility was also impaired, and that the patient used neither hair-dye nor drank impure water, nor was exposed to the dangers of lead poisoning of any kind, I was forced to abandon this idea. A species of spastic contraction drew down the fin- gers of UN? right hand, and there was some cumulative tremor, such as characterizes sclerosis (expressed by a gradually increased tremor, aggra- vated by will control, and terminating in a species of spasm). This at first led me to suppose that there might be some degeneration of the lateral columns, but as the tremor disappeared and there were no other symptoms of such degeneration, and especially as there was gradual atrophy and mus- cular paralysis, I dismissed this possibility. The loss of electric contrac- PROGRESSIVE MUSCULAR ATROPHY. 2G5 tility, and the limited field of the paralysis, excluded cerebral paralysis ; and the fact that the patient had never received an injury, and that the affection was beginning to affect the opposite group, negatived the theory of traumatic paralysis. All that was left was the diagnosis of progressive muscular atrophy; and the subsequent appearance of fibrillary contractions made me quite sure of my decision. The slow progress of the trouble and its site were, however, doubtful points. The individual had not exercised any particular member, and as he was a man of leisure, there was no trade or occupation in which constant use of the hands or excessive labor was required that could account for its origin. The hands preserved their contour ; there was no atrophy ; no prominent thenar eminences ; nothing suggestive of the main en ffriffe. None of the muscles of the back were affected, and the deltoids were of good volume and power. The fact that others in his family had suffered, that the disease began on one side and extended to the other, that fibrillary contractions were present, that sub- sequently I was enabled to get slight, and afterwards stronger contractions of the paralyzed and atrophied muscles, determined me in my diagnosis of this anomalous case. I call it anomalous, because I have been taught, and my own experience convinces me, that this is a very rare seat of progres- sive muscular atrophy. Protean as is the malady, I have not seen para- lysis of the extensors, as a primary symptom, in any one of the twenty- eight cases of the affection I have met with from time to time. In lead paresis the invasion is rapid, the paralysis the same, and the atrophy is secondary, which is not the case in the wasting palsy. There is sometimes the lead line or lead colic, and electric contractility is im- paired from the first. From traumatic paralysis it can be diagnosed by the irregularity in situation of the muscles atrophied. In traumatic paralysis we may look for ati-ophy of groups of muscles which are sup- ported by a common trunk, as well as loss of electric contractility and secondary atrophy. Prognosis Occasionally the disease may be arrested or cured en- tirely, and this fact seems almost incredible when we bear in mind its organic character. I have succeeded in arresting the disease in ten cases, and think that, when there is the least muscular response to electricity, there is still a chance for improvement, if not complete relief. This is, of course, in proportion to the extent of invasion. If the atrophy be confined to the muscles of one forearm, there need be no reason to give a bad prognosis. The majority of cases, however, go on to an unfavorable termination, and perhaps one reason is, that patients delay so long to seek medical advice, considering their disease to be rheumatism, and amenable to domestic treatment. Roberts' thinks that the prognosis is bad when hereditary predisposition can be traced, or when the upper and lower extremities are both impli- cated. Treatment. I know of no other remedies than those which are local (except when a syphilitic taint is suspected). Electricity is one of these; 1 Art. Wasting Palsy, Reynolds's System of Medicine, vol. ii. p. 349. 266 DISEASES OF THE SPINAL CORD. muscular rest is the second when the affection has followed overuse of certain muscles. The galvanic current from not less than twenty cells should be used, one electrode being placed over the nucha, and the other in the supra- clavicular space. Seances of ten minutes every day cannot fail to do good. In addition to this, the faradic current should be employed for the muscles themselves. I have tested the plan of Duchenne, who recom- mends painful and ]>owerful currents, and have not found it successful. I prefer rather to make each muscle contract several times, and then allow it to rest, and repeat the operation some minutes afterwards. Violent electri/ation, I am convinced, fatigues these crippled muscles, and does more harm than good. Vivian-Poore and Fagge 1 have had wonderful success with this agent, and have cured a number of apparently hopeless cases. I have been induced to try the " rubber muscle," as arranged for h-ad paresis. This forms an admirable means for support of the hands, should the extensors be affected, as was the case in the history I have just related. In every case it is well to insure perfect rest, if possible, for all affected muscles. If the muscles of the shoulder be so atrophied as to allow the arm to drop, it is well to arrange some contrivance to sustain its weight, and relieve the strain upon the affected organs. Sulphur baths and mineral waters have been recommended, and in some hands have been successful. PARTIAL FACIAL ATROPHY. Synonyms Trophic neurosis of the face (Romberg) ; Laminar aphasia (Lande) ; Progressive facial atrophy (Hammond). The disease was first described by Romberg 1 in 1837, and subsequently by Lande,* Samuels, 4 Bergson, 6 Eulenberg, 6 Fremy, T and Moore, 8 who have all reported cases. Eleven example's were collected by Lande alone, who studied the disease quite faithfully. The only American case, besides those reported by Hammond 9 and Bannister, 10 was presented at a meeting of the New York Society of Neurology, December 20, 1875, by Dr. Wil- liam II. Draper," and I then hud the opportunity of examining her, and subsequently obtained a photograph, a copy of which is presented. 1 London Practitioner, Dec. 1868. 1 Klinisrhe Wahremung und Beobachtungen, Berlin, 1851. 3 These de Paris, 1868. 4 Dor Tropischen N erven, Leipzig, 1860. * DII Prosopodymnorphia sive Nova Atroph. Fac., Berlin, 1873. 6 Lehrlnieh der Funct. N. K., Berlin, 1871. Ktmle critique de la Troplionevrose faciale, Paris, 1872. 8 Dublin Quarterly Journal, 1852. * Op. cit., p. 543, ct seif. 10 Journal of Nervous and Mental Diseases, 1877. " Reported in Am. Psychological Journal, Feb. 1876. PARTIAL FACIAL ATROPHY. 267 The patient, who was a stout, hearty Irish girl, aged 18, and without any hereditary predisposition, presented herself, with the following his- tory : About two years ago the muscles under the body of the lower jaw of the left side began to diminish in size, and after a few months there was gradual extension of the atrophy, so that finally a district bounded by the symphysis of the lower jaw, angle of the nose, and middle of the Fig. 38. Partial Facial Atrophy. upper lip in front, lower edge of zygoma above, and ramus of the inferior maxillary behind, became entirely affected. The skin is bound down to the periosteum of the lower jaw, and is shiny, tense, and white. There never has been pain of any kind, but the only sensory alteration occurred in the beginning, when a slight itching was felt. There is no anaesthesia anywhere, not even in the tongue, one side of which is markedly atro- phied. In the beginning there were occasional cramp-like pains about the insertion of the masseter muscles on the left side, but none dn the other. There was slight paresis in some of the muscles involved. In twelve Continental cases collected by Draper, eight of whom were women and four men, the atrophy appeared in one at three years of age, and in another at twenty -two years of age. The beginning of the atrophy in these cases was not always the same. In two instances it began by pallor ; in the others by red spots, next followed by loss of color ; and finally there was a parchment-like appearance of the skin. Sensibility was not lowered in any instance, but in two there was itching, as in Draper's case. In one the disease was preceded by spasms of the mas- seter muscles ; in six the tongue was atrophied ; in one the tonsil ; and in the rest the soft palate. In two cases there was deafness. In no case was there affection of the secretion of saliva ; but in one there was dimin- ished pulsation in the carotid of the affected side. In none were there indications of central disease. The cutaneous changes alluded to are peculiar, and a variety of trophic alterations may attend the disease ; 268 DISEASES OF THE SPINAL CORD. such, for instance, as falling out of the hair, or changes in color and the appearance of eczema. The atrophy is sometimes quite extensive, involv- ing the bones, which, in some cases, have been measured and found to be greatly reduced in size. Electric contractility of the muscles does not appear to be in the least diminished. The temperature of the affected side is generally lowered, but there is no diminution of sensibility. The left side appears to be the more common seat of the disease, and of the twelve cases already alluded to, but one was of the right half of the face. Causes In some of the reported cases there was a history of pre- vious intermittent fever, scarlatina, and scrofula, and in one case there was a traumatism, but it is a question of great doubt whether these were concerned in the development of the atrophic condition. It seems, how- ever, to be a disease which is more common between the tenth and the thirtieth year. Pathology Undoubtedly this disorder is one of a trophic nature, and of central origin. The absence of motorial or sensorial disturbance makes this theory very plausible. Hammond considers the unilateral character of the affection a strong argument against the theory of its peri- pheral origin. If the lesion were of a peripheral character, it is highly probable that both sensation and motion would be affected, for I cannot conceive a diseased condition of trophic filaments alone when they are found in company with other sensor and motor filaments, as in a nerve- trunk which is diseased. This hypothesis seems more reasonable when it is borne in mind that the parts atrophied are supplied by other cranial nerves than the seventh. I therefore think that the theory of degeneration of the trophic cells of the bulb is a much more acceptable one than that held by Bergson and others. Kulenberg considers it to be essentially a lesion of the fifth pair, in which opinion he is sustained by Romberg, Samuels, Charcot, and Vulpian. Against this it may be urged that lesions of the tit'tli nerve of a trophic nature are generally followed by corneal changes, which, as far as I can learn, have never been witnessed in this disorder. Diagnosis Progressive muscular atrophy and facial paralysis seem to be the only diseases with which that under discussion may be con- founded. Against the first it may be said that there are never the pecu- liar cutaneous changes of the disease under discussion no dark spots, no falling out of the hair, no tightness of the skin ; and, moreover, this site of atrophy is very rare in progressive muscular atrophy. Facial paralysis is nearly always of sudden appearance, and the muscles lose their electric contractility. Prognosis As far as I can learn no deaths have been reported, and no cures by drugs. From its progressive nature (and particularly if we concede it to be a central disease of a degenerative character) the prog- nosis must be bad. though two or three cases have been related, however, in which there was an arrest of the atrophy without any treatment. In Helot's 1 case the disease became stationary after a year. 1 Quoted by Draper, Am. Psy. Journal, Feb. 1876. PSEUDO-HYPERTROPHIC MUSCULAR PARALYSIS. 269 Treatment. Electricity is indicated, but its use has only once been attended by slight improvement in the hands of Moore, 1 who reported a case Avhich was benefited. PSEUDO-HYPERTROPHIC MUSCULAR PARALYSIS. Synonyms Myosclerotic paralysis ; Sclerose musculaire progressive (Requin) ; Lepomatosis musculorum luxuriam (Heller). Though first described by two Italians, Coste 2 and Gioga, in 1838, and subsequently by Meryon 3 in 1852, the affection attracted little notice till 1868, when Duchenne 4 presented to the profession a critical analysis of thirteen cases. It is hardly worth while to enter upon the discussion of what has been published since the appearance of Duchenne's book. Suffice it to say that Clymer, 5 Ingall, 6 and Webber,? Pepper, 8 S. Weir Mitchell, 9 Hammond, 10 Drake, 11 Gerhard, 12 and Poore, 13 in America, and Barlow, 1 * of Manchester, in England, have all reported cases; and I find, in the little brochure of the latter writer, the records of additional cases by Heller, 15 Seidel, 16 Wernich, 17 Scheltzemberser, and other Continental writers. So far nearly one hundred cases have been reported. Symptoms Duchenne details the symptoms in the following order: 1. In the beginning feebleness of the lower limbs. 2. Lateral balanc- ings of the trunk and widening of the legs during walking. 3. A pecu- liar curvature of the spine, or saddle-back, both in walking and standing. 4. Talipes equinus, with an over-extension of the first phalanges of the toes. 5. Apparent muscular hypertrophy. 6. Stationary condition. 7. Generalization and aggravation of the paralysis. In illustration of the progress of the disease, I may present a very well marked case, which I was permitted to examine by Dr. V. P. Gibney. F. E. M., aged 13. Previous health excellent, her only illnesses being whooping-cough at the age of nine months, and scarlet fever a year ago, which was followed by some otitis. Her family history is good, as far as nervous disease is concerned. Her father died of phthisis, and her mother I Op. cit. 2 Quoted by Poore. 3 Trans, of Med.-Chir. Soc. 1852, quoted by Poore and Barlow. 4 De 1' Electrisation localisee. 5 Clymer's Appendix to Aitkin's Practice, 1868, and Med. Record, 1870. 6 Boston Med. and Surg. Journ., 1870. 7 Phil. Med. Times, June and July, 1871. 8 Photo. Review, Oct. 1871. 9 Op. cit., 1st ed. 10 Phil. Med. Times, Aug. 29, 1874. " Ibid., Oct. 16, 1875 (previously reported by Mitchell). 12 X. Y. Med. Journ., June, 1875. 13 On Pseudo-hyper. Paralysis, Liverpool and Manchester Med. and Surg. Reports, vol. iv. II Deutsches Archiv fur Klin. Med., torn. i. 1865. l5 Centralblatt, 1867. 16 Deutsches Arehiv fur Klin. torn, ii., 1864. n Quoted by Barlow. 270 DISEASES OF THE SPINAL CORD. is alive and healthy. Her ancestors were long-lived people. She tells us of an injury received in 1870, a boy having fired a brick at her, which struck her 'in the small of the back. No fever or pain preceded her present trouble. Her disease was of gradual development, and the hyper- trophy followed the injury which has just been alluded to. At the end of six months she found it difficult to go up stairs, and her helplessness in- creased until the time of admission into the Hospital for Ruptured and Crip- pled April 7, 187G. The following history was then taken: Complexion, light; hair, brown ; eyes, hazel. She is small for her age, though well developed. She stands with abdomen prominent, chest and head thrown backwards; walks with an unsteady, waddling gait. Upper extremities, with exception of elbow-joints, which permit extension beyond an angle of 180, normal. From the sixth dorsal to the sacrum there is a lordosis of three inches, the point of greatest incurvation being at the third lum- bar vertebra. There is tenderness on deep pressure over the twelfth dor- sal vertebra, while both trochanters stand out prominently, and the limbs are widely separated, and there seems to be no trouble about the hip- joints. There is marked diminution in power of the extensors of the legs, preventing her from holding the limb at a right angle to the body. There is no marked loss of power in the flexors. But there seems to be some loss of power in the anterior foot muscles ; no comparative atrophy of limbs. The muscles of the back seem small and poorly nourished. The girl has difficulty in arising from, or assuming the sitting posture. The lordosis can be overcome by the voluntary act of stooping forward. Treatment Spinal brace to restore normal form, and electricity. Through the kindness of Dr. Virgil P. Gibney, I was permitted to ex- amine the patient. I found her to be a rather well-nourished girl. I was immediately struck by her gait, which was characteristic of pseudo-hyper- trophic paralysis. The feet were planted widely apart, and when propul- sion was attempted the whole pelvis was seemingly twisted, and the leg clumsily swung forward. The body swayed from side to side, the abdomen was prominent, and the shoulders drawn back, so that the extreme lordosis described so clearly by Uuchenne was very beautifully shown. When stripped, this exaggerated curve was found to be very great. A plumb line held at the seventh cervical spine fell about four inches back of a line drawn across the upper edge of the sacrum. When my hand was placed upon her abdomen, and an attempt was made to force her to stand erect, the nates were immediately thrown backwards, and she would have pitched forward if not supported. When she attempted to walk, the pelvis seemed to be lifted on the side of the limb which was raised, and at the same time the corresponding side of the abdomen became quite flat. Her gait was waddling, and she progressed very slowly. There was some spinal ten- derness, but no other disturbance of sensibility either in the sound or hy- jK-rtrophicd muscles. The latter were those of the back of the leg, which wen- much larger on both sides than they should have been, and were quite hard and in marked contrast to the other muscles of the body, which were flabby and poorly nourished. The muscles of both thighs at the inner side seemed to be atrophied, as were all the muscles of the back ; but the arms were of normal contour, and apparently unaffected. There was considerable loss of power in the lower extremities, the patient being unable without great effort to rise from her chair, and when she attempted to do so she planted her feet widely apart and approximated her knees. The color of the skin was rather darker than it should be, and especially PSEUDO-HYPERTEOPHIC MUSCULAR PARALYSIS. 271 on the feet, legs, and hypertrophied calves was there mottling and imper- fect incubation. No difference in tactile sensibility could be noted. Meas- urements of different parts gave the following results: About shoulders ........ 29 inches. About waist ......... 24 Middle of right thigh 14 Middle of left thigh 13 Right thigh, just above knee . . . . . .11 Left thigh, just above knee . . . . . .12 Right calf 12 Left calf 12 A case reported to me by my friend Dr. G. H. Swazey is the following. This patient was also seen by Dr. J. Lewis Smith : J. D., aged 2 years 8 months. Has always been a healthy boy until four weeks ago, when it was noticed that he seemed weak in his legs, especially in the morning, or after sitting awhile. Has not complained of any pain. When the child walks, it is in a peculiar wabbling sort of a way, with his legs wide apart, and his shoulders carried well back. He cannot stand well with his legs close together, but soon totters and falls. After he has walked a while this peculiarity of gait is not so perceptible. The left leg measures around the calf eight and one-eighth inches, right leg around the calf eight inches. Just above the knee left leg measures nine and a quarter inches ; right leg, same place, nine and one-eighth inches. The weakness in the legs has been steadily increasing from the first. The grandmother of the child on the maternal side has epilepsy ; the grand- mother on the father's side has what the mother calls weak spells, appa- rently of an epileptic character. An aunt and uncle on the father's side have epilepsy, and there is also a history of syphilis in the family. The mother has had miscarriages, apparently due to that cause. The father has had eruptions and other symptoms. March 28th commenced treat- ment with the faradic current to the muscles, which was continued three times a week for six weeks ; the disease slowly progressing. At this time the patient left off coming, and has not since been seen. Weakness of the lower extremities is one of the earliest symptoms, and is gradual in its appearance, and not preceded by fever, as is generally the case in infantile spinal paralysis. This impairment of power may begin imperceptibly, and first attract the attention of the parent by the inability of the child to walk at the usual time, or may appear subsequently, the child falling frequently or moving clumsily. In Poore's collection of 85 cases, it is shown that "3 never walked at all, 24 never walked well, 1 is reported as coming on gradually, 52 walked well at first, and in 5 cases no mention is made of the period of walking." " Of those who walked well, 2 began to walk at eighteen months, 3 at two years, 3 at two-and-a half years, 4 at four years, 1 at five, and 5 are reported as walking late and badly." Duchenne and Drake reported cases in which convulsions were the be- ginning of the disease. Pain in the calves of the legs or back is some- times the first symptom, but is by no means one to expect as a rule. The appearance of the patient is most striking. The belly seems to be thrown 272 DISEASES OF THE SPINAL CORU. out, the lumbar curve is increased, and the feet are widely separated. When the child attempts to walk, his movements are very much like those which we might expect to see in an individual laboring through a quag- mire. There is a certain amount of waddling, the legs being separated, and the feet planted at some distance apart. In progression the body is inclined to the side on which the foot is planted, and there is some jerk made in the effort to carry the foot forward. The patient rises from the sitting posture with some difficulty, as there is great impairment of the extensor muscles of the spine. This weakness is the cause of the difficulty in keeping his balance. The next stage of the disease is the development of the hypertrophy. Very often this change is an Fig. 39. The Spinal Carve In Pseudo-Hypcrtrophtc Paralysis. early one, and may follow closely after the commencement of the impaired motor power. The calves are generally first enlarged, and this enlarge- ment may begin with the difficulty in walking, or within a period any- where from six months to several years after the beginning of the disease. This enlargement is not, however, always conh'ned to the calves, but may affect the other muscles of the lower extremities, or even those of the upper. The glutei, gastrocnemii, deltoid, and many other muscles have been involved in cases reported by different observers. When the mus- cles are contracted, they stand out quite prominent, and in one of the cases reported by Barlow 1 the child's appearance resembled that of the 1 Op. cit., p. 11. PSEUDO-HYPERTROPI1IC MUSCULAR PARALYSIS. 273 Farnese Hercules. The child is unwieldy and awkward, and though there is at this stage some increase in strength of some of the members used in locomotion, the child does not seem to have very much motor power, for he can scarcely walk. The muscles not hypertrophied may undergo an atrophic change, greatly adding to the deformity. In regard to the talipes that may be produced, the extensors are agitated by spas- modic contractions, which become more aggravated as the attempt to walk is persisted in, so that, after a few steps, the child is quite likely to fall. The skin may often be greatly discolored in patches just as it is in infantile paralysis, and Duchenne has called attention to this mottling, which is due to modified cutaneous circulation, and is seen especially during the later stages of the disease. It is more often confined to the lower ex- tremities, and the patches which at first appear as bi'ight red discolorations gradually become more dusky as they are exposed to the air. This mot- tling is increased by muscular action, and in certain regions was found by Benedikt to be connected with local sweating. The temperature of the hypertrophied muscles is higher by a degree or two than those that are atrophied ; and in the early stages electric contractility is rarely affected, but in the later it is greatly diminished. Of course, this depends upon the fatty substitution which the muscular tissue has undergone, for but a small amount of normal muscular fibre remains to be called into action by the electric stimulus. Causes Beyond the question of heredity it is impossible to go in our search for causes. One or two cases, however, are mentioned by foreign observers in which injury preceded the disease. Kesteven 1 re- ported one of these, and in this case the hypertrophy appeared at the fifteenth year. Poore's table 2 includes the following examples of heredity : " In two cases a maternal uncle and aunt had this disease. " In one case three maternal uncles and aunts had this disease. " In one case one maternal uncle and one half-uncle had this disease. "In one case three maternal half-brothers had this disease. " In one case a maternal half-brother, three maternal uncles, and other members on the mother's side, had shown the symptoms of pseudo-hyper- trophic paralysis. "In thirty-seven instances, two or more belonged to the same family. It will be observed that it is only on the mother's side that this hereditary influence is transmitted; while the disease shows itself almost exclusively in the males. Thus, in a case reported by Duchenne, the mother, while she escaped, transmitted the disease to the children of her marriage. The same fact is stated in Foster's case. "In one case a maternal grandfather was hemiplegic. "In one case a paternal grandfather was insane. "In one case a father was insane. 1 Journal of Mental Science, vol. xvi., April, 1871, p. 48. 2 Loc. cit. 18 274 DISEASES OF THE SPINAL CORD. " In one case a father was intemperate. " In one case two brothers died of granular meningitis. " In one case a brother was an idiot. "In fifteen cases of the eighty-five the family history was good. "In thirty-three cases no mention of family history is made." Pathology and Morbid Anatomy According to Barlow, the first examination of the muscles in pseudo-hypertrophic paralysis was made by Greisinger and Billroth in 1865. Greisinger excised a small portion of the left deltoid, which was hypertrophied and paralyzed, and microscopically examined the muscle, which resembled adipose tissue. He found the fasciculi in a perfect state, but surrounded by fat. Kulenbcrg 1 and Conheim 2 found the muscular fibres reduced to fully one- sixth their normal size, and in some localities there were masses which they supposed were the sheaths of empty sarcolemmae. Auerbach 3 found hypertrophy of the muscular fibres, and an increased development of nuclei, but no interstitial fat deposit ; but this was in a patient who died during the early stages of the disease. Berger's* expe- rience was identical in an early case. Charcot 5 examined a case (that seen by Berger), and found the psoas in a state of primary alteration. Fig. 40. I Appearance of Muscular Tissue. (Charcot.) The primitive muscular bundles were separated by broad spaces of con- nective tissue containing cells of a spindle shape, and nuclei. Other muscles were likewise affected. The pectoral muscles, and those having a sacro-lumbar attachment, contained fewer nuclei, and the internuclear spaces were filled with wavy connective tissue. In muscles which had undergone still more advanced degeneration, there was some evidence 1 Archiv fUr Heilkunde, 1865. 1 Verhandhinjr der Berliner Med. Ges. i., pp. 101-205. 3 Viirhow, Areliiv., vol. iii. p. 224. 4 Deutsche Archiv fiir Klin. Med., 1872, p. 303. 5 Archiv. de Physiol., etc., 1872, p. 1. PSEUDO-IIYPERTROPHIC MUSCULAR PARALYSIS. 275 of fatty deposit. In this case he witnessed three stages of degene- ration. In the earliest there was atrophy of muscular bundles, indistinct longitudinal striae, and sometimes transverse strias. The sarcolemmae were filled with a hyaline substance. Duchenne 1 denies the existence of empty sarcolemmae, and regards the enlargement due to an increase of connective tissue containing fat-cells. Diagnosis Progressive muscular atrophy seems to be the only dis- ease with which this condition may be mistaken. If the patient is seen at a time when the conditions of atrophy and hypertrophy coexist, it is not always easy to tell whether there is an increase of volume, or simply an atrophic condition of some muscles, while others are of normal size ; but the other symptoms alluded to, the exaggerated lumbar curve, and the waddling walk, should settle the question of diagnosis. Progressive muscular atrophy is also generally a disease which rarely appears at so early a period as does pseudo-hypertrophic paralysis. Increase of size from determination of blood to a muscle, such as that reported by Maun- der, 2 and sometimes fatty development, without paralytic symptoms, may deceive the incautious. Prognosis. The disease is slowly progressive, and death occurs generally from some other disease. Poore reports thirteen deaths. Phthisis, pleuro-pneumonia, uncomplicated pneumonia, and croup appear to have carried off most of these cases ; and it seems as if pulmonary dis- ease bore some special relation to organic disease of the cord, particularly when trophic disorder accompanies such disease. In several of the spinal affections, especially when the anterior cornua3 are affected, there is generally the development of phthisis or other pulmonary maladies. The deaths that have been reported occurred rarely before the eighth year of the disease, and generally between the fourteenth and thirtieth. Treatment Duchenne reports two cures by the faradic current. This seems to be the only remedial measure that promises anything at all. The abolition of fatty food might be recommended, and massage should be employed at least every day. The well-known fact that phos- phorus produces fatty degeneration should contraindicate its use. 1 De 1' Electrisation localii-ee, Paris, 1872, 3d edition, p. 604. 2 Med. Times and Gazette, March 27, 1862. 276 DISEASES OF THE SPINAL CORD. CIIAPTEK XI. DISEASES OF THE SPINAL CORD (CONTINUED) POSTERIOR SPINAL SCLEROSIS. Synonyms Progressive locomotor ataxia ; Tabes dorsalis ; Ataxie loeomotrice progressive ; Locomotor asynergia, etc. When induration of the posterior columns of the cord takes place, we are furnished with a very interesting and striking train of symptoms, which are chiefly expressed by pronounced disturbance of the locomotory func- tions, and defects in coordination and sensation. Symptoms After exposure or prolonged dissipation, the individual may first notice the commencement of the disease by fulgurating pains which dart from the feet up the legs and thighs, and for the time he may suppose he has simply neuralgia. These pains are worse at night, and may be aggravated by damp or cold weather. They appear and disappear rapidly, and Clarke 1 calls attention to their tendency to move suddenly from one place to another; remaining located in one spot for some hours at a time, and then shifting to another. They may shoot through the soles of the feet, the inner part of the legs, the knees, or even the thighs. After a time, which varies from a few weeks to two or more months, there may be a most disagreeable sensory change of a lesser grade, which is confined to the feet. When walking, the patient complains that " the ground feels as if it were covered by fur, or a padded cushion." Sometimes the sensa- tion is likened to that produced by a stocking down at heel, or as if his shoe >vas filled with sand ; or, again, as if he were walking in the air. There is no loss of muscular power, nor general loss of sensibility, in the preponderance of cases ; but there only seems to be a perversion of tactile sensibility, and that only limited to the sense of contact. Heat and cold are appreciated, but the shape or size of the cold or warm object cannot be jK'rceived by the tactile sense alone. Painful impressions are appre- ciated, but this is all. Circulation becomes sluggish in the limbs, and subjective cold is felt in the lower extremities. If the individual is seated, and the hand of the examiner be held against the sole of the boot when the patient's thigh is flexed, it will be found that he is generally quite able to extend the leg forcibly, but there may be sometimes a slight loss of power in subsequent stages when the anterior parts of the cord become affected. In the early stages of what may be called the descending form, there are various ocular troubles. Amblyopia, strabis- mus, or diplopia is among the more common, and it is not unusual 1 St. George's Hospital Reports, 1866. POSTERIOR SPINAL SCLEROSIS. 277 to find some atrophy of the optic disk of either one or both eyes. In both forms of sclerosis of the cord, ascending as well as descending, it is neces- sary for the patient to look at the objects which surround him in order that he may preserve his equilibrium. If he shuts his eyes, he is apt to topple over ; and it is utterly impossible for him to walk in the dark with- out holding on to something for support. The patient very often finds that when he closes his eyes, as he is about to wash his face, he is quite apt to pitch forward against the wall. This test is an important one, and if he is able to stand with his heels and toes approximated and his eyes shut, it may be inferred that either his disease has not advanced to a seri- ous extent, or that it is not locomotor ataxia at all. The early ocular trouble is strabismus, which is an inaugural symptom, and is very often accompanied by amblyopia ; and if the strabismus be single, the ambly- opia will be on the same side. Various paralyses of cranial nerves may also follow, and ptosis is not an unusual symptom. Nothnagel 1 publishes the notes of a case where hyperaesthesia of the parts supplied by the fifth nerve was a prominent symptom. The lost power for localization is not uncommonly associated with this disease. With closed eyes the individual is unable to place the tip of his finger on his nose, or upon any desired small point ; and, when told to touch the point of a pin held by an ob- server, he will be unable to do so, his finger missing the mark. When awaking, he is often undecided as to the whereabouts of his legs, or some- times feels for a moment that he has none, and needs the aid of vision to see that there are such members. The nerve-fibres in the posterior columns lose their facility for the conduction of sensory impressions ; and it is sometimes several seconds before an impression made at the peri- phery is received at the sensorium, and appreciated by the individual. A symptom sometimes found in this disease, as well as in myelitis, is the sense of constriction which is referred to the waist. The bowels, in the early stages, are generally confined ; and there is some loss of control over the bladder, and constant desire to empty that organ. Romberg calls attention to the fact that the stream seems to have no force, but falls to the ground on leaving the meatus. The individual is also troubled by erections during the early stages, and there is greatly increased sexual power. This, however, is diminished towards the end of the disease, and in males impotence follows. Irritability of temper, occasional mental disturbance, and loss of memory are not rare evidences of intellectual failure, and occur at differ- ent stages. The electro-muscular irritability seems to be rather increased than diminished, and reflex action is usually exaggerated. 2 The locomo- tory trouble appears quite early, and is one of the most distressing fea- tures of the disease. It begins by an awkwardness in progression, and 1 Berlin Klin. AVoch., xvii. 18G5. 2 Westphall has recently shown that, when the legs are crossed, if the tendon of the rectus femoris on the side of the suspended leg be struck, a contraction of this muscle will follow, and the suspended leg will be agitated. In locomotor ataxia, this is not the case. 278 DISEASES OF THE SPINAL CORD. the feet fly out and tire planted with a kind of jerk, the heel touching the ground first. The individual totters, and is eventually unable to walk at all without support, and the gait cannot be mistaken by any one who h:is once witnessed it. The sense of appreciation of weight also seems to suffer to a decided degree. Jaccoud 1 found that this is lost to a great extent, and that there is a variation in the power to perceive weights on the two sides of the body. In one case mentioned by him, a pressure equal to 3000 grammes was perceived on the right side, and 2HOO on the left. The pains before spoken of generally disappear as the disease be- comes confirmed, though they may List throughout. Fibrillary con- tractions are occasionally seen ; and, speaking of this, I have often wit- nessed a curious phenomenon which follows the use of faradism. 1 have noticed that when a muscle of one leg was agitated by clonic contraction, sometimes the same muscle in the other leg would be contracted syn- chronously with that under electric stimulation : the patient is gene- rally timid, and easily disconcerted by any sudden noise or unexpected excitement. When crossing the street the desire to avoid being run over on the approach of a wagon will produce such demoralization as to prevent him from taking another step, and he sometimes falls to the ground. There is rarely trembling, unless the disease has involved the upper part of the cord, when this symptom, as well as the inability to appreciate toj>o- graphicsU points, will be marked. The patient is generally worried, anx- ious-looking, and wo-begone, and is full of complaints. The disease may last for from five to t.wenty years, and the patient is carried off by tuber- culosis or some intercurrent pulmonary affection. Atrophy of all the muscles of the extremities generally takes place towards the end of the disease, and bedsores and arthritic troubles are annoying and painful fore- runners of death. Charcot has called attention to certain cutaneous eruptions which not infrequently are found with posterior spinal sclerosis, and which are usually of a papulous and pustular character. He mentions the case of one person, who, while under treatment at La Salpetriere, presented large patches of urticaria, the appearance of which was coincident with the attacks of pain. The eruptions generally mark out the course of the nerve which is the seat of pain. Hutchinson, however, considers that this arrangement of the eruption is usually- misinterpreted, and that, instead of the eruption following the direction of a nerve-trunk and its branches, the corymbiforin distribution of the skin-disease in reality corresponds with the course of the small vessels. C'harcot and Raymond, 1 in alluding to the disappearance of the heads of the long bones, relate the case of a woman, aged 52, who had been ill for many years. The autopsy revealed atrophy of the different processes of the Immerus, femur, tibia, and scapula, with muscular degeneration of n fibrous character. In another case there was hip-joint affection, and great brittleness of the bones, which broke when subjected to inconsidera- 1 Op. eit., p. 341. * Gaz. M6dicale de Paris, Feb. 19, 1876. POSTERIOR SPINAL SCLEROSIS. 279 ble force, and afterwards united quite readily. During life the evidences of such arthropathies are sometimes numerous. They may be illustrated by the following case of Bourcere. 1 The patient was a woman who entered La Charite April 8, 1875 ; she was middle-aged, and presented many of the symptoms of locomotor ataxia. These began about ten months before. The left leg seemed to be more affected than the right. Three days after admission the left thigh and buttock began to swell rapidly, and in a few hours the swelling, which was not cedematous in the strictest sense of the word, but hard and not painful on pressure, reached its maximum. It extended as far down as the knee, where it stopped abruptly. There was no fluctua- tion, nor any evidence of pus. The swollen part was almost double the size of the other limb, while the leg was shortened, and the foot was to some degree rotated outwards. There was also some swelling and hard- ness unattended by tenderness in the left iliac fossa. The swelling disap- peared almost entirely in a week, when vaginal examination .was made, and a hard, smooth tumor was discovered, which apparently sprung from the pelvic bones of the left side. Pus was soon afterwards detected in the psoas sheath above and below Poupart's ligament. She became pros- trated, and died on the Gth of May. After death, decided osseous changes, to be hereafter described, were observed. Locomotor ataxia may be associated with progressive muscular atrophy, or may sometimes terminate in general paresis of the insane. West- phall, Obersteiner, and others have written much upon the relation of the two diseases and their possible coexistence. Obersteiner, 2 in an excellent paper upon Locomotor Ataxia and Mental Disease, considers that mental symptoms are found in the greater propor- tion of cases of this disease, and calls attention to the fact that these expressions of psychical trouble may be very slight ; still, an acute ob- server will know that there is a departure from the normal intellectual condition. The patient's character is often changed markedly. I have been often astonished at the apathy of an individual, or, on the other hand, at his irritability of temper, the violence of his anger, and his petulance, which are more than transitory evidences ; and they are as important symp- toms, I think, as neuralgic pains, difficulty of coordination, etc. These changes were well displayed in a patient of my own ; in health he was a most amiable, high-minded person ; in disease a morbid, bad-tempered, whining wreck. He had been noted for his gallantry on the field during the war ; but after this disease had become established, his character seemed to undergo a complete transformation. He wrangled with every one, be- came irritable over petty things, and made himself generally disagreeable. Obersteiner and Simon 3 both agree that these patients should be exam- ined most carefully, and that the prognosis depends much upon the facts relative to mental alteration. The latter says : " It is not enough that the patient keeps himself quiet, and answers the questions relative to his 1 Progrfes M6d., Oct. 9, 1875. 2 Wiener Medizinische Woch., No. 29, 1875. 8 Archiv fur Psychiatric, i. and ii., 1875. 230 DISEASES OF THE SPINAL CORD. age, how he feels, etc., und does not show marked delusions ;" these are not enough to assure us that liis intellect is intact. In regard to the grave secondary mental changes, Tigges considers general paralysis to be a complication, while Obersteiner is convinced that the symptoms of this latter disease indicate a progression of the sclerosis upwards. He considers the lesions to be identical, and that it is only the seat of the change which has anything to do with the symptom expressed. He has also found, in general paralytics who have died, a sclerosis of the cord. M. Rev has observed nine cases of insanity associated with locomotor .ntaxia. In three of these the spinal sclerosis preceded the cerebral trouble, and in one the induration had extended from the posterior to the lateral columns. He found that the diagnostic difference between locomotor ataxia combined with cerebral induration, and simple descending general paralysis of the insane, was the walk. In the former the patient could not stand with his eyes shut, and in the latter there was no difficulty of the kind. "NVe may also take for granted that the walk of the ataxic is an early symptom, and that of the general paralytic a late one. Both are examples of defective coordination, and I think the latter is unwisely called paralytic. The difficulty of turning around is marked in ataxia, and I think it is not a prominent symptom in general paralysis. A case lately came under my charge where the sclerosis of the cord was ascending, and in an incredibly short time the cerebral symptoms which indicate the general paralysis of the insane were evident. M. F., aged 29 ; United States. On admission to the Epileptic and Paralytic Hospital, March 0, 1876, I was immediately struck by the woman's walk, which was ataxic in the extreme; and on questioning her and her husband we ascertained that about two years ago she had neu- ralgic pains in the legs and feet ; her walking became defective, and has continued so. Her mind was clear up to a short time ago. Her pupils are now unequally dilated, the left being the largest. Her lips tremble distinctly. Her tongue, when protruded, also quivers ; when told to keep it quiet, the motion is greatly exaggerated. There is some ptosis of the left eye. AVhen told to close her eyes, she is unable to co- ordinate delicate muscular movements. She cannot find the tip of her nose with her forefinger by more than an inch. When her eyes are open, she cannot touch small points, such as the markings upon my watch-dial. When she stands with her eyes closed, she topples over almost instantly. When she walks, her toes are thrown out, and she comes down upon her heel. Her feet are planted far apart when she attempts to stand. When walking across the room, she reels, and has difficulty in turning around. When attempting to answer questions, she talks slowly, each word being uttered with some effort; the words containing the letters " f " and "p" are explosive, and the lips seem to have a great deal of work to form them. The consonants are slurred over ; for instance, the word " man" is pro- nounced u mah ;" the '* IV are dropped, as are many other letters. Her writing is very scratchy and irregular, although her husband says she formerly wrote an excellent hand. Mentally she is silly, and laughs im- moderately at wrong times and without cause. She has no idea of time, POSTERIOR SPINAL SCLEROSIS. 2Sl but seems to know what she is saying. She has had several delusions, one of which was that she had been home the day before. May 12th, two months after admission Her walk is much worse ; no urinary or other difficulty. There is some festination ; pupils still uneven. The difficulty in speech has markedly increased. Her tottering walk is striking. "VVe at first thought she had syphilis, but this is not so. Being unmanageable and restless, she was transferred. Here undoubtedly was an ascending condition, beginning with the pains and gait of loco- motor ataxia, and ending with several early symptoms of general paralysis. Charcot 1 has described a peculiar train of symptoms accompanying the pains of the earlier stages. These are the crises gastriques, which are expressed by pains which begin in the groins, and run up the abdomen on either side, finally becoming fixed at the epigastrium. They are violent, and occur during the exacerbations of lancinating pain in the lower ex- tremities. During the time they last, there is violent palpitation, vertigo, and vomiting, the latter symptom occurring without relation to the con- dition of the stomach. If there be no food to be expelled from that organ, there may be a quantity of frothy and bloody liquid ejected. These crises last two or three days, and disappear quite suddenly. Some observers have noticed the appearance of ptosis during their existence, which gradually disappears ; and Stewart 2 has seen several cases in which these symptoms varied, and instead of there being pain which started from the groin, there was deep-seated pain in the dorsal and lumbar regions. Reynaud has called attention to a species of renal neuralgia which is not at all an uncommon complication. One of his cases, which was mis- taken for renal colic, presented lumbar pain, vesical tenesmus, retraction of the testicle, and other suggestive symptoms. There was temporary cessation after a few days, but a second and third attack followed. Char- cot and other French writers have alluded to various additional visceral disorders, as found with this as well as other organic spinal diseases, and the functions of the kidney are sometimes greatly disturbed. I do not think that sufficient attention has been paid to forms of hysteria which resemble locomotor ataxia. These, I believe, are the cases which are cured. Isnard 3 has extensively considered the functional form ; and Webb, of Philadelphia, has reported a very interesting case of genuine hysteria which counterfeited the organic disease so closely as to lead to a primary error in diagnosis. Causes Dissipation has much to do with the development of this terrible disease, while onanism and venereal excesses, especially, play an important part ; so we may expect to find it among men about town, hard drinkers, and other people of bad habits. Injury, exposure to rain and cold, syphilis, and protracted mental excitement, favor its origin. Some sudden exposure, such as a fall into the water, or a night in the rain, may be the exciting cause, and several of my cases had such a beginning. 1 Op. fit. 2 Med. Times and Gazette, Oct. 7, 18C7. 3 L' Union Medic-ale, 131, 134, 135, 137, 141, 142, 1862. Abst. in Lancet, Sept. 30, 1875. 282 DISEASES OF THE SPINAL CORD. Rosentlml 1 reported sixty-five cases, forty-six of which were males and nineteen females ; and of this number thirty-one were traced to libidinous excesses, seven to exhaustion, and twenty-seven to cold and exposure. The youngest of these patients was nineteen, and the oldest sixty-eight. The ages at which the disease appears is rarely before the thirtieth, and never after the sixtieth year. Heredity seems to have much to do with its development. For instance, N. Friedrich 8 reports six cases which occurred in two families ; and two of these patients were males, and four were females. The heads of the families were drunkards. Syphilis, as I have said, is sometimes at the root of locomotor ataxia, and perhaps is the most fortunate cause to discover, as it greatly alters the prognosis of the disease. It must be understood that the lesion is purely syphilitic ; and the symptoms result simply from the presence of a gummy infiltration or tumor in the posterior columns, and not from any induced sclerosis. Morbid Anatomy and Pathology The cord of the ataxic, when cut into, will present an appearance which is distinctive. The posterior columns will be found to be more gray and dark than they should be, and there may be hard deposits on either side of the posterior fissure. Be- neath the microscope the peculiar thickening of the connective tissue will be found to have taken place at the expense of the nervous elements. Lockhart Clarke thus tersely describes the changes that take place : " The morbid anatomy of locomotor ataxia consists chiefly of a certain gray degeneration and disintegration of the posterior columns of the spinal cord, of the posterior roots of the spinal nerves, of the posterior gray substance or cornua, and sometimes of the cerebral nerves. A variable number, and frequently in the latter stages of the disease nearly all the fibres of the posterior column and posterior roots, fall into a state of granular degeneration and ultimately disappear. Usually the posterior columns retain their normal size and shape in consequence of hypertrophy of con- nective tissue which replaces the lost fibres. "In this tissue, at wide but variable intervals, lie imbedded the remaining nerve-fibres with the de'iris of their neighbors in different stages of disin- tegration. In some places they are severed into small portions, or into rolls or lobular masses formed out of the medullary sheaths of white sub- stance, which has been stripped from their axis cylinders. In other places they have fallen into smaller fragments and granules, which are either aggregated in the line of the original fibres or scattered at irregular dis- tances. Corpora amylacea are usually abundant, and oil-globules of dif- ferent sixes are frequently interspersed among them and collected into groups of variable shape and size around the bloodvessels of the part. I am inclined to believe from my own investigations that in the course of the disease the posterior cornua of gray substance are more or less affected, and it appears to me to be a question whether they are not the first parts, or at least among the first parts that are morbidly changed. I have also 1 Wirn, Mod. Woch., 1869, No. 251. 2 Virehow'frArchiv, xxvi. pp. 391, 433. POSTERIOR SPINAL SCLEROSIS. 283 shown that in some cases the deeper central parts of the gray substance are more or less injured by areas of disintegration. These latter lesions, however, are not essential to the production of locomotor ataxia, the peculiar symptoms of which depend solely on lesions of the posterior columns of the posterior nerve-roots, and probably of the posterior cornua. The cases in which they occur may be considered as mixed cases, partak- ing of the nature of locomotor ataxia and common spinal paralysis." Charcot and Vulpian consider sclerosis of fillets or columns of Gall to be the essential lesion of the disease under consideration. These occupy the space on either side of the posterior fissure, and from them pass the most internal sensory roots. I do not think, at this stage of our knowledge, that it is possible to make the distinction between symptoms indicative of sclerosis of the columns of Gall and of other parts of the posterior column. It has been shown that the nerve-roots themselves need not necessarily be affected, although the cornua may be degenerated most completely. The sclerosed parts of the cord in this disease are more commonly the lumbar and lower dorsal, although the cervical portion may be invaded as well. The case mentioned by Nothnagel presented sclerosis of the entire poste- rior columns. The bones undergo remarkable changes, and after death the result of such arthropathic alterations may be seen in atrophy, exfolia- tion, shortening, and destruction of their articular surfaces. The appearance of old fracture is admirably shown in Fig. 41, which is taken from Charcot. The cranial nerves are not rarely atiected, Fig. 41. Appearance of Trophic Bone Changes in Locomotor Ataxia. (Charcot.) their course being sometimes interrupted by patches of degeneration. The induration attacks the periphery first, and extends to the centre, and the changes begin at the point of origin of the nerve and progress towards its distal end. The optic disk is nearly always found to be atrophied and blanched, but there seems to be no change in the size of the retinal ves- 234 DISEASES OF THE SPINAL CORD. sels. There are often evidences of injection of the investing membranes of the cord or actual meningitis, and six cases which were reported by Krird- rich presented opacity, and thickening of the pia mater, which was adherent to the cord, and I doubt if there are many examples in which some form of meningitis has not existed at some time or other. Charcot 1 alludes to the gray degeneration of the optic nerves as an evidence of amaurosis that is so prominent a symptom, and he calls the pathological condition " nev- rite parenchymateuse." Much of the interest belonging to this disease is connected with the phenomena of incoordination, and a lesion that may affect the integrity of the organs intended for the transmission and reception of visual, auditory, or tactile impressions will result in a loss of equilibrating power. Accord- ing to Ferrier, the apparatus provided for the maintenance of equilibrium consists of: 1, a system of afferent nerves ; 2, a coordinating centre; 3, efferent tracts in connection with the muscular apparatus concerned in the action. Of course lesions of one or all of these parts must result in a loss of balancing power. Perhaps the most important factor in the pn-srrva- tion of equilibrium is tactile sensibility. The frog, deprived of his skin, loses the power of coordination, for the coordinating centre is deprived of the exciting organ from which impressions are transmitted. So, too, may this loss follow sudden destruction of one of the peripheral organs of spe- cial sense. As has been shown by Volkmann, the exposed ends of the nerves are not sufficient to transmit the sensory impression, but it is neces- sary that their cutaneous terminations shall exist. When the tactile sen- sation in the ataxic is blunted, or the impressions are interrupted in their upward course, as has been held by Schiff, we have a loss of coordinating power which is a striking feature of locomotor ataxia. It is not neces- sary for consciousness to enter into equilibration and coordination, for, as we well know, many acts are purely spinal in character, and become auto- matic to some degree ; and walking is notably one of these acquired automatic movements. Acephalous monsters have performed a number of acts which were strongly reflex ; and animals from whom the brains have been removed are able to coordinate to a certain degree after the first shock of the operation has passed by. In the disease under consider- ation consciousness enters to a decided extent when the harmony of the coordinating centres is lost. This consciousness is exhibited in vertigo, and is exerted in the ineffectual effort to regulate the actions of the limbs, the brain endeavoring to supply the lost automatic sense. Broadbent 2 considers that there are two coordinating centres; one in the cerebellum, and the other, as I have stated, in the cord. Vision holds the same relation to the cerebellar coordinating power that tactile sensibility does to the cord centre. For instance, a tight-rope walker would fall were it not for the aid of vision, although the tactile sensibility becomes so perfectly educated that it may take the place of the eyes in enabling the 1 Logons sur le Syst. nerveux, 2feme seri6, 1 fascic. 2 Brit. Mod. Journal, April. 1875. POSTERIOR SPINAL SCLEROSIS. 285 Fiji. 42. performer to regulate his actions. 1 The tactile sense is of a lower grade, and when this fails the individual, as is the case with the ataxic, requires more than ever the aid of vision. In the normal condition he may close his eyes, and still be able to walk in the dark with some ease ; but if the tactile sensibility be affected, as it is in the disease under consideration, and if the aid of his vision be denied him, he is utterly helpless to regulate his muscular movements. In the daylight he still has the power of help- ing himself, for vision comes to his assistance. In health this delicacy of coordination may be trained to a marvellous degree. I have repeatedly witnessed the feats performed by a French juggler, which illustrated the nicety of appreciation of weight it is pos- sible to arrive at by practice. He would throw into the air a heavy cannon ball and a pellet of paper, alternately catching them and tossing them up again, and the mus- cular movements were regular and harmo- nious, and indicated no effort whatever. In locomotor ataxia this power of appre- ciation is sometimes lost to a marked degree. To the ataxic individual a four- pound weight seems no heavier than one of two pounds would if he were in nor- mal condition, and if his muscular move- ments were properly coordinated. The arrangement of the sensory fibres of the posterior column is such that a lesion of either the white or the gray mat- ter itself must interfere with the conduc- tivity of sensory impressions. Lockhart Clarke's histological researches have thrown much light upon the subject. According to him, the posterior root-fibres enter the cord in three directions, some passing in at right angles to the longitu- dinal fibres of the posterior column, then passing across the same as well as the gray substance, then bending and continu- ing longitudinally downward, next pass- ing into the gray matter of the anterior cornua, and finally terminating in fasci- culi which intermingle with the fibres of the anterior roots, or extend into the an- terior columns. Other fibres (those of the second class) run across the posterior The Course of Posterior Nerve-Roots. (Clarke.) 1 I have no doubt some of my American readers have witnessed the perform- ance of a tight-rope walker, who goes through his feats of balancing and walking with bandaged eyes, meanwhile perfectly preserving his equilibrium. 286 DISEASES OF THE SPINAL CORD. columns, or cross to the other side of the cord in the posterior commissure, or extend deeply into the posterior columns of the same side ; and others pass forward into the gray matter of the anterior cornua. The third kind of jK)sterior spinal roots enter obliquely; and certain fibres pass upw;mU and downwards, and become associated with fibres above and below them. The remaining fibres take an oblique course, and run upwards and down- wards, the greater number taking the former direction and passing finally into the gray matter. It will be seen that a lesion affecting the pos- terior columns of the cord will destroy the communication of the nerve- roots with the gray matter, or press upon the sensory fibres, causing peri- pheral pain. The communication with the parts above is destroyed, and should the sclerosis involve the anterior gray matter there may be parah -i< and atrophy. A favorite theory, accepted by many writers, is that which considers that there are numerous centres of coordination in the cord, which are connected by longitudinal fibres, and that when these fibres are destroyed there results a species of incoordination. Dieulafoy 1 divided the posterior fasciculi at different heights, but without producing any marked defects in coordination, which seems to disprove this theory. Diagnosis It is important to distinguish locomotor ataxia from chronic myelitis, progressive muscular atrophy, chorea, and cerebellar disease. The former disease occasionally resembles ataxia, but with or- dinary care no mistakes need be made. The paralysis of the first disease is very marked, and the implication of tl:e bladder and sphincter ani causes the patient to void his urine and feces involuntarily, which is not the case in locomotor ataxia. The strong ammoniacal odor of decomposed urine is itself almost a sufficient diagnostic mark. There is an absence of power in the legs, and none of the pain which characterizes sclerosis of the pos- terior columns. Ocular trouble and incoordination are likewise absent. If the gait of the two diseases be compared, it will be found that in the for- mer the legs will be thrown out with some degree of violence, and the heel will come down forcibly. In the paraplegia of myelitis, the legs will be drawn after each other, the inner edge of the sole scraping the ground ; and there is often a shrug of the body required to bring the feet forwards. The walk of the hemiplegic is also different, as one leg is swung forwards, the toe describing an arc, or else the foot is advanced in a straight line, the sole hardly clearing the floor. Myelitis in its early stages sometimes resembles posterior spinal sclerosis. The pain in the back, however, is characteristic, and the ulterior paralysis and bladder trouble are sufficient in themselves to clear up the diagnosis, though the constricting band about the waist may excite our suspicion. Cerebellar disease has been spoken of by Radcliffe 2 as a condition that may sometimes be mistaken for locomotor ataxia. The movements are somewhat different, however, for the patient rolls and sways to a greater degree, and does not present the peculiar jerking gait of the ataxic. Local pain is another symptom peculiar to the cerebellar condition, and vomiting is also suggestive ot du Concours, 1875. Op. cit., vol. ii. p. 683. ( POSTERIOR SPINAL SCLEROSIS. 281 this affection, but not of locomotor ataxia. Progressive muscular atrophy in its earlier stages is apt to be mistaken for locomotor ataxia. The wasting of the muscles in anomalous cases may be imperceptible, and the unsteadiness of the individual may alone attract attention. This, with the pain, may raise a doubt as to the true nature of the malady. Syphilis, in some of its forms, also occasionally produces symptoms which are very much like those of this disease ; and there may be paralysis of cranial nerves, with pain over 'the tibia, which may be misleading, when in reality no spinal disease exists. Prognosis Among the number of cases reported by various ob- servers. I have not found more than one or two well-authenticated cures. Hammond has cured some lighter cases, which he does not, I believe, really consider to be genuine examples of locomotor ataxia ; but others have been less fortunate. A peculiarity of the disease is the long inter- vals of improvement which occasionally occur ; and the disease may be stationary for years, but this is very rarely the case. I know of two cases which were so much improved, and remained so well for three or four years, that I flattered myself that I had cured them ; but I have since seen a change for the worse in both patients. Balfour 1 presented a case of locomotor ataxia which he claims to have cured. Pollard 2 reports a case which began rather suddenly, and disappeared quite rapidly under treatment. Yidal, 3 Duqueit, 4 and Herschell,* all report cures. Vidal's patient, a man of 45, recovered in three months, and Duqueit's and Her- schell's cases I consider doubtful as regards diagnosis. Treatment From the very nature of the disease the treatment must be empirical, and no one remedy seems to have done much good, although nitrate of silver has been recommended by Wunderlich, Char- cot, Yulpian, and others, and has enjoyed great popularity as a remedy. Balfour, already alluded to, states that he cured a patient in three months by half-grain doses of this salt repeated three times a day, and by the use of a foot-bath in which a quantity of common salt had been thrown. The feet were also submitted to the influence of a faradic current passed through the water by proper appliances. The salts of silver (FF. 77, 78, 79) may be used with considerable impunity without discoloring the skin, though an unnecessary degree of timidity has been shown in its employment. It is well, however, to begin with a quarter-grain dose, and it may be increased to a half, or even a grain, thrice daily. 6 One case of my own was greatly benefited by this drug in combination with nux vomica (F. 79). I have lately tried the phosphate of silver in one-third of a grain doses, with great success, and prefer it to the nitrate (F. 80). In administering the silver salts it is well to give them continuously for several months, and then permit an interval to elapse before beginning 1 Brit. Med. Journal, 1875. 2 Lancet, 1872, vol. i. p. 437. 3 (iaz. des H6p. 127, 1862. 4 L' Union, 122, 1862. 5 Bulletin de Therapeutique, Ixiii., Oct. 1862. 6 De 1'emploi du nitrate d' argent dans le traitement de 1'ataxie progressive. Bull. Gen. de Ther., 1862. 288 DISEASES OF THE SPINAL CORD- again. In the early stages of the disease I prefer the fluid extract of ergot, either in combination with the bromide of sodium, or alone (FF. 5, (5.) It certainly seems to control the pain. Among the more efficacious remedies to which I may allude is the sulphur bath, which is too little used at the present day, and has been praised by the French writers especially. 1 It seems to possess, in some cases, powers which are almost marvellous. A small lump of sulphide of potassium is to be thrown into the tub in which the patient bathes, after which he is to be thoroughly rubbed. In regard to electricity, Meyer has reported several cures by the galvanic current. Oniinus has used the inverse current, and I believe has done some good. The indication seems to be that the positive pole should be placed over the painful point, if one can be found, and the negative above. These cases in which cures have been wrought were, I infer*ataxic conditions of a functional character. Faradization of the muscles of the legs and thighs seems to comfort the patient more than anything else. Duchenne thinks that the muscular anaesthesia is benefited greatly by its use, and that co- ordination is improved. Dr. Drinkhard, of Washington, 2 suggested that strychnine, injected hypodermically, is a remedy which should not be lost sight of. In one case it promptly relieved the pain. He, however, com- pares the dangerous appetite of possible formation to that which grows out of the medicinal use of large doses of opium, and fears such trouble. I have used the actual cautery to the spine quite frequently, and have found that constant revulsive effect kept up for some weeks not only diminished the pains, but really improved locomotion. It should be applied down the whole length of the back, on either side of the spinous processes; and, after the epidermis has shrivelled off, subsequent applications are to be made. Belladonna and turpentine are recommended by Trousseau (F. 81), and not only relieve the pain, but seem to help any vesical trouble that there may be. Should we suspect syphilis, the iodide of potassium (F. 20) will be indicated, and a saturated solution should be prepared, and given in in- creasing doses till forty or fifty grains are taken three times a day. Above all, it must be remembered that nutritious food, cod-liver oil, and moderate stimulation are perhaps more important than medication. I have observed the necessity for quiet and rest. Prolonged muscular exercise is bad, and drives are to be preferred to walking. The patient should seek a warm climate, for this disease is affected by damp cold weather, very much as is phthisis, and a cold winter always tells upon the patient. The pains also are aggravated by cold and sudden changes, and I find Florida or other Southern States to be the most comfortable places for these invalids. Much benefit has been derived from the dark room treatment, and I saw one gentleman who had been greatly improved by a few months of bed rest in a dark chamber. Dissipation thwarts any chance of success, and late hours or a debauch will produce a relapse some time after encouraging improvement has taken place. Sexual indulgence (when it is possible) is likewise to be interdicted. 1 It has acted wonderfully in cases even of long standing, and deserves a faithful trial. * Am. Jour. Med. Sciences, July, 1873. ANTERO-LATERAL AMYOTROPHIC SCLEROSIS. 289 AXTERO-LATERAL AMYOTROPHIC SCLEROSIS.' Synonyms Amyotrophic lateral spinal sclerosis (Charcot). In- flammation of the lateral columns of the spinal cord, and of the anterior tract of gray matter (Hammond). When the anterior tract of gray matter and the lateral columns of the cord are conjointly the seat of destructive changes, we find permanent contractures following loss of muscular power in both upper and lower ex tremities, together with extensive atrophy and subsequent bulbar symp torn*. Symptoms The disease begins without fever; with loss of power in the muscles of the upper extremities, which becomes quite marked after a short space of time, and then follows a general atrophy of the muscles ot the paralyzed members. In this way the malady differs from progressive muscular atrophy, in which one group of muscles, or even a single muscle, becomes atrophied before others, and in advance of any paralysis. Char- cot calls this wasting process " atrophie en masse." Attendant upon the paralysis are deformities, and these are highly characteristic of the disease, and result commonly from contractures of muscles which are less para- lyzed than others, so that the stronger muscles overcome the weaker. The flexors of the hands are commonly affected, and these members are flexed and distorted, the fingers being drawn up so that their ends press into the palms, as is the case in other forms of post-paralytic contractures. The arm may be adducted to the side, and forcible abduction or extension is impossible. Pain is usually produced by any violent effort made to over- come the deformity, and the physician is obliged to desist. The patients are able, though their muscles are paralyzed and contracted, to perform certain limited movements, but the same tremor takes place which we observe in other forms of sclerosis when a voluntary effort of any kind is made. In the late stages the emaciation is complete, and the appearance of the hands resembles that seen in progressive muscular atrophy. There are the elevated thenar eminences and the flat forearms, but the limb is still contracted. Charcot alludes to a condition which sometimes affects the muscles of the neck, so that they are contracted to such a degree that the head is fixed and immovable. He relates a case where the mus- cles of the interior maxilla were so contracted as to greatly interfere with mastication. The progress of the disease is marked by involvement of the tongue, and later by destruction of the nuclei of the several cranial nerves, so that various losses of special function rapidly follow, and death termi- nates the patient's sufferings. The inferior extremities are paralyzed in their turn, and are the seat of contractures which resemble in some re- spects those of the upper extremities, so that the patient's condition is one 1 I prefer this compound title, as it obviates confusion and more definitely ex- presses the seat of the disease. 19 290 DISEASES OF THE SPINAL CORD. of helplessness. The legs become rigid when he attempts to walk, and are agitated by tremors so that he is obliged to desist. The contrac- tures in the lower extremities are much more marked than in the upprr, and when finally the victim seeks his bed he presents a most abject and pitiable appearance, the legs being twisted and contracted so that he re- quires the services of an attendant, as he is utterly unable to do anything for himself. 1 Fibrillary tumors' may be present just as in progressive muscular atrophy, but are not so constant as in the latter disease. The symptoms which usually herald the approaching end of the disease are those which indicate invasion of the bulb. Paralysis and atrophy of the tongue, vermicular movements of that organ, and affections of speech, are among these, and the orbicularis oris and facial muscles are next attacked, when there may be drooling of saliva and other indications of bulbar degeneration. In short, the symptoms are very much like thosectoralis major, and biceps. When I endeavored to straighten the arm he suffered great pain, and begged me to desist. There seemed to be no involvement of the lower extremities, and the patient walked without embarrassment. Seeligmuller* saw several curious cases, which were not only valuable as instances of heredity, but which illustrated the course of the disease. 8 The cases came under the observation of Seeligmuller in January, 1876. The family history, which was carefully inquired into, was remarkably good, with one significant exception that the parents were first cousins. There was no evidence of syphilis. Seven children six girls and one boy were the result of the marriage. Of these, the eldest, aged eleven, 1 There is never cutaneous anesthesia, the bladder and rectum are never affected, and there is no tendency to bedsores (Charcot). * Deutsche Medicinischc Woeli., April 22 and 29, 1876. 8 London Medical Record, Juue 15, 1876. ANTERO-LATERAL AMYOTROPHIC SCLEROSIS. 291 was quite healthy ; the second, aged ten, was in an advanced stage of the disease ; the third was, if anything, worse still, but was not seen ; the fourth, a boy, aged six years and nine months, was in the middle stage ; the fifth and sixth were healthy ; and the seventh, aged one year and nine months, was in the first stage of the affection. The disease began in a similar way in all. Strong and healthy when born, they continued so up to the age of about nine months, when a change took place. Able pre- viously to sit up without trouble, they began to lose this power, and would fall to one or other side ; later, the head and chest sank forward. At the ji.ire of two years attempts were made to teach them to walk, but their efforts resembled those of an infant six months old. This was exemplified in the youngest patient, who, when supported under the armpits, made jumping movements, the legs being raised from the ground simultaneously. Subsequently the children learned to support themselves with difficulty against a chair, but even this power was lost again. The boy had lately been rapidly losing ground in this respect; he could still, however, drag himself about in bed, and, by means of a specially constructed chair on wheels, could walk. The two eldest children, when supported in the upright position, could not put one foot before the other; even when lying down, they were unable to move, the upper extremities being useless as supports. The youngest girl could sit for a short time on the table, but cried all the time, and soon fell to one side ; she sat with her head and chest inclined forwards, the spine equally curved, and the thighs greatly abducted ; when on the lap, however, she could move her arms and legs in all directions. Contractions at the joints were present in a high degree in the three eldest. In the eldest girl the hands were adducted and pronated; pain was produced by attempts at passive supination, and the hand, when re- leased, jerked back to its old position. The fingers were rolled in towards the palm, but she could still extend them, though very gradually and with great difficulty. The grasp was still perceptible; the right better than the left. The elbows were slightly bent, and nearly fixed. The knees were half flexed, but could, with great force, be moderately extended or flexed still more, though on leaving them they sprang back with a jerk. The feet were in the position of advanced equino-varus ; the tendines Achillis were perfectly rigid. All attempts at passive movement produced considerable pain. The boy was put under the complete influence of chloroform, and the rigidity of the joints then so increased that the whole body could be raised from one leg and held out like a piece of wood. The youngest girl had so far no contractions. Atrophy of the muscles was marked in the tAvo eldest under observation. With the exception of those of the face, it was evenly spread over the whole system. The wasting in the case of the girl was considerable, so that the head seemed too large for the attenuated neck, and was moreover unsteady. The parents were confident that in all three the wasting was not visible for some time after the loss of power showed itself. In the eldest child the reaction of the tibial and peroneal nerves was normal with both currents ; but the irritability of the muscles was decidedly lowered everywhere. Of those on the back of the forearm, the supinator longus alone responded promptly. In the youngest girl, faradic excita- bility of both nerves and muscles was perceptibly lowered in all extremi- ties, but especially in the left lower. Galvanic excitability was lowered in the same way, and in the tibial nerves was almost nil. Ordinary reflex 292 DISEASES OF THE SPINAL CORD. irritability not increased. That of the tendons, however, was present in a high degree in all. Fibrillary contractions were markedly present in the eldest girl, and could be produced by simply blowing on the skin. Sensibility was normal in all. Of the symptoms noticed by the parents, that which made its appear- ance last was the gradual loss of the power of speech. Thus, in the two eldest girls, this was tolerable until their sixth year, when it became less and less distinct, until finally only inarticulate nasal noises could be made. In the girl, the lips, soft palate, and uvula were all paraly/ed, and the tongue lay in the mouth like a mass of dead flesh; its tip could be ad- vanced only as far as the teeth. In the boy the same symptoms were present, but in a somewhat less degree. The youngest child could say a few words, but these had a slightly nasal tone. Swallowing in the two eldest girls was difficult ; in the boy, tolerable. The form of the skull was unusual in all, but especially so in the eldest. It was very broad between the parietal eminences, and very undeveloped in the frontal region. The forehead was low, and the head appeared altogether too small for the face. In the eldest girl the features were coarse ; the expression was vacant, but usually amiable; the pupils were much dilated; the saliva flowed con- tinuously out of the half-opened mouth ; and, indeed, her general appear- ance was that of an idiot; though, in point of fact, the intellect was very fairly developed. The faradic excitability of the facial muscles was de- cidedly increased ; the galvanic was normal. Causes. No definite causes are known, though exposure is believed to have much to do with its origin, and Charcot's and Hammond's cases are thus accounted for ; but we may also consider that dissipation and hereditary influences play an important part in the etiology of the affection. It is a disease which rarely occurs before adult life, as far as we are enabled to judge from the limited number of cases which have been reported. Fig. 43. A. Antcro-latcral sclerosis. B. Posterior spinal sclerosis. (After Charcot.) Morbid Anatomy To Charcot belongs the credit of having made the distinction between progressive muscular atrophy and lateral amyotrophic sclerosis. Previous to 18G7, these were considered to be cases of progres- sive atrophy, which were anomalous in the fact that the lateral columns were affected. Jaccoud 1 considers the sclerosis as circumscribed or diffused 1 Op. cit., p. 319. LATERAL SCLEROSIS OF THE SPINAL CORD. 293 Like sclerosis in other regions, the tissue-changes may be observed with the naked eye, either invading the white or the gray matter separately, or more often together. In this case the lesions are of ancient date. The connective tissue is firm and shrunken, and the color of the hardened spot is gray or pinkish-gray. The meninges may be adherent to the cord if the sclerosis be circumferential, but it is more common in uncomplicated sclerosis to find no such change. The microscopical appearances are like those seen in locomotor ataxia, as the character of the lesion is identical, the only point of difference being the location of the tissue-change. Cir- cumscribed sclerosis is more rare than the diffused variety, and few cases have been observed. Of examples referred to by Jaccoud, in one the lesion was confined to the lumbar enlargement, and invaded the entire anterior columns and a part of the lateral columns ; and in another, in which the autopsy was made by Frommann, 1 "the sclerosis occupied the lumbar segment and the inferior portion of the dorsal region. It involved in different degrees all the white matter, and the gray was not affected except in the gelatinous substance and in the parts of the posterior cor- nua which bounded the lateral column." The sclerosis has involved the entire antero-lateral columns, the anterior columns alone, or the lateral and the lateral and posterior conjointly. In diffused sclerosis, nodules are found in various parts of the brain and cord, but the predominance of the sclerosis in the antero-lateral column gives prominence to the symptoms which I have described. Diagnosis It is possible that this disease may be confounded with either progressive muscular atrophy, lateral sclerosis, or spinal para- lysis. In the first we find a train of symptoms consisting of neuralgic pains, atrophy of single muscles or groups, and involvement of other muscles progressively, and secondary paralysis. There are besides no spasmodic contractions. In lateral sclerosis there is no atrophy beyond that resulting from inaction. In the disease known as spinal paralysis the lower extremities are generally affected first, and reflex excitability and electric irritability are diminished, which is not the case in the disease which has just been described. Prognosis Hopeless. Treatment I think it may be said that no treatment offers any chance of success, though in the early stages Duchenne claims to have cured several cases by means of faradization, massage, and other forms of local treatment. LATERAL SCLEROSIS OF THE SPINAL CORD. Synonym Primary symmetrical lateral sclerosis. Symptoms Paralysis of an incomplete character without atrophy, and with subsequent contractures, is the marked feature of the malady. Like most other diseases of this nature, a loss of power is complained of 1 Anatomie des Riickenmarks, Jena, 1864. 294 DISEASES OF THE SPINAL CORD. in the beginning. The patient is easily fatigued, and it becomes disagree- able for him to take the least exercise whatever, on account of the wearied feeling of the muscles of the leg and thigh which results. The hamstring muscles tire the soonest, and it fatigues him excessively to remain for any length of time in the erect position. The knees after a while become bent, and the lower extremities may grow rigid, while the tendines Achillis may perhaps be contracted so that there may be a species of talipes. Contracturcs of the adductors may take place to such a degree that the thighs are drawn across each other so that locomotion after a while is impossible. Hammond lias reported a case of this kind. The walk of the patient is decidedly peculiar, as he is unable to lift his feet from the ground to any extent, and he consequently stumbles and finds great difficulty in progression. Hammond thus describes the gait : " Owing to the fact that the patient's extensor muscles are weak, he is unable to lift the feet high enough to cause them to clear the ground, and hence he throws them out by means of the adductor muscles of the thigh, and thus causes them to describe an arc of a circle. Then in putting them down the heel strikes the ground a longer time before the sole than it does in the natural gait, and hence the foot comes down with a jerking motion. This is the ordinary manner of walking practised by a person afflicted with the disease under notice. In another form of locomotion the body is moved laterally on the thighs, first to one side and then to the other, in such a way as to cause the feet to be raised high enough without the com- ' plete action of the extensor muscles. The gait is therefore similar to that of a duck, or of a woman with a very wide pelvis. The motion of the body is almost serpentine, and the feet glide over the ground barely lifted high enough to avoid contact." 1 Sensibility is rarely affected, and reflex excitability is as much exaggerated as it is in other forms of sclerosis, for instance in locomotor ataxia. The disease runs its course in ten or fifteen years, and death is the ordinary result, though several cases have been reported ;is cured. Morbid Anatomy The limitation of the sclerosis to the lateral columns is nearly always well defined. The sclerosis is symmetrical, and Fiji. 44. A, A. Lateral sclerosed patches. (Chareot.) confined to the white matter, bounded in front by the external angles of the anterior horns, and behind by the anterior border of the posterior horns. It may extend centrifngally to the circumference of the cord, but is more often, according to Chareot, shut off by a tract of white matter. 1 Diseases of the Nervous System, p. 569. TETANUS. 295 Diagnosis Locomotor ataxia, lateral amyotrophic sclerosis, and spinal meningitis may be said to be the disorders with which it may pos- sibly be confounded. The presence of contractures enables us to dispose of the first affection, and the absence of atrophy and bulbar symptoms the second. Occasionally the diagnosis will be more difficult, and this is when chronic spinal meningitis exists alone, or when the lateral sclerosis is found to be a result of such meningitis, as sometimes happens. Treatment. Hammond recommends large doses of ergot in the early stages. I see no reason why the same remedies spoken of in the treatment of locomotor ataxia should not be administered. Conium sug- gests itself as a physiological remedy for the relief of the spasmodic con- tractions, but, not having used it, I am unable to attest its value. TETANUS. Synonyms Rigor nervosus ; Mai de cerf ; Tetanos (Fr.) ; Locked jaw. Definition. Tetanus is an affection characterized by tonic spasms of a great number of muscles, particularly those of the jaw, neck, back, and lower extremities. It is never attended by loss of consciousness, and nearly always approaches an unfavorable termination. It is a disease which may be either idiopathic or traumatic, and is not confined to any age or sex, as it may be a condition at birth (trismus nascentium), or occur at any subsequent time. Symptoms The more familiar examples follow traumatism, and such injuries may be exceedingly slight the wound of a rusty nail, a needle, or a blunt instrument being often likely to give rise to the attack ; or it may be of distinctly idiopathic origin. The first symptoms generally noticed are a stiffness of the neck, a slight soreness of the throat, and a contraction of the jaws so that it may be difficult for the patient to open his mouth. There may be general malaise and discomfort, which may last for several days, and the patient is unable to masticate or swallow his food properly, and consequently eats but little. He may think that he has simply caught cold, and neglect to seek medical advice; but new developments will show the condition to be more serious than he imagines. The closure of the jaw may become more complete, and within the next twenty-four hours (the fourth or fifth day of the affection) he will show unmistakable signs of the increasing violence of the disease. His face wears the peculiar expression which has been called the risiis sardonicus, the features appearing pinched and set, and the corners of the mouth are drawn upwards, while the eyes are prominent and the hair and eye- brows quite bristling. The brows are knit, and there is a characteristic appearance, which, if once seen, cannot be mistaken. Radcliffe considers the risus sardonicus quite pathognomonic of tetanus. Pain in the epigas- trium becomes very severe, and is not relieved by medicine. It is impos- sible sometimes to open the jaws even when we desire to give food or 296 DISEASES OF THE SPINAL CORD. medicine, and it is sometimes necessary to use quills and other delicate tubes for the purpose of feeding. Spasms of the pharyngeal muscles may also defeat all attempts of this kind, for, even if the teeth are parted and nourishment is inserted, the food is forced with great violence through the nostrils. Other spasms now mark the progress of the disease. The muscles of the back begin to be convulsed, and finally those of the lower extremities, and as a consequence we observe the appearance of opisthotonos, which is an extremely striking symptom, and much more common than emprosthotonos, which may also take place, orpleurosthotonos. It is hardly necessary to say that opisthotonos is the result of a tonic spasm of the muscles of the back, so that the patient's body describes an arc, the head and heels touching the surface upon which he is lying, and the middle of the back being raised some distance therefrom. When the body is bent in the opposite direction forwards the condition is known as empros- thotonos; and when the muscles upon one side of the body are contracted we designate the lateral curve produced as pleurosthotonos. During this tonic convulsive state individual muscles may be the seat of painful spasms, which are very agonizing. Muscles have been torn across and bones broken by the great strain, and the force exerted is something wonderful. The tongue is rarely affected, and the hands are not usually at any time rigid or contracted. The spasms are easily produced by slight agen- cies, as reflex irritability is decidedly exaggerated. Jarring the bed, tickling of the soles, or a draught of air allowed to blow upon the surface will immediately bring them on. This convulsive stage lasts until death, but when the end is approaching becomes less sthenic as the patient grows more and more exhausted. There may be an occasional severe paroxysm before death, but it is not at all like the form of violent convulsion of the middle stages. The pulse throughout the developed disease is very rapid and fluttering, and ranges between 120 and 140, and the respiratory move- ments are irregular and catching, as the spasms affect the muscles of the thorax as well as others which are directly concerned in this process. Dyspnoea is very distressing, and is expressed between the seizures by much gasping and anxiety of countenance. The skin is dark, and large rings about the eyes are indicative of collapse while the face of the victim is haggard and depressed. The patient perspires quite profusely, and the skin is excessively hot; and a prominent feature of tetanus is the marked elevation of temperature, which rises even sometimes as high as 110, and actually reaches, a higher point after death. In a case observed by Wunderlich 1 there was a marvellous elevation of this kind, and a very tardy fall after death. 1 Archiv dcr Ileilkunde, Bd. ii., iii., and v. (18G1-G3). Reported by Radcliffe. TETANUS 29T Date. Respiration. Pulse. Temperature (Fahrenheit). 24th July, 1861 25th 26th 9 " 6 " 9. " 9. af A.M. P.M. 20 P. 35 P. ter de M. ! M., death, . ith, 2' 5' 20' 35' 55' 60' 70' 90' 100' 6 hours 9 " 12 " 13 " 24 22 20 32 36 96 82 96 112 180 102 102 104.45 103.55 110.1 112.55 112.77 113 113.22 113.55 113.67 113.55 113.22 113 111.8 106.25 104 102 101 ft.. Dr. Joseph Jones, of New Orleans, the author of one of the most able articles upon this subject that has ever appeared, has made numerous exami- nations of the urine. He found that the quantity of urine excreted during the "active stages was greatly diminished from the normal standard, and in the successful cases treated the amount increased with subsidence of the symptoms." He also found that the urea was increased during the active stages, and the uric acid was diminished. The diminution of the excretion of urine is by him supposed to be accounted for by the small quantity of fluids taken, and by the loss of liquid in profuse perspiration. The mind is perfectly clear throughout the disease, and the patient suf- fers great mental misery as he fully realizes his terrible condition ; and sleep is nearly always absent, this being one of the most distressing fea- tures of the disease. If this is obtained, even in brief snatches, the mus- cles are relaxed, and all spasms disappear for the time, but immediately reappear upon awaking. The probable cause of death is either the closure of the glottis, or exhaustion, which is an inevitable result of the violent muscular action. In new-born children the disease sometimes appears between the first and fifth days, the first symptoms noted being restlessness, trembling of the lower jaw, and desire for the breast, which the child leaves almost immediately. At the end of twenty-four hours, or even earlier, the muscles of the jaw are felt to be contracted and rigid, and it cannot open its mouth; there is a peculiarly aged expression upon its face, the skin of the forehead being wrinkled. The eyelids are closed, and the lips are compressed over the teeth. The head is drawn back, and general spasms of the muscles of the back follow. Periods of remission occur, and the patient is thrown into a paroxysm by the most 298 DISEASES OF THE SPINAL CORD. trivial agencies. The skin is very red and dark, and after a series of paroxysms, which may continue for several days, death closes the scene. Causes. Exposure to damp and cold are the only known exciting causes of the idiopathic variety; and traumatisms of certain kinds, or accidents during parturition, precede the other form. A punctured wound, which may be received from a nail or splinter, is much more likely to give rise to tetanus than an incised wound ; and injuries in which there is mangling or crushing of muscular tissue are frequently concerned in the production of the disease. Railroad injuries are therefore especially dangerous. Tetanus sometimes follows surgical operations, and it has been thought in these cases to depend upon partial section of some nerve-trunk. Dupuytren 1 goes far enough to recommend re-amputation. It may be stated that in certain regions there are apparent endemic influences at the time of such predisposition, when any surgical operation may have this termination. This local influence prevails in Cuba and other tropical countries, and in Long Island and in other parts of the American sea- board. Jones has collected the statistics of tetanus, and the following table shows its prevalence in hot climates : Place. Period. Total deaths. Deaths from tetanus. Proportion. London Ireland Now York Bombay . 1850-3-4 1831-1851 1819-1834 1851-1853 224,515 1,187,374 83,783 42,651 73 238 112 912 1 in 3075 1 in 4987 1 in 748 1 in 46 I am indebted to Dr. Charles Findlay, of Havana, Cuba, for the following concise table, which shows the prevalence of the disease in that island : Logons Oralt-s, tome ii. pp. 599-612. TETANUS. 299 1872. 1873. 1874. 1875. 1876. Average. ni 00 j- 00 m 00 i. CO 00 00 d d d d d Z d 3 a 3 <2 < 3 3 <2 3 (OS 2 d - d 2 d tj d 2 d d 3 January, 4 47 4 39 34 4 33 G 17 4.2 34.0 Pop. of Havana, 250,000. February, 5 29 1 30 3 18 4 30 4 30 3.4 27.4 Births per annum, 5000. March, 6 24 3 28 4 31 5 24 4 29 4.4 27.2 Deaths by tetanus in. April, 6 26 5 30 24 4 18 5 26 4.0 24.8 Adults = 0.192 a year per 1 000 inhabitants. Mav. 3 27 1 29 3 33 5 30 3 35 3.0 30.8 June, 2 24 3 33 2 36 5 29 5 39 3.4 32.2 Deaths of infantile tetanus. July, 4 25 5 20 4 31 3 36 3 35 3.8 29.4 7 per hundred births. August, 3 35 5 33 5 45 5 38 2 46 4.0 37.4 September, 3 28 1 29 3 41 3 42 6 33 3.2 34.6 October, 1 42 6 32 3 36 1 43 4 37 3.0 38.0 November, 6 45 4 42 4 29 3 37 6 41 4.6 38.8 December, 2 36 4 23 4 31 5 28 7 40 4.3 31.6 12 months, 45 388 42 368 38 389 47 388 55 408 48.4 382.2 Yearly average. 4.0 31.8 Monthly average. Long Island, it seems, has gained an unenviable notoriety as a place where tetanus is exceedingly common ; but it will be seen that there is much exaggeration in the reports which, as a rule, come to us in the newspapers, and which are nearly always sensational. During the past year I have devoted some time to the investigation of the subject, have written to several well-known physicians of eastern Long Island, and have received two or three letters in reply. Dr. Stilwell, an old settler of Sag Harbor, whose opportunities for research have been quite extensive, writes as follows: "About 20 years ago I came to this place to practise, and learning the fact of the preva- lence of tetanus, or its liability from certain accidents, I attempted an in- vestigation, but failed of any success or satisfaction. Several supposed cases having recovered naturally brought many cases under my observation, but most of them died. Several did not, and from my after-remarks here you will perceive the reason. I have never known the disease to exist as an epidemic, but it is apt, at certain seasons of the year, to follow wounds. Hot and damp weather, with cool evenings, is its favorite season." The Doctor has known but two instances of recovery from traumatic tetanus. When a patient has recovered from tetanus it has been by a very slow process, the period between the spasms lengthening until they finally dis- appeared. Under favorable circumstances this required several weeks. " I have known fatal cases of idiopathic tetanus in July and August caused by fatigue and overheating, and sitting down to cool off in the ocean breezes. Farmers have often informed me that the white frost on grass 300 DISEASES OF THE SPINAL CORD. would give cattle lockjaw. I have known a horse driven to fatigue turned out to pasture in a cool night when white frost formed upon the grass, and die with tetanus. I have known horses, in the heat of summer driven seven miles to the seashore and there cooled off in the ocean breezes, die of the same disease. The multiplicity of cases occur in summer and in the heated term with cool nights. A farmer bruised his thumb-nail and pulled tur- nips in a frosted field ; he died of tetanus." The other letters I have received are in substance very much like that of Dr. Stilwell, and none of them suggest that the disease is as frequent as it is generally supposed to be. Dr. Benjamin, of Riverhead, says : " I have practised thirty years in this village, have an average of about one case each year (others claim twice that number), and should think the other physicians in the Assembly Dis- trict would average about the same; if so, it would make nineteen cases each year with a population of 19,000. My opinion is that there has been no marked change in the past forty years as to its frequency or fatality. A very large proportion of our cases prove fatal in from one to three days. Of trismus nascentium I have had six cases during the past thirty years, all of which were fatal." The information that I have derived from popular sources is, however, somewhat contradictory. I learn that about Good Ground, which is nearly twenty miles west of Sag Harbor, there are times when traumatic tetanus is very common ; and it is not safe for any person who has received even the most trivial injury to remain in the neighborhood. Capt. Foster and Capt. Joseph Penny, of Ponquogue, which is upon the sea-coast, state that they have known of tetanus, which was very common at certain seasons ; several of their friends have died, and others have moved tem|M>rarily from the place as soon as injured. It was not uncom- mon for women about to be confined to leave the locality ; and cases ot trismus neonatorum were of quite frequent occurrence. One man whose foot had been crushed by a horse died in a few days. From Mr. Wells, of Quogue, I ascertained that the disease is con- fined almost entirely to the district extending from Moriches to East Hampton, and that at the extreme easterly end of the Island (Mon- tauk Point) no case has been known to occur. So perfect is the immu- nity at this place, that colts are taken there to be castrated and not removed until the wound is healed. The disease is more common during the fall than at any other season. Mr. Wells has known of from twenty to twenty-five cases, mostly men and boys, in a district forty miles long, during the past five years. In this region castrated colts generally die soon after the operation. In one case, of which my informant knew, a man was shooting ducks in a battery ; his shot-gun accidentally went off, the charge removing about one-half of the great toe. The wound was not especially painful, but at the end of eight days convulsions began, and he died in thirty-six hours. Mr. White, of South Hampton, scratched his thumb with a brier in the field, and afterwards died. Mr. Hand, of Canoe Place, died after a slight TETANUS. 301 injury to the ankle. Mr. Wells also told me that several cases followed wounds received in the field where a form of shellfish known as the "horse shoe" (king crab) is used for manure. By the fall these craw-fish have undergone advanced decomposition, and their long spines, which project in any direction, are very apt to wound the bare-footed field hand. These statements are entitled to some credence, for the Doctor was very often not called in. At the eastern end of the island several cases of fatal teta- nus within a very short time occurred in the practice of Dr. Trudeau, then of Little Neck. Along the Atlantic sea-board I am told that this disease is by no means uncommon, and that on the Southern sea-coast it is much more frequently met with than in higher latitudes. In a very interesting communication from Dr. Findlay, of Havana, he mentions a case in which the application of a blister in a case of pleurisy was followed by fatal tetanus. The accompanying map will enable the reader to perceive the geographical distribution of endemic tetanus on Long Island, the dark spots showing the limit of the region, and the points where it prevails to the reatest extent. Fig. 45. /S 20 so miles 1o / mc7i/ f LONG ISLAND SOUND MAP OF SUFFOLK COUNTY, LONO ISLAND. 1. Manor. 2. Riverhead. 3. Sag Harbor. 4. East Hampton. 5. South Hampton. 6. Ponquogue and Good Ground. 7. Quogue. 8. West Hampton. 9. East Moriches. 10. Centre Moriches. 11. Seatuck. 12. Greenport. 13. Montauk Point. 14. Bridge Hampton. Darkest spots indicate points of greatest prevalence. Cold climates have something to do with the production of tetanus, aa we would infer from Dr. Kane's statement that intense cold produced "an anomalous spasmodic affection allied to tetanus," which affected most of his party, destroyed two men, and killed all his dogs. Trismus neonatorum is supposed by Vogel 1 to depend upon the formation of the cicatrix when the cord is roughly handled, and there is probably pressure of some nerve by the contraction of the cicatrix. 1 Diseases of Children, p. 65. Translation by Raphael, N. Y., 1870. 302 DISEASES OF THE SPINAL CORD. Frost-bite may sometimes give rise to tetanus, and the following cases are examples of this kind: They occurred under the care of Dr. Bethune, of Toronto. The first was that of a farmer who was exposed to intense cold for about three hours while driving. His feet and fingers became severely frost-bitten without his becoming aware of the fact until he arrived home. On admis- sion to the Toronto General Hospital, four days later, the toes and the greater part of both feet were found in a condition of moist gangrene. The fingers and parts of both hands on the dorsal surface were black and dry. Four days after admission he was seized with tetanic symptoms, which rapidly developed. Chloral hydrate in thirty-grain doses, with extract of Calabar bean in one-fourth-grain hypodermic doses, until five grains had been given, failed to combat the disease, and the patient died in thirty hours after the accession of the attack. The second case was that of a man who, having lain out in a barn all night, had both feet severely frost-bitten, subsequently becoming partially gangrenous. In this case trismus set in nine days after exposure, and soon developed into well-marked tetanus, to which the patient succumbed in about thirty hours. 1 Morbid Anatomy and Pathology The older writers have written a great deal in regard to the morbid anatomy o't' tetanus, but the collected facts throw no light upon the pathology, and are to a great degree valueless. Lockhart Clarke 1 in 18G5 found in six cases that there was degeneration of the gray substance of the cord. " The first case was reported at some length, and the lesion was found more or less from the origin of the second cervical nerves to the lumbar enlargement. At the second cervical nerve, streaks and irregular areas of disintegration were observed in different parts of the gray substance, and particularly around the central canal, on the right side of which was a space of considerable size containing a finely granular fluid, with the debris of bloodvessels and nerves. The posterior and lateral white columns, especially along the edge of the various fissures which transmit bloodvessels, were damaged in a similar way, and in some sections the deeper portions of the posterior columns which rest upon the transverse commissure were softened to a considerable degree. This dis- integration was still more marked in the cervical enlargement, chiefly be- hind and at the sides of the canal. The posterior commissure was wholly and the anterior partially destroyed by a fluid transparent and granular area. Throughout the cervical enlargement similar lesions were dis- covered, varying from a state of softening to one of complete solution, and diminishing at intervals or almost disappearing, to return shortly in the same form. At the upper part of the dorsal region the shape of the cord was much altered, and extensive lesions of the same kind were everywhere seen. In both lateral halves of the gray substance, the left lateral col- umns, the right antero-lateral column, the superficial portion of the ante- 1 London Lancet, March, 1875. * Mcd.-Chir. Trans., 1848 and 1365, and Mcd. Times and Gazette, 1805. TETANUS. 303 rior columns, and in the posterior columns, similar appearances were found. Below this point there was less disease as far as the fourth dorsal vertebra. Here, in addition to the areas of disintegration, large extrava- sations of blood were found along the whole lateral part of the gray sub- stance on both sides of some sections, in one side only of others ; while the lumbar region manifested the same lesions as the cervical." Dr. James Tyson 1 has detailed two cases in which softening of the pos- terior columns occurred. In one of these there was extravasation of blood in the posterior columns, and to some extent from the vessels of the pia mater. The central gray commissure was destroyed. In the other case no extravasation was found in the posterior columns, but there was venous congestion of the dura mater. I was presented by Prof. L. McLane Tiffany, of Baltimore, with a piece of the cord of one of his patients who had died with tetanus following a severe burn. The pia mater was greatly thickened, and the small posterior arteries were enlarged. Throughout the section, which was viewed at first with a low power objective, I per- ceived a rather extensive increase of the neuroglia. The anterior nerve- roots appeared to be very well defined. Throughout the white and gray matter there were visible numerous round cells quite translucent and bright, which resembled somewhat colloid bodies. These were more plentiful in the posterior column. The vessels of the gray matter were all more or less enlarged, and some of them were surrounded by spaces which were considerably wider than the diameter of the vessel. The cells of the anterior cornua were quite disintegrated, and some had taken an oval form. Those that could be recognized were found to have broken processes, and many had granular contents. The nerve-trunks were unaffected. Arlong 3 and Tripier, Erichsen, and Bouillaud found that the end of the nerve in the wound was diseased, and Lepelletier 3 and Froriep* dis- covered in one case that the neurilemma of the nerves in the vicinity was the seat of inflammatory changes, which extended from the periphery to the cord. This latter appearance indicates an exceptional condition of affairs, and as for the nerve-change in the wound, it is not to be won- dered at, for if there is any importance to be attached to the circumstance of the morbid appearance of an injured nerve, it is certainly inconsidera- ble, when we consider how frequent must be such a pathological condition, and still there is not a proportionate amount of tetanus. Our knowledge of the pathology of tetanus is based almost entirely upon the experiments of physiologists, and we are left somewhat in the dark as to the questions : 1. Whether it is a central disease resulting from a mor- bid peripheral irritation which is reflected upon the cord. 2. Whether it is a central disease per se, and the appearances noted after death are pri- mary. 3. Whether the morbid changes are secondary to the symptoms, and due to mechanical causes. We have so far been taught how general spasm may be produced. 1 The Practitioner, Aug. 1877. * Archives de Physiol., 1870. 3 Revue Medicale, iv., 1827. 4 Neue Notizen, 1837. 304 DISEASES OF THE SPINAL CORD. Mitchell 1 and Morehouse caused in animals very violent convulsions by injecting into the vertebral canal a half ounce of fluid, and very hot or very cold water seemed to aggravate the spasms. Cold applied to the spine, whether produced by the rhigoline spray or by ice, gave rise to the same phenomena. Cold to the medulla caused the animal to topple backwards. Upon examination the vessels were found to be intensely congested. So far, we are furnished with the first link in our chain. Assuming that the spasmodic movements are due to a congestion of the cord, and con- ceding that pathological anatomy has furnished us in nearly every instance with evidence of congestion of the gray matter, we are to discover what is the factor of such congestion. It may depend upon a reflected im- pression transmitted to the vaso-dilators, or it may depend upon local irritation by impure blood which produces secondary hypenemia. In strychnine poisoning, the symptoms of which resemble those of tetanus very closely, the spasmodic phenomena are undoubtedly due to the im- perfect oxygenation of the blood ; consequently the cord is supplied with blood loaded with carbonic oxide. It seems to me very possible that the same condition of affairs exists in tetanus ; that there may be direct irritation of the nervous matter of the cord dependent upon some primary blood condition. Fox* very clearly expresses himself as follows : " The abnormal blood imperfectly nourishes the cord. An imperfectly nourished cord is ipso facto an excitable, an impressible cord; this impressibility renders arterial spasms abnormally facile, whether the exciting cause is the circulation in the cord of more of the morbid blood, or reflected irritation from a diseased nerve at the periphery, or reflex irritation from any other cause and from any other point in the body, and if this arterial contraction goes on for any protracted period, or is frequently repeated, we may find various lesions due to imperfect blood-supply in addition to those due to dimin- ished nutrition from the original nature of the blood, while, as a sequence of the spasmodic arterial contractions, we get hyperaemia and perhaps exudation, and lastly the pressure of the exudation or some peculiarity in its nature may lead to some disintegration of the nervous centres." This theory seems to me to be tenable for several reasons: 1. Injuries of peripheral nerves are common, and the cases of resulting tetanus are out of all pro|K)rtion to those presenting no subsequent nervous symptoms. 2. Its endemic nature, its prevalence in certain districts, and its not uncom- mon idiopathic origin when there is no ascertained eccentric cause. 3. The appearances of the cord are of a destructive character, and it is a matter of doubt whether they are not more a result than a cause. Considerable discussion has taken place in regard to the cause of the high elevation of temperature. Verneuil does not consider it due either to myelitis of the superior part of the cord, or to asphyxia or muscular con- 1 Am. Journ. Med. Sciences, 1866. * Op cit., p. 362. TETANUS. 305 tractions ; but Huron is decidedly of the opinion that such increase in temperature is alone the result of muscular action. Mason has experi- mented, and found that the temperature of a tetanized muscle is often increased from one to two degrees. The medulla has been found in more than one instance to be the seat of grave lesions, and it is probable that the trismus and other evidences of an excited state of cranial nerve innervation, which occur in the begin- ning, are indications of primary disturbances in the bulb. Diagnosis The diseases with which tetanus may be confounded are hydrophobia, strychnine poisoning, hysteria, and acute spinal meningitis. In the first there is no risus sardonicus ; the convulsions are clonic ; there is the noisy hawking and effort to spit ; the dread of water, the delirium, and finally the history of a bite by a rabid animal, which, however, is not always to be ascertained. Strychnine poisoning is very easily mistaken for tetanus. In poisoning by a large dose of the alkaloid the symptoms appear rapidly, and death takes place in a short time. The hands are clenched and rigid, but the jaw can be opened, which is not possible in tetanus. This resemblance between the two conditions has been made use of in more than one poisoning case as a ground of defence, and in that of Cooke, who was poisoned by Palmer, the question was narrowed down to the appearance of the cord. Cases of hysteria sometimes present symp- toms which not rarely counterfeit those of tetanus. The jaw may be locked, but there will be few of the other features. Hysterical patients are nearly always seemingly unconscious, and there are no evidences of suffering whatever. In spinal meningitis the muscular rigidity seems to be dependent, in a great measure, upon the patient's effort* to relieve the pain which is produced by an uncomfortable position. The locked jaw, which is an early symptom of tetanus, is absent in acute spinal meningitis. Prognosis Dr. Jones 1 has collected 480 cases of tetanus, 213 of which recovered under treatment, the mortality being 49.2 per cent., or one death in 2.02. These were all cases of traumatic tetanus. The per- centage of death in the British army during the Crimean War was 91 per cent. ; and Baron Larrey's estimate of mortality of the French army under Napoleon was at about the same rate. In regard to the time of death Dr. Jones found that of 50 cases, in which the disease followed slight injury of the extremities, 43 proved fatal in a short time, and of the whole number of deaths reported 24.14 per cent, ran a rapid course after slight injuries, and terminated in death in a few days. One case died on the second day. Cases are reported which have termi- nated fatally in twenty -four hours after the appearance of symptoms. In one case, mentioned by Dazelle, they appeared on the third day, and the patient died the same night. Hammond lays stress upon the statement that the prognosis is governed by the interval that elapses between the receipt, of the wound and the appearance of the symptoms, and that the longer this interval is the more favorable are the patient's chances. Many 1 Medical and Surgical Memoirs, vol. i., Xew Orleans, 176. 20 306 DISEASES OF THE SPINAL CORD. writers agree that elevated temperature playa an important part in the prognosis, and that any increase is to be looked upon with alarm. The duration of the attack is to be taken into account, and every day bridged over by the patient after the fourth or fifth increases his chances of recovery. Of course the gravity of the affection depends much upon the violence of the paroxysms. Treatment It would be useless to discuss the merits of the many drugs that have been brought forward from time to time. Our most clli- cacious remedial agents are the depresso-motors, and among these may be mentioned chloroform, chloral hydrate, Indian hemp, Calabar bean, and conium (FF. 56, 39, 3, 4, 82, 51). Calabar bean, which has enjoyed a deserved popularity, has been inside use of with great success by Eilert, Holhouse, Wood, Watson, and a host of others. Holhouse in 1864 reported two cases, one of which was 'cured after having taken 3-4^ grains of the extract every two hours. Ashdown wus not so successful, and Spencer and Dickenson had the same discouraging experience. Even Watson was one of the first to use the remedy, and three out of his four cases of tetanus were cured by the administration of ten drops of the tincture every hour, and by a subsequent increase in the dose. The drug may be given in full doses, say from one-quarter to one- third of a grain of the extract every two hours. The chloral treatment has certainly been more efficacious. Surgeon- Major Hunter 1 reported two cases : one a boy, and the other a man of 40. In the first case chloral was combined with cannabis indica. R. Tr. cannabis ind. n^x; potass, bromid. gr. v, every third morning; and chloral hydrat. gr. xij, three times a day, together with inhalations of chloroform as required. The other patient took 20 grains of the chloral thriee daily. Opium and chloral in combination have perhaps been more effec- tive than the chloral alone, and Del sal* saved three cases out of four by this treatment. II. C. Wood reports 9 cures out of 18 cases by chloral. Chloroform has not proved to be the valuable remedy that many have supposed it to be, and it has only the power to "crowd down the bad symptoms which burst forth usually with additional fury when the narcosis subsides." Aconite has been of service upon many occasions. It was first used by Page 8 in a case of traumatic tetanus. The toxic effects of the dnig were produced, and during their continuance there was a remission of symp- toms. The patient was first reduced to a condition bordering on syncope, and afterwards stimulated. De Morgan and others cured tetanus with this remedy, and its place in the therapeutics of the affection is by no means an inferior one. The pulse is markedly lowered, the muscular rigidity relaxed, and a condition of akinesis and prostration takes the place of the irritable ner- 1 Indian Med. Gaz., Feb. ], 1875. 2 Quoted in Practitioner, August, 1877. * Lamrvt, April 4, 1846. TETANUS. 307 vous state. Curare, nitrite of amyl, and belladonna, as well as a host of remedies of the same character, have been praised from time to time, but most of them are useless. Chloral hydrate, either in combination with aconite, or chloroform, and cold to the spine, which may be ap- plied by the ether spray as recommended by Carpenter, I think is the best form of treatment, and should be resorted to as early as possible. If these remedies fail, Calabar bean, curare, or nitrite of amyl may be tried, and conium, which is a powerful depressor of spinal excitability, may be given a trial. Warm baths have been recommended. " Dr. F. Franzolini 1 relates a case of tetanus arising from exposure by sleeping on the damp ground after great fatigue successfully treated by prolonged warm baths and the continual use of chloral and morphia. The chloral was given frequently by the stomach, and the morphia by subcuta- neous injection. The first bath was for six hours, at a temperature of 40 C. (104 F.), and subsequent ones lasted five, four, three, or two hours. This treatment was carried out from the 18th to the 30th of the month; but the daily use of chloral and morphia was continued some time longer. Of the first ninety hours of his disease, the patient passed forty -eight in the bath at 40 C. In twenty-nine days he consumed nearly four ounces of chloral hydrate, and about twenty-two grains of hydrochlorate of mor- phia were injected. Although kept so long in a state of almost constant narcotism, the mental powers of the patient were in no way affected." H. de Renzi, 2 of Genoa, has spoken highly of the dark-room treatment. His patient was kept absolutely quiet. He ascribes the success to the belief that the absorption of oxygen and elimination of carbonic oxide are impeded by darkness. The other indications seemed to be perfect quiet, and during and after the attack ample nourishment. Niemeyer 3 believes in clysters containing twenty or thirty drops of laudanum. He also recommends chamomile baths in the infantile variety. 1 The Doctor, Oct. 1, 1875. Abs. in Phila. Med. Times, Oct. 30, 1875. 2 Gaz. M6d. do Paris, No. 32, 1877. 3 Text-Book of Pract. Med., vol. ii. p. 352. 308 BULBAR DISEASES. CHAPTER XII. BULBAR DISEASES. EPILEPSY. Synonyms L'Epilepsie (Fr.); Fallsucht (Ger.); Mai caduco(ItaL). Definition This most familiar of all nervous diseases is characterized by loss of consciousness of variable duration, attended or unattended by either slight muscular spasms or general convulsions. The relation of these two elements, the psychical and physical, is not always the same, as in some forms of the disease there is a momentary loss of consciousness .and perhaps no appreciable spasm, or the two may coexist, there being protracted loss of consciousness and violent convulsions. There are sometimes very peculiar combinations of symptoms which will receive mention hereafter. The scope of this work does not permit me to consider the history of the disease ; suffice it to say that its antiquity dates back to the days of Hip- pocrates and Aretteus, and biblical references to its existence are common. Cooke 1 thus speaks of the early writings : " Epilepsy has been distin- guished by a great variety of names such as morbus sacer, comitialis her- culcns, caducua, etc. Aretaeus says, it may have been called sacred on account of the magnitude of the evil, it being customary to call what is great by that name ; or because it is to be cured rather by the Divine than by human power, or because persons laboring under it have been thought possessed by demons. 7 Some of the ancients were of opinion that epilepsy was denominated the Herculean disease because Hercules was subject to it ; but Galen says it was so called on account of its form or magnitude." " Epilepsy was denominated morbus comitialis, either because it fre- quently occurred in the crowded assemblies of the Romans called comitia, in which the passions of the people were often much excited, by which it might be occasioned, or because it was customary to dissolve the comitia if during the sitting any person should be affected by it. " The application of the term caducus, a falling sickness, is too evident to need illustration." In our description of the affection it is impossible to make any well- defined division ; suffice it to say that all writers recognize forms known as Hant mal or Epilepsia gravior, and Petit mal or Epilepsia mitior. Reynolds divides the latter into two varieties, viz. : 1st. A form with evi- 1 Treatise on Nervous Diseases, Am. ed. 1824, p. 326. 1 Aret. de Caus. ct Sign. Morb., lib. i. c. 4. EPILEPSY. 309 dent spasms, and another without evident spasms. Besides these, various irregular forms have been included, such as masked epilepsy and hystero- epilepsy. THE GRAVE ATTACK. Symptoms The most familiar variety is known asJSpilepsia gravior, and it may be described as an attack expressed in four stages : 1st. A premonitory stage ; 2d. Stage of convulsion ; 3d. Stage of subsidence ; and 4th. A stage of stupor, or "after-stage" (Reynolds). The first stage may often be absent, for in many cases there is a sudden debut ; but if such be not the case, the patient may have well recognized warnings which may be either psychical (mental or emotional), motorial, sensorial, or vascular, these latter being objective indications. Though these warnings are spoken of by many patients, it is almost impossible to rely upon their testimony, as the demoralization dependent upon the anticipation of the attack, or the short duration of such premonitory symptoms, is sufficient to prevent them from analyzing their feelings. It is, however, possible in many instances to collect information from a number of cases which shall be a basis for the general classification of premonitory symptoms. Very often the attack will be immediately preceded by a vague dread, or an undefined fear of some impending trouble. In one of my cases a remarkably clever and intelligent young lady there is a condition of exhilaration of spirits, and a mental activity which lasts for some hours. Although deeply under the influence of the bromide, she will come out of her apathetic state and chat with her friends upon all subjects in the most entertaining manner. Twitching of the eyelids or of the lower extremities, vertigo with rotatory movement, and tremor are examples of the disorders of motility which occasionally precede the attack. Sometimes there is an elevated sensitiveness of the organs of special sense. Hallucinations of hearing, or visual hallucinations, are not uncommon. One of my patients has often seen a fiery cross ; and another refers to a locomotive with a glaring headlight, which rushes upon him ; while a third hears voices ; and in two cases the patients say that they " smell smoke." Morbid sensations, which cannot be defined, are spoken of oc- casionally, and a vague sense of weight in the epigastrium, head, or some other part of the body is a frequent precursor of the attack. Occasionally the peculiar sensations begin at some remote part of the body, and seem to move rapidly towards the head ; such phenomena are known as aurce. These aura have been compared to the blowing of wind over the surface, the creeping of insects upon the skin, or the pricking of needles. They last but for a few seconds, and are sometimes perceived, but not always. In the wards under my charge at the Epileptic Hospital, the patients sometimes have perceived the aurce in time to seek the nurse or to attract the notice of the other patients. Careful investigation of twenty-nine cases resulted in the discovery that eighteen of them had a warning of 310 BULBAR DISEASES. some kind, four had none, and the rest gave us unsatisfactory answers. After a long process of condensation of statements, I find that seven had an aura starting from the epigastric region, two complained of constriction of the chest, seven had slight vertigo, and one had an aura starting from the extremities, and in one there was trembling of the right hand. Headache preceded the attack in four, and the " indescribable feeling" of the coming fit was alluded to by a number. In one remarkable case the first intimation of the attack was the violent jerldng of the head to one side, and a species of vertigo. In another case the patient muttered in- coherently for a full minute before the actual attack. A third case was equally curious. The patient, whose mental condition was good, would, without any apparent reason, attract the attention of persons about him by the repetition of the syllables " be-lub-be-lub, be-lub, lub, lub-a-luh, a-lub," pitching his voice in a high key, and gradually lowering the tone until the last part of his utterance was hushed and low, and then, after giving vent to a species of groan, he would become convulsed. Trousseau 1 calls at- tention to the " vascular prodromata." A local determination of blood may occur in the finger, for instance, causing it to swell, reddening the skin, and rendering it successively, within a very short time, red, and of a more or less deep violet color ; or, again, the skin may become exces- sively pale after having been injected for some time. The swelling is real, not apparent ; for rings previously easy suddenly become too tight for the finger. The only premonitory symptom may sometimes be an involuntary discharge of urine. It is difficult to distinguish this accident, however, and it is very liable to be considered a part of the attack, which it may be in reality. 2d Stage (Stage of Convulsion) In many cases the first indication of the attack is a wild cry, which startles those about the patient. I have seen a soldier marching in procession throw up his gun and shriek so loud as to be heard half a block away, and fall to the pavement in a convulsion. This shriek is a psychical manifestation, and different from another form of cry which the patient may utter. This second variety is less noisy, and is produced by the forcible expulsion of air through the vocal cords which follows spasm of the thoracic muscles. It is more a species of groan. Simultaneously there is loss of consciousness, and the patient falls to the ground, and is agitated by tonic contraction of all the muscles of the body, but usually those of one side more than the other; so that his body is twisted and bent. The muscles of the neck are strongly con- tracted, while the face is generally distorted. The stronger contraction if some muscles than others draws the weaker side so that movements are produced which are not the result of clonic contraction, but rather an evi- dence of unequally expended forces. 9 Respiration stops, or there may be a long expiration, and then stoppage al together for a few seconds. The pulse is now rapid and very small, a result, probably, of compression of the arteries by muscular masses, and the heart-beats are strong. At the 1 Cliuicul Medicine, Am. et the right side was the consequence, but this gradually disappeared. For some time past he has been the subject of attacks, lasting from twenty- four to forty-eight hours, attended by very extraordinary phenomena. During these he seems to act exactly like an automaton, walking continu- ously, incessantly moving his jaw, knitting his brow, and appearing al>-o- lutely insensible to all that surrounds him. Not uttering a word, he walks straight forward, and when he meets with an obstacle, stops short, explores it with his hand, and tries to pass on one side of it. Surrounded by a circle of persons, he stops at each, and endeavors to pass by the intervals formed by their joined hands, then turns back, comes in contact with the next person, and resumes his round. All this time he never manife>t> the slightest consciousness, just as if he were in a state of somnambulism. lie is absolutely insensible to pain, so that pins may be thrust through the cheek or into the fingers, or very powerful electrical shocks may be admin- istered without the slightest sensibility being manifested. What, however, is very remarkable, is that by bringing him in relation with certain objects we are enabled to determine in him the entire series of acts which are cor- relative with the sensation thus aroused. Thus, if a pen be placed in his hand, he seeks for ink and paper, and writes a letter in a very good hand, in which he speaks very sensibly about different matters which concern him. If a leaf of cigarette paper is placed in his hand, he feels in his jMx-ket for the tobacco, rolls up the cigarette very adroitly, and, having found his match-box, lights it. If the match be extinguished just as it reaches the cigarette, he finds another, and that several times, until he is allowed to light his cigarette. If at the moment when the match is ex- tinguished, another already lighted is presented to him in its place, it is ini|Ktsi4ible to induce him to light the cigarette by means of the substituted match, lie allows his moustaches to become burned without offering any resistance, but he will not employ the light thus presented to him. If chopped eharpie be placed in his pocket instead of his tobacco, he makes the cigarette with this, and lights and smokes it without seeming to pay any attention to what he is smoking. Among the various experiments devised by Dr. Mesnet, there is one which is particularly curious. The young man is a singer at concerts by profession, and if gloves be placed in his hands he immediately puts them on. and searches for paper. When a roll of this, resembling music in form, is given to him, he places himself in the proper jwsition and begins to sing. It would seem, in fact, that tactile sensation induced in him becomes the point of departure, and as if of escape, of a series of acts correlative to this initial sensation acts which he accomplishes automatically, without letting them deviate from their habitual and regular succession. Lastly, it is to be noted that, while in this singular condition, the patient steals all that EPILEPSY. 315 comes within his grasp. If he touches any person, he feels for his watch- pocket, and invariably detaches the watch and puts it in his own pocket, whence it may be immediately removed without his making the slightest opposition. The crisis once over, he has no recollection whatever of what he has been doing, and becomes again perfectly reasonable." 1 An irregular form of the disease is known as " masked epilepsy." The patient in this state may not fall to the ground, but while in a state of un- consciousness will evince a great deal of muscular activity. An epileptic in my ward is in the habit of tearing through the hall, colliding with such patients as may happen to be in ber way, and finally recovering conscious- ness, when she has no recollection of her attack. I have noticed the same phenomena in other cases. Another form is connected with the commission of purposeless acts. Hammond reports the case of a gentleman who disappeared and travelled about the country for some days, and when found could not give the slightest history of his whereabouts. The individual, in reality, leads a double life, and while the automatic state prevails he may commit deeds of violence which may subsequently cause him a great deal of trouble ; and in such cases only, the history of undoubted epilepsy should alone be sufficient to exonerate him. I believe it is strongly improbable that there is ever an attack of masked or aborted epilepsy without expression of some of the evidences of the true paroxysm. The sequences of epilepsy are various, but it does not necessarily follow that any mental impairment should result. It is true that in some cases such a termination is possible. Idiocy and epilepsy some- times go together, but it must be remembered that the former is a con- genital state. Examples of general mental failure are by no means rare, and in some cases the disease slowly undermines the patient's intellectual condition. An apathetic state is the primary result. Any one who has seen one of these old cases (especially if the patient be the victim of petit mal'), with dull fishy expression of the eyes, a leaden, sallow countenance, a full lip with imperfectly defined vermilion border, sluggish cutaneous circulation, loss of memory and dulness of wits, will recognize the condi- tion I have endeavored to describe. An epileptic convulsion in infancy may give rise to cerebral hemorrhage from a vessel ruptured during the paroxysm, but the accident is almost unheard of in adult life. Epileptic mania, which Reynolds considers to occur in about one-tenth of all the cases, is not confined to any particular time. It may occur be- fore the attacks, or, as is more often the case, succeed them. In this con- dition epileptics may be occasionally very dangerous, and give way to outbursts of violence, for which, of course, they are entirely irresponsible. A man who was a patient in the out-door department of the N. Y. State Hospital for Diseases of the Nervous System, and who had been treated by my confrere, Dr. J. J. Mason, for epilepsy for a long time, was subse- quently discharged, as it was supposed, cured. A month or two after- 1 Med. Times and Gazette, July 25, 1874. 316 BULBAR DISEASES. wards, having an attack which was undoubtedly epileptic mania, he pur- sued his wife through the streets, and, drawing a pistol, shot her through the heart. After the deed he expressed great remorse, and gave himself up to the authorities, hut, notwithstanding the medical testimony, was sentenced to the State's prison for life. Causes Of the one hundred and eighty-three cases of epilepsy I have seen at various times, the ages at which the disease appeared were as follows : Male. Female. Total. Under 10 years 16 10 26 Between 10 and 20 years 23 48 71 Between 20 and 30 " . . 27 14 41 Between 30 and 50 " 29 11 40 Over 50 " 4 l 1 5 99 84 183 Reynolds and Hammond show very much the same result. The former saw one hundred and seventy-two cases, and the latter five hundred and seventy-two. Hugon* has recently made a valuable addition to the literature of epi- lepsy in an excellent brochure upon the subject of etiology. He gives a table prepared by Martinet to show the proportion of cases beginning between the 10th and 20th years. Of 307 cases collected by Musset, there were . .107 " 68 " " * Herpin, " .- . 27 " 83 " Maisonneuve, there were . 46 " 306 " " Alegre, " . 105 " 106 " Leuret, " . 42 " 230 " " Moreau, " . 76 " 43 " " Dunaut, " . 26 " 70 " Pelusiauve, " -17 " 75 " " Dussart, " . 40 It will therefore be seen that nearly half of all the cases begin before the twentietli year. Bean collected 273 cases, 43 of which began between the fith and 12th years; 49 between the 12th and IGth years; and 17 be- tween the IGth and 20th years. The attacks of early life are exceedingly irregular, and may begin as jMiorly develop! paroxysms, which are by many classified under that most convenient term eclampsia, which oftentimes means nothing. A number of these attacks of an undefined type usually precede the genuine explosion of the real disease. In regard to sox, it may be said that Beaumes, Esquirol, and Moreau were of the opinion that the disease was more confined to women than men ; but on the other hand Celsus, Joseph Frank, Leuret, and Sandras, as well as Hammond, Reynolds, and others, take the opposite ground. In two of these cases there was an indication of syphilis. * K6cherches sur les Causes de 1'Epilepsie, etc., Paris, 1876. EPILEPSY. 317 From the number of cases I have collected and tabulated, I am inclined to adopt the same view as the latter. Of HugonV cases, 32 in number, 25 were men, and 7 women. Professions seem to have very little to do with the production of the disease, if we except bartenders and liquor-dealers. In regard to the predisposing influence of temperament, climate, .and season, it has been shown by Foville, 3Iarce, Falret, and Delasiauve, that the nervous and sanguine temperaments predispose to the development of the disease. Maisonneuve found that of 65 cases, 25 were of a sanguine and 20 of a nervous temperament. Moreau considers that epilepsy is more frequent in winter than in summer, while others take the opposite view. Whether climate affects the development of epilepsy, I am unable to say; but, after very carefully conducted experiments in regard to the influence of temperature, I am prepared to state most decidedly that the attacks are much more frequent whenever there is a sudden change of weather. A writer in the JRevista-Sperimentale, of May or August, 1875, has given tables showing the influence of atmospheric changes, temperature, etc., upon the occurrence of attacks. At that time I began a series of observations at the Epileptic Hospital. These, when compared with the accurately taken charts of temperature, barometric pressure, wind, etc., of the Health Department, conclusively prove the truth of the assertion I have just made. The number of attacks seemed to increase just at the change ; and a very hot day, followed by a cool one, would show an in- crease of from ten to fifteen seizures among my patients during the cool day, and vice versa. The influence of heredity is more strongly shown in epilepsy than in any other nervous disease, except it may perhaps be progressive muscular // atrophy. In cases of my own the taint can be traced back for several generations either by epilepsy, neuralgia, insanity, or other nervous dis- eases. In one case the maternal grandfather died insane, the paternal grandfather died of apoplexy, the mother was living though subject to neuralgia, one brother had chorea, and the other had committed suicide in a fit of temporary insanity. Other examples are very much like this. Leuret 2 found among 126 epileptic cases that there was a history of he- reditary epilepsy in seven cases. Beau's 3 experience was equally interest- ing. Of 273 epileptics, there was hereditary predisposition in 18 cases. Leech and Fox 4 fixed the proportion of epileptics in whom hereditary taint was found at-36.8 per cent., which, as far as I can judge, is no exag- geration. Reynolds 5 states that in the upper classes this hereditary pre- disposition exists to a much greater extent, but calls attention to the diffi- 1 Op. cit., p. 7. 2 Leuret: Recherches sur 1'Epilepsie, Arch. G6n. de M6d., 1843. 3 Archiv. G6n. de M6d., 1836. 4 Manchester Med. and Surg. Reporter, quoted by Reynolds. 5 Syst. of Med., vol. ii. p. 295. 318 BULBAR DISEASES. culty of obtaining information. I have often been disappointed in getting reliable information, for this "skeleton in ^the closet" is krpt closely guarded. I have been repeatedly astonished' to find how strong this ele- ment is in the higher walks of life. In one family I find a long succession of insane ancestors, idiot children, and dissolute progeny, which fully accounted for the transmission of the disease. It is a fact, however, that it does not follow that, because a parent has been epileptic, the offspring shall inherit the disease. Voisin found among 96 cases 24 which followed hereditary alcoholism and phthisis. It is often due in the first instance to exciting causes, which, if removed, would probably be followed by dis- appearance of the disease. As to exciting causes, I may enumerate bad habits, excessive venrry. syphilis, and uterine disease, which last I believe to be one of the most important of all. Fright, grief, anxiety, overwork, blows on the head, and other traumatisms, also enter extremely into the etiology of the dis- ease ; and the disorders of digestion and the exanthematous di.-casrs often play a jirt in its causation. Onanism is a very common cause; and of 24 male cases I have seen during the past year, this vice existed in 9. I may extract the following data from a paper which I read before the American Neurological Association at their last meeting: One-third of these patients (from the Epileptic Hospital) suffered from intercurrent diseases; two had advanced phthisis; several had nephritic disease; and a great many were anaemic. In regard to the complicating neuroses, I find that twelve were subject to headache, two were heiniplegic (right), the epilepsy following the hemiplegia, two suffered from sclem-is (one locomotor ataxia, the other diffused cerebral sclerosis), and one was an idiot. "When we came to examine into the causes we found more difficulty than we anticipated. The intelligence and memory were much below par in all. Scarlatina and variola preceded the disease in two, syphilis in one. In nine the attacks were connected with menstrual irregularities and ute- rine disease (versions and flexions), two of these were masturbators (by confession), one of whom has been cured since the habit was broken. One case only was traumatic, four were congenital, and several gave absurd answers which were unsatisfactory. These are examples of chronic cases, and of course many arc intractable. Morbid Anatomy and Pathology The variety of morbid appearances that have been found from time to time give no satisfactory explanation of the pathology of this disease, and we will not enter exten- sively into their discussion. Spicula of bone growing into the brain-sub- stance, thickened meninges, deformities, or depressions of the cranial bones, vascular anomalies, cysts, tuberculous deposits, softening, and a host of other changes have been observed. Some of these are important appearances which should not be dismissed too hurriedly. Undoubtedly the osseous changes are quite satisfactory causes. In three cases 1 found spiculae or nodules or bone growing into or pressing upon the cerebrum. In one of these the exostosis had attained a length of one inch, and varied EPILEPSY. 319 from one-eighth to one-quarter of an inch in diameter. In other cases I have seen decided depressions of the parietal bones, which infringed to a great extent upon the brain-substance beneath. As far as the deep lesions go, nothing very conclusive has been found. Van-der-Kolk has dwelt at length upon the increased vascularity of the medulla and the softened patches sometimes present, but these changes are just as likely to be the results of the disease as they are to be the lesion which produces the Convulsion. It seems likely, however, that the investigations of Cazauvieilh and Bouchet, Bourneville, Charcot, and Delasiauve in France, as well as those of Meynert in Germany, must throw some light upon the pathology of this puzzling disease. All of these observers found distinct induration of the cornu ammonis, or pes hippocampi, which is known to be situated in the lateral ventricle. Cazauvieilh 1 reports eighteen autopsies made at La Salpetriere. In nine of these one or both of the cornua ammonis were indurated, and at the same time there was induration of the white matter of the hemispheres. Bouchet, 2 in forty-three cases, found the same condition of affairs. He says, " La corne d'ammon est la partie cerebrale qui a le plus frequemment presente 1'induration. Cette alteration a souvent ete si frappante, et quelquefois si constante, que bien eVidente neuf fois de suite pour quelques medecins assistants, elle leur a donne la conviction qu'elle representait exactement la cause pathologique de 1'dpi- lepsie." Bourneville observed this lesion five times out of thirty-four during the years 1866-1874. Meynert has repeatedly discovered induration of this part, and considers it a pathognomonic sign. In his examination the cornua ammonis were found atrophied, and appeared to be of a cartilagi- nous hardness, and had undergone a general alteration. Of ten autopsies that I have made, six presented this lesion, and in one I found it to be uncomplicated. The other four cases presented nothing distinctive. In two the left hippocampus major was indurated, in three both were indurated, and in one the right was the seat of the same change. In one of these the extreme exterior part of the pes hippocampus was quite firm ; the little crenations or irregularities were more marked than in the healthy brain, as there had evidently been some atrophy with contrac- tion. In one the gray matter just adjacent to the hippocampus major con- tained several indurated patches. In two cases the veins which skirt the inner edge of the corpora striata at the line of the velum interpositum, and receive branches from these bodies, were quite distended with blood, as were the venae galeni. The white matter in both anterior lobes was quite hard in three cases. In one case there were minute extravasations throughout the brain and in the medulla. In two cases there was effusion into the 1 Archiv. G6n. de Med., 3me Anne, 1825, i., ix., p. 510, et 4me Ann6. 1826, i., v., p. 5. 2 Sur 1'Epilepsie (Annales M6d. Psychologiques, 1853, 1. v., p. 209). 320 BULBAR DISEASES. lateral ventricles. The cranial bones in one case were found to be con- siderably thickened. In all of the cases there were evidences of great meningeal hypenemia. In three of these cases I found microscopical dis- organization of a granular character of the nerve-elements in the medulla. The vascular walls were thickened, and at certain points ruptured, the places of rupture having no special pathological relation as far as the nuclear involvement was concerned. In three cases which are not included in the ten referred to, I found osseous growths. Although this lesion of the cornua ammonis very rarely exists alone, it seems to be quite a constant morbid appearance, and it now remains for us to discover whether the condition is peculiar to epilepsy. Epilepsy is, without doubt, an organic affection, the established disease beginning, perhaps, after a peripheral irritation has been transmitted re- peatedly to the centres ; but after the disease is fairly developed, the con- vulsions are not necessarily produced by the excitement of such distal irritation ; for, as Nothnagel shows, in eases dependent upon a cicatrix the attacks are not, as a rule, excited only by irritation of the cicatrix. The clinical features of the disease prove the truth of this rule ; for, in any well-established case, gastric, uterine, or any other reflected irritation may give rise to the seizures, or they may take place in an apparently spon- taneous manner. We must, therefore, consider that epilepsy is a disease of an organic character, expressing itself after either some distal or central stimulation in an irregular manner, or the result of both. That it is connected with central changes there is no reason to doubt ; though these changes are by no means uniform. The experiments of Brown-Sequard have thrown much light upon its pathology, though Nothnagel and others do not accept his views in their entirety. Spinal epilepsy, which has been described by Brown-Se"quard as an independent and local affection, is thus spoken of by Nothnagel : " Of course, if we use this designation (spinal epilepsy) for those cases in which an actually existing epilepsy is developed in consequence of an affection of the spine, it would have a certain justification. Still it is superfluous ; for here the name of secondary epilepsy, as above pro- posed, in, in our judgment, amply sufficient. We must, however, very decidedly protest against the abuse which has recently come into vogue of describing as spinal epilepsy the clonic and tonic spasmodic seizures which occur as a symptom in spinal affections, which remain confined to the extremities or even to the legs, and are not accompanied by any trace of mental changes. With just as much propriety could we speak of a spinal accessory or median epilepsy in the case of clonic twitchings of the mus- cles of the fingers or neck which proceed from a peripheral affection of the median or spinal accessory nerve. In our opinion it is most judicious to let the expression fall entirely into disuse ; for on one hand it is unne- cessary, and, on the other, it leads only to confusion." The experiments of Brown-S6quard were chiefly made upon guinea-pigs. He produced epilepsy by division of the trunk of the sciatic, internal pop- EPILEPSY. 321 liteal and posterior roots of the nerves innervating the lower extremities, and by injury of various parts of the brain, the corpora quadrigemina, and cerebral peduncles. He also divided the cord at different points par- tially or completely, and found that injury of the lower part of the cord seemed to have more to do with the subsequent epilepsy than when the upper part was mutilated. After these experiments, the first appearance of epilepsy occurred in from four to six weeks. The attacks were either spontaneous, or followed irritation of certain parts of the skin which were included in the so-called " epileptic or epileptigenous zone." This in- cluded the cheek, anterior part and side of the neck, and a portion of the l.;;ck. This region became anaesthetic, and the hair usually fell out. Any irritation of this tract, such, for instance, as pinching, gave rise to an at- tack. Ultimately the anaesthesia diminished, and the attacks subsided, so that it was impossible to excite them. The " epileptic zone" corresponded to the side upon which the nerve or cord injury had taken place. Other forms of experimentation have produced convulsive attacks, or a condition resembling epilepsy. These were blows upon the back of the head (Westphall) ; irritation of the cortex-cerebri (Hitzig) ; ligation of the carotids and vertebral arteries (Cooper, Hall, Kussmaul, and Tenner); irritation of the peripheral sensory nerves (Nothnagel, Krauspe). The labors of these, as well as others, indubitably show that the epileptic at- tack is connected with cerebral antemia, and the experimental production of this vascular state when irritation of peripheral sensory nerves has been made furnishes another link in the chain. The question of localization next arises. Brown-Sequard, Schiff, Rey- nolds, and Kussmaul, and Tenner have all demonstrated that the me- dulla oblongata is the probable pathological seat of the disease. It has been proved by them that a so-called " convulsive centre" is here located, which, when excited by reflex stimuli, gives rise to extensive spasms of both kinds of the voluntary muscles ; that whether the irritation comes <>x chorda or ex cerebro, there is a primary bulbar ^congestion, a cerebral anaemia, and a secondary cerebral congestion ; that such congestion follows reflex spasm of the cervical muscles, and that a condition of venous en- gorgement ensues from pressure upon the large vessels of the neck. The pathology of the confirmed disease may be briefly stated as A. The existence of a condition of reflex excitability of the medulla from a long-standing reflected irritation. B. An exciting impression transmitted from the periphery, or from a central part. C. The irritation of the vaso-motor centre (described by Dittmar and others) through congestion at the floor of the fourth ventricle. D. A secondary anaemia and hyperremia of the hemispheres. The production of symptoms is probably due to 1. a. Anaemia of the brain ; b. Consequential primary loss of conscious- ness, etc. 2. Irritation of " convulsive centre," with tonic muscular contraction, 3. a. Irritation of nuclei of lower cranial nerves ; b. Consequential 21 322 BULBAR DISEASES. asphyxia. Contniction of muscles of neck, pressure upon vessels, etc., secondary stupor, clonic convulsions. Van-der-Kolk 1 explains tlie tongue-biting as the result of irritation of the nuclei of the hypoglossal nerves. The observations of Hughlings Jackson 1 and Hitzig throw much light upon the pathology. The former proves " that those p:uts are \voiu to sutler first and most which serve in the voluntary (special) operations, and those last and least which serve in the more automatic (general opera- tions)." Briefly to illustrate this, he quotes from an article in the Lancet, demonstrating that the three points at which the convulsions often begin are: " (1) in the hand ; (2) in the face, in the tongue, or both ; (3) in the foot." This confirms the idea that the onset begins in the parts devoted more particularly to the execution of voluntary movements. He has been enabled to prove that in this manner the parts first attacked are those which are more commonly affected in hemiplegia. He also calls attention to the phenomenon of aphasia, with epilepsy beginning in the right cheek. " Epilepsies," he says, " are the results of the second class of functional changes ; they are, sj>eaking briefly, discharging lesions. But there are many varieties of discharges. Defined from the paroxysm, an epilepsy is a sudden, excessive, and rapid discharge of .gray matter of some part of the lirain ; it is a local discharge. To define it from the functional alteration, we say there is in a case of epilepsy, gray matter which is so abnormally nourished that it occasionally reaches very high tension and very unstable equilibrium, and, therefore, occasionally explodes It will be observed that the discharging lesion of epilepsy is supposed to be a perma- nent lesion ; there is gray matter which, since it is permanently under conditions of abnormal nutrition, is permanently abnormal in function. That this permanent abnormality is a varying state, has been said ; it has been remarked that the gray matter occasionally reaches high tension, and, therefore, occasionally discharges (or is discharged). There are waves of stability and instability. It follows from this that the first fit is supposed to be a discharge of a part which has for some time before been in a state of malnutrition ; and a still further inference i that such 'causes' of epilepsies as fright are only determining causes of \\\c first explosion. Many of the premonitory symptoms of a first attack are probably results of slight discharges; they are miniature^/iVs." That irritation of the auditory apparatus may give rise to a variety of epilepsy there can be no doubt, but such cases I believe to be rare. Brown-Sequard* states that Mr. Ilinton, an Knglish surgeon, has reported several where, after death, no lesion was discovered, except evidences of disease of the middle ear. My friend Dr. lloosa tells me that out of five 1 Brain and Spinal Cord, Sydftiluun Trans. * W. Riding Reports, vol. iii. p. 315, et seq. * Central Nervous System, p. 96, and Claz. M6J. de Paris, 1842, p. 25. EPILEPSY. 323 or six thousand cases of aural disease he has seen, he does not remember but one of this kind : John W. P , aged 15 years and 6 months, a stout and apparently healthy boy, well nourished, and presenting no external evidences of dis- ease ; family history good. His mother stated that he had always been a rather dull boy, and that at school he was generally behind in his studies, and did not seem to learn easily, and when sent on errands he was unre- liable and forgetful. There is no history of injury or sudden fright, nor lias there been any known predisposing or exciting cause, but at the age of eight years he had a severe attack of scarlatina, which left him with a remaining otitis, most severe on the right side, and resulting in a profuse discharge of pus, which still continues in a modified degree, but is not so excessive as it was a month ago. About six weeks ago he began to syringe his ears with a carbolic acid solution, which had the effect of removing a large mass of what was probably inspissated pus ; and his hearing, which had before been quite defective, became greatly improved, and he no longer complained of various subjective noises, such as buzzing and roaring. When the quantity of discharge was diminished his ears became painful, and pressure on the mastoid processes caused much suffering. Ever since the scarlatina he has had frontal and occipital headache, which is always constant. About a month ago he had his first epileptiform attack, and this occurred about noon one day when he was using his syringe. Without warning he suddenly fell to the floor, became convulsed, and in a few minutes recovered, and did not fall asleep ; but a semi-unconscious state, however, supervened. The next attack came on four days after, at 3 P.M. While he was chatting with a friend, he suddenly stopped talking, and fell. This attack was much more violent than the first one. They now become more and more frequent, until about two weeks ago, when on one occasion lie had fifteen during twenty -four hours. Since then he has not had so many, having had between one and five attacks every day but one, which was the only day he missed the attack since the commencement. During some of the attacks he is very violent, while in others not so much so. His ap- petite has been irregular for some time past. An examination made by Dr. Baldwin, House-physician of the Epileptic and Paralytic Hospital, and myself, revealed tenderness on pressure over mastoid processes, but mostly on the right side. He has had no definite aura, but peculiarsensations which he cannot describe, preceding his attacks. He complains of vertigo and nausea, and muscular weakness after the slightest exertion. He in- variably returns to consciousness almost immediately after the attack, at- tempts to rise and walk, but is usually quite feeble. Examination of Ears R. : Discharge scanty, thin, and sero-purulent ; and, on examination, the membranum tympani is found absent. The tick of a watch is heard only when the watch is pressed against the ear. A roaring sound is always present. L. : The same examination shows more or less congestion of the tympa- num, with evident signs of otitis media ; but there is not so much pain on this side, and the hearing is better, the ticking of the watch being heard at three inches. Patient has complained lately of deep, severe pain in the frontal, but extending back to the occipital region. With this pain there is dizziness, especially when he stands, thus making it difficult for him to 324 BULBAR DISEASES. preserve his equilibrium, which is strikingly shown by his irregular move- ments. When sitting up in bed, he complains that objects move up ;iml down, ivnd not horizontally, as we should expect to find in ordinary audi- torv vertigo ; and a very interesting and peculiar symptom arc tin move- ments he makes to preserve his relation with surrounding objects, his body moving up and down and his head swaying strangely. lie is very suscep- tible to noises and bright lights, either being capable of inducing a spasm at times. Vomiting froth an empty stomach is occasional, with dilatation of pupils. The vision of right eye is at times entirely lost, but at others is unimpaired. Muscie volitantes are frequently complained of. Exami- nation of urine affords negative results. Observations during an attack or convulsion, which occurs at no regu- lar intervals, but is a constant result of irritation of the internal auditory apparatus : Ear syringed at 9.55 A.M. Patient calm, and not at all nervon* : skin of normal hue ; pulse regular ; temperature normal ; pupils somewhat dilated. He passed a good night, and suffered but little pain, though his vertigo was still troublesome. He was placed upon a bed, and the point of an ordinary two-ounce syringe, filled with tepid water, was inserted in the external meat us of the right ear, and the contents gradually expelled. This caused some pain and dizziness, which increased as more water was injected ; and when one ounce had been thrown in, the patient became suddenly unconscious, and the head was drawn from one side to the other by rapid clonic contractions of the muscles of the neck, and almost at the same time the convulsion became general, the muscles of the back being extensively involved. About five seconds after this, there were clonic spasms of the muscles of the jaw, so that the patient snapped his teeth, and, at the same time, forcibly inspired, giving vent to a peculiar noise which might be easily compared, by a person of lively imagination, to the bark of a dog. This paroxysm lasted two minutes, and during its continuance the pupils were widely dilated. The patient remained unconscious ; but then* was neither pallor nor suffusion of the face. Thirty seconds afterwards, a period of muscular relaxation succeeded, a fresh attack followed, during which there was more marked opisthotonos, much more noise, but no frothing at the mouth. Pupils still dilated, though perhaps not so much so as at first, while the skin was slightly suffused ; but there was no duski- ness. Duration, one and a half minute. Ten o'clock and thirty seconds, after slight relaxation and subsidence of movements, the lateral jactitation of the head again began ; and at ten o'clock and one minute a violent ac- cession of clonic, and afterwards tonic spasms made their appearance. The eyeballs had throughout been uncovered, and at first were stationary and immovable, or almost so ; but now they were agitated by nystagmatic movements, and the pupils were dilated. This paroxysm lasted but thirty seconds. At ten o'clock and three minutes there was another seizure, during which the left sterno-cleido-mastoideus was involved in a prolonged tonic contraction. The pupils now partially returned to their normal con- dition, which was one of slight dilatation; and at ten o'clock and four minutes the patient became semi-conscious, answered questions in mono- syllables, and after a few minutes recovered entirely. The pulse suffered no variation, except, perhaps, after two minutes had elapsed from the be- ginning of the seizure, when it seemed to increase in volume, and perhaps slightly in rapidity. There was an entire absence of any external EPILEPSY. 325 evidence of asphyxia, which is so marked in the more familiar form of epilepsy. I have ascertained that the convulsions may be precipitated by simply blowing into the external auditory meatus. Diagnosis. Epileptic attacks may be mistaken for the convulsions of Bright's disease, infantile convulsions, hysteria, alcoholism, opium poisoning, syncope, and softening, and the disease is occasionally simu- lated by malingerers and others. I may briefly dispose of the above : 1. Vrzemic convulsions are generally preceded by drowsiness or coma, delirium, and stertor. The limbs may be ccdematous, and the urine con- tains albumen. '2. Infantile convulsions from worms, dentition, and other eccentric causes, are usually attended by a febrile condition. The convulsions are of short duration, and are characterized by complete loss of consciousness. The discovery and removal of the cause usually effect a disappearance of the attacks. 3. Hysteria. (See article Hystero-Epilepsy.) 4. Alcoholism and opium poisoning are characterized by a more pro- tracted stage of unconsciousness and a contraction of the pupils in the latter. 5. Fainting attacks may resemble the petit-mal, but there are no spasms, and the pulse is feeble. 6. Softening and other organic states give rise to convulsions, but the accompanying symptoms should enable the observer to make the diagnosis in every instance. Simulated convulsions may deceive a careless person, but the normal condition of the pupil, and the eagerness of the individual to play his part, perfectly which he does not do, lead to the detection of the imposition ; and the excessive pallor of the first stage can never be simulated. The syphilitic form of the disease resembles much the ordinary variety, but in some instances it is of the greatest importance to distinguish it? specific nature, as of course the treatment is entirely different from that employed in the non-specific disease. Buzzard, who has given us an admirable little work on the syphilitic neuroses, lays great stress upon the necessity of recognizing the variety of pain as a differential symptom. " If pain in the head be associated with convulsive attacks," he snys, " it generally precedes the attack in syphilitic convulsions, and is often localized in one particular spot In simple epilepsy (if it be present) it almost always follows the fit, is diffused over the forehead, and is at no time a strongly marked symptom." The age of the patient, and the time from which the attacks date, are also of great importance in this connection. It is not probable that syphilitic epilepsy would begin early in life, or, at least, before puberty, but simple epilepsy dates from early childhood. Prognosis The duration of the disease has much to do with the prognosis, and the mode of origin, form of expression, and complicating conditions must all be considered before an opinion is given. If the disease be of idiopathic origin, or if it be due to violence, i. e., injuries to 326 BULBAR DISEASES. the head, the prognosis is had. If it be due to eccentric causes or syphilis, there is reason to he hojieful. Hereditary predisposition is an obstacle in our path which sometimes blocks the way to a cure. I have found that the petit mal is also less amenable to treatment than the severe form, and that it is pretty sure to produce an impaired mental condition. Reynolds thinks that the attacks which recur rapidly are more amenable than those which take place at long intervals, but this has not been my experience. If there be any considerable congenital lack of intelligence the case may be considered as incurable. The unfavorable conditions are the occurrence of a great many attacks in a short space of time, the biting of the tongue, and a condition which has been known as the " status epi- lepticus," in which there are a comatose condition, and a number of fits in close succession. Death from epilepsy is not common, and I know of but six fatal cases: five from the disease, and one from falling upon a sharp iron point which penetrated the orbit. Treatment. Before entering upon the discussion of particular modes of treatment, I desire again to refer to certain etiological facts which bear to a great extent upon the selection of remedies. I may be pardoned for calling attention to practical points which may appear unimportant to some; but an experience gained from the management of a great many cases teaches me that they are to be carefully considered in selecting a plan of treatment. These simple indications, I sun convinced, sire too often overlooked even by painstaking and careful medical men. I allude to the necessity for discovering the exciting cause. I am every day made to feel that the idiopathic cases do not form so large a proportion as they were once thought to. With this belief I am satis- fied thsit empiricism and routine management are bad methods. Any one who examines sill his cases thoroughly will recognize the delicate shades in epilepsy, variations which are exhibited in other diseases presenting more pronounced and better defined symptoms; consequently there :in> evidences of pathological action, which sire not always grouped alike, ami therefore sill cases are not to be treated in the same manner. I ascribe the moderate success I have had in the msinsigement of this disease to the recognition of these differences. Not only may obstinate epilepsy result from masturbation, but it may be due to many of the diseases of women, and it is produced by eccentric irritations of various kinds, or by centric irritation, such as msiy be asso- cisited with toxsvmia. Sir C'luirles Locock 1 called attention to many cases he had treated where uterine irritation wsis the exciting cause; and I think others hsive had the ssime experience. In one of Locock's cases the patient was affected partieuhirly at the menstrual periods. Some of those peripheral causes are curious in the extreme. Through the kindness of Dr. Gibney, of New York, I was enabled to see a child who luid accidentsilly injured her ear with her parasol, the brsiss tip of which remained for some time imbedded in the external auditory meatus. 1 Mcd. Times and Gazette, May 23, 1853. EPILEPSY. 32T As a result, convulsions of an epileptic character were caused, and it was not until some time afterward that the foreign body was discovered and removed. In another case I treated, the epilepsy was unmistakably due to a bad habit the woman had of wearing a number of heavy garments about her hips, which produced some uterine change. When this condi- tion of affairs was noticed, and the skirts removed, she immediately re- covered. At the root of many epilepsies, as well as other neuroses, are reflex causes the starting-point being the organs of digestion, or those contained in the pelvis. Of course the varieties of epilepsy of an idio- pathic nature, or those caused by traumatism or organic disease, will defy the best efforts of the physicians. In prescribing for our patient there are five indications to observe : 1. Removal of exciting causes, if possible. 2. The diminution of exaggerated reflex susceptibility of the medulla. .'3. Equalization of cranial circulation. 4. Abortion of paroxysms. 5. Improvement of general condition. For the accomplishment of these, it is imperative that a judicious and discreet selection of drugs should be made ; and among those which are the most effective I may mention : The Bromides : sodium, potassium, ammonium, calcium, lithium, iron. Chloral hydrate. Mercury. Belladonna. Arsenic. Digitalis. Amyl-nitrite. Strychnine. Tri-nitro-glycerin. Ergot. Cod-liver oil. (FF. 23, 84, 29, 44, 77, 76, 43, 85, 86, 32.) I have not classified these remedies, as it is unnecessary to do so ; but will now say a word in regard to their usefulness. No one drug can be declared a specific, as I am sorry to see has been done; and we must not be too eager to accept the sanguine results of certain over-enthusiastic authorities, and be governed thereby. I allude more especially to the almost universal use of the bromides to the exclu- sion of everything else, and also to their employment in quantities which often ruin the patients, or, at any rate, produce a condition of diminished vitality, which is inconsistent with any hope of success. Badcliffe's 1 idea in this respect is a good one : " There is reason to believe that the thera- peutics of convulsion must be based upon the notion that vital power has to be reinforced, and not upon the contrary opinion." What the proper lose is has not been clearly settled by any one. There are neurologists who believe in toxic doses, and there are others who prescribe quantities which are almost small enough to be inert. In England it has been the custom to prefer the very small doses. I have seen the prescription of a very distinguished general practitioner, who thinks five grains of the bromide of potassium a sufficient dose. Ringer 2 recommends from 30 to 1 Pain, Epilepsy, and Paralysis, p. 215. 2 Handbook of Therapeutics, p. 92. 328 BULBAR DISEASES. GO grains in the day ; Radcliffe, 1 45 grains ; Russell Reynolds,* 30 to 90 grains ; Bartholow, 8 30 to 240 ; and Hammond, 4 90 to 240 grains during the day. Handfield Jones 5 remarks that there is a great difference in the tole- rance of individuals in regard to the bromides some persons not being able to stand five grains, while others will not be affected by doses of !<-- than forty grains. My own experience has taught me that the best effect can be gained by the repeated administration of sixty grains in the twenty-four hours. Tin- larger doses produce rapid bromism, while the medium dose seems to be better appropriated, but will do just as much mischief in the way of bromism as the larger ones, if given for a length of time. My records show me that the average time for development of symptoms of this kind is about three months, while anaesthesia of the fauces is produced in a few weeks, or even a much shorter time ; and I agree with others that it is necessary to produce this condition before we can say that the medicine has produced its physiological effect. But when once reached, the further toxic action of the drug is deleterious instead of beneficial. Brown- Se"quard considers the appearance of acne to be an indication that the medicine has begun to do its work, in which opinion he is joined by Dr. Putnam-Jacobi. 6 Voisin 7 considers the " point of saturation to be indicated by the anaesthesia of the pharynx and nares, so that in one case nausea is not produced by titillation with a spoon, and in the other sneezing and weeping do not follow the introduction of a straw into the nasal cavity." I should consider the latter a rather severe test. According to Danton, 8 the bromides act as vascular medicaments, diminishing excito-motor power. They act on the unstriped muscular fibre, producing local ana>- mia, and moderating excitation resulting from temporary or permanent congestion. u They are agents that pass very rapidly into the blood (Ringer), 9 and consequently their effects are very immediate, and they accumulate till the point of saturation is reached before they are elimi- nated in anything like considerable amounts." We are all aware that repeated and large doses of these drugs are followed by a most disagreea- ble and pernicious state of affairs. Voisin 10 has referred to two forms of bromism, which he has divided into the slow and rapid. In the first the complexion becomes muddy, the eyes sunken, sight and hearing poor, and memory obscure. The patient cannot write, and cannot express himself, 1 Op. oit., p. 202. 4 Op. cit., p. 323, vol. ii. 3 Matcria Modica and Therapeutics, p. 371. 4 Clinical Lectures on Nervous Diseases. 5 Functional Nervous Disease, p. 325. 6 Oral communication before Am. Neurological Association. 7 Voisin, Archiv. de Medecine, Jan. 1873. 8 Danton, Tlifese de Paris, 1874. 9 Op. cit., p. 91. 10 Voison, Archiv. de M6decine, Jan. 1873. EPILEPSY. 329 as he forgets words ; thei-e is tremulousness. In the other variety of the slow form there is dementia, or delirium with maniacal outbursts. Ataxia is also a feature of this variety. In the rapid form that with which we are most familiar somnolence, headache, uncertain walk, difficulty of speech, loss of expression, " fishiness" of the eyes, drooling of saliva, etc. etc., are the ordinary symptoms. Various grades of toxaemia, or even a state which Voisin calls the " cachexie bromique," and which terminates in a typhoid condition, may result from a reckless use of this drug. As regards the variety of bromide, I think the sodic is the most reliable and stable, the potassic salt varying very much in strength. The others either have a tendency to deliquesce, or are expensive. It will be advis- able to keep the solution in a tight-stoppered bottle, and have fresh quan- tities put up constantly, as it is very apt to undergo changes in which the bromine is evolved. And now a word regarding the time of adminis- tration. It has been shown repeatedly that these salts are much better absorbed when the stomach is empty. I have found also that a heavy dose at night is apt to do more good than if the amount prescribed is equally divided up through the day. In a great many patients I have found the attacks to occur at the waking hour, and I suppose this is due to the sudden change in the cerebral circulation. A mild diffusive stimulant has over- come this, and in many cases warded off the attack. I direct my patients who have their convulsion at this time to keep a glass or a small quantity of spts. ammonia? aromaticus near at hand, to be taken before rising. Cold douches to the head are valuable. If the attacks be irregular, it will be found necessary to divide the dose. The treatment of the disease in women should be directed as well to the pelvic organs. It will be found that the bromides will markedly affect the flow, and relieve the pain or uneasiness which is connected with the men- strual period. Locally I have found that cold applied for a few minutes daily over the ovaries will modify the attacks should they be connected with irritation of any of the pelvic viscera. The progress of the disease should be soon modified by the doses I have recommended; and it will be seen by the table condensed from that prepared by Dr. Hollis, 1 that even smaller doses modified or cured the majority of the cases he cites. At the Epileptic and Paralytic Hospital, where most of the cases are the very worst that can be collected as regards chronicity, I find that sixty grains a day will cut short the attacks of a great many patients, and I have cured a number of private patients by this method. Dr. Hollis' cases were not selected, and are evidently hospital patients, like my own. 1 British Medical Journal, July 1, 1876, p. 4. 330 BULBAR DISEASES. Analysis of Eleven Cases of Epilepsy. S. B. Sodic bromide. P. B. Potassic bromide. 1 *3 K 1 j 3 4 6 8 10 11 Sex and age. Duration of disease. Average No. of attacks befure treatment. Maximum Minimum dose. dose. Diminu- tion. Remarks. Main, 15 Hale, 22 Male, 2J Female, 2 Female, 18 Male, IS Female, 11 Female, 17 Male, 20 Male, 13 Male, 2-< Since birth Two years One year IS months One year Five years Five years Several months 19 years Two years 11 years 1-2 weekly 1-2 weekly 1 or more In wepk, s >roetime.s many in a day 1-2 weekly, sometimes 3 in a day 1 in week 4 in week 2-3 in week Sometimes 4- > daily 2-3 weekly 3 weekly 1 in 2 weeks S.B. gr. xx. S.B. gr. xv. t. i d. t i. d. 2 in 8 weeks 1 in2J w'ks None In 8 weeks None in 8 weeks None in 4 weeks None from 5 weeks 1 in 5 w'ks N >ne after trentment No fits fur - weeks 1 in 3 w'ks 1 in 5 w'ks Weak intellect. Disease followed sunstroke; treat- ment lasted three months. Hard drinker, feeble intellect ; potassium salt Inert. Fits followed den- tition ; rickety constitution. Tuberculous dis- ..!-.-. No affection of intellect. Followed a blow ; subject to head- ache. Has bitten tongue No aura. Well developed disease, facies epileptica well marked. No fits since be- ginning of treat- ment. S.B. gr. xv SB. xxv.. S.B. gr. ij. P.B. gr. XXX. doses S.B. gr.xxx Gr. xx. S.B. gr. xv S.B. gr. xx. S.B. gr. xv. S.B. gr. xv S.B. gr. xl. S.B. gr. xv. S.B. gr.xxv S.B. gr. xv. S.B. gr. xx liy this table it will be seen that from fifteen to twenty grains of the soilic salt were required to immediately decrease the number of attacks. Ilelow will be found two tables. In one are tabulated the interesting features of twelve cases of epilepsy. They are old hospital patients, and had applied for admission after outside treatment had l>een exhausted. Kven here the bromides, in the doses I have given, seem to do much for the sufferers. Traumatism and actual insanity make the prognosis as bad sis it well can be, and treatment is simply palliative. Large doses have aggravated many of these cases. The other observations are selected from my note-book, and are illus- trative of the efficacy of the dose I have advocated. liromism occurred in spite of all I could do in most of them, though it was a mild form and under control. The patients were all of the better class, and of course had all the advantages of comfortable homes, attentive friends, substantial food and good air, although many of them were inclined to over-eating, as in fact all epileptics are. In this respect there is an advantage in favor of the poorer patients, who cannot obtain rich food. EPILEPSY. 331 -c; -*^ ^ I a OH s=-51i o a jj-c"^ SS" 5 ?-d ^ *O ^ ^ M 9 4 = 5 5 o *** = *r *, ^ o*^*3 fl IS 3 S o a o p. * P.O d S ** ^^ 2 S 9 > o ^ * a. < M Hill JL --Sj "ll 5 |2 a * 5 .2 s = jrff~i |xi o 5 1 = - c -u ? ^ o -2" s ^-2 c = "S 3 - '"" d '- ^"3 iSj'5 2 c s,^ 3 0. 3 .2 " 4 3 E *O o CQ o PQ 6 "=*=; If y c * M o 1 J !*> -5 ll ,fi P^ o -r < I* Is 3 _j| "< ffi .* TS N 3 3 Z 5 I 1 d S Q = 53 |-|| ^ 0) "^ ^ MO pa T ! j 3 - S 0U j "^ =3 ._ . "1 a .S 0*8 t; .-"S _^ X - > -*- - 3 C 5 33 X o"5)'3l " ' S-S i o >> 5- i A 'a ,J3 i4 C S o o._5 ^.o H O J a o> m O5 JO s 5 -i - os .a "~3 c) M **' a *i a 1 I a o * 11 Q o < < < si Ibf'l I .2.J, 4 -o -2 o- || a * X " M ""1^*1 "5 o w 3 ^ ^" m ' "O -3 H (^ J- z> T3 '5 a "1 ' P. X ** X ^ 1 y ." 3 5 r > "= *t-=" X 2 . '^ S 3 8 t, -^ g; W ^ p x * CO M : 5 C3 E ?-3oS - ? >> K -! -3 * 5 2 >> i a a _c a TS S ta "*a ^ a a a a pa'""' a ir J3 4J" * ' 5 S 3-" 3 ^ .? . . " Q d B 3 ^ a O *-^ : jf- " w '^ -|li'S ^"I X ij s "3 s ci wg | x a *2 *2i" y \ J o _x = ^" =5 5 . O S Q = go -^ a d *. | -2^ a a = ^ S C3 S S o _ fa < on M -* - n | g | ^ 3 s p. .. j>, o ts w *lf "m ^ -E e ^ ^ 3 fc d f * f S |Bi a h S i B ^ 3 X> >> ^ >. ft~ t?l X8S a fa S fa eSy ^2 s IP ^ 1 -ON rt (N 1 ^ 332 BULBAR DISEASES. rj K .. M I -2 2 S >S in ^ 5 REMARKS. 11. Br. for 1 month flts increased. B or S. Br. attacks were 3 in month. complications. Has taken Molanch >1 When und Masturbat I Menstrual Bad habit Bad habit 1 | g . . . JO . . " 1=1 "5 i 6 mont o B 6 mont - o a 4 mont C mont 9 mont 6 mont 4 mont 4 moat 6 mont 3 mont - s d> o s s - s es U. ca CD CO cc ca O a 3 e _: J _; o B 9 **_ t> J ; : M X "2 ca CO 2 J j CO * Hi OB X M = a w o o o g X X X X M a es M M o X g * - to - ~ & .i M kl bo u n I CO - ea - - n - CO * e - S u - 3D Pk Pk PU ^ P< i s. c ~c ti J* 4 I | i in 2 months monthly -. : > monthly monthly in 6 weeks JS - o 1 monthly in 2 months in 3 months " . *v -5 1 - 2 3 -= - 2 3 3 3 3 49 ^= S d 1 1 1 s B - a - B - B S = a S i - i S - 1 a CN ? - a i i CO a S to a it it : | d - - - e -- 5 \ e i i ID a - 2 : 8 3 A e B * a s 2 M 8 a f* s 3 8 s a / a -: a O BS 1 - m CO " o * - OB j3 2 EPILEPSY. 333 And now regarding the large doses. If the idea is to thoroughly ruin the patient's health, enfeeble his mind, or perhaps drive him to an asylum, the toxic administration may be indulged in. It is very true that some- times a rapid restoration may be brought about by "iron and quinine;" but there are many cases where the recovery is not quite so complete as one could wish for. Memory is enfeebled, and there is a cachexia which remains for an indefinite time. A darker side of the picture is not always displayed when brilliant results are detailed. This is the list of demented and those that have died. My friend, Dr. Janeway, was present at the autopsies of two patients who died brominized, for certainly the examina- tions disclosed no other cause for death. I myself have seen several demented cases, and I have no doubt others could tell the same story. I have used the bromides in combination witl^chloral hydrate, and have obtained the most excellent effects. Such good results as diminished stu- por and eruption follow the administration of equal parts of chloral and the bromide of sodium. 1 Belladonna and its alkaloids are of great value when the seizures occur in the daytime, or are of the variety known as petit mal. I have injected the sulphate of atropia in ^ gr. doses beneath the skin at the back of the neck with good effect, and have used it in the manner directed by Trousseau. In either way it should be administered until dryness of the throat is obtained, and should be given a patient trial. The property possessed by belladonna of blunting reflex susceptibility assures it a great advantage over other methods of treatment, when there are centres of irri- tation such as in gastric epilepsy. In ergot we have a remedy which controls the cranial circulation much more readily than any drug with which I am acquainted. As the object is to diminish the congestion at the floor of the fourth ventricle, its combination with the bromides greatly increases the action of the latter. Ergotin may be given alone in the form of Bonjean's capsules. To Tyrrell 2 belongs the credit of suggesting strychnine. Pie believes that this remedy controls excitation of the medulla oblongata. In one individual who averaged fifty-one attacks in a month, the number was reduced by the strychnine to eleven in two years. Handheld Jones does not favor the remedy, nor do others, although it has advocates in this country. In small doses it certainly does good ; but I have found that in larger doses than ^ gr., ter in die, it rather aggravates the disease. Arsenic is excellent, both for its anti-periodic and alterative action, and as an agent to relieve the acne. Clemens, of Frankfort, has lately advo- cated the bromide of arsenic, but in such small doses as to seem useless. He claims for it remarkable virtue when the disease depends upon idiocy, and appears in patients with deformity of the skull. He reports two cures. 1 While these pages are going through the press the preliminary report of the New York Therapeutical Society confirms what I have said in regard to this mixture, which is undoubtedly the best. 2 Med. Times and Gazette, May and August, 1867. 334 BULBAR DISEASES. Where there is an irregularity of heart action, sluggish circulation, blueness or duskiness of the skin, I think digitalis is indicated ; in fact, I generally use it in every chronic case. It is a drug well tolerated by epileptics, who can take it in surprisingly large doses. An agent has been lately given to the profession which seemed all that was needed at first, but which I am convinced is very much over-estimated, except as an abortant. I speak of the amyl nitrite. Drs. Weir Mitchell, Zeigler, and Alexander McBride, as well as several foreign writers, have praised it, and several cures have been reported. In epilepsy there seems to be a "habit" (if I may use the expression) or tendency to periodicity. Amyl is well adapted to stop this, as is any other remedy of the same class. Crichton Browne alludes to the effects of this drug upon the stalim epilepticits. His patient bad had a great succession of fits, and was ;it the point of death; the pupils were contracted to an intense degree, pul-e 1 16, temperature 102, with stertorous breathing. Voluntary movements and yawning were caused by inhalation of the amyl nitrite, and the pa- tient subsequently raised his head, looked about him, and recovered. Dr. Browne relates ten other cases which were seen with Dr. Mierson. Dr. C. Steketec 1 draws the following conclusions in regard to the action of this drug in epilepsy: "It exerts an important influence where the epilepsy is due to or con- nected with cerebral anjemia, for the reason that it ' anticipates the attack when there are prodromata; cuts off the attack when it appears; relie\t - symptoms due to interrupted innervation after the attack; and the attacks become less frequent' " (? by the author). He also considers it injurious where the attacks are due to cerebral hyperamia, for the reason that they last longer and become more frequent, and when either maniacal or con- vulsive, increase in intensity. My own experience with amyl nitrite has clearly settled in my mind the fact that it lias great virtues in cutting short or averting attacks, but that it has no permanent influence. Whether we can or cannot make the delicate distinctions of Dr. Steketec, future clinical experiences I think must decide. Those who have used it say that it does good in a very lim- ited number of cases; and it is a difficult task to decide which are to be benefited. I have tried it in every grade of epilepsy, and find in some of the worst cases, where the fits occur all through the day with very slight intervals, and even where there is time enough to be prepared, that it is often of no avail. It may be given inclosed in the little glass capsules invented by Dr. McBride, of New York, for hospital use, and for patients who are not intelligent, in alcoholic solution. I may be pardoned for bringing another remedy to the notice of the profession, and one that has never been used for this purpose. I allude to tri-nitro-glycerine. Its reputation is almost enough to intimidate the patient, but it is as powerful a medicinal agent as it is an explosive. The 1 Thesis abstracted by Chicago Journal of Nervous and Mental Disease, April, 1874, p. 260. EPILEPSY. 335 tenth part of a drop touched to the tongue is sufficient in a space of time which is almost inappreciable to produce a rapid cerebral hyperaemia. The face is flushed, the eyes become bright, and the temporal vessels throb, while at the same time there are marked sensations of fulness. It produces more lasting congestion than does amyl nitrite, is much safer, and I have found it to act better as an abortant than the latter. Any good pharmacist can prepare a solution containing one drop to ten of alco- hol. This can be further diluted, so that ten drops of alcohol shall contain one-tenth of a drop of the nitro-glycerine. It may be kept safe in this way, for alcohol prevents its explosion. A dose of a tenth of a drop is sufficient in the majority of cases. Last of all, it seems almost unnecessary for me to direct attention to that most familiar remedy, cod-liver oil, which is so valuable in all nervous diseases. Anstie treated a number of cases by cod-liver oil alone, and cured seven out of twenty patients put upon this plan of treatment alone. In all cases I am convinced that it is a valuable remedy which is not appreciated as it should be. I have witnessed its great virtues when the bromide cachexia was profound, and believe that it should always be used in delicate sub- jects. Picrotoxin, a remedy recently brought forward, I have tried, and consider valueless. The subjects of diet and personal habits are very important ones par- ticularly as the stomach is so often the seat of irritations which are trans- mitted to the over-active centres. Beyond the question of over-eating, it has been found that a vegetable diet is better suited to this class of patients. Mierson, in one of the late volumes of the West Hiding Reports, publishes cases, and makes comparisons between those epileptics placed upon a meat and those placed upon a vegetable diet. The results pointed to the superiority of the latter. As the greater number of epileptics have inordinate appetites, the diet should be strictly regulated. It is a good plan, I think, to combine the remedies I have alluded to ; and I take the liberty of presenting a prescription I have used for several years : R. Strychnite sulph. gr. j. Fl. ext. ergota?, iss. Sol. potass, arsenit. gij. Sodii bromidi, .^iss. Tr. digitalis, giij. Aquae menth. pip. ad ^iv. M. Sig. A toaspoonful before eating, in a half tumblerful of water. If the attacks be of the form known us petit mat, I think either ergot or belladonna is our best agent. With either form of treatment it may be found often necessary to use auxiliary general treatment. The syrup of the combined phosphates, or the syrup of the lacto-phosphate of lime, is a good adjunct ; and salt baths, cold head douches, regular food, early hours, and the breaking off of bad habits, will often cure the disease, even when it has lasted many years. 336 BULBAR DISEASES. As ft last resort, should continued medication prove useless, the actual cautery or a deep seton at the back of the neck will occasionally arrest these bad cases. A variety of other remedies have been suggested (and the list of drugs alone would fill several pages such as this), but as most of them have been found inefficacious, I do not think it worth while to further weary the patience of my readers. Galvanism, which has been recommended by Hammond, I find to have but little value. BULBAR PARALYSIS. Synonyms Glosso-labio-laryngeal paralysis (Hammond) ; Glosso- laryngeal paralysis (Trousseau). In the year 1841 Duchenne 1 first called attention to a peculiar group of symptoms which were connected with progressive degeneration of the medulla oblongata; and some years later Trousseau 2 noticed it in his admi- rable lectures, and presented several cases reported by Davaine, 8 long before Duchenne's observations were published, but which were before considered to be examples of double facial palsy. Hughlings Jackson,* Dumesnil, 5 Charcot, 6 and Joffroy, Hammond, 7 and lately Dowse, 8 have added new facts to the literature of the subject. The condition under discussion may be described as a disease character- ized by gradual loss of functions of parts supplied by the nerves taking their origin from the medulla, though the fifth nerve is rarely affected. It may be the result of morbid changes which are limited to the floor of the fourth ventricle ; or, as this region may be the chance site of scleni>. which atfrets other parts as well. Such may be the lesion, whether " pseudo-bulbar paralysis" (the result of arterial occlusion), sclerosis, or glosso-labio-laryngeal paralysis exists ; the special symptoms are alike, and they appear one after another as the different nerves are involved. Symptoms The earliest expression of the disease is a certain loss of power of the lips ; the lower lip especially. If the individual attempts to whistle, his efforts may be unsuccessful, and the lower lip hangs so that the mucous surface is largely exposed. The tongue next follows, and its protrusion by the patient is a matter of difficulty. The individual is un- able to bring the tip in contact with the roof of the mouth, and incompe- tent to use it in the formation of certain consonants (the linguals). When he tries to speak or read aloud he finds great difficulty in pronouncing 1 Op. fit., 2 me edit. 2 Lectures on Clinical Medicine, trans., vol. i. p. 908. 3 Quoted by Trousseau, vol. i. p. 909. 4 Philosophical Transaction:', part i., 1868. s (iaz. Hebdomadaire, Juin, 1859, p. 390. 6 Archiv. do Physiol., torn, in., 1870, p. 247. 7 Diseases of Nervous System, p. 502 et seq. 8 Brit. Med. Journ., Nov. 4 and 11, 1876. BULBAB PARALYSIS. 337 words containing the letters 1, n, c, d, g, h, j, t, w ; and in one of Trous- seau's cases the patient could not utter any letter but a. He may remain in this condition for some time say for a year or two, when the tongue and lips become more extensively affected ; and not only are acts of a voluntary character impossible, but the automatic movements of the tongue become almost totally embarrassed. The use of this organ in the management of food during mastication and deglutition is much impaired, and particles of food become lodged between the teeth and the gums and cheek. The patient's mouth is generally open, so that his teeth are exposed, and from either side, trickles a glairy stream of saliva. Next he cannot arti- culate the labials, and consequently his speech becomes worse than ever. His face wears an inane expression, and he is apt to attract the atten- tion of the people in the street by his open mouth and silly appearance. The condition of the tongue has been noted by Dowse ; its papilla? become atrophied, and the surface very smooth. I have noticed that there is no loss of the sense of taste at any time. The palate next becomes the seat of the paralysis, and the pharyngeal muscles are so weak that deglutition is at first difficult, and finally impos- sible. 1 Fluids are especially troublesome to swallow, and are apt to be regurgitated through the nares, and the voice becomes nasal and metallic as the upper part of the vocal apparatus becomes involved. The facial expression, always a marked feature of the disease, is now very pitiable. The tongue lies in the bottom of the mouth utterly devoid of power, so that the patient cannot protrude it, and it becomes useless for all purposes. If the posterior wall of the pharynx be irritated, there is none of the reflex response which is so marked in the normal state, but only pain is produced. Such was the condition of affairs noticed in one of Dr. Dowse's patients. The epiglottis does not cover the larynx ; and there is a tendency to choking from the accidental introduction of food, so that eating becomes a dangerous undertaking. The voice grows very weak, and the sufferer can no longer even make the almost unintelligible sounds which charac- terized the early stages of his disease. His breathing now becomes very irregular, his inspirations are quite slow and shallow, and he sinks from exhaustion due to insufficient nourish- ment and becomes a mere wreck, dragging himself about, and looking for- ward to death as something which alone is to bring relief. As the pneumo- gastric becomes more and more involved, the respiration undergoes changes which result in asphyxia. For some time before the end, his sufferings grow intense. Mucus collects in the bronchi, which he is unable to remove by coughing, and lie sits in his chair with a feeling of greater security than when lying 1 Sometimes the bolus of food finds its way into the larynx and suffocates the patient. 22 338 BULBAR DISEASES. down, for in the supine position the saliva finds its way into the larynx, and produces suffocation. Loss of consciousness or mental impairment is never a symptom of the disease unless it be of the complicated form. The following interesting case was reported recently by Dr. A. H. Smith, 1 of this city : The subject was a clergyman, aged sixty-one years. About fifteen years ago, after prolonged and severe exercise of the voice in preaching, he be- came hoarse, and ultimately his voice failed so that he could speak only in a whisper. After the lapse of a year he gradually regained the use of the larynx, but as he did so he became sensible of an imperfection in his enunciation of certain syllables, especially those containing the letters p, t, d, s, etc. This difficulty has increased until now the power of uttering the labial and lingual sounds is almost entirely lost. Later a difficulty in swallowing was gradually developed, which has reached such a degree that only warm fluids can be taken, and these with great care and hesitation, as they are apt to cause strangling, and to re- turn through the nose. Mucus accumulates in the fauces, which he has great difficulty in getting rid of, and which causes a sense of strangulation. He finds that the movements of the tongue are very much restricted, and he has not the full control of his lips. His sight, taste, and smell are as perfect as is usual in persons of his age. The sense of touch, even in the paralyzed parts, is not impaired. He feels much less distress when the weather is warm, and dreads the approach of each winter. Such is the account which the patient a very intelligent man gave of himself. As to the objective appearances, the patient moved slowly and feebly, but this was evidently the result of mere debility. The next notable thing at a cursory glance was the expression of his mouth. The orbicularis muscle was entirely paralyzed, permitting the lower lip to fall away from the upper, and to become partly everted. There was also relaxation and eversion of the upper lip from the same cause. The leva- tores menti and the depressores ang. oris were not involved in the para- lysis, and by their aid the patient was able to bring the lips into contact ; but when so approximated they projected forward, leaving a space be- tween them and the teeth, and giving a very peculiar expression to the face. When the month was opened the movements of the tongue were ob- served to be very slow and very much restricted. The tip could not be turned upward to touch the roof of the mouth, nor backward beyond the bicuspid teeth. The tongue was not notably changed in shape or size. All the muscles of the soft palate, including the palato-pharyngi and palato-glossi, were paralyzed, so that when the head was thrown back- ward the relaxed velum fell of its own weight against the posterior wall of the pharynx. The finger carried into the fauces produced scarcely any local reflex action, showing that the constrictors were complicated ; but sensation was perfect, and the reflex action of the stomach seemed unim- paired, efforts at vomiting being readily excited. There was a very profuse secretion of mucus from the larynx and . Record, Nov. 24, 1877. BIJLBAR PARALYSIS. 339 pharynx, which was gotten rid of with the utmost difficulty. There being perfect inability to contract the cavity of the pharynx, the air which was forced from the larynx in the act of hawking escaped into a great loose bag, instead of into a narrow, firm passage, and thus it failed to drive the mucus before it. The paralysis of the soft palate added to the difficulty, for when by great labor a portion of mucus was coughed up into the back part of the mouth, the non-closure of the isthmus faucium permitted it to fall back again upon the larynx. Examination with the mirror showed that the laryngeal muscles re- tained their activity, and the cords, with the exception of slight hyperae- mia, were normal. The respiratory muscles were as yet unimpaired. In this case it is not probable that the loss of voice, which occurred in the early stage of the disease, was owing to a central lesion, since, after a your had passed, the larynx gradually regained its power. Moreover, laryngeal paralysis of bulbar origin does not usually occur in this associa- tion until after the paralysis of the lips, tongue, and soft palate has become 'well-marked. It is more than probable that the aphonia was the result of a catarrhal affection, and that if life continues long enough there will be a return, but this time from advancing changes in the medulla. The greater ease in swallowing warm fluids is characteristic of clyspha- gia from almost any cause. Thus it is observed in both organic and spas- modic stricture of the oesophagus, and also when dysphagia results from the pressure of a tumor. Dowse 1 considers the disease to be either progressive, stationary, or re- trogressive, and if it were not for the single case of the last variety, which he publishes, I should not be prepared to accept the two latter divisions. This he calls reflex bulbar paralysis. His patient, a woman aged 59, suffered from Bright's disease and inflammation of the maxillary and parotid glands. After her recovery from the last-mentioned condition, there was paralysis of the hypoglossal, facial, and spinal accessory nerves, as well as the third division of the fifth. The vocal cords acted feebly, and she could scarce speak in a whisper, being able to pronounce only the linguals r and s, and could not protrude her tongue ; food lodged in the cheeks ; saliva dribbled from the mouth ; she was unable to blow out a candle, while deglutition was interfered with to some extent. Strange to say, there has been improvement. It would be well, however, if Dr. Dowse had allowed a longer time to elapse before coming to a conclusion in regard to the retrogressive character of the disease in this instance, for the parotitis may have been simply a coincidence. I am inclined to think that the history of any genuine case thus far reported has shown a ten- dency to progressive decline which, though delayed in some instances, has nevertheless steadily advanced to a fatal termination. Causes The disease is one of middle age, and attacks men more often than women. It is usually the result of syphilis, and sometimes fol- lows exposure and mental worry. Dowse considers the causes of the peripheral symptoms to be the following : 1 Brit. Med. Journ., Nov. 11, 1876, p. 615. 340 BULBAR DISEASES. Direct. 1. Progressive interstitial neuritis. '2. Thrombosis. 3. Hemorrhage. ^ 4. Morbid growths. - Rare. "). Vascular spasm. ) Indirect. 1. Reflex action from peripheral irritation. 2. Inhibition from shock to central cerebral ganglia. Morbid Anatomy and Pathology. Trousseau's autopsies re- vealed induration of the medulla, atrophy of the roots of the hypOgkxiiMd and spinal accessory nerves, thickening, and gray discoloration of the dura mater on a level with the medulla, which extended as far down as the roots of the fourth cervical pair. " This thickening was due to a consid- erable increase in the amount of fibres of connective and fibre-elastic tis- sue, and seemed to result from a chronic congestive process, as shown by the great number of capillaries and of deposits of ha-matin external to them. The motor nerve-roots of many cervical nerves were found thinner than they should be from disappearance of nerve-tubes. The fifth and glosso-pharyngeal nerve-roots were healthy, and the muscular tissue of the paralyzed parts was found to be normal." Dumenil published a case which was probably progressive atrophy, but some of the symptoms were those of the disease under consideration. In this case there was extensive atrophy of the roots of the hypoglossal, pnemuogastrie, and facial nerves, as well as a great many other changes. Fox 1 considers an absolute or partial disappearance of the nerve-tubes, witli preservation of the neurilemrna at the nerve-roots, to be a constant lesion; and Wilks 9 found the roots of the hypoglossal and spinal accessory nerves had undergone atrophy, and become reduced to " little thin gelatinous threads." Sclerosis may occasionally involve the medulla, and produce symptoms characteristic of loss of function in the nerves to which I have alluded. Chareot* gives, among other cases, one that involved the medulla ex- tensively. A patient of his presented, besides the ordinary symptoms of disseminated sclerosis, three months afterward, evidences of invasion of the pneumogastric and hypoglossal nerve-roots. There were dyspnoea and dysphagia. The patient was obliged to eat more slowly ; and oftentimes the food was regurgitated through the nostrils. Death followed in about six weeks afterwards, and was preceded by asphyxia. The autopsy revealed the following state of the nervous centres : A section made one centimetre below the protuberance, at the point of origin 1 Op. cit., p. -234. 2 Guy's Hosp. Rep., vol. xv. 3 LeQons sur leg maladies du systeme nerveux, Paris, 1872-73. Pr6mifere partie, p. 234. BULBAR PARALYSIS. 341 of the trigeminus, disclosed a point of sclerosis. Other transverse sections were made at the smaller part of the olivary bodies, and a sclerosed patch was discovered. Another patch was seen at the root of the pneumogastric. Examination by the microscope revealed a number of broken nerve-tubes and broken-down cells at the nuclei of the hypoglossal, and traces of irri- tation in the white substance of Schwann in the pneumogastric fibres. The pharynx and larynx were healthy. The observations of Lockhart Clarke have shown the intimate relation- ship of the nuclei of the important cranial nerves which become affected in bulbar paralysis. There is a set of nerve-cells common to these nerves, and disease of the nuclei of one nerve is very likely to extend to others of the group, so that ultimately there is a general invasion, which is bilateral and never one-sided. The destructive process is probably myelitis, as Leyden has suggested, and disappearance of the motor-cells is the direct cause of the paralysis. It is a curious fact that the sixth nerve invariably escapes when we remember that it arises from a common nucleus with the seventh, as demonstrated by Lockhart Clarke and Stilling. In regard to the partial paralysis of the facial as an early symptom, and the subsequent increase in the area paralyzed, we must remember Romberg's statement that in organic brain-disease the entire distribution is not affected, but that the fibres involved are those that supply the muscles of the upper lip and alae of the nose; and this is an important point in the diagnosis from peripheral paralysis ; and Dowse calls to mind the fact that bilateral paralysis of the muscles supplied by the facial is connected with lesion at the root of the nerve. The aphonia may result, according to Dumenil, either from paralysis of the thoracic muscles, or of those of the larynx. The ptyalism I am inclined to ascribe, in the later stages, to paralysis of the chorda tympani, but agree with Hammond that the accumulation of saliva in the first stage is due more to the patient's inability to swallow it than to anything else. Respiratory troubles may be due to paralysis of the pneumogastric and its motor, the spinal accessory. Dowse has divided the disease into three stages as regards the difficulty of swallowing, the first of which is connected with paralysis of the hypo- glossal ; the second with paralysis of the motor branches of the glosso- pharyngeal ; and the third with paralysis of the spinal accessory. Voisin, in speaking of the alterations in speech, defines them into stut- tering, drawling, hesitation, jabbering, stammering, and quavering. The first three are due to lesions of the nerve-tracts which pass from the anterior cortex to the medulla oblongata, and which traverse the corpora striata,. crura ccrebri, and pons, and are connected with disturbances of will. The other three have no such origin, but depend upon incoordination of the muscles supplied by the hypoglossal, facial, and glosso-pharyngeal nerves. Diagnosis Facial palsy, general paralysis of the insane, progressive 342 BULBAE DISEASES. muscular atrophy and diphtheritic paralysis may suggest themselves, and some are rather difficult to exclude : 1. Facial palsy may be suggested, but as this disease is of sudden origin, and affects other muscles than those about the mouth, there need be no reason to confound it with bulbar paralysis. 2. The early symptoms of general paralysis of the insane somewhat resemble the initial symptoms of the disease of which we are speaking. There is tremor of the tongue, however, in addition to the embarrassment of speech ; and subsequent psychical symptoms make the diagnosis clear. 3. Progressive muscular atrophy rarely attacks the tongue primarily, and only one case has been reported (by Charcot) where there were any bulbiir symptoms. The subsequent atrophy of other muscles will dispel any doubts the observer may have. The affection of the medulla is ordi- narily a final result of the extension of the central disease in progressive muscular atrophy. 4. Diphtheritic paralysis is symptomatized by initial paresis of the mus- cles of the pharynx, and the tongue is seldom involved. A previous his- tory of diphtheria will confirm the cause of the paralysis, should there be a suspicion. Prognosis. As I have said, Dowse believes that there are forms of the disease which may bo cured, viz., the stationary and the retrogressive, I cannot believe that, when once affected by inflammatory disease, such extensive alteration and such decided symptoms as he mentions can ever be removed. The histories of the cases reported by the several observers already mentioned certainly offer a gloomy prospect and little encouragement for the victim. The only case reported as actually cured was that of Cheadle, 1 and from the pain, visual trouble, and unilateral paralysis, it is improbable that the case was one of genuine bulbar paralysis. Treatment. Nothing has been done which has resulted in any decided improvement. Hammond* relates a case which was somewhat benefited by faradization, but I am sorry to say that electricity did no good in the one case I have treated. Dowse recommends cod-liver oil, iron, and phosphorus. 1 Glosso-labio-laryngfal Paralysis, St. George's Hosp. Reports, vol. v., 1871, ]>. i^.'J. 8 Up. cit., p. 518. CEREBRO-SPINAL MENINGITIS. 343 CHAPTER XIII. CEREBRO-SPINAL DISEASES. CEREBRO-SPINAL MENINGITIS. Synonyms Spotted fever ; Me'ningite foudroyante ; Head pleu- risy ; Myelitis petechialis ; Cerebral or Cerebro-spinal typhus ; Menin- gite cerebro-spinale ; Fivere cerebro-spinale, etc. Definition A disease characterized by inflammation of the meninges of the brain and cord, symptomatized by pain, tetanic spasms, and herpetic eruptions, and occurring in an epidemic form. This most terrible disease has of late years received a great deal of atten- tion at the hands of German and French writers. Niemeyer 1 was one of the first of the former to direct attention to the disease ; while in France Broussais and others contributed extensively to the literature of the sub- ject. There is no doubt as to the antiquity of the disease, for among the writings of Hippocrates a nearly perfect description of the malady is to be found. In our own country the epidemic character of the affection was noted by several of the older authors, among them North 2 (1811), Gallup 3 (1815), and Minor* (1823), and their contemporaries. Outbreaks occurred at Medfield, Mass., Litchfield Co., Conn., and at various points in the Eastern and Middle States during the early part of the present century. Clymer, 5 Jones, 6 and others have since written exhaustively on the subject. Cerebro-spinal meningitis is certainly an irregular disease ; it is not contagious, and it is influenced seemingly in no way by climate, origin, or soil. Symptoms The appearance of symptoms is usually quite sudden, and their course is remarkably rapid and ordinarily tends to a fatal termi- nation. In exceptional cases pain in the back, headache, vomiting, or malaise may constitute a premonitory stage, which lasts a few hours ; but usually there is no such delay. A severe rigor, an attack of vomiting which is followed by headache of an intense description, and an elevation in pulse and temperature mark the commencement of the trouble. The child may present these symptoms, and in addition another symptom 1 Treatise referred to in Niemeyer's Text-Book of Prac. Mod., vol. ii. p. 218. 2 Treatise on a Malignant Epidemic, etc., 1811. 3 Sketches of Epidemical Diseases, etc., 1815. 4 Essays on Fevers and other Medical Subjects, Middleton, Conn., 1828. 5 Aitkcn's Science and Practice of Medicine, pp. 492-505, 3d Amer. edit. 6 Mod. and Surg. Memoirs, pp. 412-507. 344 CEREBRO-SPINAL DISEASES. which is invariably patbognotnonic. 77ie head is drawn backwards and doicmcards, and the muscles at the back of the neck are rigidly con- tracted. At the same time the pupils are contracted. The child moan- constantly, and is restless ; this is an early symptom, and may appear at the end of twenty-four hours, and be the first to attract our attention. The pulse is now quite rapid, and may beat 100 to 120 per minute. The pain meanwhile increases, and affects the head as well as the entire length of the spine, and is increased by pressure. Just as in other forms of meningitis, the movements made by the patient aggravate his suffering, and he usually strives to keep quiet. He is conscious for the first two or three days should he live so long, but at the end of this time he loses his intelligence after first growing delirious. The pulse, temperature, and respiration are increased. The former sometimes beats 130 per minute, while the thermometer may indicate an advance to 104, but it usually remains at about 100. At an early period crops of herpes appear upon the face and limbs, and the skin is hyperaesthetic, and the patient cannot bear handling. After the first ninety-six hours the convulsions succeed the primary rigidity. Opisthotonos or other tetanic contractions make their appearance. Stupor follows, and he dies in a condition of coma ; and according to Niemeyer death takes place with symptoms of cedema of the lungs. The bowels are constipated during the entire disease, and during the later stages the patient has involuntary discharges of urine. The above description is of an ordinary case. There are great varia- tions, and either death may take place in a few hours, or there may be a tardy convalescence accompanied by structural changes of a very serious nature. The course of the disease may open with chill followed by rapid convulsions and coma, when the patient may die in less than twenty-four hours. In other cases, after the subsidence of the acute symptoms, which may last for a week or two, convalescence takes place, attended by headache and muscular contractions, which continue for some time. Deafness very often results; and I have several times met with total loss of vision, and paralysis of some of the facial muscles. In one case brought to me from the interior of the State, there was rigid contraction of the muscles at the back of the neck ; and in another, seen with Dr. F. II. Kankin, now of Newport, besides ptosis and paralysis of the pharynx, there was an otor- rha>a, with extensive middle-ear disease. This patient was quite an im- becile, intellectual impairment lasting after the subsidence of the acute stages. One of these chronic cases has been under observation for several years, but I have been unable to effect more than trifling improvement. Causes Epidemic cerebro-spinal meningitis seems to be much more common during cold weather, and is much oftener met with during infancy than at any other period of life. Adults are not exempt ; but the disease prefers the young. It is a disease, like typhus, which usually attacks the poor; and bad ventilation and insufficient food seem to prepare the way for epidemics. In the city of New York, the first outbreak of the disease appeared in I860; and subsided, to reappear, February, 1872. CEREBRO-SPINAL MENINGITIS. 345 In the sparsely settled wards of the city (the 19th, 20th, 22d), where building was going on and fresh earth turnfed up, it seemed to prevail. There were 45 fatal cases during the winter quarter in these wards, while the entire number of deaths in New York during the same period from this cause was 108. During the spring quarter there were 492 deaths, 148 being in these wards. It subsided in the spring of 1873, but reappeared during the autumn of that year. It would seem, from these statistics, that overcrowding had but little to do with the disease, but that bad drainage (this portion of the city being imperfectly drained) had undoubtedly some influence. Morbid Anatomy The meninges of the brain show evidences of intense hyperremia, the sinuses being distended with blood which slowly coagulates, and the dura mater is the seat of ecchymotic spots. There is usually a aero-purulent exudation beneath the arachnoid, and this is found at the base of the brain as well as in the ventricles. It may be recognized, also, in the different fissures and sulci. The spinal meninges are the seat of the same exudation, it being found beneath the dura, or between the arachnoid and the pia mater. All of the spinal membranes are vascular, and opaque in spots. The exudation appears to be confined to the posterior parts of the cord ; and usually, when infiltration in the cord has taken place, small elevations may be observed beneath the pia mater. According to the German pathologists, the cervical portion of the pia mater is not com- monly the seat of exudation. The membranes are often adherent, and patches of false membrane are visible, so that sometimes the sub-cerebral nerve-trunks are bound together and connected by bridges of organized lymph. The nervous tissue proper is extensively softened in rare cases, especially if the inflammatory action has been at all severe. Spots of localized softening are, however, not uncommonly observed. Diagnosis Cerebro-spinal meningitis sometimes resembles certain irregular forms of malignant malarial fever, on account of intermissions in the febrile state. This is the case more especially during convalescence, when the affection assumes a periodical character. The chill in cerebro- spinal meningitis is not so marked as in the true malarial affection, and contractions of the muscles are rare in any form of malarial trouble. The other points of difference may be thus summed up : CEREBRO-SPINAL MENINGITIS. CONGESTIVE PERNICIOUS MALARIA!, FEVER. Bowels constipated. Not usually so. Pulse and temperature do not suffer Both subject to great variations, rapid variations. feeble and irregular (Jones). Temperature does not undergo peri- Temperature undergoes decided peri- odical changes. odical changes. Face flushed ; eruption. Complexion sallow. Delirium and coma not affected by All symptoms modified usually by large doses of quinine. negative treatment with quinine. Increase of fibrine, and rapid coagu- lation of blood when drawn. 346 CEREBRO-8PINAL DISEASES. A malignant typhus, or a masked variola, might counterfeit cerebro- s])inal meningitis ; or, on the other hand, aero-narcotic poisoning might simulate the affection. The absence of tetanic spasms of the post-cervical muscles is, however, so prominent a symptom that when it is present the probability of cerebro-spinal meningitis is considerable. Prognosis. This disease, like other forms of meningitis, has a bad character. Death is generally the rule, recovery the exception. In the city of Xew York the total number of deaths from all causes was 29,084 during the twelve months ending Dec. 31, 1873. Of these, 9593 were placed under the head of zymotic diseases ; and the number of deaths due to cerebro-spinal meningitis was 290. Of these, 69 were under one year, and 104 under five years. Very few cases were over thirty. In the ma- jority of cases the disease runs its course in from 4 to 20 days. In fatal cases death occurs generally before the 12th day, Treatment In regard to treatment, little can be said that will be encouraging. The ordinary antiphlogistic treatment, consisting of abstraction of blood by leeches applied to the mastoid processes, and bladders of ice to the head, and large doses of calomel, according to some observers, have cut short the disease, especially when these reme- dies were used at its commencement. The almost wonderful results that have followed the use of ergot in large doses suggest this remedy to us, and I have no doubt that it will prove to be very efficacious. Ziemssen recommends morphine, and has never observed any unpleasant effects following its employment. CEREBRO-SPINAL SCLEROSIS. Synonyms. ScleVose en plaques dis.6minees (Charcot and Bourne- ville) ; Insular sclerosis (Moxon). For a long time this disease was mistaken for paralysis agitans (Parkin- son's disease), chorea, and other neuroses ; and even after it had been shown to be a separate neurosis a certain amount of confusion existed in regard to its nomenclature and its position among the scleroses. Charcot and Moxon 1 are to be thanked especially for their successful efforts to give it a distinct character. Symptoms. AVe may divide the progress of the disease into three stages. 1st Stage. Tin; first symptom, which is common to several other neu- roses, is gradual loss of power in the lower limbs, which, by itself, does not attract attention to the grave nature of the disease in its incipiency. "With the weakness there is no atrophy and no loss of sensation, while reflex excitability is either normal or only slightly increased. The rec- tum is not affected, nor is the bladder, and there is simply a paresis which lasts for a variable time, perhaps for two or three months, or for a much 1 Eight cases of insular sclerosis of the brain and spinal cord, by W. Moxon, M.D., Guy's Hospital Reports, vol. xx., 1875. CEREBRO-SPINAL SCLEROSIS. 347 longer period. The partially paralyzed limbs become agitated by tremors, which are seen best when the patient takes some constrained position, or attempts to walk a straight line. He may have the gait of an ataxic, but generally the walk is more like that of a general paralytic, being charac- terized by weakness of the extremities. As the disease invades a higher portion of the cord, we will find tremor of the upper limbs and paralysis of the cranial nerves, indicated by symptoms I shall describe in speaking of the descending variety. I may allude, however, to a particular de- fect in articulation, the patient being unable to pronounce some of the labial consonants. 2d Stage Rigidity of the limbs supervenes, with various contractures of a spasmodic character, and exaggeration of the tremor. One of my patients died in her bed with her knees drawn up to her chin, her legs flexed on the thighs, and her arms drawn closely to her chest. It required quite violent exertion for me to extend the limbs, and the tremor was markedly aggravated when I did so. Electro-muscular irritability is next greatly increased, and reflex excitability heightened. Epileptiform at- tacks may now appear, as well as apoplectiform, and death may occur at this period from the invasion of some cerebral vessel and consequent cere- bral hemorrhage. 3d Stage This stage is marked by rapid decline of the patient's strength. Incontinence of urine and feces, bedsores, and dementia follow, and, after other evidences of gradual wasting away, death may end the scene. The course of this form is : First, paresis of lower extremities and tremor ; second, contraction, and aggravation of tremor ; third, general dissolution. 1st Stage of Descending Form : This is the condition of affairs when the cord is attacked secondarily. When the disease begins in the brain, the early symptoms may be headache, convulsions, vertigo, or, what is more common, paralysis of some of the cranial nerves ; there may be ptosis, strabismus, loss of hearing, and facial paralysis, or troubles, of speech and embarrassment in swallowing. The important symptom next in advance is the appearance of tremor, which is first seen in the tongue, which, when protruded, trembles visibly ; or it may affect the lips, as may be noticed when the patient speaks. The eyeballs oscillate (nystagmus), and the head may become agitated, and afterwards the upper extremities. A peculiarity characteristic of all forms of sclerosis is not absent here, viz., the aggravation of tremor by voluntary efforts made to control it, and its diminution during rest. If the individual attempts any complex action, he is utterly unable to complete it properly, for the movements increase until muscular control is entirely lost. I have alluded to the lost sense of location, which is also seen in advanced locomotor ataxia, and I may state that it is also a symptom of this form of sclerosis. 2d Stage : The limbs lose their power to a great extent as the disease advances, and permanent contractures of the upper and lower limbs, which by this time are affected, render the patient very uncomfortable. His forearms may be flexed, and the fingers are doubled up, as is the case in 348 CEREBRO-SP1NAL DISEASES. uncomplicated lateral sclerosis. The thighs are even flexed on the pelvis, and the legs may be as well. The knees are approximated quite forcibly, and it is often difficult to separate them. This stage may last for several years. 3d Stage : Meanwhile the tremor has continued, and increased in vio- lence; but it may sometimes be stopped by flexing the great toe, just as Brown-Se"quard has shown may be done in epilepsy. The bladder and rectum are now involved, and the patient suffers terribly from cystitis. and is prostrated by diarrhoea. Bedsores form, and he gradually sinks into a state which invariably has a fatal termination. In both varieties there is great difficulty in articulation, and disturbance of function in those organs supplied by the lower cranial nerves. The lower lip falls, and there is dribbling of saliva, while food often remains in the mouth wedged between the teeth and between the gums and cheek, and liquids find their way through the nostrils. Beyond slight irritability and restlessness, there are usually no mental symptoms at the outset, or until the fixed stage, when sometimes there is intellectual as well as physical decay ; but this is not the rule. A case which seems to be of great interest, because of the atrophy of the upper limbs, came under my notice two years ago. E. W., aged 37, salesman, no family history of nervous trouble. Father and mother alive; nothing to account for his present condition. Five years ago he was employed in a drygoods store, and his attention was called to a slight weakness in his thumb and forefinger of the right hand when he used his scissors. There was subsequent tremor, which annoyed him excessively, and which subsequently became quite general. About the same time he was subject to very severe headache, vertigo, and sometimes vomiting. The tremor meanwhile increased, and it became so violent when lie attempted to execute some fatiguing act that he was forced to desist. He next noticed that his vision was beginning to be impaired, that he saw double, or that "mist floated before his eyes." The trembling continued, and when lie came to me I found his condition to be as follows: The pa- tient is a tall man, of decidedly nervous temperament, quite feeble and emaciated, and very much depressed. Both arms are convulsed by tremors, but especially the right. The biceps and the extensors of the hand are much atrophied, and there is great loss of power, lie tells me that the tremor has been much more violent than it is now. The sensibility of the cuta- neous surface is rather lowered, and there is a certain amount of analgesia, so that pins may be run into the dorsal aspect of the forearm without pro- ducing pain, lie was able to press the fluid in the dynamometer up to 7.r0 with the right, and to 17 with the left. There is still headache at times, and some dix.xiness. The left eyelid seems to cover the eyeball more fully than the right, and the muscles of the left side of the face were trembling quite violently. When I told him to whistle, his lips trembled so much that he could not do so; and when I requested him to repeat the (tutterj line "Ben Battle was a soldier bold," he did it as follows: "Me-e-n (hdiutlon) (1ow) (explosion) (cxplolon)l m-m-ni-etta was a s o o g a m-mold." His articulation was quite defec- 1 The intonation was very much like what we would expect to find in "cleft palate." CEREBRO-SPTNAL SCLEROSIS. 349 tive, and I bad great difficulty in understanding him. His tongue trem- bled, and his lower lip seemed to sag and fall forwards, and he was obliged to wipe his mouth quite constantly, as there was a considerable escape of saliva. When I told him to hold his head in such a position that I might examine his eye with the ophthalmoscope, it shook to a great degree, and I had great difficulty in illuminating the retina. He says this is recent, and that his head was not affected by tremor until a month or two ago. His mind is clear, and his memory unimpaired. I have seen him but once, and there has been no advance in his condition. The following case is reported by Bourneville: l Rosine Spitale, 20 years old. At 17 years of age she was suddenly ati'ected (after crossing a small stream and becoming chilled) with loss of power, first in the right lower extremity, and then in the left, and some time after the hands began to tremble. At 18 there was some subsequent improvement, but it was very slight. Soon afterwards menstruation ceased, and some time after this the symptoms reappeared. Hemiplegia occurred without loss of consciousness or convulsions, and the tongue and eyes were involved. The disturbances of sensation were moderate; there was a certain amount of numbness in the lower limbs, and a sense of clum- siness of the tongue, with difficulty in articulation, and some diminution of mental power. At the beginning of 1853 the patient was well nourished. A half grain of strychnine daily has produced an amendment for ten or twelve days. Electrization produced movements in the lower limbs, and increased the trembling in the Upper extremities. In the course of the month the paresis of the inferior extremities was nearly complete, the trembling of the eyes with dilatation of the pupils is quite pronounced, and the patient has become very stupid. January, 1854. The hands tremble less than they did. There are in- voluntary discharges of urine. Ergot JU P er day has been used for several months. It acted once upon the sphincters, and seemed to improve the weakness of the limbs, for several movements were possible. Spring, 1854. Bedsore on sacrum. September. In a state of decline; the bedsore has extended very rap- idly; pain in the head; pulse 136. October. Repeated rigors ; sensibility of the inferior limbs returned ; feebleness of the extensors of the back; scoliosis towards the right; the trembling in the extremities persists. Noiiember 1. Death, preceded by involvement of the muscles of the pharynx. Autopsy The gray matter is hard; the nervous substance in the neighborhood of the lateral ventricles and that of the protuberance were hard. We found gray nodules superficial and deep. The white substance had become hard in spots. Beneath the microscope the indurated nodules (white) consisted of a fibrous, mass-like, connective tissue; the elements of the nervous matter had almost entirely disappeared; and the white nodules were pressed beneath the surface of the cut. The spinal cord was indurated. The great vessels and viscera were healthy. Dr. Geo. S. Gerhard 2 has presented the following interesting case of this disease : 1 La Scl6rost>, etc., Paris, 1869, p. 92. 2 Philadelphia Medical Times, November 11, 1876. 350 CEREBBO-SPINAL DISEASES. Samuel A., ret. 57, a native of Ireland, and a blacksmith by was admitted into the out-patient department of the Infirmary for Nervous Diseases on September 17, 1870, and gave the following history. His health had always been good until about seven years ago, when, after no known cause, he began to lose power in the legs. One year after this his arms grew weak, and he then observed for the first time that any move- ment of the upper or lower extremities was accompanied by tremor. At a somewhat later period his speech became affected. The weakness of his limbs and the trembling gradually increased, until finally, about four years ago, he was obliged to give up work. On admission there is decided loss of power in the upper and lower extremities, and upon his attempting to use either, a large and jerky tremor is developed. He walks with the assistance of a cane, but his movements are slow, and his feet clear the ground with much difficulty. His grip, particularly that of the right hand, is feeble, squeezing the dynamometer with the former to 100 and with the latter to 1 10. In the upper extremi- ties the trembling is especially well shown during the performance of an act requiring some little time for its execution, such as lifting a glass of water to the mouth. The tremor also involves the muscles of the head and trunk, but it ceases entirely when the patient is in a state of absolute repose. There is no muscular wasting, no loss of electrical response, and no disturbance of sensibility. His mental faculties are decidedly impaired, and his speech is thick and deliberate, there being a decided interval between each word. His eyesight is poor, and examination of the fundus reveals commencing atrophic changes, as shown by attenuation of the vessels and a genenil pallor of the optic disk ; there is also slight nystagmus. The unsteadiness of gait and the tremor are not increased by closure of the eyes. His urine is in all respects normal, and he has no loss of control over the bladder or bowels. Causes. Jaccoud is of the opinion that sclerosis occurs as a disease of childhood or adult life up to 45 years, and that there is nothing to indi- cate the special liability of either sex; while Charcot considers it a dis- ease which is much more common among females than males, and that it rarely appears after 40. Of six cases I have recorded their respective ages were 18, 26, 33, 37, 41, 40; four were males and two females. Of eighteen cases collected by Bourneville fifteen were women and three men. In three of these the disease began between 30 and 40, three between 30 and 35, and the others between 15 and 30. Of Hammond's cases, eleven were men and two women. Very little is known in regard to the etiology of sclerosis; but " moist cold," emotional excitement, and venereal excesses are spoken of by the different Continental writers as causes. Bourneville found that the greater number of his cases died between 35 and .(>, and that the disease appeared in most instances between the ages of 20 and 35. In one of my patients the disease began at the oth year, in another at about the 18th year, and in the third and fourth at 32, and in the fifth and sixth between 35 and 40. Morbid Anatomy and Pathology I have spoken in another chapter about the morbid appearances in sclerosis, and nothing remains to ALCOHOLISM. 351 be said in regard to this particular form. It is only a question of location that concerns us, and after death we will probably find patches of tissue scattered through the brain and cord. The antero-lateral columns seem to be invaded in nearly all cases, and this would appear probable from the contractures. Diagnosis In the ascending form it must be remembered that the tremor follows the paresis, while the descending form is characterized by tremor as a primary affection, or at least before the muscular paresis of the extremities. Paralysis agitans may be confounded with the descending form of the advanced disease ; the tremor in the former disease is continu- ous, and is often not affected by quieting influence or sleep, but is not aggravated by efforts of the will. The early symptoms of this form may also point to progressive paralysis of the insane, and to intracranial tumors ; but the subsequent progress of the affection, the development of new symp- toms, and the common absence of neuro-retinitis, are sufficient to remove any doubts as to its true nature. Prognosis Invariably bad. Treatment I know of no remedy that can reconstruct a degenera- tion of nerve-tissue which consists in proliferation of connective-tissue cells, and nerve-tube disappearance. Nitrate of silver, chloride of gold, galvanism, bichloride of mercury, and chloride of barium have been all used. It seems that only one chance may exist the possibility of syphilis. If this be present, it is probable that specific treatment will be successful. We are to improve the patient's general condition, and relieve his tremor either by conium or hyoscyamus, and make him as comfortable as possible. ALCOHOLISM. ACUTE CHRONIC. Synonyms Ebrietas, Alcoholismus, Delirium tremens; Mania a potu, Alcoolisme ; Trunksacht ; Chronic alcoholic intoxication (Reynolds). Definition. A disease of the nervous system resulting either through direct action of alcohol upon its tissues, or through impairment of other organs which fail to remove effete substances from the blood ; and symp- tomatized by mental aberration, and by various sensorial and motorial phenomena, usually the result of lowered functional activity. The immoderate use of alcoholic beverages is usually followed by the most deplorable consequences. Sad to say, this condition is too familiar to need any extended description, as far as the appearance of the patient is concerned ; but there are other features of the disease that need earnest and careful study. The effects of alcohol upon the human being may be said to be physiolo- gical and pathological. The sensorial alterations are much more interest- ing than the motorial, and of these we will speak in detail. The imbibition of a moderate amount of alcohol, as we know, is usually 352 CEREBRO- SPINAL DISEASES. followed by a general feeling of comfort, a certain degree of exhilaration. The individual is no longer absorbed in himself. He is animated and gay, his ideas flow rapidly, and he becomes filled with greater energy and t-n- duranoe. If the dose be increased, the mental functions become more active. He is excited and demonstrative, and either violent and noisy, or tender and maudlin, according to the thoughts which have most engrossed his attention, or through the influence of temperament. Incoherence of speech and confusion of ideas succeed the ordinary mental excitement, and this may be followed by a condition of stupor, the individual IK coin- ing perfectly unconscious of injury, and unmindful of either bruises or cuts, or even severe burns. He may stagger and fall, and lie in some ex- posed place regardless of the blaze of the sun, the flies, and the noise. He has finally become reduced to what Magnan 1 calls " la vie ve'ge'tative." He is " dead drunk." This deep alcoholic stupor may last for some time, and end the patient's career ; or he may become maniacal instead, or present the condition described by Percy* under the name d'ivres&e convulsive, in which, with clonic convulsions, he grows furiously maniacal, grinding his teeth, and cursing and menacing those about him. The maniacal attacks are no doubt influenced to some degree by the character of the illusions and hallucinations. ACUTE ALCOHOLISM. Symptoms The continued use of alcohol in excess for a week or two, such as occurs during an ordinary debauch, is very apt to lead to an attack of delirium tremens. This state of acute alcoholism may also occur should the patient, who has drunk not necessarily to intoxication, but to a degree almost approaching it, be deprived of his drink. One of the earliest indications of this state of alcoholism is a tremu- lousness or " shakiness," which is quite marked in the early part of the day, and is connected with nausea and want of appetite. The patient is restless and irritable, sleeps poorly, and presents an appearance of dejec- tion and sadness. His eyes are red and watery, and his skin is of a muddy color. His features are drawn and haggard, and he is a wretched object indeed. The gastric irritability may be so great as to prevent any retention of food, and the simplest forms of nourishment are ejected by the stomach. Constipation is obstinate, and the urine is passed in small quantities and loaded with the urates, so that a dense brick-dust precipi- tate is found in the chamber. The attack is immediately preceded by great excitability, and by illusions and hallucinations, which grow very marked as the patient becomes noisy and violent. Magnan has graphi- cally described the different varieties of mental trouble. The patient may be sad and utterly dejected. He may imagine that he has committed 1 R^cherohes sur les centres nerveux, p. 11G. 1 Ivrosse Convulsive, Dictionnaire dcs Sciences Mgdicales, t. xxvi., p. 249. ALCOHOLISM. 353 some great crime ; that he has been sentenced to death ; that he is being executed ; and these delusions may markedly influence the character of his outward expression. In nearly every case there is some delusion of persecution of a horrible kind. The attack usually begins with hallucina- tions of a visual character, in which snakes and other reptiles, devils, imps, gnomes, and goblins terrify the patient. In one instance which I remember, he was tortured by devils who held lighted candles, and were about to set his clothes on fire ; in another case the patient en- deavored to escape a falling weight. The illusions are always followed by hallucinations, and finally by delusions. The irritations of the organs of sense are distorted so that the simplest and most common noises become changed by the patient's disordered imagination into the most terrible sounds. The cry of the vendor in the street is likened to the despairing shriek of a lost soul. The stroke of the clock, a funeral bell, and the voices of those in the room are supposed to be the savage yells of a howl- ing mob. The objects which the patient sees are nearly always trans- formed into animals, which, controlled by no natural laws, run over the ceiling, or gallop through the air. Odors are reversed, and food is sup- posed to be poisoned. Animals run over the skin ; sometimes they are rats or lizards ; and at others he may call attention to the torture inflicted by thousands of needles or cutting instruments. Maniacal outbursts are the common feature of the attack, the patient seeming to possess herculean strength, and it is sometimes necessary to have six or eight strong men to prevent him from throwing himself out of the window, or committing some deed of violence. He may remain in this condition for seveial days at a time, during which period he neither sleeps nor eats. His eyes are bloodshot, and he sweats profusely. The pulse 1 is very rapid, small, and irritable, and though the deep temperature may reach 102 or 103 F., the hands and feet are cold, and the palms and soles clammy. When recovery takes place, the first change for the better is sleep. The violent symptoms subside gradually in the reverse order of their appearance. He may awake, after fifteen or eighteen hours, irritable, but not much better ; or there may be a lesser degree of excitement, more sleep, and gradual improvement. In other cases death follows, there being a subsidence of the violent delirium, which changes its character and becomes muttering; when he relapses into a typhoid state, and gradually passes away. The tendency to the commission of deeds of violence is quite charac- teristic of acute alcoholism. Of 377 cases observed by Bouchereau and Magnan* in the year 1870, twenty-four attempted to commit suicide, and nine attempts at homicide were made. These cases were seen under 1 The sphygmograph has been employed by Anstie in cases of delirium tre- mens, and the tracing obtained very closely resembles that of the typhoid fevers and inflammation. It is of a marked dierotic type. 2 Op. cit., p. 129. 23 351 CEREBBO-8PINAL DISEASES. restraint, but among the cases which occur outside of hospitals and asy- lums, the number is far greater. CHRONIC ALCOHOLISM. Symptoms A much more grave condition of affairs follows the continued use of large quantities of alcohol, and no more hopeless disease exists than that of which we are about to speak. While in delirium tre- mens recovery may take place, followed by total reformation, without any serious damage to the nervous system, the more serious nerve-changes wrought by constant saturation can never be repaired, but tend to further degeneration and decay. Chronic alcoholism begins by a number of insidious alterations in the nervous substance, whereby its functional activity is embarrassed, and minor symptoms at first, and more grave ones afterwards, appear very gradually and progressively. The victim of chronic alcoholism may present the symptoms of tremor and loss of power of which I have before spoken. The tremor is rhyth- mical, and begins at first in the extremities, and afterwards involves the entire body. There seems to be an accompanying want of power, for he relaxes his hold upon any object he may grasp when his attention is diverted. His morning dram involves an effort worthy of a better cause. He grasps the glass with both hands, fearing that he may spill even a single drop of the precious liquid, and carries it carefully to his mouth, clutching the rim of the glass between his teeth, oftentimes with sufficient force to bite out a piece. The lower extremities become involved, and the patient shuttles along in a clumsy manner, his feet being scarcely lifted from the ground. His dress becomes disorderly, and his habits are no longer char- acterized by neatness and tidiness. His facial muscles lose their play, and his countenance wears a wonderfully woebegone and sorrowful expression. He wanders wretchedly from one grog-shop to another ; eats sparingly, and rarely ever, unless his worn-out stomach is stimulated by a dram. He loses flesh, and his clothes hang to his withered limbs like the vestment of a scarecrow. This is but the first step in the advancing disease. Memory becomes weakened, and forgetting even faces and names, he drops one by one his old friends, and sits in loneliness for hours at a time. The mind is utterly sapped, and lie is reduced to a state of dementia. Numerous grave changes occur in addition to these. Speech becomes thick and unintelligible. In the early stages there may be convulsions or attacks of delirium tremens ; but one of the most striking and serious expressions of the disease is the occurrence of paralysis ; and there may be hemiplegia or paralysis of a local character, the third nerve becoming implicated and ptosis resulting. The subject of chronic alcoholism is generally anaesthetic, and this to a marked degree. Not only is tactile sensibility impaired, so that he is unable to determine the nature of even a rough object, but he is unaffected by extremes of temperature. In one case which I can recall, this was illustrated by the fact that in sitting before the fire he thrust his foot ALCOHOLISM. 355 beneath the grate, and left it there for some time before his position was discovered by a member of the family. Hemi-anaesthesia 1 is spoken of by some writers, but it is an extremely rare feature of the disease, and is pro- bably a late symptom resulting from organic changes on one side of the brain. Hammond 2 alludes to the anaesthetic condition of the cornea, which is occasionally not affected in the least by the touch of the finger. Convulsive seizures of different kinds are occasional evidences of the serious effects of alcohol. These may vary from simple spasm to a variety of convulsion which closely resembles a marked epileptic paroxysm. In fact the diagnosis is oftentimes very difficult. What I have said about the mental condition in acute alcoholism may be now applied. The halluci- nations and lighter forms of sensory and mental aberration exist at different stages, but towards the end the condition is one of dementia of the most pro- found character, the patient being completely oblivious of the outside world, and of his duties to society. He is morally irresponsible, and the crimes he may commit are motiveless and dictated only by a diseased mind. Causes. Chronic alcoholism follows the steady use of large quantities of alcoholic liquors, but is rarely found among those who drink wine or malt liquor. The French, Italians, or Germans are, therefore, seldom affected in their own countries, especially outside of the large cities, where a very small amount of ardent spirits is taken. In England, Scotland, Ireland, and America the case is different, for in these countries there is no low -priced light beverage which takes the place of the wines and beer of the European Continent, Avhich are drunk in preference to water. Without entering into the discussion of the effects of alcohol upon other organs of the body than those of the nervous system, it may be said that the condition known as alcoholism springs from a protracted use of large quantities of strong liquor, so that the nervous substance is deprived of its normal nutrition, the blood being charged with effete substances which should be eliminated by the kidneys, lungs, and skin. Delirium tremens is due generally to the direct action of a large quan- tity of alcohol, which produces overwhelming toxic effects ; while chronic alcoholism implies a structural degeneration due to the continued action of the alcohol itself, and to the vitiated blood. Delirium tremens may occur either from a sudden cessation of indul- gence, or in the midst of a prolonged debauch, most commonly, however, the latter. In some persons elimination goes on so perfectly that large quantities of liquor may be taken and disposed of without any pro- found effect upon the nervous system being produced. These individuals may drink to a point much beyond moderation, and still suffer no marked inconvenience, the alcohol seemingly affecting some other organ, which may be either the liver or kidneys, so that cirrhosis or degeneration of other kinds may take the place of the cerebral trouble in the beginning. 1 Magnan considers that hemi-ansesthesia and general paralysis are quite com- mon results of chronic alcoholism, op. cit., p. 134. 2 Diseases of the Nervous System, p. 850. Acute alcoholism (D. T.) ] j 87 i 42 356 CEREBRO-SPINAL DISEASES. Males are much more often affected than females, as the statistics of Magnan show : M. F. 1870 . . 35 2 2 f 1870 . . 216 51 Subacute -j jg 7 j j^g 47 f 1870 . . 126 11 11871 . . 90 14 This fact has been confirmed by statistics collected by the Health De- partment of New York. During the year 1873, 45 deaths were reported from delirium tremens, but four of whom were females. It is probable that there were many more cases which were not reported as such. Women, however, though not so subject to chronic alcoholism as men, often drink to excess, and not rarely develop delirium tremens. This bad habit is confined chiefly to either extreme of society the very lowest class, or the highest in the social scale. Among the latter the amount of private dram-drinking is astonishing ; and though the " skeleton in the closet" is carefully guarded by the friends of the patient, it is by no means uncommon for the physician to be called in to attend cases of delirium tremens in high life. Absinthe, which is extensively used in Paris, and is beginning to be introduced into this country, produces a terrible form of delirium tremens, in which mania is a marked feature ; and a form of epileptiform attack is also quite common. Alcoholism is much more often observed between the twentieth and the fiftieth year, and is very rare before that time. As to hereditary predisposition there is a great deal to be said, but when we attempt its consideration we depart from the immediate subject. Oc- cupation and mental influences have much to do with the making of drunk- ards or hard drinkers. Barkeepers, and individuals exposed to severe weather, are commonly addicted to drink ; the one either feeling obliged to be convivial or indulging only because the liquor is so accessible, and the other because he " needs something to keep out the cold." Mental depres- sion, grief, and business worry are interesting in their social features, but do not strictly come within the scope of an article of this character. Morbid Anatomy and Pathology The prolonged use of alcohol is followed by marked changes in the structure of the nervous substance. In the early stages there may be found appearances which are ordinarily met with in uncomplicated cerebral congestion, viz., enlarged vessels, injected meninges, and effusions of serum. These may vary greatly in their extent and appearance, and may be associated with a fatty degene- ration of the vascular walls, patches of softening, or even little foci of in- duration. The disease leaves its traces most indelibly stamped as menin- geal thickening and opalescence, and perhaps encysted collections of blood, which have been described in speaking of pachymeningitis. The sinuses are engorged, and the dura mater may be adherent to its underlying mem- ALCOHOLISM. t 357 branes ; or they, in turn, may be in such close contact in spots with the cortex that their removal necessitates the tearing out of patches of super- ficial gray substance. The convolutions will be found to be atrophied and reduced in size, and the ganglia at the base are often greatly softened. Many observers, among them Carlisle and Percy, have found alcohol in the fluids in the ventricles. Besides these intracranial changes, the liver, kidneys, and stomach present appearances with which all pathologists are familiar. The arteries throughout the body are found to have undergone atheromatous degeneration, and this is seen in the brain to a very decided degree. As to the condition alluded to by various observers, viz., the* mechanical change exerted directly by the contact of alcohol with the tis- sues, I think there has been much exaggeration. The sclerosis so often seen is much more probably the result of interstitial inflammatory change than a chemical transformation. The experiments made by Anstie, 1 Magnan, 2 Percy, Marce*t, 3 and Motet 4 settle with great certainty the pathological processes which follow the toxic administration of alcohol. Anstie took a full-grown dog weigh- ing 10 Ib. 4 ozs., and injected 6 ozs. of mixed alcohol and water into the stomach at 1 P. M. No food had been taken for four hours previously. 1.4P.M. Animal obviously affected; staggers in walking, and fre- quently falls down. The hind quarters are weak, and skin of hind limbs insensitive. Resp. 24; circulation, 140. 1.6 P. M. Dog lies extended on the floor quite drowsy, but capable of being roused ; fore-limbs retain slight degree of voluntary power. Tongue protruded, and the dog " slavers" still. Skin about mouth anaesthetic ; conjunctiva sensitive. 1.7.30 P. M. Animal falls on its side, comatose and snoring. Conjunc- tiva insensitive with other parts. Resp. 20; circulation, 184, tolerably strong. Ano-genital region was sensitive to painful impressions. Pupil strongly contracted at first, but became dilated at 1.25, little sensitive to light ; anaesthesia remained ; eyes still insensitive ; continuous tremor of hind-legs began and continued for a short time. Respiration declined in frequency and became gasping, and ceased at 3.5 P. M., two hours after the ingestion of the alcohol, the heart beating 64 per minute. It remained irritable for some minutes later. Much more complete and earlier coma followed the administration of larger doses. The continued toxic use of alcohol produces changes not only upon the nervous system directly, but secondarily through other organs which are primarily affected. A large quantity of alcohol taken into the system in- duces pathological changes somewhat after the following manner : A cer- tain portion, quite small in amount, is excreted, and may be detected in the breath, urine, bile, and sweat, while the greater proportion remains in 1 Stimulants and Narcotics, p. 335 et seq. 3 Op. cit., p. 117. 3 DC la folie causee par 1'abus des boissons alcooliques, these de 1847. 4 Considerations generates sur 1'alcoolisme, et plus particulierement des effets toxiques sur 1'homme par la liqueur d' absinthe, 1859. 358 CEREBBO-8PINAL DISEASES. the blood, greatly altering its character and inducing a large number of interesting changes. Lallemand, Marcel, and various experimenters have found that the excretions contained much pure alcohol, and others have detected, by the chromic acid test, traces of alcohol forty-eight hours after- wards. Anstie declares, however, that but the merest fraction of the amount taken is eliminated in its unchanged form. In this conclusion lie differs from the authorities I have quoted. The alcohol remaining in the blood is partially eliminated in its decomposed state (carbonic oxide ami water), while a certain quantity remains. The internal organs are con- gested, notably the liver, kidneys, and lungs, so that excretion is very slowly performed, and the urine voided is scanty in amount, devoid of the chlorides, and rich in urates. The blood circulates sluggishly, and contains fat and sugar. I have also found sugar in the urine, which pro- bably resulted from irritation of the medulla as well as certain disturbances of kidney and liver function. The abundance of carbonic acid requires double duty upon the part of the lungs, and consequently respiration becomes labored and quickened. The natural oxidation of the blood is seriously embarrassed, and elimina- tion is retarded most seriously. The nervous system of course suffers from this change in its badly nour- ished state. Degeneration of the nervous elements follows, and interstitial thickening and medullary metamorphoses take place, so that the loss of function is very great. The pneumogastric being implicated, the lungs and other organs are not properly innervated, and many of the curious evidences of such disorder follow. This is illustrated by the tendency to pneumonia which often exists as a feature of alcoholism. The sympathetic system is of course implicated. The actual presence of alcohol is attended by vaso-motor paresis, and a number of vascular changes probably follow. It might be well, before closing, to refer to a condition of the cranial bones noted by Lancereaux and others. A hard- ening and thickening is due to nutritive changes, which Anstie thinks is not a true hypertrophy, as the original texture of the bone is lost. Prognosis A table prepared by Mr. Neilson from the Registrar- General's report shows that the probable duration of life in individuals who have reached the 20th, 30th, 40th, 50th, and 60th years, and who have been either temperate or intemperate, is about the following : Having reached the age of Has an average chance of still surviving But the intemperate have an average chance of surviving only 20 30 44.21 years 36.48 " 15.53 years, or 35 per ct. of the duration of life of the general population. 13.80 " " 38 ' " " 40 28.79 " 11.62 " " 40 ' " " 50 21. 25 " 10.86 " "51 ' " " GO 14.28 " 8.94 " " 63 ' " " This applies only in a general way to the subject, but is significant in showing how greatly the alcoholic habit diminishes the patient's chances. ALCOHOLISM. 359 In regard to the prognosis of the actual attack, there is rarely any rea- son to fear a fatal termination unless the patient has had a number of previous ones. Coma and convulsions should be looked upon with grave suspicion, as they greatly diminish the patient's tendency to recovery. Chronic alcoholism is more unfavorable. Should the patient survive his immediate nervous trouble, it is very likely that disease of some other organ will carry him off. Much depends upon his ability to reform ; and no assurance can be given that he will recover until this is accom- plished. Diagnosis. The only diseases for which alcoholism may be mistaken are: 1. General paralysis; 2. Sclerosis, and paralysis agitans ; 3. Soften- ing ; 4. Dementia. 1. General paralysis differs from delirium tremens in the fact that in the former the delusions are always pleasurable and exalted. The general paralytic is the king, the capitalist, the ruler of the universe ; the alco- holic patient is depressed, dejected, and sad. These differences, taken into consideration with the fact that the patient suffers from anorexia, that his face is flushed, and the conjunctivas red, ought to settle the real nature of the trouble. Anstie 1 alludes to the presence of acne as a pathognomonic sign. Chronic alcoholism may very closely resemble general paralysis, but there is more proper dementia in the latter. 2. Sclerosis and paralysis agitans are sometimes confounded with chro- nic alcoholism when there is much disturbance of coordination. The tremor and incoordination are much greater during voluntary action, how- ever, in the first conditions, and there is rarely any mental disturbance in either. 3. Softening resembles chronic alcoholism, but the paralysis and speech disturbance are much more pronounced, there generally being aphasia, and the headache besides is quite different from that of alcoholism. 4. Senile dementia may make the diagnosis somewhat difficult. The previous history of the patient, however, will generally clear away any doubts that may arise. Treatment The physician's first attempt should be to prevent the patient from further indulging his depraved appetite. How this is to be accomplished depends very much upon his surroundings, temperament, and condition. If the attack arises during a debauch, I prefer to cut off at once the supply of alcohol, unless he is utterly prostrated. If the attack occurs after cessation, we may then give small quantities of stimulants, and " taper off." Should he be irritable and excited, immediate recourse to sedatives and hypnotics should be had (FF. 87, 3, 4, 33, 39, 23). I have great faith in the bromides, lupulin, or simple reme- dies of this class. Fifteen or twenty grains of the bromide of calcium, given in a drachm of the tr. lupulin twice or three times a day, is often sufficient to quiet the nervous state. A good cathartic which shall increase the action of the liver, and hasten elimination of the alcohol, is an early 1 Article on Alcoholism, Reynolds's System, vol. ii. p. 160. 360 CEREBRO-SPINAL DISEASES. form of treatment which is generally recommended. Should the insomnia be troublesome or the delirium violent, we may administer either the bromides, or the mono-bromide of camphor (F. 87), which I make the claim of being the first to use for this purpose. It may be given in pilu- lar form, made up with confection of roses, in doses of five grains every hour until sleep is produced. The bromides of calcium or sodium in thirty grain doses every two hours sometimes succeed, or, better still, they may be combined with chloral hydrate, so that the patient shall take fifteen grains of each every two hours until the excitement subsides. Cannabis indica (FF. 81, 39) has enjoyed great popularity in the treatment of this trouble, and should be given in doses of from one-half to one grain of the extract. Should the maniacal excitement be intense, I know of no better remedy than morphine administered hypodermically, but not by the mouth, as it may lie unabsorbed for some time without producing any effect ; and the physician may be tempted to give still more than the ordinary dose, when to his surprise absorption takes place, and its cumulative action follows. Digitalis has been recommended in large doses, and Anstie preferred the powder because the alcohol of the tincture interfered with the proper action of the drug. I am inclined to think that the application of digitalis stupes to the lumbar region and the abdomen favors kidney action, and does more good than when the medicine is given by the mouth, It is of importance that the action of the skin and bowels should be increased. For the first object, small doses of tartar emetic assist the emunctory action of the skin, while the compound jalap powder induces copious and watery discharges from the bowels. Cold to the head, either by ice-bags or cloths wet with ice-water, blisters to the calves, and local abstraction of blood may be resorted to in violent cases. As to food: when the worn-out stomach refuses all ordinary articles of diet, it will rarely reject iced milk, which may be given in all cases. After a while soups, nutritious broths, or bouillon made from beef, or Valentine's beef juice, or Bonlen's extract of beef, either of which is preferable to the Liebig extract on account of the nauseous taste of the latter, may be given in lib- eral quantities. Small doses of carbonic acid, seltzer, or Apollinaris water, or coffee may be administered before eating, and gently stimulate the stomach, in this respect taking the place of the drams. The patient's nausea may be corrected by the aromatic spirits of ammo- nia, or bismuth and morphine (FF. 89, 34, 33), the latter in very small doses. In chronic alcoholism the aim of the physician should be to restore the normal action of the viscera ; to stop the supply of drink ; and to freely admin- ister the various preparations of iron, quinine, and phosphoric acid, as well as cod-liver oil (FF. 8, 9, 10, 32, 40, 12). I have found that the new preparation known as dialyzed iron (F. 11) is well borne by the irri- table stomach, does not constipate, and is therefore an excellent remedy. This may be given with tr. digitalis and tr. mix vomica (F. 90). HYDROPHOBIA. 361 HYDROPHOBIA. Synonyms Rabies canina; Paraphobia; Lyssaphobia (?). The name adopted to express that form of nervous trouble which some- times follows the bite of a rabid animal is an evident misnomer, as the definition of the term signifies "a dread of water." As this is but one symptom, and by no means a constant one, the first synonym is much more expressive and appropriate, and is in every way preferable to that in general use. Symptoms 1. Period of Incubation After the receipt of the bite, which may produce an extensive wound, or, as is the case sometimes, an insignificant scratch, a period of time extending from a few months to several years may elapse before the appearance of the second stage. The Avound may heal by first intention, giving rise to no inconvenience, or there may be redness and neuralgic pain. A history of this kind is usually given by the patient, and is based upon an exaggerated statement of the actual facts, which arises from a disordered imagination, Avhile his story of the accident and of his subsequent symptoms is tinctured with a decided tlavor of romance. Nervous derangement dependent upon fear, digestive disorders, mental worry, and others of the same category, gen- erally characterize this first stage. 2. Period of Invasion At the end of the period of incubation, the first alarming symptoms noticed are those connected with the cicatrix, which becomes painful and tender, and at the same time there are pains which dart along the nerves in the vicinity. There are next generally head- ache and a sense of epigastric oppression, with constipation, broken sleep, and a feeling of general discomfort. At the end of two or three days, during which the patient suffers intensely, we may expect the appearance of the next stage. 3. The Period of Development With aggravation of the symptoms just enumerated, we find added thereto a sense of constriction about the throat, irregular and quickened respiration, rigidity of the muscles of the neck, discomfort in deglutition, and spasms, which begin in the muscles of the throat and back of the neck, and gradually invade those of the back. The spasms give rise to much pain, which is sometimes spinal and at others muscular. The patient is at this stage delirious and flighty, and gene- rally has delusions in which dogs play an important part. The difficulty of swallowing, which next follows, is not so great when solids are taken. Fluids, on the contrary, seem to produce an aggravation of the spasms, and the mere sound of splashing or trickling water will excite a convulsive seizure. To add to the sufferings of the patient, there is excessive thirst, which is very distressing. His face becomes dusky, and his eyes promi- nent and wild. He tosses from side to side if placed in bed, the saliva running from the angle of the mouth in a viscid stream. Towards the end of the disease this secretion becomes thicker and mixed with mucus, and it collects in the trachea and bronchi. These symptoms may last 362 CEREBBO-SPINAL DISEASES. two or three days, while in the mean time the reflex excitability becomes so great as to precipitate a convulsion under the least stimulus. The pulse is rapid, the headache more severe, the air-passages become filled, and respiration is greatly interfered with. The convulsions are readily produced by blowing upon the patient, or by jarring him, or even by slum- ming the door. At this stage he becomes partially unconscious, is quite delirious, and very much agitated. Previous to death there is a marked rise in the temperature, and in one case I saw, the history of which I shall presently relate, the temperature rose to 103, and I believe there was even a subsequent rise. Hammond considers that it may often reach 110. Death occurs in two or three days in most cases, but it may be delayed a day or two longer. Incontinence of urine and feces precedes the end ; the immediate cause of death being asphyxia from spasmodic stenosis of the larynx, or obstruction of the air-passages by mucus. I had the privilege of seeing one case at the request of Dr. Augustus Viele, of the Health Department of the city, which was subsequently reported by Dr. Hadden. 1 Through the courtesy of Dr. Hadden and Deputy Coroner Leo, I was also enabled to observe the post-mortem appearances of the brain and cord after the patient's death. Dr. Hadden describes the case so clearly, that I shall mainly use his own words. " On the 24th ultimo, at 8.30 P. M., I was called to attend a young man named Win. McCormick, residing at No. 309 East 51st Street, a native of this city, aged 2(5 years, athletic in appearance, of usually good health, nervous temperament, and of moderately temperate habits ; by occupation a driver of an express-wagon. He was in bed, complaining of nervousness, soreness in his neck and throat, strange feelings of tight- ness around his chest. His countenance was anxious, pupils of his eyes were dilated, and his general appearance was like one who was in fear of impending danger, and not in extreme pain. He told me that his throat was so sore that lie could not swallow anything not even water. This, lie thought, was due to some simple medicine he had taken, and not to any serious ailment. I noticed his throat was not swollen on the outside, and that his voice was whining, and unlike a person suffering from any ordinary soreness within. I, however, examined his throat within, but found nothing to account for this difficulty ; it was perfectly healthy in appearance. His pulse, respiration, and temperature were normal, ex- cepting an occasional sigh. I observed, also, a little disposition to hack and spit, but in no way troublesome. He complained also of thirst, but said lie could not drink, he knew, for the very sight of water made him shud- der. I told him his throat was not sore, and urged him to try. He assented, and water was accordingly brought, which, at sight, caused a violent spasm, lie threw himself around in the bed, forward and backward, and told the party to take it away at once, as it would kill him. He immediately afterwards called for the goblet, and said he was very thirsty and must drink, seized it, and with a violent effort succeeded in taking a single 1 Journal of Psychological Medicine, May, 1870, p. 80. HYDROPHOBIA. 363 swallow, which was followed by a severe convulsive shudder and contrac- tion of the muscles of the neck and chest." Dr. Hadden ascertained the fact that he had been bitten by a dog, and then inquired about the symptoms antecedent to his visit. " Wednesday and the two preceding days he was complaining of general lassitude and nervousness ; had not been able to sleep at night ; was thirsty, and had drunk a great deal of water ; had eaten but little ; appetite very poor, and on Wednesday afternoon he seemed to be growing worse. He went out upon the street, but soon re- turned, saying that it was very chilly, and he could not stand the air at all. While taking a cup of tea at 6 P. M. the same evening, he first showed signs of difficulty in swallowing. Shortly afterwards, as he was going to the kitchen, he was met by a draught of cold air, which so staggered him that he nearly fell ; he then went to bed, where I found him. After giving the necessary caution to the family, I ordered fifteen grains of bromide of potassium to be given every hour. I left, and returned at 10.30 P. M. . . . Found him in about the same condition I had left him, only his pulse was irregular, and his spasms more frequent. The saliva was a little more troublesome, and he also could not swallow without great difficulty. I was called again at 2.30 A. M., the messenger stating that the patient had become very violent, and that they were unable to restrain him. I went immediately. . . . Found him in a frightful state of excitement ; had broken down the bed, and was struggling with his attendants to get at liberty. He was shouting and crying out to them to let him go, and called for water, which, when brought, he could not drink. His mind was clear, and he knew all those around him ; was spitting a viscid saliva, but was careful not to spit upon any one, not even on his clothes. It was so abundant that his attendants were obliged to wipe it from his lips. Dr. Leavitt and myself, after viewing the case in all its aspects, concluded to inject in the tissues of the leg half a grain of mor- phine and one-sixty-fourth of a grain of atropine in solution, which was done at 3 A. 31. by Dr. Leavitt. We carefully watched the effect till 3.30 A. 31., when, his violence having in no way abated, another injection was given in the same part of three-eighths of a grain of morphine and one- eighth of a grain of atropine, which in some degree produced the charac- teristic effect of morphine, and very clearly the appearances of the atropine ; for, notwithstanding he was struggling violently, the saliva, which had been very troublesome, was completely dried up ; so much so that the patient remarked that he was very thirsty, and his ' mouth felt as if he had been chewing a brick.' Fifteen drops of chloroform were then injected, with no effect whatever, unless to weaken his already weak and frequent pulse. At 4.15 A.M. three-eighths of a grain of morphine were again introduced under the skin without atropine. This quieted the patient, so that he was easily restrained, and he remained in this condition from 4.30 till 10 A.M., when the effects had so far passed off that the attendants were alarmed at his violence and the abundance of saliva that he was spitting from his mouth. At 10.15 A. M. three-eighths of a grain of morphine in solution were injected in the tissue of the thigh, which served to temper down the increasing violence of the spasms, but did not stop the flow of saliva. I accordingly, at 10.45 A. 31., injected three-eighths of a grain of morphine and one-fortieth of a grain of atropine, which had the desired effect of producing the quieting effect of the morphine and the specific effect of the atropia on the salivary glands. The poisonous effects of the morphine and 364 CEREBBO-SPINAL DISEASES. atropia were at no time apparent. He died at 4.15 P. M. June 26, 1874, about twenty-four hours after the first spasm." Dr. Hammond saw the patient on the morning of the 26th, and corrobora- ted Dr. Iladden's diagnosis. I saw him at three o'clock of the same day, and found him lying upon the floor bound with twisted sheets, the ends of which were held by his attendants. He was very violent, and, though there were no very marked convulsions, he seemed to be quite rigid, and his forearms were flexed during most of the time. He was semi-comatose, and groaned occasionally, but took no notice of those about him, and did not speak. His respirations were quick, and there was a rattling sound produced in his throat with each expiration and inspiration. A quantity of quite thick mucus and saliva was spat up during my visit, and there seemed to be a very free secretion of this substance. The pupils were widely dilated, and as far as I could judge there was no marked elevation of temperature. 1 Recent cases of hydrophobia have been reported by Francois, 8 Edwards, 8 Smith,* and Hanscom. 5 The case of the latter is so interesting and so graphically detailed, that I shall take the liberty of giving it in its entirety. On the morning of the 20th of November a good-natured pet spaniel, which had never been known to snap at any one, suddenly and without any provocation sprang at his mistress. His master whipped him, and he was left in the cellar of the house until the time for his dinner. While eating it in the company of a pet cat, as he had been accus- tomed to, without ever having molested her, he suddenly seized the cat and threw her across the room. The owner reached out his hand to catch the dog, when the latter caught him tightly by the wrist and inflicted a deep wound, biting him three times ; the skin became lacerated while making an effort to shake him off. It was supposed at the time that the dog was irritable from the whipping which he had received in the morning, and, as he expected another for snapping at the cat, defended himself by biting. Half an hour after, the patient applied to me for treatment, and believing it to be too late for excision or cauterization to be effective, and as there was no history of hydrophobia, I dressed the wound with a solu- tion of carbolic acid. It healed readily, and the patient attended to his business as usual in four or five days. Soon after the infliction of the bite the dog disappeared and he did not return for thirty-six hours ; nothing could be ascertained of his whereabouts or of his behavior during that time. W lien he returned he was very much exhausted, and had the appearance ot having been severely beaten. From what I can learn of those who saw him he gradually grew weaker, apparently losing the use of his legs, espe- cially the hind ones, which he would drag after him. He died quietly, with his head in the lap of his mistress, without having had a convulsion, excessive flow of saliva, or tremors. On the 13th day of January (fifty- ' In this case the newspapers were filled with sensational accounts.of the patient's illness, and an attempt was made to prove that the dog was not mad. It is need- less to say that such was probably not the case, and it is to be regretted that the dog was never found. Host. Mod. and Surp. Journal, May 17, 1877. 3 Ibid., March 15, 1877. 4 Ibid., March 15, 1877. Ibid., April 19, 1877. HYDROPHOBIA. 365 four days after the injury), the patient began to have shooting pains in the forearm, but not especially localized. They did not radiate from the cicatrix, and there was no change in the appearance of the latter. On the following day the pain had increased so much that he required one-sixth of a grain of morphia to relieve him ; it M*as given subcutaneously, and was repeated the next morning. After that there was very little pain in the arm, and no appreciable change in the pulse or temperature. He was despondent, and stated on the morning of the loth that ' he felt sick and used up all over ; ' he was obliged to go to bed in the afternoon, and then for the first time began to have some difficulty in swallowing. This symp- tom was not manifested by an attempt to drink water, but during an effort to swallow some herb tea which he was accustomed to take when ill, and which he believed would relieve his bad feelings. There was no trismus; he was quiet and inclined to doze. At 5 P. M. Dr. H. H. A. Beach saw the patient with me, and agreed that the history of the case in connection with the symptoms then existing indicated the probable development of hydrophobia, and an unfavorable prognosis was given to the patient's brother, who promised not to communicate it to the patient or his friends until the disease should be fully declared. His pulse at that time was 102, and the temperature in the axilla 102 F., face flushed, tongue coated. The cicatrix presented no unusual appearance, nor was it tender. A dark room was agreeable to him, but on raising the curtains the light did not disturb him in the least. He was perfectly rational, and had some thirst, but no sore throat. He made an attempt to swallow a teaspoonful of milk, but was obliged to give it up from the moment that the fluid touched his lips. Immediately after this attempt unmistakable spasmodic contraction of muscles between the chin and sternum was observed. Mentally the patient was perfectly clear, and not disturbed by the unsuccessful attempt at swallowing fluids, but said he would try it again when he should be more thirsty. This symptom, excepting when he swallowed teaspoonful doses of medicine, continued until his death. He was obliged to relieve his thirst by sucking ice and snow through a napkin. The air from a fan or from adjusting the bed-clothing caused a shudder. Occasional sighing was noticed after the second day ; it grew deeper and more frequent until the end. When disturbed from any cause his respiration was of a spas- modic character, so much so at times as to interfere with his speech. On the following morning (the 16th) his pulse was 96, and mild de- lirium first developed ; this also continued until his death. He was easily controlled throughout the disease. He became very suspicious of the people about him, believing that they were attempting to make him the victim of practical jokes, then of being poisoned. One hallucination wa* continuous from the time that the delirium first developed : he thought that some one had thrown a dirty powder on him, and he was continually making efforts to shake it off from himself and his clothing. He was also very cross and dictatorial, but showed no disposition to snap or bite. Between four and five P. M. on the 18th he began to have spasmodic contraction of the muscles of the chest, larynx, and throat ; some of them lasted nearly a minute, and prevented him from taking an inspiration. He also had a profuse discharge of saliva sufficient to wet his clothing through from his chin down to his hips. The spasmodic contractions con- cerned in respiration exhausted him rapidly, and he died quietly at 8.15, while sitting up in a chair. This position became necessary from the fact that he could not lie on his side, and if on his back the saliva accumulated 366 CEREBRO-SPINAL DISEASES. so rapidly that it obstructed his respiration. For the last twenty minutes before his deatli there was no spasm. He lived five days after the fir>t general symptom. At no time was he disturbed by the sound of ringing bells or running water. Morphia in one-fourth-grain doses, and chloral and bromide of potassium in fifteen-grain doses of each at the same time were given as needed. Anaesthetics were not required. At the solicitation of his friends he was allowed to take a pill, the prescription for which was said to be one hundred years old and to have cost originally five hundred pounds. It had the reputation of curing and preventing many cases of the disease. No change in his symptoms could be attributed to its action, nor could its composition be ascertained. It was given as a placebo, on the chances that an hysterical element existed in this case ; that whatever offered encouragement to the patient without the possibility of injury in his hopeless condition was justifiable, but so far as the evidence furnished by one case is of value its inefficacy was demonstrated. The permission of the friends for an autopsy could not be obtained. The particular symp- toms of the disease which were not observed in the dog when seen might have existed during the thirty-six hours that he was absent. The proximity of the wound to the ulnar nerve and its character (punctured and lacerated) suggested the consideration of tetanus as an explanation of the symptoms; the latter seemed to be fairly excluded, however, on the ground that delirium was continuous from the third day of the attack, and that at no time did trismus or any other form of tonic spasm exist ; the profuse discharge of saliva was also corroborative of this view. The unquestionable existence of repeated attacks of laryngeal spasm ; the fact that the symptoms developed after a considerable interval had elapsed from the date of the injury ; that for three hours previous to his death, and after he became wholly unconscious, marked spasms of the; chest and throat occurred at intervals of from three to five minutes ; that death occurred as a result and within five days following the development of symptoms characteristic of the disease, reasonably offsets a theory that the hydrophobia symptoms were simulated by an hysterical man. In Smith's case the period of incubation was about two months, and the paroxysms were ushered in by vomiting, fear of water, and febrile symp- toms. On the third day of the disease he became delirious, and on the fourth died. The sound made by the patient, which is so often compared to the bark of a dog, was likened by the author to that made by a croupy child. In Edwards's case, the period of incubation was about five months. The injury was insignificant, but with the invasion of the disease there was pain in the cicatrix which extended up the arm. In this patient there was also dread of fluids, especially water. On the second day the convul- sions began. The same day she spat up bloody mucus. At the end of sixty hours from the first local pain she died. Causes The circumstances which concern the etiology are still enshrouded in mystery. Hammond is of the opinion that rabies may be communicated by a dog that is not mad, and brings forward several cases to prove his theory. I cannot agree with him, for it seems to me highly im- probable that there should be so few cases of this disease if the bite of a non-rabid animal can inoculate an individual. Bouley states that in no way can the disease be transmitted other than by inoculation with the saliva. HYDROPHOBIA. 367 In this statement he receives the endorsement of Magendie and others. Another point remains to be answered, and this is in regard to the trans- mission of virus from one person to another without the second person being bitten. Fleming has given an example which shows that this may take place. In the spring of the present year I was subpoenaed to serve as a juryman in the case of a boy who had died of rabies. At about the same time another death occurred which the attending physician said was simply the result of fear, and not of hydrophobia. A careful inquiry and examination of witnesses revealed the following history, which I think proved beyond a doubt that the cause of death in both cases was the bite of a rabid cat. This cat had found her way into a stable on Thirty -fourth Street, and had bitten a horse. This horse afterwards died in convulsions, and from all I could leurn the cause of death was hydrophobia. In an adjoining yard the cat bit one of the boys, who also died, and a few days afterwards bit the other boy, whose inquest we attended. Both of these victims died within a short time of each other. In one of these cases there was but a slight scratch. Morbid Anatomy and Pathology Clifford Albutt, 1 Meynert, Elder, 2 and Hammond 3 have all made autopsies, and still there seems to be very little light thrown upon the pathogeny of the disease. Hammond found granular degeneration of the nerve-cells of the cortical layer of the brain, and extravasations of blood in the medulla with destruction of cell- contents. The gray matter of the nuclei of the pneumogastric and hypo- glossal nerves had undergone granular degeneration. Albutt found en- largement of vessels in the cerebral convolutions, pons, medulla, and spinal cord, and granular disintegration. Elder found absolutely nothing ; and Lockhart Clarke, who examined parts of the brain, medulla, and cord, found the utter absence of any lesion. Kolesnikoff 4 reported the appearance of the nervous centre in ten dogs that had died of hydrophobia. " The parts examined included the hemi- spheres, corpora striata, thalami optici, cornua ammonis, cerebellum, me- dulla oblongata, spinal cord, the sympathetic and vertebral ganglia. The most marked changes were observed in the two latter, and were as fol- lows : 1. The vessels were enlarged, choked with red blood-corpuscles ; occasionally, extravasated red corpuscles and round indifferent elements (probably white corpuscles) were found in the perivascular spaces. The walls of the vessels were here and there filled with hyaloid masses of vari- ous forms, which occasionally extended into the lumen of the vessels, and closed this as a thrombosis would. Not far from these masses collections of white and red blood-corpuscles could be observed, the latter deprived of color. They could be seen also in all stages of metamorphosis into hya- 1 Med. Record, i. 22. * Dis. of Nervous System, pp. 654-660. 3 Brit. Med. Journ., vol. ii. 1871. 4 Centralblatt fur Med. Wissen., No. 50, 1875. Abst. Phil. Med. Times, Feb. 5, 1876. 368 CEREBRO-8PINAL DISEASES. loid globules. 2. In the pericellular spaces of the nerve-cells could be observed collections of round indifferent elements, whose penetration, to the number of five to eight or even more, pressed out the protoplasm of the cells. This penetration of the elements spoken of was frequently suffi- cient to change the form of the nerve-cells, giving them at different times a sac -formed, bulged, or flattened-out appearance. Further, the nucleus was sometimes pushed towards the periphery of the cell and surrounded by many round elements. In other cases, only groups of round (indif- ferent) bodies could be observed in place of the nerve-cells. In isolated nerve-cells the changes described could also be observed." The body of Dr. Hadden's patient was examined by the deputy coroner and several physicians, among whom were Drs. Clymer, Hammond, Cross, and myself. The calvarium was removed, and great congestion of the meningcs and brain was observed. The sinuses were much engorged, lnit there was very little effusion either upon the surface of the brain or in the ventricles. The lower surface of the brain appeared to be slightly softened in patches, but there was nothing else to attract attention, except it might perhaps have been a great hardness of the pituitary body. Dr. Hammond's microscopical examination was subsequently made, and I have already alluded to its results. The internal viscera were all hypercemic, but there were no other morbid appearances. The larynx and trachea were found to be very much injected, and the latter contained a quantity of frothy mucus. Dr. Willis has found the blood of persons who have died from this disease to be very fluid and of a dark color. The question to be answered is, whether this affection is a primary dis- order of the nervous centres or whether it is the result of general blood- poisoning. I am inclined to accept the latter theory, as the array of facts is too meagre to permit any positive assertion as to its nervous origin. Like other disorders, not essentially nervous, there is a period of inocu- lation, of incubation, of invasion, and development. I think, then, that in this respect this disease, as well as tetanus, resembles closely some of the exanthemata. Hammond compares the disease with tetanus, epi- lepsy from reflex causes, and other neuroses of the same description, and is inclined to consider it a nervous disease per se. Diagnosis It is important to bear in mind the fact that a great many so-called cases of hydrophobia are not this disease at all, and that certain forms of hysteria bear to it a close resemblance. Fright may act so powerfully upon the nervous system that a train of symptoms may be produced very much like those of the genuine affection. A case of this kind occurred at Bellevuc Hospital a year or two ago, in which the symp- toms counterfeited those of the real disease in every respect, and the patient finally died. It was found that the individual had not only never been bitten, but that he actually died of fear, his imagination having been stimulated by the sensational articles in the newspapers. Dr. J. W. S. Arnold, of the University, who examined the brain and cord, was unable to find the slightest indication of any morbid change. The only other HYDROPHOBIA. 369 conditions from which we may be required to make a differential diagnosis are tetanus, Calabar bean, and picro toxin poisoning. In the former there are many points of resemblance, and occasionally a dread of liquids and a difficulty in swallowing. In tetanus, however, the risus sardonicus is present, the spasms are tonic, and there is opisthotonos, and the mind is clear to the last. In poisoning by both agents, to which I have alluded, the rapidity of their action is conspicuous, and a dose of either would carry the patient off in a few hours, more or less. In picrotoxin and Calabar bean poisoning there are many of the symptoms of hydrophobia, such as clonic spasms, frothing, rise of temperature ; but no dread of water, nor delirium. Epilepsy may resemble hydrophobia, but it is only when the attacks are numerous and closely connected that such a mistake could possibly occur. Marbaix 1 " gives a case of epileptiform convulsions more or less resem- bling hydrophobia, in a man who had been bitten four days before by a cut ; they were accompanied by delirium and hypersesthesia of the optic nerve, a stray light thrown across his eyes causing a convulsive attack. The shortness of the incubation, the blueness of the face, without the * vultueuse' expression characteristic of hydrophobia, the delirium, and the melancholy, not exalted, condition, combined with a history of an epileptic attack a year before, prevented the case being looked upon as one of true hydrophobia." Prognosis In true hydrophobia it is very bad. I believe there never have been more than one or two genuine cures reported ; and if others have been claimed, it is probable that no rabies existed, but that the affec- tion described was simply hysteria. The chance of inoculation seems to be a matter of interest, for of the reported cases in which individuals have been bitten, it has been found that about two-thirds of them subsequently developed symptoms of rabies. Treatment We rarely see these patients until actual evidences of madness have appeared. If, however, we are fortunate enough to be called to the individual immediately after he has been bitten, we may either incise or cauterize the wound. It is well to ligate the limb as soon as possible, and then remove en masse the piece of the muscle which has been pene- trated by the teeth of the rabid animal. Various writers recommend the cupping-glass, which should be applied to the excised part till it abstracts several ounces of blood from the wound. A pencil of nitrate of silver may be thrust into the punctures made by the teeth of the dog until they are well cauterized, and a strong solution (3u'-oj) should be applied afterwards by means of a piece of folded linen, \vhich is to be covered by oil silk. I am convinced that no remedy can do good where the disease has already appeared, except, perhaps, curare, which has been tried; and in one case, where it was prescribed by Dr. Austin Flint, Sr., it is said to have saved the patient's life. The case must be desperate, however, when this powerful substance is 1 Presse M6d. Beige, 1869, 237. 24 370 CEREBRO-SPINAL DISEASES. resorted to, for its preparation is not always the same, and no two speci- ments are of the same strength. It lias been injected hypodermically in doses of one grain. Oftenberg 1 reports the cure of a girl of eighteen. She received at first hypodermic injections of morphine and chloroform, but there was no im- provement in her condition. Seven hypodermic injections, aggregating three grains of curare, were afterwards given in the course of six hours. The muscular disturbance subsided at once, and there was ultimate recovery. The convulsions were succeeded by paralysis, which gradually disappeared. Hot baths have been recommended, but I cannot find that they have ever cured a case of this kind. HYSTERIA. Definition It would be almost impossible to give a concise defini- tion of this most protean of nervous affections, for it simulates a multitude of onranic and functional diseases so perfectly, that the task of considering it in any systematic manner would be attended with great difficulty. The nervous system in this respect is like the " general utility" actor. It plays the most varied parts. Sometimes we are presented with a hemi- plegia or paraplegia, and at others witli contractures which seem to be the result of organic disease, so permanent and intractable do they appear. Convulsions, anaesthesia, urinary and other troubles of a more or less grave character, swell the list, until we are almost inclined to look upon it as a "disease of the Devil," and cease to wonder at the credulity and superstition of those who believe in demoniac possession and witch- craft. Confining ourselves as closely to the subject as possible, we con- clude that hysteria is a disease of an emotional character chiefly among women, in which the symptoms are rarely the same in any two instances, but among a large number of cases there can be noticed a certain simi- larity. Symptoms. These symptoms may be grouped as sensorial, moto- riV//, and visceral. Sensorial symptoms are of three kinds : hyperaesthetic, ana-sthetic, and mental. Hypercesthesia, though much more common than ana-sthesia, is not so marked. Large areas of hypersesthesia may be de- tected by careful examination, though the patient usually saves this trouble, for she calls attention to the weight of her clothes, the pressure of some fold of her underwear, or the contact of some very light substance which is pronounced unbearable. The external organs of generation are extremely sensitive, and the slightest touch of the finger or speculum pro- duces a spasm and great agony. 7 Coition is impossible, and one patient 1 Wion. Med. Presse, 1876, No. 1. 2 1 have been able to stop an hysterical paroxysm by firm pressure upon the ovary. Light pressure greatly aggravated the patient's discomfort. Other ob- servers have called attention to this phenomenon, among them Charcot. HYSTERIA. 371 called my attention to a horrible shooting pain which occurred whenever her husband approached her. Hypersesthesia about the nipples, at the end of the coccyx, and in other parts of the body, is alluded to by vari- ous writers. Charcot has directed attention to the prominence of these ; and Briquet has described fixed pains of the abdomen which he called caelalgice, and of 450 cases he found 200 presenting this symptom. They were hypogastric and iliac, but more commonly the latter. These have sometimes been mistaken for the pain of peritonitis; there is, however, no tenderness, but simply superficial elevation of sensibility. The patient often calls attention to vague pains in different parts of the body, of a transitory, and sometimes permanent character. She complains of strong light and loud noises, and insists upon perfect quiet, although she will her- self talk and cry in a very noisy manner. All of her pains are increased when her attention is concentrated upon them, but when her mind is diverted she will bear very rough treatment without complaint. Neuralgic pain, a familiar variety being the clavus hystericus, is a com- mon form of complaint. Various local pains are also experienced, and these, among others, include alterations in sensibility which simulate lum- bago ; indeed, a very constant hysterical complaint is backache, which the patient generally attributes to the kidneys. A most interesting form of hysterical dysaesthesia has received mention from Skey, Paget, and others, and is very often mistaken for rheumatism. The joints are neither swollen nor red, however. Moriz Meyer, 1 in an interesting article upon the sub- ject, gives the leading points in diagnosis as follows : " 1. The neuralgia is of a diurnal form entirely. 2. Light pressure of joints produces pain, but comparatively violent handling is not at all painful. 3. The temperature of the affected joint undergoes variations. 4. There is no loss of sub- stance of the muscles of an unsound limb. 5. The cure is usually spon- taneous." The mental disturbances are of the most interesting character, whether expressed by transient emotional excitement or apparent pro- longed unconsciousness. Examples of the lighter grades are too familiar to need description, and it is only necessary to allude to the outbursts of immoderate laughter or crying which occur when there is no reason for either emotional elation or depression. Such individuals may indulge in laughter at church or at a funeral, and, while perfectly aware of the im- propriety of their conduct, will be utterly unable to restrain themselves. Illusions, hallucinations, and even delusions are evidences of a very irri- table condition of the nervous centres, as are ecstasy and mental excite- ment of various kinds, such as belief in impending calamity or death. The involuntary use of foul words and gestures, and a remarkable eccen- tricity of behavior, are additional suggestions of a disordered state of the emotions. Wynter, 2 in his excellent little book, thus alludes to a condi- tion which, after all, is but a manifestation of hysteria. 1 Berliner Klin. Woch., 1874, No. 26. 2 Borderland of Insanity, p. 3. 372 CEREBRO-SPINAL DISEASES. "There is a terrible stage of consciousness in which, unknown to any other human being, an individual keeps up as it were a terrible hand-to- hand conflict with himself when he is prompted by an inward voice to use disgusting words, which, in his sane moments, he loathes and abhors. These voices will sometimes suggest ideas which are diametrically opposed to the sober dictates of his conscience. In such conditions of mind, prayers are turned into curses, and the chastest into the most libidinous thoughts." 1 The will is quite weak, while the emotions, far from being held in abeyance to the extent which they are in health, respond to trivial id a- tional impressions. The hysterical person firmly believes herself to be the subject of various disorders of a greater or less serious character; is hope- less ; believes in a speedy fatal termination of her imaginary trouble ; and can only be convinced of her mistake by fear of the remedy suggested, or by some strong appeal to her appetite or comfort. While in a state which may sometimes appal the observer, the patient declares her inability to walk. If, however, some powerful excitement be produced, such as an alarm of fire, she quickly recovers the use of her legs. I have recently seen a most interesting case of hysterical torticollis, in which the patient refused to turn or raise her head. I quietly seated myself at her other side, and engaged her attention so fully that after a while she turned her head and talked for some time; and it was only when I referred to the subject of her troubles that she quickly resumed her original position, and I could not persuade her to change it. She may at times believe that she is deaf or dumb, and remain in such an uncomfortable condition for years, punishing not only herself, but making all about her uncomfortable. Hysterical anaesthesia has received a great deal of attention of late years from the French observers, especially from Charcot and Briquet, as well as I'iorry and Gendrin. Briquet* has found that this condition occurs more frequently on the left than upon the right side. It may be superfi- cial or deep, even affecting the muscles and bones. Reynolds has found it limited often to the back of the hand or foot, or alxmt the mouth and nose. The vaginal canal and the lining mucous membrane of the mouth are also places where there may be loss of sensation. Hysterical anaes- thesia not rarely follows, or comes on during a convulsive attack, and lasts for a variable time. It may subside in a few hours, or continue for months at a time. During its existence the most violent stimuli will fail to restore sensibility ; and I have often used powerful counter-irri- tants, electricity, or even the hot iron, without any response whatever. The loss of sensation may extend more deeply, so that the underlying 1 Hysterical girls and women occasionally evince a depraved appetite, eating all sorts of extraordinary things. The school-girl habit of eating slate-pencils is an example of this. I have personally observed this evidence of hysteria on many occasions. A young lady recently under treatment ate enormous quantities of nutmegs. The morbid apjwtite of pregnancy is probably an hysterical dis- order. f Trai(6 Clinique ct Th6rapeutique de I'Hystfcrie, Paris, 1859. HYSTERIA. 373 muscles may be utterly without sensation. This peculiarity probably ex- plains the insusceptibility to pain spoken of by Carre" de Montegeron. The Janseniste or Convulsionnaires " became so wrought up by religious ex- citement that they fell, twenty or more at a time, into violent convulsions, and demanded to be beaten with huge iron-shod clubs, in order to be relieved of an unbearable pressure upon the abdomen. One of the bro- thers Marion felt nothing of the thrusts made by a sharp-pointed knife against his abdomen." Not only may there be analgesia, but loss of appreciation of heat or cold, and the surface may become blanched and white, and the skin even bloodless. Brown-Sequard has demonstrated the absence of blood ; a fact which has an historical interest in connection with the tests of the early religious enthusiasts. Charcot alludes to the epidemic of St. Medard, when the cut of a sword failed to produce any flow of blood. The tem- perature of the anaesthetic spot is sometimes lowered two or three degrees, and varies in different regions. There may be anaesthesia of the mucous membranes of the mouth, the pharynx, and larynx; or the organs of spe- cial sense may be implicated, and a resulting amaurosis, amblyopia, or deaf- ness ensue. In a paper upon "Hysterical Affections of the Eye," by Dr. Geo. C. Harlan, 1 of Philadelphia, attention is directed to retinal anaesthesia and various hysterical disorders of an interesting character. "Almost any derangement of vision may be counterfeited. A little girl of eight years complained that every object that she looked at seemed covered with diagonal white lines, the direction of which she indicated with her finger. As the ophthalmoscope revealed a normal fundus, a favorable prognosis was given. This was made more positive the next day, when the white lines changed to blue, and was justified by the early disappearance of the difficulty. " In the second class of cases we have more or less retinal anaesthesia, with anomalous and variable symptoms, changing, perhaps, at each exami- nation. " In the third class of cases the parts affected have been the retina, the muscle of accommodation, the external muscles of the eyeball, and the elevator of the upper eyelid. " It is not veiy uncommon to meet with patients who have apparently perfect eyes and full acuity of vision, but who say that the test letters be- come blurred and unrecognizable after they have looked at them for a few seconds. That this is due to an exhaustion of the sensibility of the retina, which disables it from the sustained performance of its function, and not to an irregular action of the accommodation, is shown by the fact that it persists when the eye is fully under the effects of atropia." Taste and smell are sometimes impaired, so that there is a greater or less extensive loss or a perversion, the patient declaring that natural odors are reversed, or that articles of food are tasteless. 1 Phil. Med. and Surg. Rep., August 12, 1876. 374 CEREBRO-SPINAL DISEASES. The motorial symptoms are numerous, and may be either of a sthenic or asthenic character. The simplest include spasms, violent gesticulations, and contractures : the more obstinate, paralysis of either a hemiplegic, or paraplegic, or even a local form, and chorea and convulsions, as well as various kinds of muscular incoordination. The individual may assume the most painful positions, the limbs being rigidly flexed or extended, and the face distorted by grimaces of the most absurd description. Sometimes there is torticollis, or spasm of some small group of muscles, or the muscular rigidity may even amount to opisthotonos,pleurothotonos, or emprosthotonos, and these forms of trouble are much more marked in conditions of hystero- epilepsy and hystero-catalepsy. The dependence of these motorial pheno- mena upon reflex excitement is their marked feature, slight peripheral irritations, uterine trouble, or sexual excitement of any kind, often being the origin of the affection. The pharynx, larynx, and not rarely the stomach are implicated, so that difficulty of swallowing, loss of speech, and vomiting are resulting phenomena. Hysterical attacks of a convulsive character are met with sometimes, when the patient is apparently unconscious, but is in reality not at all so. There is slow respiration, which is scarcely perceptible, and small weak pulse. The legs and arms may be wildly thrown about, or rigidly extended, and there may be opisthotonos, while the skin is livid, and maybe bathed in perspiration. A lighter grade of attack is frequently seen, in which the patient, after a period of excitement, screams, and falls to the floor (being very careful not to hurt herself) ; her muscles become contracted; she breathes heavily, froths at the mouth, talks incoherently, and berates those about her. She may cry, and in doing so sobs violently, sometimes catching her breath in an alarming manner, frightening her attendants and attracting sympathy. If left to herself and not noticed, she may fall asleep or gradually recover. The patient looks about the room during the attack, and is undoubtedly conscious of what transpires. One significant mark of hysteria, previously alluded to, is that, however much the patient throws herself about, she is always careful not to do her- self injury. Pomine 1 was among the first to describe hysterical contrac- tures, and later Gorget related a case of hysterical flexion of the thigh upon the pelvis which was supposed to be due to coxalgia. In hemiplegic contractures the upper limb may be drawn in to the trunk, the forearm is flexed at a right angle, the thumb is bent so that the point is buried in the palm of the hand, and it is covered by the other fingers. According to Strauss, 1 extension of the upper limbs is quite rare. The lower limb is extended, so that the foot presents the appearance of talipes equiuus, the toes having a claw-like appearance. The thigh is extended on the jK'lvis, and the whole limb is adducted. Hysterical contractures of a permanent character may affect the body, 1 Trait6 . Fowler's solution increased, so that she takes n\,x, t. i. d. Movements somewhat lighter. Sept. 20. Gave birth to a healthy boy after a short labor. Oct. 10. Cured. Discharged. There were no special temperature variations at any time. A case of interest is that of Lena C., aet. 44 ; Germany ; married. Her mother had chorea at the same age. About four years ago, without any appreciable cause, convul- sive movements of the whole body began. These were not general at first, and were limited oidy to the upper extremities. The movements are bilateral, and agitate the hands more than any other part. The facial muscles are slightly affected, and there is a jerking upwards of the corners of the mouth, more especially on the right side. The movements are neither aggravated nor controlled by the will, but cease during sleep. Her cutane- ous sensibility is in no way affected, and her sight and hearing are both CHOREA. 399 good. She has a strange habit of clutching her dress in front, probably to steady her hands, and when spoken to she seems greatly disconcerted and moves more than ever. June 25. Fl. ext. conii, n^xl, t. i. d. ordered by visiting physician. 26th. Xo marked toxic effects of the drug apparent, except dilatation of the pupils ; and the patient says that there is a " complete lightness of the body," and that "she could fly." Some improvement in movements. With a strong voluntary effort the movements are stopped for a time. July 10. Great improvement; patient can hold her arms quite steadily ; medicine stopped (case-book does not say why). Discharged at her own request Dec. 15, 1875. She re-entered Dec. 22, 1875. I found the patient in probably the same state in which she first came into the hospital. She is a spare, tall woman, very restless and emotional. She cannot express her- self at all, for when she attempts to speak the tongue refuses to do its part in articulation, and the result is the utterance of ill-arranged sounds, which are not properly formed into words. She smacks her lips, and " clicks" her tongue against the roof of the mouth, and the sounds which come forth are tremulous and agitated, and just such as one would expect to hear from a person who was agitated by some great fear. The con- tortions of the arms are very violent and irregular, and almost defy de- scription. The body seems to twist upon the pelvis ; the arms are thrown backwards and forwards, and the hands and fingers are constantly work- ing. She seems to have no volitional control over her limbs, and has very little muscular force. She walks without any apparent embarrassment, but when seated the movements in the lower extremities are more active than when she stands up. She was somewhat analgesic, as was demon- strated by pinching. Treatment with strychnine considerably moderates the violence of the spasmodic movements. Chorea may often present a periodic character, especially if malaria enters into its causation. The tendency to relapse is quite a striking feature, and, in many cases which I have seen, it appeared either during the early fall or spring, and reappeared the following season. It may be accompanied by other nervous troubles, or exist in an uncomplicated form as a result of debility arising from repeated nervous exhaustion or fresh eccentric causes. In one case I found it to appear as soon as cold weather came, and at the same time an extensive eczema upon the calves of the legs and scalp was developed. This disappeared, together with the movements, under the use of arsenic and oil, but both reappeared the following winter. Dr. E. Frankel has reported a similar case, and I have no doubt there are others who have had a like experience. The disease usually wears itself out in a short time, the tendency to relapse rarely lasting after puberty ; and if a cure can be effected, the maintenance of a high standard of general health and certain precautions as to overwork or study prevent a return. Causes Various writers agree that the disease is confined to the period between the third and fourteenth years, and this has been my ex- perience. I do not know of a case under three years, but Hammond has seen the disease in a child of eighteen months. Watson limits the time at which chorea may appear to the period between the first and second 400 CEREBRO-SPINAL DISEASES. dentitions ; and Hillier, of Great Ormond Street Children's Hospital, has given a table, which is referred to by Radcliffe. He found that of 422 cases at the above institution, 104 were between the ages of ten and twelve. Girls seem to be more often affected than boys, for what reason I cannot say, except that it may be the more delicate organization of the former, and the preparative changes going on before menstruation. Niemeyer believes the malady to be very rare before the sixth year and after the fifteenth. When the disease appears after puberty, it generally takes an eccentric form, or it may be due to central organic changes, or fol- low hemiplegia. This latter form, denominated by Mitchell post-paralytic chorea, has already been described. In chorea there is a general derange- ment of the digestive organs and loss of appetite ; constipation and palpi- tation are quite common alterations of function met with in these cases. In the anaemic patients, and they are generally all so, there is often an aortic murmur, and the skin is pale and cool. The existence of cardiac disease or the previous history of rheumatism is considered by many authors to have much to do with the causation of the disease. Romberg, Hughes, and West, besides many others, have so decided ; and when we consider the pathology of the disease, it will ap- pear to us very reasonable. Of 104 cases of chorea at Guy's Hospital, but 15 of the number were free from any indication of cardiac or rheumatic difficulties. The disease often follows scarlatina or other zymotic febriculae, or takes its origin from an attack of acute rheumatism. It may result, and gene- rally does, from some directly exciting cause, such as over-study, bad air, or food, worms, or sudden fright. My recent investigations in regard to the occurrence of the disease among school children revealed the astound- ing fact that over twenty per cent, of young school children of the public schools of New York were affected with choretic affections of greater or less gravity. West 1 expresses it as his opinion that over-study is a com- mon cause, and my investigations are sufficient to prove this. Many cases are supposed to result from association of unaffected children with those who are the subjects of chorea. Niemeyer alludes to the prev- alence of tlii.s u mimetic form" among boarding-school pupils. This view has been very popular with the laity, and I am convinced has some im- portance, still, I cannot but think that the influence of example has been grossly exaggerated. Malaria seems to play a decided part in the etiology of the disease. This was pointed out by Kinnicutt, who reported some interesting cases in which the movements were aggravated at certain hours on alternate days, and were characterized by something like periodicity. 1 Am. Psychological Journal, Feb. 1876. A number of papers containing questions wore sent to the public school teachers of this city. In most instances the answers were intelligent and satisfactory. The cases alluded to above varied from movement of the hands and twitching of the facial muscles to general move- ments which attracted the attention of visitors. CHOREA. 401 Morbid Anatomy and Pathology But few cases of fatal chorea have been reported. Twenty-two of these are brought forward by Dr. Dickinson, whose excellent article upon the pathology of chorea deserves the attention of every student of neurology. One case has been reported by Ellischer, 1 which is instructive, as it exhibits changes in the nerve- trunks ; and Ogle, 2 Kirkes, 3 Hughes, 4 and Romberg 5 have made autopsies in other cases. In Dickinson's cases the heart was found to be healthy in five ; in the remaining seventeen the following lesions were observed : Recent vegetations on mitral valves only, . . . seven. " " " " with old thickening, one. Recent vegetations on mitral and aortic valves, . . one. Recent vegetations on mitral and aortic valves, with peri- cardial adhesions, . . . . . . two. Recent vegetations on mitral and tricuspid valves, . one. Recent vegetations on mitral and tricuspid valves, with pericardia] adhesions, ...... one. Recent vegetations on mitral and aortic valves, with recent pericarditis, ...... two. Recent vegetations on mitral valves with old pericardia! adhesions, ........ one. Of the patients affected with recent endocarditis, 6 originated from rheumatism, 2 from mental causes, 3 from uterine, 1 from rheumatic and uterine, 2 from mental and uterine, and 3 from unknown causes; thus showing the connection between the rheumatic origin and the cardiac changes. The brain and cord were affected in 11 cases, there being congestion, softening, and appearances similar to those noted by the other observers I have mentioned. In one of his cases (No. V.) he made very thorough microscopical examinations, and I present his account of the appearances noted : " Sub- sequently sections from almost every region of the brain were examined microscopically. They were in most instances natural, the nerve-cells invariably so, save some injection of the vessels, not enough to be decidedly morbid; though the veins were much distended, in particular about the dentate bodies of the cerebellum, the vessels and their canals were nor- mal. There was no extravasation, effusion, or erosion. Two situations, however, were remarkable exceptions to these statements. In the deeper white matter of one of the cerebral convolutions were many conspicuous spots, which consisted of accumulations of crystals of haematine mingled with indefinite debris, probably of nervous origin, swelling the canals around arteries which still remained distended with blood. 1 Archiv fur Path. Anat., etc., t. Ixi. 2 Brit, and For! Med.-Chir. Review, 1868; Med. Times and Gaz., 1866. 3 London Med. Gazette, 1850; Med. Times and Gaz., 1863. 4 Guy's Hospital Reports, vol. iv., 1846. 6 Op. cit. 26 402 CEREBRO-SPINAL DISEASES. " The other region referred to as the seat of significant change is that of the corpora striata. These bodies were more minutely injected than the rest of the brain. The capillaries, as well as the larger vessels of both classes, being packed with blood-corpuscles and numerous spots, striking objects under the microscope, were closely set in their substance. These consisted each of an artery in section, empty, crumpled and collapsed, and surrounded by a mass of globular debris, which had been formed at the expense of the surrounding tissue. They had evidently been produced by a solution or destruction of tissue around the vessel consequent upon effu- sion from it, the result of injection which had -now ceased to exist. In time these mixed effects of extravasation and disintegration would have disappeared and left mere vacuities. "The spinal cord displayed loaded vessels and eroded fissures, such as were seen in every other instance examined. In addition to these com- mon changes, the gray matter had undergone extensive transformation of the kind to which the term sclerosis has been given. This was slight in the cervical region extreme throughout the dorsal absent from the lum- bar. The change was confined to the gray matter, which it affected on the same side of the cord nearly symmetrically. In the dorsal region it involved at least a third of the gray matter as seen in section ; the affected portions on each side being adjacent to the attachment of the transverse commissure, and at the root of each posterior horn. In the cervical region, though the change was less extensive, its position was the same. The altered gray substance had been converted into a wool-like entanglement of curving areolar fibres, among which nerve-fibres could be sometimes traced, especially near the edges, but from which all other nerve-elements had disappeared, leaving a mere confusion of connective tissue. The nuclei proper to the healthy structure were present, but had undergone no increase, nor was there any other evidence of fibroid or con- nective new growth. The change seemed to consist essentially of a destruction and removal of the nervous elements, their fibroid skeleton only remaining." A fatal case of chorea was reported by Dr. Jas. H. Hutchinson. 1 The heart was found affected, the aortic valves incompetent, the leaflets being "swollen and softenod," and the aorta was atheromatous above the sinus of Valsalva. Ellischer, 2 who made an autopsy, found that the vascular changes in the brain were marked, the walls of the vessels being changed, and the surface covered by dark granules. In certain places the calibre of the vessels was narrowed, and there wjis an accumulation of blood-corpuscles, and consequent effusion of the watery parts of the blood. Some of the vessels contained coagula. The connective tissue about these vessels was thick- ened and increased in size, and contained yellow pigment and granulated nuclei. The large; ganglionic cells in the brain were filled with pigment, and the cell contents much changed. Sections of motor nerves exhibited IMiilu. Mcd. Times, August 5, 1876. 2 Op. cit. CHOREA. 403 red patches, and destruction of nerve-fibres. These changes show, then, great vascular alteration, and degeneration of normal nerve-tissue. In regard to the pathology there is much dispute, some observers con- sidering it to be but a functional condition, while others are well satisfied as to its organic nature. The original observations of Kirkes first demonstrated the relation be- tween chorea and rheumatism. Ogle contends that this relationship (or at least the evidences of rheumatismal causation in the brain, such as em- boli) is only demonstrated by fatal cases. He considers the excess of fibrin in the blood to be only the result of the same influence that pro- duces the chorea, and that the blood state, instead of being a cause, may be a consequence of chorea, the result of tissue metamorphosis due to excessive muscular action. He raises a question as to the disappearance of the movements, and considers this condition of affairs incompatible with organic lesions. This objection, however, seems to lack force when we remember that in aggra- vated cases the movements do not stop during sleep. Another fact is to be thought of, and this is the tendency to relapse which the simplest cases present. The embolic theory has been reported by nearly every investigator, and its strongest supporters are Broadbent, Hughlings Jackson, and Bastian. The original investigations of Kirkes served as a basis for this new theory. He found that particles of fibrine were washed into the cerebral vessels. Hughlings Jackson located the place of final deposit in the gray matter of the convolutions in the neighborhood which are supplied by the middle cerebral artery. Jackson very cogently considers the significance of its one-sided character as compared with hemiplegia from embolism, and has since brought up the question of involvement of the muscles more con- cerned in special voluntary acts, which are likewise conspicuously affected in hemiplegia and epilepsy. Against this theory, some writers have raised the question in regard to the existence of the hemichorea on the same side of the body as that of the brain where the lesion is found, and contend that there must be crossed action. Dupuy and Brown -Se'quard have made experiments which prove that such a condition of affairs may exist, and I have myself done the same thing. Since my experiments, I have heard of a case, related by Dr. Walter Hay, of Chicago, in which post-mortem examination revealed a cerebral hemorrhage on the side of the hemiplegia. In one of these experiments made by Dr. F. H. Rankin and myself upon a monkey, electrical irritation (galvanic) of the white matter just beneath the cortex of the left ascending parietal convolution produced convulsions in both extremities of the same side. Broadbent localizes the lesions entirely within the corpus striatum. He also calls attention to the existence of peripheral irritation, shock, and various causes which may produce a depraved functional condition. Bastian adopts the theory that the emboli consist of masses of agglome- 404 CEREBRO-SPINAL DISEASES. rated white corpuscles, and that the location of the lesion is in the corpus Btriatum. Dickinson is disposed to regard the chorea as the result of rheumatism rather than of endocarditis, and considers the central condition one of hypera-mia of the nervous centres, " not due to any mechanical mischance, but produced by causes mainly of two kinds: one a morbid, probably a humeral, influence which may affect the nervous centres as it affects otli'-r organs and tissues ; the other, irritation in some mode, usually mental. but sometimes what is called reflex, which especially belongs to and dis- turbs the nervous system, and affects persons differently according to the inherent mobility of their nature." In regard to localization he agrees in the main with the other observers. ''The spots of peri vascular change are widely scattered throughout that large region which lies interiorly to the cerebral convolutions between the corpora striata and the lower end of the cord ; the district of the motor and sensory as distinguished from the mental functions." It seems, then, that the quality of the lesion is only disputed. I am .strongly inclined to accept the embolic theory, not only because the pare- sis of the limb may precede any muscular movements, but because lesions in or about the corpora striata, which produce hemiplegia, may also give rise to chore ic movements. Diagnosis. The movements of chorea must be differentiated from those of sclerosis and paralysis agitans. This will not be a difficult task, as the peculiarity of the choreic movement is t\\ejerk^ while the tremor of the other affection is rhythmical and usually Jine, and varies under certain circumstances. The rapid recovery should also be an element in the diagnosis. That chorea may result in some secondary disease, such as softening or meningitis, is well settled ; and in these cases it will be necessary to take into account the character of all the new symptoms, and the history of the old ones. The exceptional forms of the disease may be mistaken for hysterical troubles, and then the diagnosis will be difficult. It must be borne in mind, however, that this mistake can be made only in adult cases. The paralysis of chorea may be differentiated from true cerebral or spinal para- lysis by its gradual development, and by the age of the individual, as these two forms are quite rare in infancy. Choreic movements usually stop at night, and the exceptions to the rule of quiescence during sleep include those in which the patients have "dreams of movement," such as were alluded to by Marshall Hall. Prognosis Chorea is an affection which may very often disappear, without any treatment whatever, in from six weeks to four months; but there are very likely to be relapses. If properly treated, the movements should disappear in from six weeks to two months, or even in a shorter time. If the disease appears after puberty, the prognosis is unfavorable, and all we can do in some cases is to moderate its violence. There is a tendency to recovery in other cases, among them those of pregnancy. CHOREA. 405 Death is a very unusual termination, and it rarely occurs as a result of the disease itself, but rather of some cardiac complication. Treatment Internal remedies : Strychnia ; arsenic ; iron in its various forms (bromide, carbonate, etc.) ; phosphorus and cod-liver oil. External remedies : Cold to spine ice, ether spray, and cold douche ; Russian or Turkish baths; and salt baths. Rest, diet, and fresh air. (FF. 7, 9, 10, 11, 13, 14, 24, 28, 29, 32, 42, 43, 51, 58, 72.) Some of these may be combined with good effect. The plan of treat- ment I generally employ is the following: Should the child be "run down," as is generally the case, I begin with some preparation of iron, and administer at the same time cod-liver oil. As regards special treat- ment, I find strychnine serviceable, carried up to the point where stiffness of the sural muscles is arrived at. Next to this stands arsenic. It must be given in large doses ; but when we find that digestive troubles are produced very quickly by this drug, strychnia may be substituted. Cold to the spine cannot be overestimated as a plan of treatment. "NW may either use the ether spray, which was first suggested for use in this disease by Subetski, of Warsaw, in I860, or apply ice-bags every day, allowing them to stay on about ten minutes. Perroud, who has used the ether spray, makes applications from four to eight minutes in duration every day. Of thirty-five cases I have treated in this way (I mean with the ether spray), from fifteen to twenty applications produced permanent benefit ; and here I would say that the spray should be directed chiefly to the upper part of the cord, over the upper cervical vertebra}. Eserine has been lately recommended, and Bouchut has given the results of 437 cases, 205 of whom took it in pilular form, and 232 hypodermically. The ave- rage dose was from two to five milligrammes. He obtained temporary benefit, which seemed to wear off; but when the drug was repeatedly ad- ministered, he accomplished many cures. He reports twenty-three cures by an average of seven injections. It is a dangerous remedy, however, and produces severe gastric symptoms. The salts of zinc have occasionally proved valuable in cases of this dis- ease ; and conium is occasionally efficacious, but its effects are temporary ; but I prefer the remedies I have mentioned. I have found phosphorus, with cod-liver oil, to be a most valuable curative agent, and in cases where everything else failed it has succeeded. This seems reasonable, when we consider how much impaired must be the nutrition of the nervous matter. Da Costa 1 and Mills, 2 of Philadelphia, have used the bromide of iron ; but the latter has had very unsuccessful results. In twelve patients to whom he administered the drug, there was no improvement after its use. Dr. Mills says : " It was usually given in plain syrup and water, com- mencing with five grains three times daily, as recommended, and rapidly 1 Med. and Surg. Reporter, Jan. 30, 1875. 2 Phila. Med. Times, Sept. 25, 1875. 406 CEREBRO-SPINAL DISEASES. increasing the dose to twenty. The treatment was continued from two to four weeks. Twenty grains very generally caused vomiting. It seems to be a remedy which quickly irritates the intestinal tract." Oulinent and Laurent recommend hyoscyamin in doses of one-sixtieth of a grain, in pill form, at first twice daily, and afterwards more frequently. Amelioration is said to begin in eight or nine days. Should the presence of worms be suspected, we may either use an injection of quassia and carbolic acid solution (gtt. x Oj) after each stool, or pursue the ordinary santonine treatment. The use of ferruginous tonics is generally indicated, and those should be selected which are best assimilated and which tax digestion the least. I would therefore recommend either the carbonate of iron, or dya.l- ized iron. The addition of digitalis seems to increase their good effects quite materially. Chalybeate waters are useful, and sulphur baths arc recommended by Baudelocque and others. Trousseau recommends morphine and strychnine, but I have never seen any good results follow the use of the former ; of the virtues of the latter I have already spoken. II. C. Wood recommends a tincture made from the fresh leaves of the skunk-cabbage, with which he has had some suc- cess. Electricity I have no faith in, except, perhaps, when the so-called " general electrization" is used as a cutaneous and muscular stimulant. Benedikt has cured many cases by galvanism ; but, as far as I can learn, his results are exceptional. There are instances where nothing does good. It is well to put the patients in a dark room, and keep them perfectly quiet. We will be often astonished at the result. There are little things that must be watched. The diet, above all things, should be regulated with judgment. Plenty of fresh air and sleep come next, and absolute mental rest must be enforced. The school-books and the school-room are to be parted from, and agree- able diversions planned. An excellent auxiliary to our medication is the salt-bath. A handful of rock-salt in the water, and the energetic use of the rough towel, will infuse a tone and vigor that will soon become appa- rent. In conclusion, I must say that decided medication is useless in these patients if their personal habits are not looked after. PARALYSIS AGITANS. Synonyms Shaking palsy ; Parkinson's 1 disease ; Trembling palsy; Tremblement ^diiile ; Chorea senile ; Chorea festinans. It is unfortunate that so much confusion exists in regard to the proper classification of this tremor of old age. It has been and is to this day confounded with cerebro-spinal sclerosis. I shall speak of it as a disease of advanced life, symptomatized by paresis, involving usually the upper extremities, with tremor which is not increased by voluntary muscular action. This tremor rarely affects the muscles of 1 Essay on Shaking Palsy, London, 1817. PARALYSIS AGITANS. 407 the face, except in advanced stages of the disease, and is accompanied by festination, and in certain cases by bending of the body forwards, and inclination of the chin forwards and downwards. Symptoms. The extremities first become the seat of tremor, the fin- gers being agitated in the beginning ; the hand is next involved, and after- ward the arm. This tremor is bilateral, and it may not make further advances for some time, but ultimately the head and other limbs are included. The tremor may involve one hand before the other, or the leg of the same side may be next affected, then the leg of the other side, and next the opposite arm. After a variable time, extending from one to ten years, a species of muscular rigidity takes place, so that the head is drawn down, and ultimately the body is bent and the head is thrust forwards, or the chin is drawn down to the breast. The forearms and hands are flexed, and the arms may be drawn to the side of the body. The constant move- ments may produce an actual abrasion of the skin by friction of the elbows or hands, should the muscular contraction bring them in contact with the body. Any attempt at locomotion is attended by what has been called " festination." The patient may rise slowly from his seat, and perhaps in the early stages walk, slowly though awkwardly, by taking long strides, but when the muscles of the back lose their power, and the body pitches forward, the patient's attempts to preserve his equilibrium result in a shuffling gait, and finally he is compelled to run and gladly clutches the nearest chair or support to avoid falling. The voice is weak and the speech broken and abrupt, and the form of interruption has been compared by Charcot " to that which affects a novice in equitation when his horse begins to trot." This interruption is caused by the violence of the muscular movements. The patient pitches his voice when he begins to speak, and never changes the tone until he has finished, so that his phonation is decidedly monotonous. He is greatly fatigued by the constant muscular movements, and is restless and inclined to seek new positions which may give him ease. A disagreeable symptom is the oc- currence of cramps of temporary duration, which are more common during the day. During the tremor the fingers or toes may be rigidly flexed or extended. The face is utterly devoid of expression, but the mind is never impaired, and there are no affections of the organs of special sense. The tremor in the beginning ceases at night, but in the established form it is present at all times. The termination of the disease may be in death through exhaustion or complicating diseases, such as pneumonia, which carried off three cases reported by Trousseau. The functions of the bladder and rectum are not usually involved, except when the disease has become confirmed. In one case Topinard found sugar in the urine, but it is hardly necessary to say that this circumstance is exceptional. After suffering for a number of years the patient is finally obliged to seek his bed, sloughs form over the sacrum, and he gradually sinks, the tremor, perhaps, moderating slightly before death. 408 CEREBRO-SPINAL DISEASES. The following interesting csise is one that illustrates the course of the disease perfectly : Mr. M., the patient, during his early years led an active life, and after following the occupation of a peddler gradually worked his way up t< prosperity. For years he went about the streets of New York carrying. many hofks in the day, a heavy pack upon his hack, and during this time he suffered many privations of food, rest, and sleep, and was exposed to the elements, after going home wet and cold. Ahout fifteen years ago he first noticed the appearance of his present disease. He is a stout man of large frame, and about 70 years old. The trembling began after slight exertion, and continued for some time. It became more pronounced and constant during the next two or three years, and he was unable to un- button his clothing, feed himself, or use his hands. His general health did not seemingly suffer, but he was " nervous" and depressed, and fully aware of his pitiable state. He did not tremble so much when lying down, but when he moved about or assumed the erect position the hands shook and the head shook constantly from side to side. The movements always stopped at night, but it was some time before he could sleep. He gradu- ally lost power; the right arm losing strength primarily, and afterwards the left. Coincident with the loss of power there was tremor. AVhen I saw him two years ago, I found him seated in a chair in which he had difficulty in keeping his place. His upper extremities and head were chiefly affected. The head was inclined forwards, and was constantly agitated by movements of a rhythmical character, which did not appear to be increased or diminished by any act of volition. He could not raise his chin, but looked up at me when I entered the room with his son. When asked a question, he answered in a tremulous voice, speaking as would one wlio was chilled. His body was curved forwards, and his arms were semi- fiexed, the elbows being drawn to the chest ; and forcible or voluntary extension was impossible. There was no atrophy of the muscles of the arms or forearms, and no decided loss of sensation. The hands were agi- tated by the same rhythmical tremors as the head. When he was lifted up he could not walk, and would have pitched forward if not held. In this position I noticed that the knees were also affected by the tremor. His bladder and rectum did not seem to be involved, at least not as a result of the disease, for beyond symptoms of enlarged prostate he suffered no im- pairment of function. For the past two years he has needed powerful opiates to procure sleep, the movements continuing unless they are given. He swallows with difficulty, and there is a drain of saliva from the corner of his mouth. As far as I can learn there have been no disorders of the organs of special sense, and certainly there are now none. His mind seems to be somewhat affected, as he is irritable and silly, and his memory is deficient. It may be stated that the affection may exist in a modified form (Parkin- son's disease), and that tremor alone may be the only symptom. Festi- nation and rigidity are by no means constant expressions of the affection. Causes Nothing is known in regard to the causes of paralysis agi- tans. It has followed mental distress, or has been preceded by neuralgia and rheumatism, but these seem to be connected with so many nervous diseases that it is difficult to say just how much they have to do with the etiology of paralysis agitans. I have seen seveial cases, and in none of PARALYSIS AGITANS. 409 them was there any history of predisposing or exciting causes. We know that the disease is rare before the fortieth year, and that the male sex is more often affected than the other sex. Morbid Anatomy and Pathology Handfield Jones 1 and Ham- mond 2 are supporters of the doctrine that the affection is purely of a func- tional character ; and the latter is of the opinion that the paralysis agitans of Charcot is a multiple cerebral sclerosis. In an excellent review of the recent writings of Charcot and Moxon, which has appeared lately, the reviewer says : " There is a certain satiric humor in Prof. Charcot's notice of the morbid anatomy of paralysis agitans. He divides the autopsies hitherto made into three groups. In the first group nothing at all was found. The second group comprises cases of supposed paralysis agitans, which Prof. Charcot considers were in reality sclerosis ; and the third group contains the case of Parkinson subsequently mentioned, and a similar case by Oppolzer, which is treated with similar distrust. There are, however, other cases on record which give much more satisfactory results. Leyden has reported one in which the agitation was limited to the right arm, and a sarcoma the size of a large nut was found in the optic thalamus of the opposite side. Murchison and Cayley have reported a case in which very definite changes, partly of sclerosis and partly of cell growth, were found in the cord; but as in this case the symptoms are described but very briefly, it is possible that Prof. Charcot would place it in his second group. Joffroy, however, took especial care to investigate this point, as to whether the cases were really paralysis agitans or insular sclerosis, and he states that two out of his three cases were clearly paralysis agitans. In these two cases there was exube- rant growth of the epithelium of the central canal and of the nuclei around. In the third case, which seems not to have been a very doubtful one, there Avas in addition a sclerosed patch in the medulla." 3 The pathology of tremor is still so imperfectly understood, and there is so much to be said, that it would involve a much more protracted con- sideration than the size of this book will permit. We may, however, con- sider some of the physiological conditions of muscles which, when disturbed, result in the pathological state known as tremor. The variation or interruption of any compound entity is followed by an inharmonious relation of its parts ; thus a musical sound is the result of a number of more or less rapid vibrations and waves, their number influencing pitch. If a catgut string in a state of tension is twanged, vibrations are in- duced and a musical tone is produced ; but if a stick be loosely held against the string, without actual pressure being made, the vibrations will be inter- rupted, and a discordant noise will be the result of such contact. It has been demonstrated that a visible muscular contraction is, after all, the re- sult of an incredible number of smaller contractions, which cannot be seen 1 Functional Nervous Diseases, p. 382. 2 Diseases of the Xervous System, p. 785. 3 Brit, and For. Med.-Chir. Rev., Oct. 1875. 410 CEREBRO-SPINAL DISEASES. with the nuked eye, but may easily be appreciated with the aid of the myographium or some other registering instrument. Upon faradizing a muscle this may be experimentally demonstrated. Short breaks are fol- lowed by visible contractions of the muscle and movements of the liml> ; but if by a proper current-breaker this interruption be repeated many hundred times a minute, the intervals will be so short that, though an im- mense number of rapid contractions take place, there is but one grand contraction of the muscle which is appreciable. In the physiological state this coordination (if I may use the word) of the minor contractions is so perfect that the muscular movements are steady and separated by regular intervals ; but when the rhythm is lost, or the har- mony destroyed, the smaller contractions will be separated by intervals of sufficient length to be seen, and tremor results, the degree of tremor being proportionate to the length of the interval. The filaments of a tired muscle, the motor centres being worn out, do not contract evenly ; so, as a consequence, there is a visible tremulous- ness. In functional tremor, such as characterizes the disease in question, this is undoubtedly the pathological condition. Diagnosis The tremor of cerebro-spinal sclerosis may be mistaken for that of paralysis agitans. Let us compare the points of difference : PARALYSIS AGITAXS. CEREBRO-SPINAL SCLEROSIS. Tremor continuous, but not increased Tremor subsides during repose, and by voluntary efforts. is always aggravated by volitional at- tempts at control. Tremor regular and "fine." Tremor "coarse." Facial muscles unaffected. Usually cranial nerve paralysis, or tremor of facial muscles. Runs forward to preserve balance. Only staggers when walking is at- tempted. Speech slow, or affected by violence Speech-defects those which arise of muscular movements. from paralysis. A disease of old age, or advanced Usually a disease which appears be- life. fore middle age. Mercurial tremor, lead tremor, and alcoholic tremor sometimes resemble that of the disease in question ; the former is, however, more violent in the morning ; the tremor from lead is attended usually by colic and other symptoms of plumbism ; while no doubt need arise in regard to the third, which is attended by evidences of alcoholism. Post-paralytic chorea may be excluded by the history of hemiplegia or some other equally prominent organic condition, and the tremor is aggravated by voluntary efforts. A functional tremor of a very light grade, which is simply a personal pecu- liarity, is met with sometimes, and should not be magnified to the dignity of a disease. This may affect several members of the same family, as is the case in one example of which I know. The head of the family is a vestryman of an Episcopal church, and in passing the plate he sometimes is obliged to exercise the utmost self-control to prevent the contents from being thrown out, and more than once this infirmity has given rise to PARALYSIS AGITANS. 411 insinuations concerning his habits. His two children, both very young and healthy people, are affected by the same tremor. In such a case the trouble does not increase with time, and there are none of the other pro- gressive signs of the time affection. Prognosis. The course of paralysis agitans is decidedly progressive, though very gradual, and the individual may live for ten, twenty, or even thirty years after the appearance of the tremor. When death takes place, it is in nine cases out of ten the result of some other disease. I am convinced that genuine paralysis agitans is never cured, though it may be relieved ; and it is highly important to distinguish simple functional tremor, Avhich is not uncommon, from the disease under consideration. This functional disorder is amenable to treatment. Treatment Handfield Jones 1 considers that nothing can be done for the disease among very old people when it has become decidedly chronic. He has used electricity, conium, and a variety of remedies. " The general tenor of experience in this and in kindred disorders is to the effect : (1) that the main indication is to nourish and support the fail- ing power of the nervous centres affected ; (2) that this is best accom- plished by remedies drawn from the class of sedatives, or by the milder tonics. Henbane, conium, chloral, subcutaneous opiates, bromide of potas- sium, belladonna, hypophosphites, or phosphorus, cod-liver oil, carbonate of iron, and sulphuret of potassium baths, with electricity in one or other of its three forms, appear to me the most hopeful remedies. But steady persistence in appropriate treatment is doubtless essential, and the want of this may account for many failures. Trousseau's adage should be borne in mind, ' A longue maladie, longue traitement.' " He refers to a cure reported by another observer. The patient was a woman, eighty years old, in whom the disease followed severe labor; and she was ultimately unable to carry trays or heavy loads. The faradic cur- rent used several times effected the disappearance of the tremor. I am inclined, however, to consider this case one of functional tremor, and not of the grave variety I have described. I have used conium with good results, and find that it relieves the patient, but after the use of the drug has been discontinued for a few weeks, the tremor is pretty sure to reappear. It should be given in doses of the fluid extract of from MLv-n^viij thrice daily. Elliotson 2 has cured a case by the carbonate of iron in large closes, and strychnine has been suggested, but it is doubtful whether it does any real good. Galvanization of the spine, one pole placed over the spine, and the other as near as possible to the point of exit of the spinal nerves, has been advised ; and in some instances it has improved, if it has not cured, the affection. . 1 Brit. Med. Journ., March 8, 1873. 2 Quoted by Jaccoud, op. cit., vol. i. p. 427. 412 CEREBRO-8P1NAL DISEASES. EXOPHTHALMIC GOITRE. Synonyms Bsisedow's disease ; Graves' disease ; Exophthalmic cached ique ; C'ardiogmus strumosus. This interesting disease has i-eceived but little attention until within a few years, and it is only lately that it has been considered as a neurosis. Definition Exophthalmic goitre is a disease connected with vascular excitement and circulatory disturbance ; there is not only enlargement of the thyroid gland, but an excessive engorgement of the intra-orbital ves- sels, so that the eyeballs are pressed forward, giving rise to a hideou- deformity. Symptoms The first symptoms of the disease are generally indi- cated by violent action of the heart, and great acceleration in the circula- tion ; and with this there is hyperaemia of the cerebral vessels. Palpitation and pain over the left side of the chest, shortness of breath, and flushing of the face are other symptoms of this early stage. This early vascular disturbance is, perhaps, the first evidence of the disease noticed by the patient, but the enlargement of the thyroid gland may have been pro- gressing for some time. There may be other early symptoms which ap- pear with increased growth of the goitre, and protrusion of the eyeballs. These are falling out of the hair of the eyebrows, as well as the eyelashes. The heart's action is violent throughout the disease, and the pulse may beat from 120 to 140 per minute ; while the temperature is one or two degrees higher than the normal standard. There is nearly always a sys- tolic bruit and a carotid murmur. The hand, when placed over the goitre, may receive a peculiar sensation, which is produced by the agitation of the thyroid by the rapidly circulating blood in the enlarged vessels. There is rarely any visual disturbance, although troubles of accommo- dation are met with ; and there are no changes to be observed in the retina. Digestion is nearly always impaired, and there may be some diarrhoea or attacks of vomiting; while sleep is troubled, and the patient suffers greatly for want of rest. 1 1 is ap|K-arance is unmistakable. One or both eyes are prominent, and uncovered by the lids ; and the sclerotic is exposed above the cornea to a great extent. The patient is hypermetropic, and suffers considerably from conjunctivitis produced by the irritation of foreign bodies which lodge there. Dr. Yeo reports two very valuable cases, which are presented in admi- rable shape in a late number of the British Medical Journal* In one of these (Fig. 48) there was exophthalmosof the left eye only, the goitre being on the right side. The second case was thus described by Dr. Yeo : "The patient is a young single woman, 23 years of age, robust and strong-look- ing. She shows no signs of the pronounced cachexia (phthisical) so evi- dent in the other patient. But she is especially interesting now, as being 1 March 17, 1877. EXOPHTHALMIC GOITRE. 413 also the subject of unilateral exophthalmos. In her case the right eye only is prominent. There is very little, if any, enlargement of the thyroid, but there is constant palpitation. The pulse has varied during the time she has been under observation from 116 to 140. She comes of a healthy Fiiain>. some of them quite dark, as if the parts had been bruised the 'remains of the lumps; the hands and arms were manifestly swollen, and there wnv urticarial wheals on the liaibs and body." The following case is one of unilateral thyroid enlargement, with double exophthalmos : Mrs. L. B., 28, U. S. ; milliner. Was always well until eight years ago, when her present difficulty began. She was then living in New York, and actively employed. At this time she noticed the growth of a goitre upon the right side of the neck, which pulsated violently when she was excited or over-fatigued. She then flushed easily, and often had headaches, which were quite intense. These she has now, and her pain is of the congestive variety, and diffused. She presented herself at the out-patient department of the New York Hospital, complaining of a pain just beneath the border of the last rib on the left side, which was quite con- stant, but not increased by pressure, or by taking a long breath, or after eating. The pain was most severe in the morning, and seemed to move off towards night. Her heart seemed healthy, as far as valvular lesions were concerned, for no abnormal murmur was present ; but there was great rapidity of action, the pulse-beats varying from 106-120 per minute. The pulse was also quite bounding, and full. The carotids pulsated quite strongly, and there was a very marked venous thrill perceptible in the jugulars. Upon the right side of the neck, just above the sterno-clavicu- lar articulation, and extending laterally, there was a tumor measuring 2^ inches in length, and about 2 inches in breadth. The marked pulsa- tion of this growth led Dr. Slaughter and myself to suppose at first that it was an aneurism, but we were unable to reduce it by pressure, or to diminish its size by compression of the carotid ; and there was no history of injury. The peculiar movement was due to the pulsation of the carotid UJKUI which it rested above, and laterally passed the right jugular vein, which was also agitated by the transmitted pulsation of the carotid. When the hand was placed upon the enlargement there was perceived an nndulatory or " purring" movement. No bruit was heard with the stetho- scope, but the tracheal sound was readily perceived. This growth under- went variation in its size. Cold weather seemed to influence it in this way, and stimulants, or other agencies which increased the blood pressure, materially modified its sixe. The face was puffed, bloated, and red, and the eyeballs were somewhat prominent, while the pupils were dilated, and the iris rather sluggish. She was not hypermetropic, and there were no other defects noticed. By steady pressure I was enabled to perceive the " cushion feeling" alluded to by medical writers who have observed this disease. Her companions twitted her in regard to her fixed stare, which resulted from the exophthalmos. Her ankles and feet were oedematous, and pitted deeply on pressure. Her urinary organs seemed to be in order, and there were no indications of renal disease. She has noticed at times patches of rusty discoloration which appeared about her neck and upon the left side of her face. These lasted for several days, and then faded away. She has had several minor symptoms, such as nose-bleed, which occurs even now, every two or three weeks. Her menses are scant, but there is apparently no interior disease. Her digestion is feeble, and she is slightly constipated. R Ext. ergotze fl. $j, t. i. d. EXOPHTHALMIC GOITRE. 417 Causes The disease is one of middle age, and there are about twice as many females as males affected. It is connected, in some cases, with metrorrhagia, or hoemorrhoidal bleeding, or in others with heart disease. Examples of traumatic origin have been noted by Begbie 1 and Von Graef'e, 9 and others have been apparently of idiopathic origin. The case of the first followed head injury. Morbid Anatomy and Pathology The observations of those who have made autopsies differ greatly. Morel Mackenzie found soften- ing of the corpora quadrigemina and the posterior part of the medulla. The heart was not much affected, there being only slight atheromatous deposits on the mitral and aortic valves, with thinness. Other observers have found hypertrophy of the heart and insufficiency of its valves, but in other cases there were no heart lesions whatever. The thyroid gland has been found to contain enlarged vessels, and the orbits an increased quantity of fatty tissue. In one of Begbie's cases there was sinking of the eyeballs in the orbital cavities after death. Much discussion has taken place in regard to the pathology of the affection, but recent investigations point to the nervous origin of the dis- ease. The cervical sympathetic has been found to be altered, and numerous instances of the change have been brought forw r ard by Reck- linghausen, 3 Trousseau,* Archibald, 5 and others. Notwithstanding this explanation (the sympathetic origin), others contend that it is a disease of the brain ; and still another theory is accepted by those who consider it a cardiac disease per se. The nervous origin seems to me to be that which is most acceptable. Not only does the use of galvanic treatment, which cures the disease, suggest this neurotic character of the affection, but the hysterical phenomena mentioned by Basedow, and noticed fre- quently by others, are certainly significant. We may, I think, consider the disease to be dependent upon an affection of both the sympathetic and spinal accessory nerves. The condition of the vessels of the thyroid gland and those of the orbit, the flushing of the face, and general disturbance of digestion, are probably due to the altered function of the first-mentioned nerve, and the heart excitement is a con- sequence of deficient innervation of the accessories. Diagnosis There need be no mistake made in the diagnosis of this affection from simple goitre, and after this is accomplished there is nothing else suggested. One inspection of the enlarged thyroid, and the protruding eyeballs, and the detection of the vascular excitement, are sufficient to enable us to say that the case is one of exophthalmic goitre. Prognosis A cure is recorded by Cheadle ; another by Mackenzie, 6 1 St. George's Hospital Reports, vol. iv., 1869. 2 Arclu'v fur Ophthal., 1857. 3 Deutsche Klinik, 1863. 4 Trousseau and Peter, Gaz. Hebdom., 1864. 5 Med. Times and Gaz., 1865. 6 Op. cit. 27 418 CEREBRO-SPINAL DISEASES. who also reported a death. Bartholow 1 has cured three patients ; Ham- mond* tour, and reports one death. Dr. J. P. Thomas, 8 of Kentucky, details a very interesting case which ended fatally in five years. Very little can be said in regard to the diameter of the disease, but it has been cured in certain instances in a year or two. It may last for several years, however, and is essentially a chronic affection. Trousseau, Charcot, and Corlieu 4 report cures, in which pregnancy, uterine hemorrhage, or some such complications occurred during the disease, influencing its disappear- ance. Treatment Galvanism, it seems, has succeeded admirably, and Uartholow has cured three cases by this agent. Chalybeate preparations, digitalis, ergot, and cod-liver oil are all excellent remedies (FF. G, 8, '2 1 . 4(1). If galvanism be nsed, we should bring the sympathetic nerve under its influence by placing one pole (the positive) at the angle of the IOVMT jaw, and apply the negative over the epigastrium. 1 Op. cit. 2 Op. cit., p. 797. 3 Richmond and Louisville Med. Journal, 1877. 4 Rep. by Jaccoud, vol. i., p. 672, 2d edition. NEURALGIA. 419 CHAPTER XY. DISEASES OF THE PERIPHERAL NERVES. NEURALGIA. Synonyms (See special varieties.) Definition Neuralgia may be defined as " a disease of the nervous system, manifesting itself by pains which in the majority of cases are unilateral, and which appear to follow accurately the course of particular nerves, and ramify sometimes into a few, sometimes into all, the terminal branches of those nerves." 1 Neuralgia is essentially the result of lowered vitality, and is never a consequence of any sthenic condition. This is proved by the circum- stances under which it occurs ; it taking its origin from general debility, rheumatism, syphilis, or malaria, or some other disease which produces a cachexia. Anstie very justly considers that it is the first expression of a condition which later on becomes paralysis one being a partial disturb- ance, or cutting off of the nervous supply ; and the other a complete inter- ruption of the nervous force ; and it is a familiar fact that neuralgia very often precedes loss of power in parts supplied by an affected nerve. Neuralgia is, then, a disease in which pain is the prominent symptom, and with which circulatory, trophic, and motorial disturbances may be con- nected. Pain Neuralgic pain is quite distinct from that of any other disease. It is not at all like that of neuritis, which is constant and aggravated by pressure, but it is paroxysmal, and is characterized by a stage of increas- ing intensity and rapid recurrence, and by a second stage of " wearing out" or subsidence. It appears suddenly, disappears, and returns, being broken by a period of rest. These breaks or intervals of remission be- come shorter as the attack increases in severity, until the pain seems almost continuous. When the climax is reached, the intervals grow in length, and the pain diminishes in severity, and finally subsides. Repeated neu- ralgic attacks leave the nerve in a hyperoesthetic condition, so that at par- ticular points it is tender and sensitive to pressure. These foci of exalted sensation have been called by Valliex 2 " les points douleureux," and correspond to the points of emergence of the nerve from its foramen, or at u point when it passes from a deep to a superficial course. The terminal ends of nerves are much more often the seat of this tender- ness than any other part. The external ramifications of the supra-orbital branch of the fifth or the small filaments of other nerves the ulnar and 1 Anstie, Neuralgia, etc., p. 14. 2 Traite des Xeuralgies, Paris, 1841. 420 DISEASES OF THE PERIPHERAL NERVES. radial for instance are not rarely painful to pressure. These painful points are met with very frequently in cases of facial neuralgia. A gcn- tleinan who consulted me some time ago presented this indication of facial neuralgia, there being several hyper-aesthetic spots in the roof of his mouth, and his gums on one side were exquisitely tender. Circulatory disturbances, of a quite marked character, are pronounced features of the neuralgic attack. The pulse at first is irritable, small, and quite rapid. A species of fluttering palpitation is also present, and the surface is pale and cool. In the later stages of the attack, after the pain has grown decided, the face becomes flushed ; the pulse soft, full, and quite bounding ; and the eyes may be suffused and bloodshot, should the attack be one of facial neuralgia. During this stage, and after the subsidence of the pain, the patient may sweat profusely. Trophic Disturbances These may be connected with the acute pa- roxysms, or may result from repeated attacks. Among the former may be pemphigus, and herpetic and bullous eruptions ; and among the latter, loss of teeth or hair, or alteration in the coloring matter of the hair, atrophy of muscular tissue, and various cutaneous changes. Charcot and AYeir Mitchell, as well as various writers upon dermatology, have called atten- tion to the connection of aggravated neuralgic pain, with various cutaneous diseases. The most striking of these neurotic skin diseases is herpes zoster, in which are eruptions of a vesicular character, a cluster of patches being found here and there along the course of the affected nerve. The pain precedes the appearance of the eruption, and may continue during its existence, and for some time after, or there may remain a pruritus, limited to the parts which have been the seat of eruption. The neurotic character of this complication may be proved by its very rapid disappearance after galvanization of the affected nerves, or administration of large doses of quinine. 1 The other trophic alterations, which are secondary, will be con- sidered at a later period. Motility Connected with some forms of neuralgia are certain conditions of spusm. In a form of facial neuralgia which has been known as tic epileptiform or tic douloureux, tonic spasm of the eyelid or of the masseter muscles is present as a decided symptom. Convulsive movements of the legs, due to spasms of the flexors, have also been observed in sciatica by Anstie; but in cases in which I have noticed this symptom, it seemed rather a result of excessive pain, and an effort upon the part of the patient to relax the pressure upon the affected nerve. Local spasms are quite common ; and the muscles of the face, of the trunk or limbs, and the vomiting of sick headache, are varieties of spasmodic action which may be cited as examples of this kind. In a case lately under treatment, I have been reminded of a condition which I have several times observed a species of heart pain resembling that of angina pectoris, and connected with facial neuralgia. With this pain there would be spasmodic contraction A form of skin disease lately denominated pompholyx by Dr. A. R. Robin- son, of New York, is an example of a neurosis of this kind. NEURALGIA. 421 of the muscles of the thorax. Mitchell 1 "has encountered from time to time certain forms of neuralgia, accompanied by muscular spasms and extravasations of blood in the affected part. He relates three cases, all occurring in females, and explains the circumscribed hemorrhages by nutritive changes in the walls of the vessels, occasioned by conditions of the nervous system analogous to atrophic changes in the skin and nails in nervous diseases." Valliex has divided the neuralgias into the superficial and the visceral, and classifies them as follows : A. Superficial. 1. Neuralgia of the fifth nerve (trifacial or trigeminal neuralgia). 2. Cervico-occipital. 3. Cervico-brachial. 4. Intercostal. 5. Lumbo-abdominal. 6. Crural. 7. Sciatica. B. Visceral. 1. Uterine or ovarian neuralgia. 2. Neuralgia of the urethra. 3. " bladder. 4. " " rectum. 5. " " testis. 6. Hepatic neuralgia. 7. Neuralgia of the heart. 8. " " stomach. 9. Laryngeal and pharyngeal neuralgia. Among the first group the most important is neuralgia of the fifth nerve, which may also ex.ist with a motor complication, as tic epileptiform, or with gastric complications, as migraine or " sick headache.' FACIAL NEURALGIA. Synonyms Face-ache ; FothergilFs face-ache ; Prosopalgia ; Tri- geminal neuralgia; Tic douloureux; Migraine; Sick headache. The supra-orbital branch may be alone affected, and the pain confined to the brow and top of the head, or it may be quite generally diffused over the face and head, the three branches being involved. The first division of the nerves is, however, the most common seat of neuralgia; but it is not unusual for an attack to begin above, and finally extend to all of the divisions of the nerve on one side. Migraine, or " sick headache," presents the following features : The attack may be preceded by some chilliness, pallor, and uneasiness, and is 1 American Journ. ofMed. Sei., Iviii. 16. 422 DISEASES OF TUB PERIPHERAL NERVES. ushered in by a twinge of pain, which begins just above the eye on one side, and radiates over the head. The pain is often erroneously referred by the patient to both sides of the head, when, in reality, but one-half is affected. Deep-seated orbital pain, photophobia, hcmiopia and nausea, with an irritable, thready pulse, and increase of pain, immediately usher in the attack, which rapidly increases in severity; the pulse after a while losing its asthenic character, and becoming full and bounding. The patient's face becomes flushed, and his skin red and sweaty, and in rare cases the sweating is confined to one side of the face. The paroxysms of pain, which at first were separated by intervals of relief, next become almost continuous, but after a time, during which the patient may feel like vomiting, they become less severe, and finally, after his stomach has been emptied, may disappear altogether. The features of an attack of this kind are too familiar to need elaboration. The following case will serve as an illustration : Mrs. G. is a delicate, hysterical woman, who devotes most of her time to duties of society. Her domestic affairs are worrying, and the constant excitement of entertaining, late hours, and the management of several un- ruly children, have so worn upon her that now, at the end of the winter, she is anannic, " run down," and suffers from want of appetite, insomnia, and general debility. About twice a week, at irregular times, she suffers in the beginning from light pains, radiating from the right eye, and over the head, which become quite severe, and increase during the next hour or two. She usually becomes cold, and bundles herself up in shawls and wraps. Her eyelids feel heavy, and the " skin covering" her " face feels as if it were drawn tightly." She is nervous and irritable, and cannot bear the presence of her children, and is sometimes so depressed that she bursts into tears. She has a vague dread of some trouble, the character of which she does not know. The pain increases in severity, and becomes almost unbearable. Her eyes are hot, and " it seems as if a peg was being driven in from behind." Her face becomes very hot, and her temporal vessels throb. The slightest step she may take in walking so jars her head that it gives rise to intense pain. She " feels as if" her " head would split open." She cannot look out of the window, but lies upon her bed, and buries her face in the pillows. Nothing seems to relieve her. She may lie so for hours, panting for breath, and pressing her aching head. After a variable time, sometimes two hours, sometimes a day, the pain is dimin- ished somewhat, and she becomes nauseated ; not because food lies undi- gested, for she has taken none for some time, but the vomiting is of a purely cerebral character. She attempts to vomit, but cannot bring up anything. The effort at retching jars her body, and increases the pain. After this state of affiiirs has lasted for some little time, she becomes exhausted, and falls back upon the bed, sweating profusely. The pain grows very much less severe, is dull and throbbing, and finally she sinks into a deep sleep, from which she awakens somewhat relieved. The variations in pain and circumstances which give rise to the disease have led different observers to apply such names as " rheumatic," " hys- terical," " sympathetic," " organic," " syphilitic," and " clavus." These terms have little value, and it seems that a nomenclature based upon the anatomical situation of the neuralgia is all that is needed, and it certainly NEURALGIA. 423 would do away with much confusion. Facial neuralgia, unless it be due to temporary exciting causes which may be readily removed, is rather an obstinate affection. It may take a periodic character, especially if it be connected with malaria ; or it may be more intense at night, should it be of syphilitic origin. The true attack rarely lasts beyond a few hours, but attacks (especially of tic-douloureux) may be so frequent as to become almost continuous. The tendency is, I think, for the disease to become firmly rooted, and to increase in severity. If there be a rheumatic, mala- rial, or anaemic form, there is no reason why the disease should not subside when these morbid conditions are removed. As to clavus, in which the pain is compared to that which would probably follow the driving of nails through the skull, it may be said that this is an hysterical condition, and the patients' descriptions are based upon the workings of a disordered im- agination. There are very few cases of facial neuralgia in which all the branches may not be involved at some time or other. If the neuralgia be confined more particularly to the first and second branches of the fifth, the temples and forehead, upper eyelid, root of the nose, and the orbits will be the points at Avliich the pain will be the most severe. Toothache, above and below, will indicate involvement of the middle and lower branches, and if the lingualis be affected, which it quite rarely is, the tongue will be the seat of the violent pain. The painful points are to be found principally over the supra-orbital notch, the infra-orbital foramen, the " malar point," or in the roof of the mouth, over the mental foramen, and in front of the ear. During the attack it is not uncommon to find hypersecretion of sa- liva, that fluid passing from the angle of the mouth in great quantity, and when the supra-orbital and infra-orbital branches are involved there may be a corresponding profuse lachrymation. 1 Erb s has called attention to the occasional increase of secretion from the nasal mucous membrane. This has been referred by Vulpian to irritation of one of the spheno-palatine ganglia. The patient is nearly always excited and irritable, and if the paroxysms be of frequent occurrence he suffers from insomnia, and is en- tirely unfitted for his daily occupations. It must not be supposed that the vomiting of migraine has any direct connection with the condition of digestion. The attacks are, however, aggravated by the presence of un- digested food in the stomach. The deep neuralgias of this nerve are very obstinate, and often beyond the reach of any treatment. This is notably the case when the superior maxillary or its orbital branches are affected. The ocular symptoms are then of the most formidable description, and life to the patient is a burden indeed. The following is one of the most inveterate cases of neuralgia of this kind I have ever observed. The patient's trouble began in 1863, while at school, and then affected the superior maxillary and infra-orbital 1 Sometimes there is spasmodic closure of the orifice of the lachrymal dut't. 2 Ziemssen's Encyclopaedia, vol. ii. 424 DISEASES OF THE PERIPHERAL NERVES. branches of the fifth nerve. His sufferings were intense, and after trying almost all forms of treatment, and consulting medical men in Europe and in this country, he consented to subject himself to an operation for CXMT- tion. The history he brings, which was taken by the house surgeon, Dr. Peale, of Chicago, details the surgical procedures undertaken. "Patient has for a long time suffered from neuralgia of supra- and iiil'ni- orbital nerves, and the superior trochlear nerve. Prior to this he had a closure of the lachrymal ducts of both sides. He had been in Central America, where he was exposed to severe forms of malaria. About two years ago, Dr. Strawbridge, of Philadelphia, cut oft' the supra-orbital nerves at their point of exit from the supra-orbital foramen. In 'either eye there is loss of accommodation, and a high degree of hypermetropia. Prof. Holmes, of this city, after an ophthalmoscopic examination, told him that the veins of the retina were diminished in size. He still suffers intensely with the infra-orbital nerves, and comes in de- siring to have them excised. He receives 3^ grs. morphia, hypodermically, each day. Dec. 18, 1876. An incision made downward from the location of each infra-orbital foramen to the length of one inch through the tissues of the cheek, the nerves raised on a blunt hook, stretched well out, and chipped off at their point of exit. Ether used as the anaesthetic, collodion and silk sutures to approximate the edges of the incision. 19^/j. Patient suffering from intense pain referred to outer edge of right lower eyelid. 23d. Considerable cellular inflammation of right side of neck and face. 2(>th. Considerable discharge of pus from incision on right side of face ; swelling very much diminished. 2'.)th. Discharge of pus from both incisions has now about ceased ; con- siderable cellular inflammation of right side of face in parotid region. He claims he has still the neuralgic pain, but deeper in the infra-orbital re- gion. 31st. Considerable swelling and a great deal of tenderness on either side of the neck below the jaw. Patient cannot move the jaw. Jan. 5, 1877. Face continues swollen, and very painful ; thinks he still has the old neuralgic pain on right side. Quantity of opiates in 24 hours considerably diminished. '2'.)th. Patient, again placed under the influence of ether. An incision made on the right side in the site of the old one, and the nerve raised on a blunt hook and divided. Following the operation the pain became severe, and the hemorrhage excessive. For a couple of hours all sorts of efforts were made to stop it, and finally we were obliged to resort to ol. terebinth, and ferri persulph. These, with compresses bound on as best we could, checked it so that it only oozed. A large quantity of anodyne was required to allay -pain. 30th. There has been no further hemorrhage. Morph. pro re nata. Feb. 2. All dressing removed without hemorrhage ; wound left open and suppurating ; dressed with carbolic acid ; pain controlled with morph. 4t/i. Complains of pain in right temple. P. M. Severe headache ; wound dressed twice a day. \\th. Patient had been doing well until yesterday. There was a hem- orrhage from the wound in the morning, controlled by syringing with cold water. Last night another very severe hemorrhage ; used dry ferri NEURALGIA. 425 persulph. Has had three hypodermic injections of f gr. morph. each, daily. Ordered iodoform to be sprinkled in wound. March 27. At 3 P. M. patient was etherized, and Prof. Bogue pro- ceeded to resect the orbital branch of the superior maxillary nerve. A circular flap begun in the old cicatrix on the right side, and curving backwards, laid bare the molar bone. An opening was then made through its quadrilateral surface with aTtrephine into the antrum ; the floor of the orbit was then gouged away and the nerve hooked up and ruptured. There was, following this, hemorrhage. A plug of sponge was then stuffed into the antrum and left. In the evening there was a severe hemorrhage from the nostrils and mouth ; the nostrils were plugged. Later in the evening the sponge and plug were removed ; the antrum washed out ; there was a brisk hemorrhage. Monsel's styptic was freely injected ; finally the antrum was again plugged with sponge soaked in the same solution. The eyeball was noticed to project considerably more than its fellow, but the sight was not much impaired. Patient has had, till the present time (10 A. M.), morph. gr. iij, by hypodermic injection. This morning complains of great pain in the eye and upper jaw. Plugs not removed. Ordered whiskey and morph. to allay pain. P. M. Pulse, 76 ; temp. 103. 30th} A. M. Pulse, 72 ; temp. 100. On yesterday evening the sponge plugs removed from the wound ; no hemorrhage occurred ; they were not replaced ; water-dressing continued through the night. This morning the wound is suppurating slightly ; face not swollen quite so badly. Patient has had one grain morph. by hypodermic injection every 4 hours for the past 48 hours. Water-dress- ing continued. Patient still complains of great pain in the right eye ; swelling is considerable ; eye closed, with conjunctiva protruding from between the lids. A pledget of lint saturated with alcohol was laid in wound, and water-dressing continued. April 1. Is feeling better; wound is suppurating considerably; is not swollen so badly ; plugged with lint saturated with alcohol, and the cold compresses continued. 3d. The surface of the wound is covered with healthy granulations. The eye very much improved ; can open it ; can distinguish objects at some distance. 4th. The patient's condition rapidly improved. 6th. Cavity granulating finely ; appetite good ; everything appears fa- vorable at this time." The patient came to New York and consulted me October 17, 1877. In spite of all the surgical operations the pain is as severe as it ever was, the focus of intensity being evidently the orbital branch. The eve is without sight, but no retinal changes can be discovered, except paleness at the fundus. The conjunctiva is injected, and the eye is suffused. I gave him two hypodermic injections of morphia, of one grain each, within an hour, but none of the physiological effects followed, and the pain re- mained unabated. Nothing remains to be done but deep section of the nerve. A formidable neuralgia is that connected with spasm of the facial muscles, which has received the name of tic douloureux or tic epilep- tiform. The former term is that applied by Benedikt, and has been 420 DISEASES OF THE PERIPHERAL NERVES. generally accepted by most writers to express the violent and sudden twinges of pain which are accompanied by very forcible spasms of the facial muscles. These spasms may be of varying degrees of severity. The eye may be tightly closed during the paroxysm, or the face violently drawn to one side. The attacks are generally supposed to be con- fined to those individuals in whom there is a neurotic predisposition; and Erb, Eulenburg, and others consider tic douloureux to be a disease of central origin, which seems very probable for some reasons, but not so much so when we take into account the fact that in some cases the disr.-i-i- may appear and disappear, there being occasionally a long period of qui- escence, and then a relapse. Anstie considers that the spasm is not di- rectly connected with the pain, but is rather inclined to look upon it us a coincidence, or as a result of the epileptic tendency, the pain and epilepti- form spasm being separate expressions. A very interesting case, to which I have already casually alluded, was sent me by my friend Dr. Sayre, of New York. Mr. K. had for ten or twelve years suffered from neuralgia of the fifth nerve of the right side. His habits had been very good, and there was no history of syphilis, nor any evidence that it had existed. About ten years ago, after exposure, he first noticed the commencement of his trouble, and at this time there was no facial spasm or very decided pain ; his attacks, however, which, during the first two or three years, occurred at intervals of two or three months, became much more frequent, and, within three years, have become almost continuous, so that there is rarely an in- terval of five or ten minutes between each paroxysm. Sleep is utterly impossible, and he has been obliged to resort to an immense quantity of stimulants for the purpose of procuring rest. He tells me that very often he drinks a pint of whiskey before retiring. During his visit he had several attacks of tic, during which his face \\;is drawn up and agitated by clonic spasm of the muscles of the right side ; these attacks lasted one or two minutes, during which his face became flushed, his eyes injected, and from the corner of his mouth trickled a quan- tity of saliva ; the gum was very tender, and painful points before alluded to were found to be very sensitive. Numerous painful points w'ere also found upon the scalp over the supra-orbital notch, and at different points over the temporal bone. Before I saw him he had been under several varieties of treatment, but none afforded him the least relief. CERVICO-OCCIPITAL NEURALGIA. "When the posterior branches of the upper cervical nerves are the seat of neuralgia, the patient will complain of pains beneath the occiput, be- hind the ear, and sometimes at the under part of the lower jaw. The pain at the base of the occiput is most severe; but when the neuralgia in- volves the anterior nerve branches, and pain appears behind the ear and over the lower part of the face, this affection may be mistaken for neu- ralgia of the fifth pair. The pain is often insupportable, and is of a parox- ysmal 'character. It is, on the other hand, of a localized form, and so constant in some cases. that the medical man may be led to suspect inflani- NEURALGIA. 427 matory conditions of other parts. During the active pain the patient may be unable to turn his head or open his mouth, and any muscular move- ment is attended with distress. The skin may be either hypersesthetic or anesthetic, but more often the former, and I have had patients who were unable even to bear the pressure of a collar or other neck gear. The skin feels to the patient as if it were tightly drawn over the tissues beneath, and it sometimes may be red and appear swollen. The hyperasthesia, when it involves the scalp, is so distressing that the patient is unable to place his head upon the pillow, or wear a hat unless it is much too large for him ; and heat seems to increase the discomfort to a marked degree. The post-cervical muscles may be the seat of cramps, during which the pa- tient's head is drawn "backwards or laterally downwards. Painful points may be found in two or three situations, but most frequently where the great occipital nerve emerges. The spinous processes of the upper cer- vical vertebrae are often the seats of painful spots, and it is not rare to find that distress is caused by pressure at different places over the occipital bone. CERVICO-BRACHIAL NEURALGIA. A form of attack manifesting itself in severe pains, which shoot down the arms, hands, and back of the neck. Exquisite cutaneous hyperses- thesia is by no means a rare accompaniment, the skin being so tender to pressure that the slightest touch of the clothing will produce intense suf- fering. The distribution of pain corresponds to the parts supplied by the lower cervical nerves or regions which are innervated by sensory branches of the brachial plexus. Erb 1 has given a diagram which demonstrates the districts of pain, and their source of supply, which may be made use of in tracing the course of the affected nerves. (See page 441.) My attention has been directed by Dr. Burral to a condition of neu- ralgia which is often mistaken for the so-called muscular rheumatism, and is probably due to an involvement of the circumflex as well as the pos- terior thoracic. The pain is not nearly so acute as that of some of the other neuralgias ; for example, the facial variety. It is dull and terebrat- ing, and resembles the agonizing though temporary pain which follows a blow upon the popularly called " funny bone," or ulnar nerve, in its ex- posed position at the internal condyle. The pain travels down into the hand, and may be attended by a spasm of the muscles. There are points of tenderness which are extremely numerous. Pressure made over the supraclavicular space, just below the lower angle of the scapula, at the exposed portion of the ulnar nerve at the elbow, and at the points of emer- gence of the superficial nerves of the arm and forearm as they pierce through the fascia, gives rise to pain. Occasionally there are tender spots over the cervical vertebrae. The skin of the arm is often cold, and areas of capillary emptiness are to be observed either during an accession of 1 Ziemssen's Encyclopedia, vol. xi. p. 146. 428 DISEASES OF THE PERIPHERAL NERVES. pain or between the attacks. In rare instances it is not unusual for tro- phic alterations to be manifested. In a patient under observation the right hand is reduced in size, the skin is dry, puckered and livid ; tin- lines of flexure of the fingers and hand are red, and much deeper than upon the other side of the body ; and the nails are crenated and irregular. Erb alludes to an excessive sweating of the fingers. This form of neu- ralgia is decidedly inveterate, and when well established is attended by nocturnal exacerbations. The use of the affected hand is sure to aggra- vate or precipitate an attack, and changes of temperature act usually in the same manner. A gentleman sent to me by Dr. Ives, of New York, had suffered in- tensely for a number of years, and his pain had become almost constant. When he neglected to cover his arm with cotton batting, but permitted his coat sleeve to come in contact with the skin, he would be in utter misery, so that he was obliged to cover it with some soft substance. He \\ us very cautious in selecting a position at night, as the arm, if unsupported, dragged the muscles of the shoulder sufficiently to produce a paroxysm. INTERCOSTAL NEURALGIA, OR PLEDRODYXIA. This is often mistaken for pleurisy. It is characterized by a pain which encircles the body, and may be referred by the patient to the region bounded by the crest of the ilium below, and the thorax above ; but it more commonly affects the lower intercostal nerves. The pain is always one-sided, and is dull and continued, but may sometimes be sharp and paroxysmal, radiating from the spine anteriorly. The skin is hypenes- thetic, and this is particularly the case if the neuralgia be attended by her|>etic patches. The painful points are chiefly over the inter-vertebral foramen, and where the nerve pierces the muscles anteriorly. The red us muscles contain painful spots at the points where the lower intercostal nerves pierce the investing sheaths. The patient during the paroxysm inclines his body to the affected side, as it were to relax the muscular strain ; he perspires freely, and his face wears a scared and anxious ex- pression, suggestive of great suffering. His breathing is "catching" and shallow, and attended by the least possible movement of the thoracic walls or diaphragm. SCIATICA. Sciatica is perhaps, next to facial neuralgia, one of the most trouble- some and familiar neuralgias. It rarely begins suddenly, but has a gradual onset, attended by a variety of disagreeable and annoying symp- toms. Cutaneous hy persist hesia, slight fatigue after walking, and "sore- ness," a sensation of dragging or of heaviness of the leg and foot, and a number of minor symptoms of a vague character precede the actual pain. This is exceedingly severe, and may exist in a dull form, and during its continuance there may be paroxysms consisting of twinges or " darts " NEURALGIA. 429 shooting down the back of the leg. Should the patient, while sitting, place his thigh so that the nerve shall be pressed against the edge of the chair, the paroxysm may be precipitated. Anstie has divided sciatica into three varieties, one of which occurs during comparatively early life, and is con- nected with hysteria. It is dependent generally upon over-fatigue, and affects anjemic people. It is the form which attends irregular menstrua- tion, and the pain is quite severe. In this variety I have rarely found any painful points. Before the fourteenth year neuralgia of the sciatic variety is very un- common. In 124 cases collected by Valliex, none were under seventeen years of age. Sciatica of the second variety is a disease of adult life, and is a result either of exposure, or some such cause as continued pressure of the nerve through sitting in an uncomfortable position. It is not rare among busi- ness men, or clerks who sit upon high wooden chairs or stools, and who generally do not support their legs by placing the feet upon the floor or the rounds of the chair. Anstie connected this " middle-aged sciatica " with premature decline, and States that the patients have rigid arteries, gray hair, and the arcus senilis ; but I do not consider that these indications of decay have any very decided bearing upon the sciatica, especially in the form last mentioned. It strikes me rather that the causes which produce the disease, with the exception of dissipation and perhaps syphilis, gout, or like affections, would be local. Some of the most intractable cases of sciatica I have ever seen were persons who were apparently in good general health. The presence of " painful points " is highly characteristic of this form. Foci of tender nerves may be found corresponding with the emergence of the sciatic nerves from the pelvis ; and also at various points corresponding to the cutaneous distribution of the posterior branches, as Avell as just below the crest of the ilium. Points of tenderness may be also found at various situations in the course of the nerve at the back of the thigh ; sometimes in the popliteal space, or at the head of the fibula, and in the depression below the external and internal inalleoli. Atrophy of the muscles of the thigh is not a rare consequence of the neuralgia in old cases, and is sometimes preceded by paresis. Tactile sensibility is diminished, and areas of anaesthesia or blanching of the skin are occa- sional results of a continued siege. The paresis of sciatica is of gradual appearance, and the patient may at first slightly drag his leg or limb. In some of the old cases the least movement of the limb is attended by pain, which is referred by the patient to the point where the sciatic nerve leaves the pelvis. Such atrophy may follow inactivity. A curious feature of the disease in some cases is the appearance of pain in different parts of the limb. In the case of a Cuban gentleman who , came to me for advice, I found that there were two districts of pain : one of which included the upper part of the sciatic, the pain never passing below the middle third of the right thigh ; the other situated at the outer side of the leg of the same side. 430 DISEASES OF THE PERIPHERAL NERVES. CRURAL NEURALGIA. When the pain is confined to the anterior and lateral parts of the thijrh. it is properly included in the cases called by this name, but the region supplied by the crural and its branches, viz., the inner surface of the thigh and its anterior aspect, as well as the inner part of the leg and foot, is more often the seat of pain in the lower extremity than any other part, except that innervated by the great sciatic. This pain is paroxysmal, very severe, and, like that of the cervico-brachial variety, most intense at night. The inner part of the leg and foot are most commonly implicated, and there is a subacute variety of pain which exists between the parox- ysms. Walking and muscular movements of any kind are painful, ami the patient may find it necessary to use a crutch, or else is obliged to keep quiet. Foci of tenderness may be detected at the point where the crural nerve is most superficial, in the groin at the inner side of the knee, at the upper and inner edge of the patella, and at various points on the inner side of the foot and leg. Muscular atrophy, which is probably a result of insufficient use of the limb, is sometimes a feature of the disease. When the pain is more severe at the knee-joint, we may find an enlargement of that articulation, and in some respects the condition may resemble arth- ritic inflammation ; but the cutaneous hyperaesthesia is much greater than in the latter affection, while deep pressure does not produce the amount of pain it would in rheumatism. THE VISCERAL NEURALGIAS. The visceral neuralgias, especially those found to be connected with the uterus and its appendages, come more properly within the province of the gynaecologist than the neurologist ; so a complete description would neces- sitate a consideration of the various pathological uterine states which would be out of place in this book ; therefore our description must be ex- ceedingly brief. The importance of these latter forms of neuralgia can- not be over-estimated. They are commonly of reflex origin, and depend very often upon some morbid condition of the uterus and ovaries them- selves. As Anstie remarks : " The amount and force of the peripheral influences which are brought to bear upon the central nervous system by the functions of the uterus and ovaries are greater than any that emanate from the diseases and functional disturbances of any other organ in the body." The menstrual period is that with which neuralgia of this kind is, in nine-tenths of these cases, associated. It is essentially connected with irritability of the pelvic organs of the female, either when there is amenorrhcea and dysmenorrhoea, or when the generative apparatus is over- excited by immoderate copulation or masturbation, or during the preg- nant state. When there is any mechanical condition of narrowing or occlusion of the cervical canal, prolapsus uteri, intra-uterine growths, ulcers, or reflected irritation, neuralgia is not at all a rare accompaniment. I have found it very often as a symptom of general aniemia, with no ap- preciable uterine disease whatever. NEURALGIA. 431 OVARIAN NEURALGIA. Ovarian neuralgia is symptomatized by excruciating pains radiating from these organs. It is not necessary that there should be derangement of menstruation, though such is generally the case. The pain may some- times be dull, but is more apt to be quite sharp. It is greatly increased by standing, or by fatigue following protracted use of the lower extremities. Among sewing-machine operators it is especially common, and many of my cases have been of this kind. It is generally connected with constipation or a sluggish condition of the circulation, sometimes leucorrhoea, hysteria, and always with a great deal of weariness and prostration. The suffering may be so intense and protracted as utterly to wear out the patient, and unfit her for any labor. It may be bilateral or unilateral. There are various other forms of neuralgia which depend upon reflected or local causes. URETIIRAL NEURALGIA. This is not infrequently associated with stricture, gonorrhoea, or mas- turbation. It may be quite obstinate and of a paroxysmal character, and is much worse at night. I have found it very often where there has been a contracted meatus, in which case the pain ran up the penis. Vesical neuralgia, which may be connected with the presence of a stone, or which occurs as a result of long-standing cystitis, is symptomatized by pain at the neck of the bladder, while there may be some tenesmus. RENAL NEURALGIA, ETC. Renal neuralgia cannot be diagnosed with certainty, and probably the pain is in many cases due to the presence of calculi. Neuralgia of the testis is symptomatized by sharp pains of a temporary character ; and it is generally due to some distant source of irritation, such as the descent of a renal calculus, or the presence of a vesical calculus. I have seen cases which have followed excessive venery ; and Anstie reports a case of epilepsy in which this form of neuralgia was undoubtedly the exciting cause. Self- abuse produced the " testicular neuralgia," which in turn precipitated the fits. With the pain there were vomiting and great prostration. Ascarides in the rectum may give rise to neuralgia of that gut. The pain is nearly always about the anus or just above the sphincter, and darts upwards. Cold and exposure are given as causes. The breasts are often the seat of a very painful neuralgia, which has been called mastodynia. This is, in reality, a form of intercostal neuralgia, in which case the anterior and middle cutaneous branches of the intercostal of one or both sides are affected. It appears at puberty, or may accompany lactation when the nipples are cracked. In both these classes of cases there must be a lowered nervous condition ; and, according to Anstie, masturbation pre- cedes the trouble in the youthful patient, while it is extremely probable that the strain upon the nervous system during pregnancy and lactation 432 DISEASES OF THE PERIPHERAL NERVES. is often much greater than the badly-nourished patient can bear. I have met with the affection in perfectly healthy patients, and am convinced that the pain was purely neuralgic, and not dependent upon any inflammatory condition of the nipples. One of these patients was a prostitute, and had assiduously followed her trade, meanwhile losing sleep, and drinking to excess. Causes For the sake of conciseness, I may group the causes which are predisposing under the following several heads : 1. Hereditary. 2. General diathetic (anemia, rheumatism, alcoholism, gout, syph- ilis). 3. Psychical (intellectual, emotional). 4. External (cold, pressure). 5. Sexual. 6. Reflex. Hereditary predisposition plays a most important part in the genesis of neuralgia, so important indeed that it is difficult to find cases of this dis- ease in whom there has not been some family history of previous nervous trouble. Insanity, paralysis, alcoholism, or convulsive disorders may be traced back ; and of twenty-two cases collected by Anstie there were but five in which there had been no family neurotic history, and in some of these phthisis was found. This disease, according to Anstie and others, seems to play quite an important part in the causation of neuralgia ; and in one minutely detailed history given by him the appearance of tubercular meningitis and other neuro-phthisical diseases followed the engrafting of the pulmonary trouble upon the neurotic stock. Epilepsy enters extensively into the causation of many forms of neuralgia, especially epik'ptiform tic ; and not only may these other neuroses have appeared among the progenitors of the individual, but they actually exist with the neuralgia. Blandford 1 has called attention to a form of insanity which coexists with neuralgia, the pains subsiding during acute mental disturbance, and reappearing with its subsidence. Migraine is too common an accompa- niment of epilepsy to need more than a passing allusion. Chronic alco- holism is associated with a variety of neuralgic headaches and pains in the lower extremities, which are quite intense. Certain general diseases, which produce a cachectic condition, quite often give rise to the disease, not only by actual mechanical disturbance of the nerve-functions by effu- sion and periostea! disease, but through the condition of mal-nutrition and enfeeblement of the nervous system which originates in malaria, gout, rheumatism, and syphilis. The influence of malaria in the production of neuralgia is markedly seen in the South and Southwest, where the most violent attacks of neuralgia yield only to large doses of quinine and arsenic. The neuralgia is generally of the facial variety, but it may take 1 Insanity and its Treatment, p. 95. NEURALGIA 433 the sciatic or any of the other forms. In many cases it is periodic, or occurs in connection with the chill and other features of the malarial at- tack. In most of the cases I have seen, it followed generally after a pro- tracted siege of "fever and ague," when there was extreme debility, " bone-ache," and enlarged spleen. Lumbo-abdominal neuralgia is far from being an uncommon malarial state, and is sometimes very apt to be mistaken for renal colic. Gout and rheumatism are not looked upon by Anstie as diseases which play a very important part in the general causation of neuralgia, from which opinion I am inclined to dissent. Putting entirely out of the question the local inflammation of the nerve-sheath, which is so often a cause of sciatica and other neuralgias, I am convinced that there are forms of the disease, aggravated by changes in temperature, coexisting with painful joints and extremely acid urine which disappear under alkaline treatment, and are not clearly examples of nerve-sheath inflammation. Gout, inducing very often a condition of general or cerebral anemia, has been in my experience a very frequent cause of facial and other neuralgias. The condition of the liver, which occasions cerebral anaemia, melancholia, and over-loaded bowels, may also induce a neuralgia of a functional character. Not only in the tertiary form of syphilis, but, long before this, neuralgia may often be a troublesome symptom. I have had recently under my care an indi- vidual who had two years ago a primary sore, and has since had secondary symptoms. A chancroid, recently contracted, assumed a phagedenic character, and there were great debility and severe neuralgia, which suc- cumbed under specific treatment and nourishing diet. Profound anae- mia is very often found to be at the origin of neuralgia of various kinds. In women who have lost much blood during the menstrual flow, or in others who have become exsanguined from hemorrhoids, neuralgia is not to be looked upon as an unusual complication. The various constitutional diseases just alluded to may produce various forms of neuralgia, by inflammation of nerve-sheaths, with deposit, or, as in the case of syphilis, gummatous growths, or periostitis may make danger- ous pressure upon the nerve-trunk at some point where the latter is unable to withstand it without injury to itself. Syphilis, in rare instances, pro- duces irritation in the nerve-trunks themselves, giving rise to pain. This irritation, however, much more frequently produces motor paralysis than sensory disturbance. Mental overwork, shock, and a continued abnormal play of the emotions are likely to give rise to neuralgia, and for this reason literary men and hysterical women suffer very frequently. The headache of the overworked school child, compelled to overtax its brain, and de- pendent upon confinement in a hot room, is far too common. Want of amuse- ment, deep grief, and the pursuit of one narrow line of thought, are all influences which lower the integrity of the nervous system, and give rise to this as well as other neuroses. Anstie's practical and judicious reasoning in regard to false religious training, and the dangers it may bring in the way of forcing the individual to become self-conscious, should suggest to the physician and parent the necessity for avoiding everything in educa- 28 434 DISEASES OF THE PERIPHERAL NERVES. tion which promotes brooding, causes the individual to torture himself with doubts and self-accusation, and narrows the mind, thus depriving tin- nervous system of its normal exercise. Constant worry about business and any strain which demands an unusual expenditure of brain-force are causes of this kind. Exposure to cold and damp, particularly if there be wind, is a fruitful exciting cause of neuralgia, and persons who are exposed to draughts in railroad cars and public buildings very often owe their attack to such agencies. Pressure from various growths, cystic, cancerous, uiul gummatous deposits, not rarely causes distressing and intractable neu- ralgias ; but a syphilitic growth has been known to entirely surround a nerve-trunk without interfering materially with its functions. 1 NeuronmUi very frequently give rise to neuralgia. Such neuromata sometimes follow amputation or gross nerve-wounds, and the neuralgia is generally relieved by extirpation of the nerve-tumor. Various local troubles, of a peripheral or remote nature, produce neuralgia, and among these may be mentioned carious teeth, ascarides, and renal calculi. When carious teeth give rise to neuralgia, it is always very obstinate, and the cause may remain unsus- pected for a long time. Salter has observed cases of cervico-brachial neuralgia from bad teeth ; the variety most frequently met with however is facial neuralgia. This cause is ordinarily supposed to account very frequently for the head neuralgias, and many sound teeth are sacrificed by the individual, while there may be neuralgia of the two lower branches of the fifth from other causes. Over- use of the eyes, and consequent fatigue of the muscles of accommodation, are supposed by some to have much to do with its production. Renal or urethral calculi, gonorrhoea, masturbation, and excessive venery, are all reflex causes of importance, and play a part in the production of lumbo- abdominal and other neuralgias. Uterine disease and overloaded bowels, or a fibrous tumor in the rectum, may by pressure often produce sciatica of a very obstinate variety, and aneurism more rarely makes pressure which gives rise to neuralgia. Digestive derangement and prolonged lactation may be mentioned as additional conditions which favor the production of neuralgia. As to age and sex, it is the opinion of most authors that neuralgia usually originates at the age of puberty, but the disease is most common between the twentieth and fiftieth years. The following table, presented by Erb (Ziemssen, vol. xi.), possesses statistical value : Valleix. Eulenburgh. Erb. Total. Period of life up to 1 years, 26 8 " 10 to 20 " 22 19 14 55 " 20 to 30 " 68 40 108 " 30 to 40 " 67 33 39 139 " 40 to 50 " 64 23 29 116 " 50 to 60 " 47 14 14 75 " 60 to 70 " 21 6 9 36 " k ' 70 to 80 " 5 1 6 296 101 146 543 1 HuebiH-r, Ziemssen's Encyclopaedia, vol. xii. NEURALGIA. 435 As to sex, Valleix collected 469 cases, 218 of whom were men ; Eulen- burgh 106, of whom 30 were men ; Anstie 100, of whom 33 were men ; Erb 146, 84 being men. Of course there are varieties of neuralgia which are confined more to certain ages and sexes. Migraine is more general among women, while sciatica is probably more often a disease of males. Anstie and Hammond botli consider facial neuralgia to be a disease of adult life. So far as climatic influences are concerned, neuralgia is predisposed, and very often markedly affected by sudden changes in temperature. Dr. Weir Mitchell 1 has written a very valuable paper upon the subject, which clearly shows the very decided influence of modifications of temperature and humidity. His article is based upon the personal notes of Captain Catlin of the U. S. Army, who suffered from stump neuralgia, and who intelligently and carefully noted the influences of atmospheric changes. Captain Catlin's conclusions were as follows : " Neuralgic intensity does not seem to be proportioned to the amount of rain-fall. At the exterior of a storm disturbance the pain is usually less severe, and, indeed, at times I have been so far from the disturbed centre as to just percepti- bly feel it. A storm, reinforced by another at an angle of say 90, producing greater eccentricities in the curves, does not seem to produce a corresponding intensity or duration of the neuralgia." He adds : " I am unable to state at what point within the disturbed area the pain would be strongest. The abruptness of the barometric fall does not seem to have much to do with the causing of pain, nor is the length of attack dependent as it seems on the length of the storm." Pathology. Neuralgia is always the result of lowered functional activity dependent upon the trophic disturbance of a sensory nerve. This is probably attended by some change in the posterior nerve-roots, which is not necessarily inflammatory. The morbid anatomy of neuralgia has thrown but little light upon the pathology of the disease, so our conclu- sions must be based upon purely theoretical grounds. Erb, in speaking of the nutritive disturbances, says : " In regard to the ordinary seat of this trophic disturbance, nothing accurate is known ; but it is probable that the seat varies, and this much appears certain, that for the most part a definite group of fibres (or their central terminations) as they are combined to form a nerve-trunk or branch, is affected. At what place in the length of the nerve this is present it is difficult to say, and perhaps may be at any length. The peripheric fibrils may be affected at various points and vari- ous lengths of their course, or the posterior roots and their prolongation in the spinal cord may be the seat of the neuralgic trophic disturbance ; or, lastly, the central fibrils running in the spinal cord or brain may be affected up to the terminal central apparatus. The investigations that have hitherto been made have acquainted us with many important facts, but have furnished no very satisfactory conclusion." The clinical features of neuralgia enable us to understand many of the phenomena which ordinarily characterize the disease, and we are allowed to assume that lowered nutrition from general or local disease, reflected 1 Am. Journ. of Med. Science, April, 1877, p. 305. 436 DISEASES OF THE PERIPHERAL NERVES. irritations, and mechanical pressure enter into its production. Instead of a normal stimulus being conveyed by a healthy nerve to the centre, the nerve may be functionally impaired for conduction, or the centre so altered in its receptive faculty that the sensation period is grossly exaggerated. The receptive faculty of the peripheral fibrils may be so exaggerated that ordinary stimuli are received and transmitted in a painful form. Why the disease should be paroxysmal we do not know. Morbid Anatomy. It is by no means a matter of necessity that a nerve which has been the seat of neuralgia is found to be changed in struc- ture. Accidental atrophy, hyperamia, and indications of neuritis are sometimes exhibited. Thickening of the nerve and sheath deposits in its neighborhood, or enlarged vessels, tumors, aneurisms, and the like, are occasionally met with. On the other hand, nerves have been removed which have been perfectly healthy. In old cases of neuralgia the posterior nerve-roots are nearly always atrophied. Diagnosis. We may briefly sketch the character of the symptoms. The pain of neuralgia is paroxysmal or dull, with paroxysmal recurrences ; rarely tenderness upon pressure, except at certain situations. Neuralgic pain is rarely constant, while that of neuritis is quite so. The pain of neuralgia follows the course of some nerve, is quite acute, and has a lanci- nating, terebrating, or shooting character. It is also connected with vaso- motor changes in the skin. The existence of a cause must be considered, and the fact whether " hereditary predisposition" is present or not. Facial neuralgia is very rarely mistaken, and should not be when the fact is taken into consideration that the pain is generally referred to one of the branches of the fifth nerve. Pleurodynia is sometimes confounded with pleurisy, but the absence of physical signs should be sufficient to make the diag- nosis clear. Lumbo-abdominal neuralgia is very frequently confused witli various painful affections of the viscera. Among these may be mentioned renal colic, the pain of nephritis, and intestinal colic. Sciatica, from its unilateral character, is not likely to be mistaken for any other affection. The important indication in diagnosis is to determine the variety of neu- ralgia, whether syphilitic or malarial, whether due to compression or con- nected with neuritis, or whether due to enlargement of and pressure from any of the abdominal organs. The following are to be remembered and consulted for guidance in making a diagnosis A. Cause ; history of previous attacks. B. Character of pain ; paroxysmal, inconstant. C. Aggravation by debility or fatigue. D. The presence of " painful points." K. Its distribution (following course of nerves). F. Karely aggravated by pressure, except at limited points, which correspond to superficial course of the nerve. G. Its general unilateral character. Prognosis Neuralgia of all kinds is more curable in early life than in advanced age, and it may be assumed that, when it has lasted for many NEURALGIA. 437 years, and is severe in character, it will be most intractable; this is especially the case in the disorder known as tic epileptiform, which may be said to be nearly always incurable. In these troublesome cases even removal of the nerve affords but temporary relief. When atrophy of mus- cles has taken place the chance of cure is very remote, and if the cause be a deep one, such as pressure for instance, nothing can generally be done. There is a bright side of the picture however. Functional neuralgias, or those of the syphilitic variety, readily succumb to proper treatment; and sometimes general nourishment and the removal of the exciting cause will speedily restore the patient to his normal condition. Those neuralgias which develop later in life are attended by structural decay, arterial degeneration, and are very hopeless. As to the curability of the varieties of neuralgia, that of the fifth nerve is most persistent, and intercostal neuralgia perhaps least so, whilst sciatica holds a place midway between the two. As an example of a severe and intractable continued neuralgia, connected probably with angina pectoris, I may present the case of Lucy L. S., sixty-five ; U. S. ; married. Previous History When a young child she fell, striking her right eye on a chair-post. For several days It was supposed she had lost her sight, but this was found not to be the case. After this she had pain in the left side and shortness of breath, whenever she attempted to run. At twenty-one, she had an attack of cerebral hemorrhage, which affected the right side, but there was no aphasia. This was accompanied by anaesthesia, which has never entirely disappeared. About this time there were diplopia and ptosis the latter symptom being now present. Supposed pulmonary trouble at twenty-four. Married at twenty-five. " Before birth of my second child, I was subject to dizziness, and neu- ralgia of the fifth nerve, which was most intense in the morning. When nearly twenty-eight, and my second child was a few days old, I ' commenced to see dark spots, sometimes like black specks, again like circles with spotted centres.' When this child was three or four weeks old, sharp pain commenced in right side of the head. After sleep, the pain would subside, and vision would improve. At intervals of from three to four weeks, or when tired, these blind attacks would return, accom- panied either by sharp pain or dizziness in head. For the next eight years I was comparatively well, having occasional ' blind turns' when tired. At these times my forehead would feel as if strings were being pulled in opposite directions, and there was much twitching in the right eye. All these years there was some pain about the heart, with palpitation. At forty-one the change of life commenced, and I suffered several years most intensely. All these years there was some difficulty around the heart. Palpitation and some pain at intervals. For the past three years pain has been about equally divided between head and heart ; sometimes commencing in one and sometimes in the other. Some six months ago pain seemed to be settling around heart particularly. Would come on with a chill and creeping sensation up the spine, and would begin with a whirling in left side. A palpitation of the heart would come on if excited or tired. Outward applications and medi- cine taken seemed to drive pain across from left side to right shoulder. 438 DISEASES OF THE PERIPHERAL NERVES. Would go into right side of the head ; follow down right arm into hand. Also into left arm and hand. Hands have been much drawn up, and streaked with red. "When pain was in face, it would be spotted red uiid white on right side only. When severest in side and heart, eyes became set in head ; face livid, and blood would settle under nails. After endur- ing pain, tremble much in limbs." I saw the patient during the past spring, and found her to be a ratlii-r spare, badly-nourished woman, and she presented the following symp- toms : Objective The right eye was examined and found to be sightless ; the retina was the seat of an old neurosis, with atrophy of the disk. There was slightly developed ptosis of this eye, and some keratitis, corneal opacity, and ulceration, so that she was obliged to wear a shade. The right side of the face was slightly anaesthetic and analgesic. jEsthesiometer contact and extremes of temperature were not readily perceived. The same was the case in the skin of the right arm, forearm, and hand, but more decidedly the latter. The hand presented the appearances to be hereafter described (see article upon NEURITIS), and was markedly anaesthetic, and the skin showed evidence of impaired nutrition. The right lower extremity was in a much better condition. There was very slight loss of motor power on the right side. Subjective She now has attacks of severe facial and cervico-brachial neuralgia which come on every two or three weeks, and lias had one within a day or two ; there is still some tenderness left at various parts of the face and right upper extremity. The pain seems most intense in the upper branches of the fifth, and has never affected the inferior maxillary to a decided degree. The arm-pain and head-pain are simultaneous in their onset, and are preceded by the ordinary prodromata of an attack of this kind. They are always paroxysmal, and seem to reach a climax and then subside. During the attack the eye is seemingly "forced forwards." After the attack she is entirely free from pain. With the seizure there is cardiac trouble, and respiratory trouble which suggests some impairment of the pneumogastric. She never has convulsions or vomiting, and there is no deep localized pain at any point in the superior aspect of the cranium ; but all pain at this point is superficial, and would evidently come under the head of hyper- aesthesia. In this case there is a decided hereditary history of nervous disease. Treatment. In nine-tenths of the cases of neuralgia the manage- ment of the disease should be undertaken with the assumption that the pain is due to lowered functional activity and depressed tone ; and while local treatment is not to be forgotten, it is absolutely imperative that the patient should be supported, and that drugs which improve the nutrition of the nervous system should be selected. It is well to minutely inquire into the existence of other disease, and reference to what I have already said about etiology will furnish the reader with such hints as may be neces- sary. Should menstrual irregularities, gsistric derangement, or constitu- tional diseases be found, it is well, I may say absolutely necessary, that these should be corrected before any local treatment is to be undertaken. NEURALGIA. 439 Neuralgic pain is very variable ; and although, for my present purpose, I shall make use of two expressions to denote its character, there is much that must necessarily remain unsaid in regard to its variation and pecu- liarities. I shall describe the pain of neuralgia as coarse and^/me, two divisions which, though somewhat arbitrary, are useful when we speak of treatment. Fine neuralgic pains may be said to be those of a sharp paroxysmal cha- racter, leaving behind no points of tenderness, and entirely unconnected with any suspicion of neuritis. Coarse neuralgic pains may be said to in- clude the brusque pains, which bring local tenderness and soreness, and are aggravated by movement. The former are those which sometimes occur during migraine and functional neuralgia of the lighter kinds; while the coarse pains may be often the result of sciatica, in which the move- ment of the limb in walking or the pressure of the chair is sufficient to give rise to them. In one form of the latter our treatment should be quite negative, and of a character which necessitates the use of counter-irritants, such as blisters and the actual cautery ; while the former is best treated by remedies which either increase the blood-supply of the nervous centres and improve their tone, or allay reflex irritability. The treatment of facial neuralgia or migraine should be the following : The use of diffusible stimulants; muriate of ammonia (FF. 93, 94) being, perhaps, one of the best. It should be given in large doses quite frequently, beginning with from twenty grains to a drachm, which should be repeated every hour during the attack. Coffee and tea, or their alkaloids, are often serviceable ; or we may prescribe guarana (F. 94), which is a very valuable remedy, in doses of half a drachm to a drachm every hour. I have never wit- nessed any bad results from the use of this drug, even when quite large doses were taken. The powder is the best preparation. Tr. belladonna (FF. 44, 70, 76), given in small repeated doses, does much good if the disease be of a reflex character. The drugs recommended for this variety of neuralgia are quite as numerous as most of them are useless. The alka- loids daturine (F. 92), and conia (F. 91), have been used in obstinate cases of tic epileptiform with varying degrees of success, but great care should be taken. I have often broken up an attack of ordinary facial neuralgia with a cup of strong hot tea, or even a cup of hot water ; and now have a patient who has been in the habit of taking an emetic, which has almost immediately given her relief. Cannabis indica, either in the form of the extract or tincture, is of service when guarana fails. Its use should be continued for several months. If the neuralgia be malarial, a " stiff" dose (say twenty grains) of quinine rarely fails .to abate the paroxysm. As local applications, various stimulating liniments are used, the best I know being the compound soap-liniment; or a mixture of chloroform, tr. aconite and camphor (F. 63), an ointment of veratria (F. 65), or of chloral and camphor (F. 67), sometimes afford relief, and I have wit- nessed the good effects of a tincture made of the berries of the belladonna (F. 95). The blister or actual cautery may be brought into requisition if 440 DISEASES OF THE PERIPHERAL NERVES. Fig. 49. Cam. 7Hn'ftli.t_ _ Dot]) Peroneal. NEURALGIA. 441 SUPERFICIAL POINTS AND CUTANEOUS AREAS OP NERVE DISTRIBUTION. 1, 2, 3, 4. Points for galvanization of fifth nerve. 5. Brachial plexus. 6. Musculo-cutaneous. 7. Median. 8, 9. Ulnar. 11, 12. Crural. 13. Peroneal. 14. Tibial. 15. Occipital. 16. Radial. 17, 18. Sciatic. ' 19. Popliteal. 20. Peroneal. ac. Acromial. Cir. Circumflex. Int. h. Internal humeral Ext.e. External cutaneous. Int. c. Internal cutaneous, c. p. Cutaneous palmaris. p. u. Palmaris ulnaris. m. Median. Had. Radial. u. Ulnar. Mus. Sp. Musculo-spiral. Ilin-Hy. Ilio- hypogastric. /. /. Ilio-inguinal. Lat. Cut. Lateral cutaneous. E S. External spermatic. Lum. I. Lumbo-inguinal. Poa. C. Posterior cutaneous, ob. Obturator, ctnm. p. Communicating peroneal. In. sa. Internal saphena. Sup. p. Superficial peroneal. cpm. Posterior median cutaneous. Cpp. Cutaneous plantaris proprius. Pll. Plantaris lateralis. painful points are found, and I have been in the habit of using the ether spray just in front of the ear in migraine. In tic douloureux I am convinced that there is no better remedy than gelseminum given in large doses, begin- ning with n^viij to n^xv of the tincture or fl. extract (F. 50). My friends Drs. Kinnicutt and Clymer have both mentioned to me the details of cases where by accident the patient had taken toxic doses of this drug. In one of these the disease entirely disappeared after the alarming effects of the remedy had passed away. Croton-chloral (F. 47), which has lately been recommended for facial neuralgia, I am convinced has been overpraised ; I have given it a fair trial, and have rarely found it of any use. If it is employed twice a day in twenty-grain doses, it will do more good than in the small repeated doses. The removal of carious teeth is often followed by speedy disappearance of the disease. Should the face become tender, as it not uncommonly does, the patient should be directed to keep it carefully protected by cotton-batting ; and if painful points remain in the roof of the mouth or gums, they may be lightly touched with the hot glass rod or iron. The treatment of cervico-brachial, cervico-occipital, and other neuralgias of the trunk may be managed after very much the same plan. In each particular case of course the treatment varies. If there be a diathetic condition, such as syphilis, mercurial inunctions, baths, and specific treatment (FF. 17, 18, 19,20, 45) are to be made use of in conjunction with local applications. The advantage of large doses of quinine in cachectic headaches, as well as in intercostal or lumbo-abdo- minal neuralgia, especially if there be an herpetic eruption, I have men- tioned. In these forms, as well as in ovarian neuralgia, the use of local cold, such as may be obtained by ice-bags, or the application of blisters, is very efficacious. The actual cautery, employed to make sweeping strokes along the course of the nerve, or down the back on either side of the spinous processes, and in paths which run at right angles to the lon- gitudinal " stripes," may be brought into requisition, and applied twice or thrice weekly. Sciatica sometimes demands most obstinate treatment. The actual cautery, and even nerve-stretching, may be necessary ; but in the majority of cases galvanization of the nerve does great good, and should be faithfully tried before anything else is done. Electricity affords very decided relief in this disease ; and galvanism, when judiciously employed, rarely fails to modify, if not cure neuralgia. In facial neuralgia it should be applied to the nerve by small sponge-covered electrodes, one pole being placed just behind the condyle of the jaw, and the other held for a few minutes over the supra-orbital and infra-orbital 442 DISEASES OF THE PERIPHERAL NERVES. foramina, or over the symphysis of the lower jaw. The current should be the direct (from positive to negative, the negative pole being peripheral). The admirable plates of Beard and Rockwell, and the suggestions of Ziemssen, will enable the reader to comprehend the situation of the points corresponding to the superficial course of the various nerve-trunks, so that they shall be brought most readily under the influence of the current. Faradism of the intercostal nerves, and of regions of distribution of terminal filaments of other nerves in various neuralgias, is of great service, and rarely fails to afford relief in sciatica. I have seen pleurodynia dis- appear in ten minutes after the use of the faradic current. The following case shows the value of electrical treatment. Mr. S. After constant exposure during the war, the patient con- tracted a low typhoid fever, which left him weak and emaciated for a long time. Since 18G8 he has had twinges of pain down the back part of the leg, which have left him in a perpetual state of misery, with only oc- casional intervals of several months when he is absolutely free from pain. In winter his trouble is worse, and any exposure will immediately pro- duce a severe attack of neuralgic pain. Any indiscretion in his diet will also be followed by the sciatica. He had gone through the usual siege of medication, including morphine, hypodermics, and stimulating lotions. He came to me in July, 1871, when I made applications of galvanism to the nerve by the conical sponge-electrode, the sponge being held firmly over the obturator foramen. At the first visit his pain was excessive, but after fifteen minutes' application he left, feeling a sense of relief which he had not known for months. Two months and a half of this treatment were sufficient to dispel the pain, which did not recur. Four months afterwards, he made a visit, when he stated that he had not had any re- turn. In the treatment of neuralgic attacks the hypodermic syringe has played a very important part. J have no doubt that it has been abused, and I have become painfully aware that individuals have thus acquired the habit of opium and morphine self-administration. For the radical cure of certain varieties of neuralgia, the hypodermic syringe has no equal. My friend, Dr. T. M. B. Cross, was the first, I believe, to use deep in- jections of morphine in sciatica. He has recommended that the point of the syringe needle be carried down to the sheath of the nerve, and the contents of the barrel gradually expelled. Strange to say, very few acci- dents have followed its use, although the wounding of an artery is not an impossibility. Chloroform has been used hypodermically by Bartholow, 1 and with great success, and though I have produced abscesses in this way, I am inclined now to acknowledge its value as a therapeutic measure. Morphine and atropine (F. a9), dat urine (F. 92), ergotine (F. 60), and other alkaloids are constantly used, and sometimes afford relief, which is generally temporary, but occasionally permanent. The general treatment is, however, all important, and iron, strychnine, arsenic, cod-liver oil, and phosphorus (FF. 24, 25, 26, 8, 9, 10, 32) rank high as valuable 1 Mat. Medica and Therapeutics, p. 321, et seq. NEURALGIA. 443 remedies. I have spoken of quinine. I may add that when given con- tinuously, either in combination or alone, it cannot fail to do good. Phos- phorus always does good, except in forms of neuralgia which are not directly dependent upon depraved nutrition, and are due to cold or at- tended by inflammatory conditions. Thompson's solution (F. 25) is the best preparation. Salt air, with alternations of mountain air, nourishing diet, which should include a large proportion of non-nitrogenous food, attention to the daily habits, the removal of fecal accumulations, and the re-establishment of menstrual regularity are of the greatest importance, and should be accomplished if possible. 444 DISEASES OF THE PERIPHERAL NERVES. CHAPTER XVI. DISEASES OF THE PERIPHERAL NERVES (CONTINUED). NEURITIS. Symptoms Inflammation of a nerve is expressed chiefly by sore- ness and tenderness, and not by the darting or paroxysmal pain which constitutes neuralgia. When confined to the nerve-trunk various depraved conditions of sensibility, motility, and trophism may follow, which are expressed by cutaneous and muscular changes ; and the course of the nerve can usually be marked with great exactness, for pressure produces great pain. The skin may be red or the seat of bullous or pemphigous erup- tions. Of course very much depends upon the character and importance of the nerve affected. Some of the nerves of sensibility, such as the fifth, when subject to neuritis, are followed by symptoms different from those which occur when the seventh or one of the mixed nerves is affected. Peripheral inflammation of the external portion of the seventh is often the cause of facial paralysis, and neuritis of the fifth may occasion disorders of sensi- bility as well as ulceration of the cornea and other trophic phenomciiii. "With neuritis there is not infrequently loss of tactile sensibility and sense of appreciation of temperature, though in the beginning the skin is hypenesthetic, and the pain is aggravated by contact with cold or hot sub- stances. Erb speaks of acute and chronic neuritis, the former depending upon traumatism, sloughing, or cancer, and beginning with a chill, fol- lowed by fever, headache, and sleeplessness. The pain commences in the affected member, and extends, until finally chronic neuritis is progressive, the inflammation spreading, and involving new nerves. This extension may be recognized by the fresh appearance of pain in new localities ; by painful points (Valleix's) at new regions, by difference in the form of pain, and by variations attending pressure ; the whole limb is affected. This author, as well as Mitchell, considers that it is most intense at night, and that it is augmented by movement. Mitchell has observed intense hys- terical excitement, and even delirium. A red line usually marks the course of the affected nerve, and there may be patches of herpes or pem- phigus, or the skin may be cedematous. In one case, observed at the Epi- leptic Hospital, the patient, a negress, presented symptoms of neuritis of the anterior tibial nerve, and the skin of the fore part of the right leg was tense, shiny, and exquisitely sensitive. A marked rigor ushered in its development, and there were subsequently nausea and vomiting. Her pulse was feeble and rapid, and she could not sleep, and entirely lost her appetite. There was no inflammation whatever of the skin or muscular tissue, and the acute pain subsided in a few weeks, but there remained a NEURITIS. 445 condition of great tenderness. Hot and cold applications increased the pain. Paralysis may follow, and is by no means uncommon. The patient generally recovers in a month or so, and sometimes in a shorter time, but the neural condition never entirely disappears. In the chronic form the onset may be gradual or spontaneous, or follow an acute attack. I have sufficiently sketched the symptoms, and will only add that muscular cramps, tremor, or permanent contractures sometimes form very distressing sequelae, and with these there is paralysis. Anaesthesia or hypersesthesia is con- nected with neuritis, the former being of late appearance. Erb calls attention to the comparative immunity of the motor nerves, as paralysis does not follow until after a long train of sensory disturbances, but reflex disturbances are not uncommon. These may consist in remote nerve pain, cramps of distal muscles, or hysterical attacks. The electric excitability in the early stages is exaggerated later, or it is lost, and if there be para- lysis there is very marked muscular atrophy as a consequence, and electric contractility disappears altogether. By far the most interesting changes are those of a trophic character. Weir Mitchell has presented the most complete description of these structural alterations. The finger-nails lose their normal character, and become horny and curved, and the skin becomes rough and is sometimes exfoliated. As additional evidences of this defective nutrition, " hang nails," crack- ing of the skin and other slight changes from its healthy condition are striking indications. The illustration (Fig. 50) which I produce is from Fijr. 50. Trophic Change of the S'.du. the photograph of a patient whose hand had been anesthetic for some years. The skin is hard, the palmar furrows are sharp and exaggerated, imd the bases are red or purple, somewhat resembling the same api c-ur- 446 DISEASES OF THE PERIPHERAL NERVES. ance in the cutaneous flexure of the knee, elbow, or other articulating parts in certain forms of chronic eczema. Causes. The acute variety is dependent upon injuries of various kinds. I have seen one case which followed a carbuncle situated upon the inner surface of the forearm, and Mitchell reports several cases following gunshot wounds. Flying splinters, fractures, and blows are various trau- matic causes, while the extension of cancerous disease or sloughing may produce a neuritis. Cold, rheumatism, and syphilis enter into the etiology of the affection, and Mitchell has produced a neuritis by the local applica- tion of ice. In one case of facial spasm, for which I used the ether spray, I was disagreeably surprised to find a remaining neuritis of the portio dura, which lasted for some time. Beau has directed attention to forms of neuritis of the intercostal nerves which undoubtedly arose from pleurisy and pleuro-pneumonia. Typhoid fever, diphtheria, and other diseases of a febrile nature are not infre- quently attended by neuritis, and in one case of typhus, reported by Bern- hardt, a neuritis involved the musculo-spinal nerve. Morbid Anatomy and Pathology Inflammation of a nerve- trunk produces very decided changes in its appearance. It becomes swollen, is of a pinkish hue, and there is often an exudation which is found between the fasiculi ; this may be also of a reddish color. The micro- scopical appearance of the nerve is still more characteristic. The nerve- fibres undergo marked changes ; the axis, cylinder, and the medullary con- tents are disintegrated ; the neurilemma may be distended by serous exu- dation, and the bloodvessels are enlarged and in places ruptured, so that blood-elements may be found scattered in different regions. In later stair"-" there may be atrophy or fatty degeneration. In chronic neuritis these appearances of advanced degenerative changes are found to consist in proliferation of connective tissues, and this takes place as an interstitial formation. Degeneration of the minute nerve-elements, deposition of oil- globules, and sclerosed patches are found in old cases. If the inflammatory action be very severe, the nerve will be found to be completely destroyed by sloughing. The nerve may be found the seat of enlargements, which are to be seen at different localities in its course, and at each of these ]K>ints there may be a different kind of change. In- flammation of a nerve-trunk, as I have said, is first attended by sensory changes, which may be local, or in other parts ; as the result of reflected irritability ; afterwards trophic changes may result either from the pro- duction of some pressure upon other parts, or through loss of function of the nerve itself. Diagnosis The limitation of the pain, its aggravation by pressure, its constancy, and its character, enable us to generally distinguish it from neuralgia. In chronic neuritis it is not so easy to make such a diagnosis. The painful |K>ints found in neuralgia may be mistaken for the sensitive 8[>ots in neuritis. I have seen very few ca*es in which the pain of neuritis was not constant, and this is not the case in neuralgia, which is essentially a paroxysmal disease. Painful swelling of the nerve and paralysis of mus- NEURITIS. 447 c\e$ supplied are also evidences of neuritis, which will aid us in discover- ing the nature of the affection. Muscular rheumatism has been spoken of by Erb as a condition with which the disease under consideration may be confounded. I consider such a distinction to be a refinement of diagnosis which cannot be made. " Muscular rheumatism" is, after all. a low grade of diffused neuritis, and the most we can do is to discover the cause of such pain. Erysipelas, thrombosis, and embolism are distinguished by the evidences of subcutaneous swelling, oedema, etc., and by their somewhat diffuse character. The presence of a traumatism should be taken into account, and its nature investigated. Prognosis Structural alteration of a nerve must follow an inflam- mation such as has been described, and unless the symptoms have been very slight there is a tendency to continuance, so that an attack of acute neuritis assumes a chronic character. If the inflammation has advanced centrally, so that a new plexus is involved, the prognosis is very bad. Treatment has much to do in some cases with -prognosis. Treatment. To Mitchell we are indebted for excellent directions for the management of neuritis. He tried elevations of the leg or arm, while bladders of ice were applied to every part of the limb, and ^ gr. hypodermic doses of atropia, with ^ gr. doses of sulph. of morphia, were injected every four hours, or oftener. He has used leeches, so that con- siderable local abstraction of blood should take place. Perfect quiet is highly important, and he recommends splints for the purpose. I have used the plaster bandage in a way to leave the course of the painful nerve exposed. The actual cautery is invaluable, especially when the disease is chronic, and it should be freely applied along the painful tract. Faradi- zation does good, but I have no faith in the galvanic current, which only increases the pain. Hypodermics, either of morphia, atropia, or ergotine (FF. 59, 60, 61), in the neighborhood of the painful point, may be continued for some time, with the effect of diminishing the pain and the violence of the inflammation. Large doses of iodide of potassium are of especial service ; and I have lately recommended inunctions of mercurial ointment with excellent results. This latter treatment is that which we are to employ when syphilis is suspected ; and the good effects are sometimes seen in a few days. As a dernier ressort nerve-section may be resorted to ; but if the neuritis has involved a nerve-plexus it does no good. It is only when a peripheral nerve is affected that it removes the disease. In nerve-stretching a new and extremely valuable surgical procedure we possess a means which, though not extensively tested as yet, promises to be of great service. The nerve is exposed, and forcibly pulled, so that the limb shall be raised. In one instance the portion of the lower extremity, including the leg and foot, was drawn up by the sciatic, which had been bared in its course down the thigh. 448 DISEASES OF THE PERIPHERAL NERVES. ANESTHESIA. Symptoms An impairment or loss of cutaneous or muscular sensi- bility, either localized or extensive, may be the result of central disease, or it may be of a strictly peripheral nature. It is of the latter that I now propose to speak. The anaesthesia may imply loss of the sense of appreciation of extremes of temperature, contact, or painful impressions. In the optic nerve, amaurosis is a result, and with this there is commonly anaesthesia of the ciliary nerve, so that the influence of light possesses no irritant effect. Deafness follows auditory anaesthesia, and loss of taste anaesthesia of the lingual nerve. Anaesthesia and analgesia may exist alone or in complication, and we are constantly reminded of this state in cases where operations are performed on insensible parts, the individual only feeling the power of traction or the contact of the surgical instrument. This is often observed in some of the uterine operations ; and Dicff'enbacli 1 alludes to the anaesthetic condition produced by some of the agents employed, which only blunt sensibility, while the sense of contact still is preserved. I have myself witnessed this phenomenon in patients in whom local anaesthesia had been used. In cutaneous anaesthesia a warm or cold body is not appreciated as such, but the individual can sometimes tell its shape, or feel the pressure made. A lump of ice is said to be irregular. The button of the heated cautery iron, if pressed against the skin, produces no discomfort, but only a sense of weight. This loss of tactile sensibility is generally abolished, however, or greatly diminished. The patient will either not feel the points of the a'sthesiometer at all, or, if he does, will be unable to tell how widely they are separated. The local temperature and vascular supply are altered in many cases, so that the warmth of the spot which lias become anaesthetic is a degree or two below that of the sound parts adjacent. The vascular alterations are attended by bloodlessness and whiteness of the affected region. This diminished blood-supply of course invites pathological alterations of nutri- tion, for, when subjected to influences of temperature or injury which other normal districts would bear without damage, the anaesthetic skin becomes rapidly altered as far as its integrity is concerned. Romberg 2 alludes to the occurrence of blisters and ulcerations which were readily caused during cold weather; and I have repeatedly seen the effects of injurious pressure, of surgical operations, and of the application of irritants. In one patient brought to me I was surprised to find an extensive ulceration of the skin of the forearm, which had resulted from the use of a stimulating liniment which the patient had used with the idea of improving an anaesthetic state dependent upon rheumatism. 1 Du JEtht'rgegen den Schmcrz, 1847, p. 61. 2 Manual of the Nervous Diseases of Man, p. 202. ANAESTHESIA. 449 Anesthesia of the Fifth Pair This form of anaesthesia is commonly of peripheral origin, and of thirty -five cases collected by Ortel-Ebrard 1 it resulted but nine times from intracranial tumors. It is of spontaneous origin usually ; and the upper branch is most profoundly affected, so that the loss of sensibility is limited to the brow and region about the eye, by anaesthesia of the cornea, and consequent nutritive changes in that part of the optical apparatus. A case of this kind was reported by Dr. H. D. Noyes, 2 of New York, in which there was very decided sloughing of the cornea. The phenomena following anaesthesia of this nerve may be thus tabulated : ( Anaesthesia of upper eyelid Involvement of ophthalmic branch. and forehead. Irritating ( substances are not felt. f Anaesthesia of middle por- Involvement of superior maxillary branch. J tion of face. Insensibility ( of gums of upper jaw. Anaesthesia of skin of lower portion of face ; increased Involvement of inferior maxillary branch. 1 flow of saliva ; mastication difficult ; gums of lower I jaw insensible. The patient sometimes finds that the edge of the tumbler or vessel from which he drinks occasionally feels as if it were broken. Several of these cases are reported by Bell. 3 In one of my cases the patient could not spit in a straight line, while the secretion of saliva was quite abundant. This same patient complained that his gums were insensitive. These peculiar buccal and labial symptoms are generally early and prominent expressions. Sense of smell and sensibility of the nostrils and tongue are lost when other branches are affected. When the radial nerve is the seat of the peripheral trouble, it will be found that the back of the hand retains its sensibility. The lower ex- tremities may be affected when the condition is the result of pressure made upon the sciatic, and in the case of several skin-diseases the loss of sensibility may be general. Leprosy, syphilitic alopecia, and other skin- diseases may all be attended by loss of cutaneous sensation, which is the i-esult of local dermal alteration of function. Bulkley 4 has very ably considered this subject. Causes. Cutaneous anaesthesia may be due to pressure made upon a nerve-trunk in its course, or to the compression of peripheral areas of greater or less extent, or to local impairment of function by exposure to 1 Paralysie du Trijemineau, Thfese Paris, 1867. 2 N. Y. Medical Journal, 1871. 3 The Nervous System, etc., 3d ed., p. 338, et seq. The Relations of the Nervous System to Diseases of the Skin. Archiv. of Elect, and Neurology, 1874-5. 29 450 DISEASES OF THE PERIPHERAL NERVES. cold, to certain chemicals, or to like agents ; while general diseases, such as syphilis or rheumatism, by local disease and infiltration, greatly alter the function of cutaneous nerve-filaments. Intense cold, liniments which contain aconite, or long immersion of the hands in fluid of any kind, will result in a loss of sensibility. One of my patients was a dyer, whose hands were kept in warm dye-liquids for many hours ; and some of the French writers give examples of the disease among washerwomen. Alkaline fluids are more favorable to its production than any others. Tight splints, blows, diphtheria and other acute maladies, hysteria, and several other conditions play a part in its etiology. Diagnosis Peripheral anaesthesia must be diagnosed from the cen- tral condition, and it is necessary that we should bear in mind not only the anatomical arrangement of the nervous supply, but the coexistence or absence of symptoms of central disturbance. Among the latter are loss of power, which usually accompanies the anaesthesia, or one or more of the many symptoms previously alluded to. Trigeminal anaesthesia is, perhaps, more difficult to trace out than that of other nerves. Romberg 1 thus enumerates the indications of anaesthesia of peripheral or central origin : " . The more the anaesthesia is confined to single filaments of the tri- geminus, the more peripheral the seat of the cause will be found to be. " b. If the loss of sensation affects a portion of the facial surface, to- gether with the corresponding facial cavity, the disease may be assumed to involve the sensory fibres of the fifth pair before they separate to be distributed to their respective destinations; in other words, a main divi- sion must be affected before or after its passage through the cranium. " c. When the entire sensory tract of the fifth nerve has lost its power, and there are at the same time derangements of the nutritive functions in the affected parts, the Gasserian ganglion, or the nerve in its immediate vicinity, is the seat of the disease. " d. If the anaesthesia of the fifth nerve is complicated with disturbed functions of adjoining cerebral nerves, it may be assumed that the cause is seated at the base of the brain." Prognosis It is by no means bad after the cause is removed. Anesthesia from pressure is rapidly restored, provided the mechanical injury be not too great. If there be division of the nerve, the process of reparation, which rarely extends for more than a few months, is followed by a healthy return. With syphilis and the skin diseases the case is different. Treatment Electricity offers the best mode of relief. The wire brush and fanidic current are to be employed every day; and at the same time applications of alternate heat and cold, friction and massage, are useful adjuvants. 1 Ronibcrg. A Manual of the Nervous Diseases of Man. Sydenham trans. vol. i. p. 213, et xffj. TUMORS OP NERVES. 451 TUMORS OF NERVES. Synonym Neuromata. A nerve may be the seat of either a syphilitic, cancerous, sarcomatous, myxomatous, or other growth which may involve or destroy some point in its continuity, or form as a benignant tumor at its point of severance. Very little has been written upon this important subject ; but among the most valuable contributions to the literature of nerve-tumors is an excel- lent thesis by Foucault, 1 and various scattered articles by Verneuil, 2 Le Fort, Axenfeld, Roger, and others. Nerve-tumors may be classified as neuromata (nervous neuroma of Weber) and medullary nerve-tumors, which involve the nervous structure itself; and pseudo-neuromata, which include the fibromata, myxomata, epithelioma, as well as cysts and tumors of a like character. Medullary or ganglion tumors are quite rare, and are of a hyperplastic character. Lebert 3 described a neuroma of the superior cervical ganglion, in which all traces of true nervous matter had disappeared, and naught remained but a fibro-fatty structure. Robin 4 has found a neuroma in the solar plexus, and Virchow has also brought forward examples. Neuroma of nervous fasciculi (nevromes fascicules) include the little painful tumors which are met with after amputation, which give rise to stump neuralgia, and attain the size often of a hazel-nut. Dupuytren, 5 Cornil 6 and Ranvier, Axmann 7 and Weissman, 8 have all described their appearance and structure, which is fibrous and hard, and the nerve-tubes are tortuous and interlaced. The pseudo-neuromata are of many varieties. They are developed usually in the course of the nerve, and the neurilemma is thickened, and should the nerve be cut across, a white or yellowish hardening will be presented. Should the tumor be fibrous, the peculiar microscopical appear- ance may be observed. Fibromata rarely exceed the size of an almond; but when there is any fluid found, as in the case of fibro-cystic tumors, the volume of the enlargement may be much greater. The accompanying cut represents a sarcoma of the ulnar nerve, and was observed by Demarquay at the Maison Municipale de Sant6. Nerve-tumors prefer the nerves of the upper and lower extremities, and in the leg the posterior tibial nerve seems to be a common site. It is not uncommon to find a great many tumors of this kind existing at the same time. In one case reported by Foucault, 1400 of them were found, but 1 Stir les Tumeurs des Nerves Mixtes, Thfese, 1872. 2 Arch, de Med., tome xviii. 1861. 3 Mem. de la Soc. de Clin. 1853, 3 fasc. 4 Comptes Rendus de la Soc. de Biol., 1854. 5 Loc. cit. 6 Memoires de la Soc. Biologic, t. v., 3d s6rie, 18G3. 7 Beitz, zur. mikr. Anat. du Ganglion Nervensystems, Berlin, 1853, 8 Ueber Xerveunenbildung (Zeitschr. f. Ratioimelle Med. 1859). 452 DISEASES OP THE PERIPHERAL NERVES. Fig. 51. this is exceptional, and it is probable that multiple neuromata are more frequently found in patients who are of the cancerous, syphilitic, or some other diathesis. Very often these growths, the result of injury, are subcutaneous. In one of my cases the growth wus found at the dhow ;i( the exposed site of the ulnar nerve, and its origin followed a blow upon that part. Pain, as I have said, is the prominent symptom of such growths. This pain may appear upon the tumor, but usually follows its establishment. It may be localized or diffused, or may be provoked by pressure on the spot or spots which mark the site of the growth; for, when the tumors are multi- ple, of course the sensory troubles are equally numerous. The pain may radiate from the tumor, or may dart down or up the affected nerve. It is not so intense with fibro- mata, syphilomata, or sarcomata, or when the tumor is composed mainly of true nervous tissue, as is the case in stump growths, and in these examples it is productive of severe neuralgia of a reflex character. Spasms, perma- nent muscular contractions, and sometimes a peculiar con- striction of the thorax of a tetanic nature, with epilepti- form seizure and centripetal pain, are indicative of certain reflex disturbances. Treatment Operation seems to offer the only hope of relief, and in stump neuromata re-amputation is often- times necessary. It will be found necessary to deeply anaesthetize the patient, as the sensibility is so morbidly active that ordinary anaesthesia is insufficient. The re- moval of a considerable piece of the nerve is advisable, for it is not rare to find considerable infiltration or deposit in its substance for some distance from the actual growth. In syphilis, mercurials and the iodides offer some show of relief, and these are the only remedies when the growth is deep-seated. Legrand 1 and others have recom- mended caustic applications in superficial regions, and Siebold pere removed a tumor in this way from the an- terior tibial nerve. The operation is rather severe, and is attended with doubtful success. Snrcoinatoug Neu- r.'init. (Foucault.) Gaz. Med., Compte-Rendus.de 1'Acad. des Sciences, 1858. FACIAL PARALYSIS. 453 CHAPTER XYII. DISEASES OF THE PERIPHERAL NERVES (CONTINUED). LOCAL PARALYSES. FACIAL PARALYSIS. Synonyms Bell's paralysis ; Histrionic paralysis. Facial paralysis may be either double or single, but is more often the latter ; and it may depend upon a lesion of a peripheral kind, or one that may be seated in the temporal bone, or at any point in its course within the cranial cavity, or else at its origin. The bilateral form is rare, and is always the result of a central lesion ; but the peripheral form is unilateral, and is a very common affection. Symptoms The patient, after exposure, may suddenly be attacked ; and the first intimation he generally has is in the morning, when he arises. He then finds his face to be all awry, and his appearance is absurd to the last degree ; one side being drawn up, while the other is immobile, as the muscles of expression are powerless. If he laughs, the contor- tion is more marked, and if he attempts to whistle he will find that he is utterly unable to do so. The corner of the mouth on the sound side is drawn up, and the furrow at the angle of the nose is more marked than natural. The opposite side of the face is smooth; and, in the passive state, the muscles seem to sag heavily downwards. It is impossible for him to corrugate his eyebrows ; and the eyelids of the paralyzed side cannot be closed, so that dust and foreign substances collect, producing irritation and discomfort. This is due to the paralysis of the orbicularis, and at the same time the levator palpebrarum contracts and keeps the eyeball exposed. The individual is unable to blow out a candle, and articulation is inter- fered with to a slight degree. Should he be an old man, any wrinkles or furrows that may have existed on the paralyzed side are effectually effaced, and give that part a most ghastly appearance. Considerable discomfort results from the insufficiency of the lower lid, so that the tears, instead of being conducted to the lachrymal canal, find their way over the cheek. If the lesion be situated within the temporal bone or the cranium, a much more extensive paralysis may result. This is indicated by a loss of power of the muscles of the palate, uvula, and other parts of the fauces. When the patient opens his mouth, the palatine arch will be found to be altered, the anterior pillars of the fauces being shorter, so that one side 454 DISEASES OP THE PERIPHERAL NERVES. falls lower than the other. 1 The uvula will also be found to be arched, the concavity looking towards the sound side. The tongue will then alx> be paralyzed, so that its surface is smooth ; and there may be a dryness of the mouth, which results from diminished secretion of saliva. Should the portio mollis be affected, there may be, in addition, deafness. If the third nerve be affected, as it sometimes is, of course ptosis with dilated pupil and paralysis of the recti will result. Roux, 1 who was panilyzed in this manner, perceived a metallic taste in the right side of the tongue. Should the paralysis be bilateral, the patient's features will denote an entire lack of expression, and there is not the slightest evidence of any emotional excitement expressed, even should the patient be agitated by the most intense pleasure or the deepest grief. The muscles are flabby, and the face seems more like a mask than what it really is ; and, as is the case in advanced progressive muscular atrophy, the only animated features are the eyes. Romberg 8 describes the appearance of a patient in these words : " In a girl of 1C, in Dupuytren's Clinique, who was affected with bilateral para- lysis, there was no distortion, but a pendulousness and entire absence of motion was perceptible in all the features. The eyelids only closed half, the lips stood apart, and played backwards and forwards from the impulse of respiration. The expressive countenance bore a serious character, which contrasted forcibly with the patient's frame of mind. She \vas heard to laugh aloud, but the laugh appeared to come from behind a mask." Sensation is not usually impaired. Causes. The peripheral form of paralysis may follow exposure to cold, rheumatic exudation, and injuries of various kinds. A cause which is frequently observed is the chilling of the face by a blast of cold wind; and the frequency of this cause has led to the adoption by the French writers of the term, " Coup de vent." I have met with many cases in which the paralysis took place after a railroad journey, the individual having sat by an open window. In one instance the patient, who was a young lady, had been dancing violently, and had afterwards gone into a damp conservatory to cool off; the palsy was shortly afterwards noticed. Rheumatic exudations may produce pressure upon some of the nerve- twigs, or an attack of parotitis may result in pressure upon the cervico- 1 Hughlings Jackson (London Lancet, Jan. 16, 1875) does not consider that deviation of the palate occurs in uncomplicated disease of the portio dura, and he does not believe deviation of the uvula to be uncommon in healthy people. Troltseh says that the levator palati is supplied by the vagus, which explains the phenomena witnessed by Jackson, viz., marked palsy of one side of the palate, with palsy of the vocal cord on the same side, as a result of intracranial disease. This case, however, is exceptional. 2 Descot. Diss. sur les Affections locales des Nerfs, Paris, 1825, p. S31. 8 Op. cit., vol. ii. p. 2G8. FACIAL PARALYSIS. 455 facial branch. Injuries of the nerve, whether such as follow coarse trau- matism or accidental section of the nerve during a surgical operation, are sometimes the cause of the paralysis. Weir Mitchell relates several cases of this kind. Three of these (Cases 61, G2, and G3) followed gunshot wounds. 1 In one the portio dura of the left side was injured, and as a consequence there were facial palsy, impaired sj>eech, and loss of gustation. Hearing was impaired from shock transmitted to the auditory nerve. Sir Charles BelP divided the facial in removing a tumor, and other cases are reported by various surgeons. Carious disease, as well as fractures of the temporal bone, often pro- duces paralysis, either by pressure, by the products of inflammation, or by direct contusion. Tumors and various aural growths are occasionally causes of this second form of facial palsy; and Romberg 3 reports a case, seen by Henle, in which a tuberculous deposit was found beneath the middle lobe of the brain, with destruction of the petrous portion of the temporal bone ; and Froriep 4 also found a deposit of tuberculous matter in the Fallopian canal, with caries of the petrous portion of the bone. Degeneration, exudation, and tumor in or near the pons may also be the cause of the deep form. The following case is an example of deep-seated paralysis, evidently dependent upon aural disease. Samuel M., aged 27 ; United States, canal boatman ; came to me July 3, 1876. Three days before the first visit, after exposure while washing the decks of his boat, he became paralyzed. He had had earache before for several days, but did not consider it of sufficient moment to quit work ; and his first intimation of trouble was the discomfort produced by par- ticles of dust which blew in his eye. He could not close his left eye, and on looking in the glass he discovered the paralysis. There was no pain, nor any subjective sensation of any kind. He found that he could not laugh, nor blow his nose, and when he attempted the latter " the wind came out of his mouth." When I saw him there was paralysis of both branches of the seventh nerve. Hearing was very imperfect, and he could not count the ticks when the watch was pressed to the left ear. The left palatine arch was obliterated, and he could not fully protrude the tongue, which was quite dry. The left side of the face is quite flat, and the mus- cles of the other side act to such a degree as to draw up the right corner of the mouth, producing the characteristic deformity. When he opens his mouth, the orifice is unsymmetrical. He cannot whistle or expecto- rate. He cannot close the left eye, but when he attempts to do so the ball is drawn upwards, so that the sclerotic is shown to a great extent. Con- tractility to both currents fair; mediate and immediate galvanization are fol- lowed by muscular response. He has some earache. When the electrode 1 Injuries of Nerves, etc., p. 392, et seq. 2 The Nervous System of the Human Body, 3d ed., 1836, p. 56. 3 Romberg, op. cit., p. 272. 4 Massalien, Diss. Inaugur. de Nervo Faeiali, Berolin. 1836. 456 DISEASES OF THE PERIPHERAL NERVES. is passed over the superficial points of the fifth, there is decided pain, no anaesthesia ; force of masseter muscles tested by putting the dynamometer bulb between the teeth and interposing two pieces of wood ; no loss of power as compared with my own attempts. Tympanum red ; and I infer that there is middle ear disease. R. Potass, iodid. and syringing ear with warm water. July 6. Has had intense pain in the left ear, throbbing and pains which radiate over the head. Pressure over mastoid process gives great distress, as does electrization. Leeching to inner tragus. 9eriphery, the nerve-fibres of the central portion undergo atrophy en masse, without their individual character being altered ; but the peripheral part of the nerve-trunk undergoes what Vulpian calls k * histopathic change," i. e., a breaking up or " splitting" of the medullary substance. Atrophy of muscles follows section of a motor nerve ; and, in addition to this, electric contractility is impaired. The absence of central symptoms of any kind, the loss of both motion and sensation in a limited area, absence of reflex contractions when tin- sensory fibres are irritated, and voluntary motion lost, are evidences of the peripheral nature of these paralyses. Treatment Traumatic paralysis, like the facial form, should be treated with an idea of removing the cause should it exist, and afterwards restoring the integrity of the nerve and muscles, and preventing muscular atrophy. If the nerve-trunk be severed, of course all we can do is to await the union of the divided ends. If a tumor makes the destructive pressure, it should be removed if possible. It is hardly necessary to allude to the paralysis following dislocations, for of course the surgical proceeding, which is indicated at first, is the reduction of the luxated bones, and this should be done as early as possible. In the management of paralysis, which, Desplats 1 says, may be due to pressure made by osseous enlargements, iodide of iron and other proper remedies, with cod-liver oil, are to be employed. If there be neuritis, it should be met with counter-irritation, emollient applications, or leeches. General supporting treatment may be necessary if there be a depraved condition of the system. The three valuable local forms of treatment are: 1. Electricity; 2. Strychnia, internally or hypodermically ; 3. Massage. The first agent may be used as early as possible. If one current will not produce contractions, we may use the other ; and, if complete sever- ance of the nerve has taken place, it may be necessary to employ gal- vanism. Faradism is especially valuable should there be anaesthesia, and may be applied to the cutaneous surface. The galvanic current may also be used at the same time, so that one electrode shall (be applied to the spine, and the other to the extremity. The individual muscles are to be subjected to daily galvanic stimulation. The production of pain is unnecessary, and I may repeat the clinical rule so tersely applied by H. C. Wood : 2 " Always select the current which produces the most muscular contractions, with the least amount of pain." Pain and over-fatigue, which follow the use of a strong current, are very 1 DCS Paralyses Peripheriques, Paris, 1876, p. 45. 2 Pliila. Mod. Times, Feb. 20, 1875. TRAUMATIC PARALYSIS. 4fi5 apt to thwart any probable success. The seance should last not more than ten or fifteen minutes every day. An excellent method of treatment is to place the paralyzed limb in a vessel of warm salt water, and to introduce therein two metallic plates connected with a faradic machine. If there be neuritis, electricity does great harm and should not be used. I have repeatedly witnessed the beneficial results which followed the use of hypodermic injections of strychnia (F. 30). An injection of ^ of a grain may be thrown under the skin over the paralyzed muscles. This may be repeated daily ; and I have sometimes seen its good effects when electricity was without avail. The use of " massage" should be employed in conjunction with the other treatment, and the muscles should be separately kneaded and rubbed for a half hour each day. This auxiliary treatment is of immense value when there is suspected rheumatic exudation. I have often employed apparatus by which the paralyzed limb could be subjected to warmth, and for this purpose have used a heated drain-pipe lined with cotton-wool, such as has been spoken of on another page. Into this the patient was directed to place his arm and allow it to remain for an hour or so each day. The paralyzed limb may be wrapped in cotton and oil silk, or India-rubber tissue. The union of divided ends has been resorted to by Tillaux, 1 N&aton, and others, and with a great deal of success. In Tillaux's case the median nerve was united by sutures, and within a day or two the patient was able to move his thumb, and there w r as some return of sensation. Mitchell 2 employs the following method : He carries a needle, threaded with one or two threads, through the loose tissue which is related to the nerve-sheath. The loops are drawn with care, so that the ends are approximated. Hot and cold douches and electricity are subsequently used. In some cases we may use Van Bibber's apparatus. Van Bibber presented the following case to the Maryland Medico- Chirurgical Society which illustrated the beneficial results of treatment of this kind : "A youth, aet. 16, about three years ago sustained a fracture of the right radius, which resulted in paralysis and atrophy of the extensor group of muscles. He first came under my observation about three months ago, when I found the following condition of the arm : radius curved ; hand flexed, and the flexors acting inordinately ; complete atrophy of the extensor muscles, it being impossible for him to move his hand ; no response of the muscles to electricity ; and the skin tightly bound over the radius. The treatment has consisted in rubbing and pinching the affected muscles, the application of electricity, and the use of the artificial muscle, which is nothing more than an elastic tubing fixed to the back of the arm. 1 Quoted by Weir Mitchell, Dis. and Inj. of Nerves, p. 238. 2 Ibid., p. 243. 30 466 DISEASES OF THE PERIPHERAL NERVES. The results of treatment have been very satisfactory ; the lost have been restored, the skin has regained its former tone and elasticity, and the motion is fast returning." J may in conclusion present a case which was reported by Bernhardt, in which electricity was used. " L., 1 43 years old ; dislocated his left humerus by falling on his left shoulder. He had pain in the shoulder, and found it impossible to use his arm, and that felt cold. The dislocation was found to be subcoracoid, ;unl after eight days it was reduced. The pain ceased, but the paralysis con- tinued. In the palm of the hand there was, after three weeks, consider- able scaling of the epidermis. Pressure on the shoulder was not painful, but a strong grasp of the triceps and of the muscles of the forearm was unpleasant. Occasionally there was a sense of formication from the middle of the arm down the extensor side of the forearm to the end of the fingers. The left arm could be raised in a straight line forward about half a foot, but could not be carried backward nor across the breast. The forearm could not be bent on the arm ; only the supinator longus was rendered tense. Extension was impossible ; supination was slight. The hand could be raised somewhat. Abduction and adduction of the hand, flexion and extension of the fingers, were impossible. The prick of a needle was felt to the upper border of the lower third of the arm on both sides equally. In the lower third of the left arm, in the elbow-joint, and the upper part of the forearm, the skin is more sensitive on the right than the left. In the rest of the forearm, in the hand and fingers, the sensa- tion is a little less on the left than right, but nearly equal. The muscles of the arm and forearm, of the hand and finger, as well as the deltoid, showed only the slightest reaction to the induction current. Likewise the use of a very strong galvanic current either to nerve or muscle, by opening or closing, failed to produce contraction. " From the 5th of January, every other day, the patient was treated with a strong galvanic current, the anode and the cathode being placed on the paralyzed muscles. After four weeks he could raise the arm forty degrees, also some distance backward, so as to touch the right shoulder with the left hand. Also, he could bend the forearm on the arm, and had some motion in the hand and fingers. After eight weeks more motion was nearly restored." DIPHTHERITIC PARALYSIS. Diphtheritic paralysis may either take place as a feature of the diph- theritic attack, or it may appear during convalescence, or even several weeks after recovery. The paralysis is generally bilateral, and does not last any great length of time if the throat is alone affected, and rarely exceeds ten or fifteen days in duration. Should the loss of power begin at the same time as the acute disease, the progress of the case is much more apt to be favorable, and the paralysis disappears in a shorter space of time than if it occurs at a period subsequent to the disease. 1 Reported by M. Bernhardt, Berliner Klinische Wochenschrift, No. 5, 1871. DIPHTHERITIC PARALYSIS. 467 Lanne states that a marked and sudden increase of temperature during the diphtheritic attack or convalescence is indicative of paralysis. The paralysis may be simply motorial, or there may be a corresponding loss of sensation which is variable in extent. The muscles of the throat are usually involved, so that regurgitation of fluids takes place through the nose, or there may be certain phenomena which are so well marked in bulbar paralysis, in which the lesion is one of a destructive character. When the limbs are paralyzed, there may be, according to Brenner, movements of a choreic character which depend upon the irregularity of the paralysis, the antagonism of certain groups of muscles being abolished. The organs of special sense are not unusually involved. There may be paralysis of the muscles of accommodation, 1 neuro-retinitis, and sometimes ptosis. Deafness is not rare, and in one of my own cases there had been tinnitus immediately preceding -the deafness. The following case is of a very interesting nature, from the fact that it is reported by the patient himself, who is a medical man. 2 " In October, 1875, being twenty-six years of age and in good health, after two months' constant exposure to diphtheria, I was inoculated from a child two years old, who, on examination, coughed portions of the mem- brane into my face. Six days after this exposure I was seized with a chill, followed the next day (October 28th) by the appearance of a diphtheritic deposit on one tonsil. The deposit was limited to the tonsils and back part of the pharynx, and in nine days disappeared. Exhaustion and great gastric irritability retarded convalescence. Four weeks passed before I was able to sit up. Two weeks after convalescence was declared, a sharp, lancinating pain in the left axilla was noticed, recurring two or three times at short intervals. In a few days, after seeing visitors or talking a little, severe and constant pain in the elbow-joints occurred, which soon ex- tended to the muscles of the arm and chest. After resting, these pains diminished or disappeared, and in a week entirely ceased. On attempting to rise, my limbs seemed surprisingly weak, but at the expiration of the sixth week a short walk was possible. After a brief period of improve- ment my legs began to grow uncertain and weak, and by December 10th I could take but a few steps. At this time a partial loss of sensation came on, beginning in the feet and gradually progressing to the trunk, together with a feeling of coldness in the feet, which, however, were not cold to the touch. This numbness increased faster than the loss of motion. Soon after its appearance in the lower extremities the ends of the fingers lost their sense of touch, the loss of power also extending in a week to the elbows, and at no time greatly affecting the arm. Loss of motion in the fingers and forearm accompanied it and increased for some weeks. The mouth, tongue, and portions of the face lost their sensitiveness at the same time and to the same degree. In a few days my voice grew thick, and was soon like that caused by cleft palate. The soft palate and uvula hung loosely in the mouth, and on attempting to swallow fluids they were regur- gitated through the nares. Dimness of vision for a short time prevented 1 See cases reported by Hutchinson, Lancet, Jan. 7, 1871. 2 Dr. A. F. Reed, Boston Medical and Surgical Journal, July 13, 1876. 468 DISEASES OF THE PERIPHERAL NERVES. reading. In three weeks my voice, then at times unintelligible, grew sud- denly better, and in four or five days was restored. The difficulty in swal- lowing also soon disappeared. The loss of motion and^ sensation in both arms and legs increased. In walking I seemed to be on velvet ; there was a sensation of coldness in my feet, and at first the circulation was retarded. The general loss of power was progressive until February 1st. It was then impossible for me to stand alone even when lifted up, to raise myself an inch from the chair by my arm, to bring my thumb and forefinger together, or to exercise my strength in any part. The toes hung lifeless, and no reflex action was produced on tickling the sole of the foot. The urine was voided with difficulty, and the power of erection was gone. The interosseous muscles were wholly paralyzed, though still reacting to the faradic current. The fingers were drawn up when the hand was at rest, but only by great effort could be straightened out again. The mus- cles of the arms were much weakened, but with those of the thigh retained more power than the rest. They were also the last to lose and the first to gain motion. All these muscles were more or less responsive to the faradic current, the gastrocnemius least of all. During the weeks previous and at this date my appetite was excellent, and my food well digested. From this time an improvement as general as the invasion was noticed. In one week I could lift my body in the chair an inch or two, and when standing felt more secure. In two weeks I could raise myself up from the chair mainly by my arms, and undressed without aid. At the end of three weeks I could walk about the room aided by a cane, and wrote legibly. The diffi- culty in voiding the urine and loss of power of erection had by this time gone. In four weeks I walked out for a short distance, and in two weeks more all paralysis had disappeared, leaving some neuralgic pains in the knees and feet, which lasted but a short time. On April 1st I walked several miles without great fatigue. Atmospheric changes made no change in my strength. Insomnia was the greatest annoyance suffered while con- fined to the house. Three or four hours' sleep was all that could be obtained. The loss of sleep did not, however, leave me unrefreshed. " Treatment : From January 1 2th faradism to the muscles every day until February 15th, afterwards three times a week for three weeks. Tincture of nux Tomica and tincture of phosphoric ether were given for ten days. The stomach rejecting these, one-thirtieth of a grain of strychnine was substituted, which was increased to one-fifteenth three times daily for six weeks. A pint of ale daily for two months. Friction and kneading of muscles every morning for one hour." Causes Morbid Anatomy and Pathology. Dowse 1 quotes Balthazar Foster, who has stated tiiat " he has never known paralysis to follow the non-febrile form of diphtheria." Dowse thinks that the vio- lence of diphtheria has little to do with the development of the paralysis, and says that he has seen cases following modified attacks. My own experience leads me to disagree with him. I have seen six cases of diphtheritic paralysis, and these were among the most violent cases. 1 See case reported by Dr. A. W. Foot, Dublin Quarterly Journal, Sept. 1872, ]). 176, of "hocomotor Ataxia subsequent to Diphtheria." This was evi- dently the ataxic form of Brenner. DIPHTHERITIC PARALYSIS. 469 Labaclie Lagrave, Andral, and others have called attention to the blood- changes in this disease, viz., diminished fibrine and an increased number of white corpuscles. Saune has found that the red corpuscles are de- stroyed, and that there is a great increase in the amount of debris with albuminous urine. The paralysis takes place, however, in a later stage, but Dowse has shown that the albumen in the urine reappears with the paralysis, and that it again diminishes in quantity as recovery takes place ; hence we may infer that a connection exists between the blood condition and the paralysis. I am inclined to think that the paralysis of the palate and muscles of the pharynx are the result of pressure made by the diphtheritic membrane. Diagnosis Diphtheritic paralysis need not be mistaken for any other affection, though occasionally, in its ataxic form, it is confounded with posterior spinal sclerosis. Its transitory nature should render such an error as this impossible. For the same reason it should not be con- fused with organic paralysis. Prognosis I have never heard of a fatal case, that is, a death which was a result of paralysis occurring during convalescence from diphtheria. When paralysis takes place before the violence of the disease has been spent, death may take place from the acute disease. The duration of the paralysis is from eight or ten days to many months. Treatment. Nutritious food, massage, strychnia, and iron, quinine, and stimulants with faradization, are the indications. The plan pursued in Dr. Reed's case will serve as a model. 470 DISEASES OF THE PERIPHERAL NERVES. CHAPTER XVIII. DISEASES OF THE PERIPHERAL NERVES (CONCLUDED). LEAD POISONING. Synonyms. Colica pictonum ; Plumbism. The toxic effects of lead, whether taken internally or absorbed by the skin, are extremely varied and interesting. Disorders of motility and sensation are produced which, though rarely alarming, are most distress- ing conditions. Symptoms Among the early symptoms of lead poisoning may be mentioned the abdominal pain which has received the name of colica pictonum, and which Romberg 1 considers a species of neuralgia of the mesenteric plexuses. Tanquerel 2 has graphically sketched the appearance and development of this symptom. At first there is constipation which lasts for some weeks, and sometimes follows a slight diarrhoea, while after a short time a sense of epigastric oppression is experienced, with nausea and eructations, and gnawing twisting pains which occupy the umbilical region. These pains are much worse at night, and rarely shift their posi- tion. Pressure relieves them to some extent, as it does in simple colic. During the paroxysms there is great muscular rigidity, and the ab- dominal muscles seem to be rigid. The skin is cool, and perhaps bathed in sweat, and the pulse is full and bounding, and quite hard. The con- stipation continues, and the feces that are occasionally voided are scyba- lous and of a whitish-gray color. The urine is of high specific gravity, is quite light in color, and voided in considerable amounts. The complexion of the individual is sallow, and the skin rough; and, if his lips be separated, the peculiar bluish line at that part of the gums which is in contact with the teeth will be seen. This line is a quite con- stant symptom ; it is perhaps one of the most valuable diagnostic marks. The remaining part of the gums is quite spongy and dark. There may be in conjunction with lead colic a very well-marked cuta- neous anaesthesia or hypenesthesia, but the latter is more common. The skin is exquisitely sensitive in parts, such as the scalp, the groin, the bend of the elbow, and other like regions. Pressure seems to relieve this ten- derness, but light irritation aggravates it markedly. A form of tremor which is apt to be confused with those of a sclerotic nature has been found as a rare symptom. Brockman observed it among 1 Op. cit.. vol. ii. p 132. 2 Traitls des Maladies de Plomb. on Saturnines, 1839. LEAD POISONING. 4Y1 workers in the lead mines of the Hartz Mountains. It may be local or general, and in the first form the hands are affected. The lips may be agitated, and the levator anguli oris is often involved, so that the corner of the mouth is drawn up. In the other form the head, trunk, and arms are all in a state of tremor, the head being bowed on the chest, and the legs unsteady. In this latter form there is usually a profound toxic condition. By far the most important symptom, and one which may or may not be preceded by lead colic, is the form of local paralysis known as " lead palsy" or " lead paresis." The onset of the malady is usually gradual, the patient being unable at first to extend the fingers. There is nearly always some numbness of the hand, and rarely tremor. It is not often that the para- lysis becomes general, but the extensors of the forearms are, as a rule, involved. In this condition the hands hang helplessly, and an appearance results which has been called " drop wrist." There is generally some paralysis of the flexors, but this is almost inappreciable. Other muscles, notably those of the shoulder, are affected if the lead saturation be pro- found, and, as a consequence, the patient may be unable to raise his arm. I have never seen a case in which the lower extremities were involved. Electric sensibility and contractility are much reduced, and there is marked anaesthesia in most of the cases. Faradism rarely provokes mus- cular contractions, and in old cases even the galvanic current fails to call forth the slightest response. Atrophy is a result of the paralysis, and the interosseous spaces of the forearm are sometimes very plainly marked, the loss of substance being quite decided. The colic generally subsides with the appearance of the paralysis, and according to Romberg 1 the two conditions rarely coexist. In the cases recorded by various observers the muscles of both extremities of one kind were affected in the great majority of instances, and from my own expe- rience I consider unilateral lead paralysis to be an anomalous condition. Occasionally a cerebral condition results from lead poisoning, and gene- rally follows the colic. This is characterized by vertigo and headache, general malaise, and tremor of the hands which is aggravated by volun- tary action. A more serious state is sometimes produced, however, which is symptomatized by delirium, convulsions, and stupor. The duration of lead paralysis, or the other condition I have noticed, is of course governed by the existence of the cause and the exposure of the patient. Most of the toxic lead states disappear, however, in a very short time, provided the patient protects himself by leaving his injurious occu- pation, and the proper remedies be administered. The following may be cited as a well-marked case of lead poisoning : Jas. McK., set. 55, N. Y. City, painter. Has followed his trade 35 years, engaged mostly on "inside work," "flatting." Never had any trouble till two years ago, when he noticed pains in his limbs, back, and subocci- 1 Op. cit., vol. ii. p. 136. 472 DISEASES OF THE PERIPHERAL NERVES. pitnl region ; not much colic, but some nausea ; loss of appetite ; not con- stipated. While actually engaged in work he became dizzy, and " a blur came across his eyes." Last acute attack was obliged to leave work sud- denly on account of severe backache. He then noticed a loss of power in right hand. He consulted me in July, 1877, presenting well-marked " wrist drop," so that he was unable to extend his hand. He complained of formication of soles of feet, insomnia, and pains in shoulders, knee- joints, and about heart. Well-marked blue line and very dirty gums. The necks of the teeth are carious and black, and he has lost several of them during the past few years. Loss of sensation of cutaneous surface. Jfand.* Atrophy of adductor of thumb, so that quite a hollow exists. Forearm Complete loss of electro-muscular contractility in common extensor of right forearm ; slight power under electrical stimulus of ex- tensor of thumb and little finger. Flexors slightly impaired, but con- tractility scarcely lost. Arm Muscles all contract well. Patient cannot take off his coat or underclothing, or cannot button his clothes. Treatment PUectricity and potass, iodid. with strychnine. Causes. The majority of cases of lead poisoning arise from the inspi- ration of finely divided particles of lead, and not from the manipulation of pieces of the metal; consequently, painters, smelters, white-lead makers, and miners are more often victims than any other classes of individuals. There seems to be an idea that printers are especially subject to lead dis- eases ; and at the request of the Board of Health of the city of New York I made an extensive examination of the printing-offices for the purpose of testing the question. I interviewed nearly 1500 men, women, and children, and found not a single case of paralysis. Among the grinders of type (those who smooth the sides and ends of the type against large rough stones), I found that the persistent use of the muscles of the thumb and forefinger, in one case, resulted in a condition resembling progressive muscular atrophy. In the lead pipe and shot manufactories my experience was the same. The painters, however, seem to be most frequently poisoned. An ope- ration known as " flatting," in which the painter closes all the doors and windows of a room, and applies thin paint, is attended with great danger. The turpentine evaporates rapidly, and carries with it minute particles of lead which the workman must inhale. Dr. Richardson, 2 in a thesis which embodies a large amount of valuable research, thus describes the manner of preparing white lead, and the dan- ger which attends its manufacture. "The metal first comes in contact with the skin of the men in being carried by hand from the cars to the melting-room. Here many tons are melted at once and cast into thin, circular, perforated plates called buckles, of such shape as to expose as much surface as possible for the weight. 1 Can only force dynamometer index to 4 with right hand ; left, 1 5. 2 Graduation Thesis, Harvard Medical School Boston Med. and Surg. Journ., Oct. 4, 1877. LEAD POISONING. 473 The temperature is very high. Bathed in perspiration the men stand for hours inhaling the minute particles of the oxide of lead which escape from the cooling buckles and fill the air. Their thirst in this part of the process is insatiable, and enormous quantities of ice-water are swallowed, whereby the dust, which adheres to the tongue and lips, is washed directly into the stomach. Having been carried to a neighboring shed, the buckles are placed over pyroligneous acid in earthen pots of about four quarts capacity. Many thousand of these pots are packed together in the refuse of stables or the exhausted bark from tanneries, and are exposed to the moderate heat which is spontaneously generated about them. The wood vinegar is vola- tilized and rises through the buckles, changing by some obscure chemical reaction the blue metallic lead into the white carbonate. After an ex- posure of this sort, lasting from six weeks to three months, the pots are unpacked and the whitened lead removed. Here for hours men breathe the vapors rising from the heated bark, loaded with poisonous particles of the now dusty metal. In English mills this part of the process is done by women, with most disastrous effects upon the health. To separate the blue from the white lead the buckles are placed in a revolving cylinder of wire-cloth, through which the carbonate, more or less pulverized, falls. . The blue portion remains in the cylinder and is melted again. To be in this room without protection is suicidal, for the air is filled with visible clouds of dust. The utmost care must be taken. The mouth and nostrils are covered by a moist sponge to catch the floating particles. The skin and clothes quickly become white with lead. The semi-powdered metal, having been shovelled into barrels and rolled into another division of the works, is mixed with water and finely ground. When it fills the water as a milky precipitate, the whole is drawn off and dried on long tables at a temperature of 140 F. Formerly the grinding was done without water, and the lead sickness was much more common than now. The drying-room is the most poisonous one in modern mills. It combines the effects of the dust which fills the air with those of a heated atmosphere. Here, as in the melting-room, the skin is kept in the best state for absorp- tion. A terrible thirst makes the men swallow large quantities of cold water with the lead which accumulates on their lips and tongues, while at every breath fine dust is drawn into the lungs. The general appearance of the men is not good. The faces are sallow and more or less worn. The sclerotic coat is yellowish. Their motions are far from energetic, and in some cases eccentric and unsteady. One would say immediately, I think, that the general appearance is much below that of the average workman. 1. The first man examined has worked in all parts of the mill for thir- teen years. His only trouble is rheumatism. The gums show a distinct blue line along the border. 2. After seven years in the corroding rooms has no symptoms excepting the blue line. 3. After grinding lead with oil has only the blue line. 474 DISEASES OF THE PERIPHERAL NERVES. 4. After working in all parts of the mill for six months has had violent colic and great constipation. Blue line marked. ,5. Reports only blue line after four years' work. 6. The machinist, after repairing in the drying-room a few hours a day for ten days, was affected with colic and constipation. Has great habit- ual constipation. Blue line very marked. I. After seven years only blue line. 8. After twelve years has only blue line and fungous bleeding gums, with occasional colic and obstinate constipation. 9. After six years in corroding-room has only blue line. 10. Has worked in all parts of the mill for fifteen years without show- ing a trace of blue line or any other symptoms whatever. Very neat. I 1 . After three years only blue line. 1 2. After four years, nothing. 13. Blue line, rheumatic pains, and fainting fits. This was a remark- ably neat man. 14. After four years no trace of poisoning. lo. After four years entirely used up. Had to leave all work. 16. After one year's work completely crippled, having paralysis of the extensors, aphonia, and general debility. 17. The carpenter, after repairing ten days in the drying-room, had severe colic, obstinate constipation, and persistent blue line. 18-75. Of the rest of the seventy-five men whom I examined all Imd a distinct blue line about the gums, and, with one or two exceptions, habit- ual constipation. There was nothing further than this to suggest the presence of lead. In addition to the above cases, three of the former employe's had suf- fered with difficulty in speaking, three with amaurosis, several with cere- bral troubles, and many with paralysis. The superintendent has observed that the most frequent complaint has been of swollen joints and aching bones. In the numerous cases of paralysis which he has seen during many years' service at these works, he has noticed that the wrists have become much swollen before paralysis of the extensors. A curious tradi- tion exists among them that they cannot drink alcoholic liquors and keep up with their work, like laboring men in other manufactories. Several cases were told me of men who quickly succumbed to the influence of the lead after beginning the use of strong stimulants." Load is often taken into the stomach without the knowledge of the in- dividual, and lead pipes are a prolific source of the contamination of water. I have seen three cases in the same family caused by tea which had been made from a specimen containing particles of sheet lead which had lined the box. The last two or three pounds were impregnated with these impurities, which had settled to the bottom of the chest. It was the custom to make tea and from time to time to add fresh leaves and pour on hot water, so that there was constantly a quantity of lead subjected to the action of the fluid. Upon analysis, quite an amount of lead was found. LEAD POISONING. 475 Cases arising from the use of cosmetics and hair-dyes are too common to need anything more than bare mention. Morbid Anatomy and Pathology Andral and Tanquerel 1 were unable to discover any pathognomonic condition of the intestines in lead colic ; but the latter authority found lead deposits in the intestines, mus- cles, and nervous substances. In a case of lead paralysis reported by Gombault, 2 there was found to be no change in the cord, and the only morbid appearances anywhere else were in the nerves, the medullary sub- stance having undergone a granular alteration. No other appearances which might clear up the pathology of the affection have been seen. Remak 3 is of the opinion that lead palsy is a central disease, and he presents several cases to show its likeness to infantile paralysis. The same electrical reaction of the muscles in these two affections, and the fact that groups of muscles are affected which act together, not necessarily being those supplied by the same nerve, lead him to think that the paraly- sis is of central origin. The blue line of the gums, which indicate plum- bic saturation, was first described by Burton in 1840. By Tanquerel it is supposed to be produced by the decomposition of food about the teeth, the sulphuretted hydrogen uniting with the lead. It occurs in people who brush their teeth as well, however, as in those of careless and untidy habits. Dr. Richardson 4 tried the following experiment: " A strong, healthy cat was fed for a week upon milk, to which had been added a small portion of a solution of plumbic acetate. At the end of a week the animal was killed, after having shown symptoms of severe constitutional disturbance. The lower jaw was excised, and the gums found perfectly clean. The upper jaw was also clean. The lower jaw was placed in water, through which a stream of sulphuretted hydrogen was passed for several hours. At the end of that time a perfectly distinct and unmistakable blue line was found throughout the juncture of the gum with the teeth. The stomach and intestines of the animal showed nothing remarkable. The presence of the blue line seems, therefore, to depend on a certain amount of putrefaction about the teeth." The elimination of lead is usually rapid when the proper remedies are administered to convert it into a form for excretion. If nature is left to herself, the process is more slow. Potain considers that it is eliminated only very slowly by the sweat-glands, and not by the kidneys or salivary glands, but I am disposed to consider that elimination does take place by the kidneys. Diagnosis In nearly all cases of lead poisoning, it is usually possi- ble to detect the cachexia, which is so well expressed by the different signs I have enumerated. If our suspicions are not verified by appear- ances in an acute case, we may test the patient's urine. A few drops of 1 Tanquerel, p. 326. 2 Archiv. G6n6rales, 1873. 3 Archiv fur Psychiatric uud Nervenkrankheiten, vi. p. 1. 4 Op. cit. 476 DISEASES OF THE PERIPHERAL NERVES. a solution of sulphide of potassium will usually precipitate any lead that may be present in the form of a black sulphide. The paralysis may be sometimes confounded with other forms, but when it is remembered that the extensors are prominently affected, and that there are lead symptoms at some time or other, it is not possible to be mis- taken. Dr. Wharton Sinkler, 1 in an admirable paper, calls attention to the resemblance between "wrist drop" due to lead poisoning, and paralysis of the extensors from injury of the musculo-spiral nerve. He has found paralysis of the flexors of the forearm after injury of the nerve, and he is inclined to think that in the beginning there is never paralysis of the flexors in lead palsy. Prognosis. With the disappearance of the cause, we may expect in most cases a rapid subsidence of symptoms. It is true the paralysis often lasts for some time, but even this ultimately disappears. Deaths by lead poisoning are rare, and I suppose when they occur are due to an affection of the brain, to which I have alluded. The mortality from lead poisoning in New York City from 1852 to 1873 was 288. 48 died in 1852 ; and, strange to say, but four in 1872.* Treatment If we have correctly diagnosed the condition, our ob- jects must be : 1. To relieve pain ; 2. To favor elimination of the lead ; 3. To guard our patient against being continually affected ; 4. To restore the paralyzed limbs. 1. No better remedy is possessed than iodide of potassium, which forms an iodide of lead which is an innocuous salt. This drug must be given in moderate doses, 3 and its elimination hastened by mild purgatives. It will be found that, if the patient is obliged to continue at his work, small doses taken daily, or acidulated drinks, will, in some measure, prevent the ab- sorption of lead. If there be colic, the hypodermic use of morphine will give great relief. It has been found that those workmen who drink a great deal of milk seem to escape the danger of lead-poisoning. In France the workmen in the lead-works are obliged to drink milk, and it is found to be an excellent prophylactic. Kichardson's case (loc. cit.) did not suffer so long as he kept his cows ; but when he parted with these animals, and stopped drinking milk, the most decided symptoms of plumbism manifested themselves. As to the employment of electricity, it is well to use the faradic current if possible ; but in some cases this produces no contractions. In such an event we may begin with the slowly intermitted galvanic current ; and, after a while, it will be found, as in some other paralyses, that the faradic will cause muscular response, particularly if the arm be so supported that the muscles shall be relaxed. Dr. H. C. Wood,* of Philadelphia, has ' Am. Psych. Journal, Nov. 1875, p. 31. 3 Report of the Board of Health, 1872. 8 Very large doses seem to increase the symptoms. 4 Phila. Med. Times, Feb. 20, 1875. LEAD POISONING. 477 noticed the fact that voluntary power may return to a great degree without a corresponding return of electric contractility. I have before alluded to an instrument devised by Dr. J. Van Bibber, 1 and it is well to apply this so that the muscles may be entirely supported. In conclusion, I may present the records of a representative case of lead palsy. The patient was under the care of Dr. Cross, through whose kindness I had the opportunity of seeing him : M. C., 2 aged 32 years, single, born in Ireland, a painter by occupation. He has been moderately temperate in his habits, and has always enjoyed good health until 1863, when he was suddenly seized with a severe attack of colic, which was preceded by great constipation of the bowels and loss of appetite. There soon succeeded nausea and vomiting of bile, accom- panied by an acute lancinating pain in the epigastric region, which was so severe that the patient was obliged to lie flat on the floor and press his abdomen strongly against that surface, in order to obtain temporary relief. 1 ' ' After many attempts to secure this advantage by means of strips of plaster, it was determined to try the India-rubber muscle as used by Dr. Lewis A. Savre in orthopedic surgery. The great difficulty in the use of such an appliance was to effect its application without causing injurious pressure upon the circulation of the arm and hand. I am not aware that these elastic tubes have been used before to correct this deformity, or attached by a method so simple and so free from pressure as that which I shall now describe. Two bands of inelastic webbing, pierced by eyelets at certain points, and each having a convenient buckle, serve as points of attachment. The one for the hand, about three-quarters of an inch wide, so made, that the free end placed upon the palm pointing toward the the- nar eminence, and the eyelet-hole resting on the ball of little finger, the band folded once around that finger and passed over dorsum of the hand, the buckle would come in a convenient place upon the palmar surface. The band for the arm about one inch in width, so arranged that the eyelet being placed upon a line a little above the external condyle, the buckle would rest upon the internal surface of the arm. As seen in the illustration, two transverse strips of plaster are adjusted to the arm so as to form an angle just below the eyelet, and thus relieve the band, which should be buckled loosely, from all injurious traction. The fold around the little finger, and the muscle resting upon the webbing on the dorsum of the hand, enable us to buckle the band loose enough to insure perfect abduction of all the fingers. Finally, a piece of India-rubber tubing of correct length and medium elasticity, with one of Dr. Sayre's metallic hooks attached at each end, consti- tutes the entire apparatus. Looking upon this artificial muscle as performing to some extent the duty of those paralyzed, I can probably best describe its application by saying, in ana- tomical language, that it arises from a point a little above the external condyle. and passing downward on the extensor surface of forearm, under the cuff, which we might call the annular ligament, forward over dorsal aspect of the hand, pass- ing between the index and second fingers, which serve as a trochlca or pulley, then transversely across the palmar surface of the hand, and is inserted at a point about the articulation of the fifth metacarpal bone with its first phalange." -V. Y. Med. Journ., May, 1874. 2 Reported in the Psychological Journal, Jan. 1871, by Dr. Cross. 478 DISEASES OF THE PERIPHERAL NERVES. These symptoms continued off and on for a period of about two weeks, gradually diminishing in severity, however, especially after an evacuation from the rectum, which was only obtained with the greatest difficulty. His right leg at this time became oedematous. In the course of two months lie resumed his usual avocation, that of a painter, but was not aware at this time that his sickness had been caused by the action of lead. During the year 18G7 his bowels again became very costive; and his stools, which consisted of only a few lumps of dry, hardened feces, were attended with much straining. Soon there followed a second attack much more severe than the first, which was characterized by nearly similar symptoms, only there was superadded great tenderness over the kidneys, which were so sensitive that the least pressure caused him the most intense agony. The urine was very scanty and high-colored, and there was a well-marked blue discoloration of the gums. In a few months, having somewhat recovered, he went to work again at his former occupation, which he pursued unin- terruptedly until the 25th of December, 1809, when, after having passed a very uncomfortable day, his former symptoms returned with increased violence, while the paroxysms of the colic came on at much shorter inter- vals than they had done in the preceding seizures ; in fact, instead of intermissions as formerly, there were only remissions of the intestinal spasm. For the first time he had pains in the feet and the inside of the thighs. The urine was more scanty and higher colored, and the bowels more constipated than before. In three weeks he again began to work, and had no more trouble, except constipation of the bowels and weakness in both his upper and lower extremities, until July, 1870, when he lost his appetite, and felt very weary and exhausted after any small amount of exertion. He was very restless and could not sleep at night, and this inability to sleep was a sequela of all the other seizures. Now came great tremor of the right hand and arm, which was soon followed by tremor in the left. In August, 1870, he had his fourth and last attack, which was the most severe of all, and lasted about two weeks. This time he vomited blood, had acute pains in the soles of his feet, and cramps in the right hand. On recovering from the effects of the colic he found that he was unable to use his arm or hand at all, and that he had lost power in his legs also. Soon after this he was admitted to the Charity Hospital, where he remained for a fortnight, and during his residence in that institution he became delirious, and continued so for about eighteen hours. He came to the out-door department of the New York State Hospital for Diseases of the Nervous System, September 12, 1870, when his condition was as follows : There was the characteristic drooping of both wrists, which was very extreme in degree. The paralysis of the supinator and extensor muscles of both upper extremities was exceedingly well marked ; the flexors were also involved, only to a much more limited extent. The paralysis was more considerable in the right forearm and hand than in the left. There was much atrophy of all the muscles of these parts, and this was very conspicuous in the abductors and adductors of the thumbs. The patient was so very weak in his lower extremities that he was unable to arise from the sitting posture without assistance, and as he walked he tot- tered at every step. Yet he did not drag the toe of either foot, nor swing his legs, as do those suffering from hemiplegia. The blue line was very plainly seen around the edge of the gums of the upper and lower jaws. FUNCTIONAL SPASM. 4T9 On testing the amount of muscular power in the right hand by means of the dynamometer, he was able to turn the indicator only 10 degrees, while with the left he could accomplish somewhat more. The tactile sensibility and the sensibility to the electric current and to pain were very greatly diminished. The temperature was also diminished; muscular contractility was so much impaired that a powerful induced current had not the slightest effect in causing contractions, and, even when the primary galvanic current (sixty cells and very strong) was used, the muscles responded very feebly, if we except, perhaps, the flexors, so almost completely had their irritability been destroyed. The bowels were regular, the urine was normal, and, although no chemical analysis for lead was made, undoubtedly it would have been found. " The appear- ance of the patient was anaemic, cachectic, and depressed ; the breath was very offensive ; the retinae were ansemic ; the lungs were healthy, and so was the heart, excepting an inorganic murmur at its base." The treatment in this case has consisted of the internal administration of the iodide of potassium, commencing with ten-grain doses three times a day, and the daily application of the primary galvanic current to the paralyzed muscles, with a hypodermic injection of the thirty-second of a grain of the sulphate of strychnia every day. September 17. The iodide was increased to fifteen grains three times a day. '2th. Slight fibrillary contractions in the right, arm were produced to-day for the first time by means of the faradic current. October 1. The iodide of potassium was increased to twenty grains three times a day. 5th. The induced current had just commenced to cause slight contrac- tions in the left forearm. November 15. Faradization of the left forearm produced good con- tractions in the extensor carpi radialis and ulnaris muscles. The blue line having disappeared, the iodide of potassium was discontinued, and a tonic substituted. 23d. The muscles of both arms respond feebly to the induced current, yet by means of it the hands can now be extended nearly on a level with the forearms. The right has improved the most. Sensibility to touch and to electricity has much improved. His bowels are regular, he sleeps well, and his appetite is good. The power in both hands is much in- creased, and he is able to work every day. January 1, 1871. The patient has almost entirely recovered. FUNCTIONAL SPASM. Under this head I propose to include the various forms of hyperkinesis which depend upon irritability of the nervous centres, and which have been specially considered, as Tetany, spasm with voluntary movements, Reflex Spasm, Torticollis, Professional Cramp, etc. These are generally due to some peripheral cause, or may result from overtraining of the automatic sense, or in certain conditions arise in a manner which is at present not clearly understood. 480 DISEASES OF THE PERIPHERAL NERVES. I. TETANY. A light form of attack arising generally from diarrhoea, cold, and con- stipation, and sometimes making its appearance during lactation. There is usually some formication of the palms or soles, and an awkwardness in the movements of the hands and feet, which is afterwards followed by a firm tonic contraction of the muscles of either of these parts. The flexors are usually contracted, so that the hand is curved, or all the fingers closed. A more decided contraction may flex the forearm on the arm. The foot may be also affected, a condition of talipes resulting, or the back part of the leg may be brought in apposition to the thigh. In marked forms the upper and lower extremities are affected together, though there is no rule governing this, and the spasm may be bilateral or unilateral. The attack rarely lasts beyond an hour or two, and in the majority of instances relaxa- tion may take place in from five to ten minutes. The spasms may come on from time to time, being separated by greater or less intervals. They are entirely uncontrolled by the will, and the patient cannot open his fin- gers when they are thus contracted. In more severe forms the muscles of the trunk or face become involved. Contraction of the ocular muscles, laryngeal spasm, trismus, or vesical spasm are examples of more violent action. The spasms seem to be produced when pressure is made upon a nerve-trunk or muscular belly, and there is loss of tactile sensibility asso- ciated with neuralgic pain in the main nerve-trunk of the convulsed limb. Tetany differs from true tetanus from the fact that the spasms affect the limbs, that they are intermittent in character, and that there are intervals of relaxation. Petit-mal sometimes resembles this condition, but there is always some loss of consciousness. II. FUNCTIONAL SPASM WITH VOLUNTARY MOVEMENTS. Mitchell 1 reports some cases of functional spasm, which somewhat resem- bles the so-called tetany. The spasm appeared during the exercise of a voluntary act ; they occur with the act of laughing, chewing, and talk- ing, and evidently depend upon functional derangement of muscles inner- vated by the first cervical and spinal accessory nerves. In one case the head was drawn back, and the spine bowed so that the patient was jerked into a squatting posture, the gastrocnemius being finally affected. In other cases the spasms occurred when the individual began to walk. In still other cases there was a rhythmical motion when the patient attempted any simple voluntary action. These Weir Mitchell called "pendulum spasms," the number of twitches averaging 160 per minute, and recurring witli great regularity. Bamberger 1 reports a case which resembled spasm of another kind, of which I shall presently speak. Whenever the child was held in the stand- 1 Am. Journ. Med. Sciences, Oct. 1876. 2 Quoted by Handfield Jones, Functional Nervous Disorders. REFLEX SPASM. 481 ing posture his legs were drawn up, and agitated by choreoid spasms, the spine and neck being twisted and contracted at the same time ; but when he was placed upon his back these movements ceased. III. REFLEX SPASM. Under this head may be classed a long list of local convulsive move- ments dependent upon a variety of causes. Sometimes there are worms in the intestinal canal, and at others a condition of irritability of the geni- tals ; while peripheral irritations of many kinds enter into the etiology of the spasm. I may illustrate the occurrence of one form of spasm by the following cases : I. A boy, 7 years old, seen at the request of Dr. Sayre, was well nourished, with rosy cheeks and well-rounded muscles of the upper ex- tremities. His morbid condition had existed from birth, and he possessed a congenital phimosis, the prepuce being firmly fastened over the glans, and the preputial orifice was very small and surrounded by a rigid ring of toughened skin. On entering the room I was struck by the extraordinary restlessness and activity of the child. He was lying on the bed, and his Fig. 53. Reflex Spasm from Genital Irritation. lower limbs AA'ere drawn up and agitated by irregular spasms. The arms were also convulsed, and their movements were distinctly choreic. When held upright the child was unable to stand, not from any psuv>N. but from the apparent loss of coordinating power, the legs becoming rigid, and the toes of both feet adducted, more particularly the left. The child was unable to speak, but attracted the attention of those around him by queer sounds. His face was distorted, just as we often see it in old cho- reic patients, but there was no evidence of imbecility. I did not infer that there was any mental trouble, except a preponderance of emotional disturbance, the boy being very fearful that he was to be hurt. Upon interrogating I found that he was quiet during sleep, that his appetite was good, and that there was no irregularity or disturbance of the functions of the bowels or bladder. The penis was' not so sensitive as I had expected to find it from Dr. Sayre's description of previous cases. Titillation did not produce immediate erection, nor any increase of the spasmodic move- ments. On taking him upon my lap the thighs and legs were immediately drawn up ; there was no evident pain produced by pressure on the spine. 31 482 DISEASES OF THE PERIPHERAL NERVES. II. Rosa A., 5 years old, very pale and delicate. Like one of Dr. Sayre's cases, tins child was almost asphyxiated when born, and it was nearly ten minutes before she was resuscitated. A year after birth she contracted scarlet fever, but no other trouble supervened. After birth it was noticed that there was want of power in the lower extremities. She was entirely unable to stand, and as soon as she was held in an upright |X)sition her legs became stiff. Her intelligence was unaffected, and she did not suffer pain in any part of the body. Present Condition The legs are well proportioned, and there is no atrophy. The temperature of either limb is not lowered, but there is slight hypenesthesia. When held in an upright position by her father, who accompanied her, the legs become rigid, the toes cross each other, and one foot seems inclined to cover its fellow. With this rigidity there are irregular convulsive movements. There is a marked contraction of the sural muscles, which draw up the heels, producing a double talipes. When laid upon her back the thighs are flexed upon the pelvis, and this, her father states, is her position at night. At this time the head is drawn back and downwards by firm contraction of the trapezius and other mus- cles of the neck. An examination of the genitals disclosed a very large cyanotic clitoris, which was quite erect. There was no history of worms. Unfortunately, for it was a dispensary case, the father would not allow anything to be done in the way of surgical interference. A form of reflex spasm of the eyelids was reported by Von Graefe, 1 which rendered the patient helpless, for he was unable to go about alone. There was no pain produced on pressure in the course of the fifth nerve ; but when pressure was made on the glosso- palatine arch on the left lower jaw, the spasm ceased at once, and the patient could open his eyes. A putrid ulcer was found at this locality, which acted as a centre of irritation upon the gustatory nerve. IV. FACIAL SPASM WITHOUT PAIN. A form of facial spasm not connected with voluntary motorial move- ment is occasionally met with, the orbicularis palpebrarum or buccinator being affected alone, or all the muscles of the face supplied by the portio dura being convulsed. The trouble differs from epileptiform tic for the reason that it is unaccompanied by pain. I have been so fortunate as to see two of these cases. One was that of a gentleman aged 56, who suffered an almost constant spasm of the orbicularis of the eye, which was always increased when he was fatigued. The eye would become red, and there was usually a discharge of tears, which were unable to find their way into the lachrymal duct, and consequently ran on the cheek. A case pre- sented at the American Neurological Society by Dr. Hammond suffered from violent unilateral spasm of all the muscles of the face, which came on every two or three minutes. 1 Schmidt's Jahrbuch., vol. 127, p. 30; reported by H.Jones, p. 390. TORTICOLLIS. 483 V. TORTICOLLIS. The sterno-cleido-mastoid muscle may be the seat of a spasmodic con- traction. This condition may be preceded by peripheral trouble, such as dentition, which was the cause in one of Romberg's cases, or by such gen- eral diseases as rheumatism. One case, which was seen by Dr. White and myself, was preceded by chorea, and another, that I saw at the New York State Hospital for Diseases of the Nervous System, was due to general ana?mia. In both these cases, as well as in others I have observed, the head was bent forward and the chin pulled downward. In one case, that of the elderly woman seen at the nervous hospital, the spasms were intermittent. Radcliffe reports a case which somewhat resembles this. The muscles of the neck were tender and the seat of soreness, and the movements were attended by pain. The spasms are usually increased by emotional excitement, but subside during sleep. The notes of my case are the fol- lowing: M. A. A., aged 56, U. S. Came to the hospital Oct. 29, 1872. Her present trouble began five years ago in a very gradual manner. There are now marked clonic spasms of the muscles of the anterior part of the left side of the neck. With their intermitting contraction, there is some pain at the lower insertion of the sterno-cleido-mastoideus muscle ; the trapezius is also the seat of spasmodic contraction. There is headache, and pain at the upper part of the cord. Patient's expression anxious and excited. Galvanism to muscles and spine, and zinci phosphidi gr. ^ t. i. d. Pa- tient complains of dizziness and constipation. The muscles concerned in this form of disease are the sterno-cleido- mastoideus, complexus, trapezius, and levator anguli scapulae. Pathology Weir Mitchell has divided the conditions under which spasms of this kind may occur into three groups : 1. "Those in which the functional activity of a muscle or set of muscles gives rise at times to an exaggeration of the motion involved naturally, and sometimes also to a more or less spasmodic activity in remoter groups. 2. " Those in which the functional action of one group results only in sudden and possibly in prolonged acts, tonic or clonic, in remote groups of muscles not implicated in the original movement. 3. " Those in which standing or walking occasions general and disor- derly motions affecting the limbs, trunk, face, and giving rise to a general and uncontrollable spasm without loss of consciousness." The central condition is one of great reflex irritability ; certain forms of repeated irritation producing an activity of the motor centre which results in an abnormal increase in reflex susceptibility. Treatment Agents which lower the excitability of voluntary muscular action are to be adopted. Of these I know of no better drug than gelsemium sempervirens (F. 50), conium (F. 51), musk, assafcetida, or valerian (FF. 52, 53, 54). Rest, and removal of the peripheral irritation, should the spasm be of reflex origin, and the ether spray to the 484 DISEASES OF THE PERIPHERAL NERVES. spine, are to be resorted to; and at the same time various measures which improve the individual's general condition are in order. If all of these drugs I have mentioned be powerless to subdue the excitable condition of the muscles, I prefer profound brominization, which sometimes controls the movements. Myotomy in torticollis has not proved itself to be a successful operation, and so I do not recommend it. In other conditions, such as adherent prepuce, an operation is the only method that promises a cure. Galvanism and faradism have proved successful in the hands of many, and their use is often attended by extremely beneficial results. The hypodermic injections of the alkaloids sometimes succeed when all other remedies fail (FF. 30, 59, GO, 61, 91, 92). PROFESSIONAL CRAMP. Synonyms. Writer's cramp, Dancer's cramp, Telegrapher's cramp ; Dyskine'sie professionelle ; Melker-krampf, Schuster-krampf, Nahekrampf. This very interesting condition, which follows the overtraining of groups of muscles, is found among all who engage in occupations which require the exercise of particular voluntary muscles of the upper and lower extremi- ties to an excessive degree. Among these individuals such protracted muscular action, especially when of a delicate kind, is likely to be followed by spasmodic movements such as would come under the first group of Mitchell. It is the first of the above varieties that at present interests us the most. WRITER'S CRAMP is the form of hyperkinesis with which we are the most familiar, and it is difficult to fail in recognizing its true character. After continued and fatiguing use of the pen the hand may become at first tired ; afterwards the patient suffers from sharp pains which run from the hand up the arm, while dull pains seated in the ball of the thumb, the dorsal aspect of the fingers, the wrist, or at the exposed por- tion of the ulnar nerve at the elbow, are to be found as well. His first intimation may be a certain tired feeling, or, as a very intelligent patient under my care expressed it, " The first idea of my trouble came from the feeling that 1 had an arm. My mind was directed to it, and whether resting or at work, it felt like a clumsy part of my body." If the indi- vidual carefully forms his words, or if he " writes with his fingers" a bad habit which schoolboys have, and which sometimes continues through life the trouble is much more probable than when he uses his whole hand in guiding his pen. He may find after a while that when he attempts to write, the hand will fly upwards as the result of a spasm of the extensors and other muscles on the dorsal and ulnar side of the forearm, so that it is often impossible to form more than one or two words of a note before the trouble begins. This impaired writing power may exist to a lighter degree ; but when the individual persists in his attempts, the convulsion is certain to take place. A light tonic spasm of the abductor minimi digit! may occur when the PROFESSIONAL CRAMP. 435 little finger is separated from its fellows, and this is sometimes an early sign of the disease. He may educate the left hand to do the work of the right, and after a while may learn to use it in a satisfactory manner ; but very soon this too becomes affected, and he can write with neither hand. Other muscular movements are freely performed, and even some which closely resemble that of holding the pen. Trembling sometimes super- venes, while fibrillary muscular contractions are suggestive of the confirmed disease. As is the case in sclerosis, the disorderly movements, or the spasms, seem to be intensified when the patient attempts to write in the presence of a looker-on, and he usually makes sad work. The fingers, forearm, and wrist sometimes become the seat of lost power, and this is marked in the three first fingers of the right hand, and the pronators and supinators lose power. Sensation is rarely lost or impaired. In some cases the flexors of the hand and the small muscles of the thumb are so weak that the point of the pen cannot be kept in contact with the paper, as the extensors seem to act independently. The same form of cramp affects the thumbs and fingers of telegraphers, so that their work eventually becomes an impossibility. Onimus 1 pre- sents a case. A telegraphic operator, 19 years of age, first experienced difficulty in making dots; " d " was made better than "u;" and it was found that when a line was first the dots were more easily made ; but letters like "h" or "p" were exceedingly difficult. 2 Dancers' cramp has also been observed. Schultz 3 describes this form of disease, of which he has seen three cases. It affects the solo dancers of the ballet as a rule, and the history of one case was the following : " The patient complained of suffering very severe pains while dancing. Beginning in the soles of both feet, the pains spread with increasing severity to the calves of the legs ; they at last became so violent that her feeling of security was lost, the feet seeming as if made of wood. These pains were accompanied with violent palpitation ; and, if she continued to dance, she felt faint and sometimes lost consciousness, the body becoming quite rigid. When the pain and palpitation were less intense, the pain continued after dancing, and ceased very gradually, leaving some tender- ness of the soles ; on attempting again to dance the suffering would recur again. Dr. Schultz found, from the examination of these cases, that the cause of the pain lay in the pas performed on the points of the feet, and is owing to exhaustion of the muscles which fix the metatarsus and phalanges of the great toe. The shoe worn by the dancer, without which the ballet step seems to be impossible, is made as follows : The dancing-shoe is made rather wide ; the sole is of soft leather, and shorter than the foot, reaching only as far as the posterior third of the ungual phalanx of the great toe. The upper part, generally of satin, projects forward, and supplies the place of the deficient leather of the sole. This part of the satin is worked threads, so that it may not be torn. In the interior of the shoe, over the leather sole, is a layer of thin, firmly-pressed pasteboard, either extending over the whole breadth of the anterior part, or limited to the length of the 1 Gaz. Med. de Paris ; Chicago Journal of Mental and Nervous Diseases, July, 1875. 2 ( U ) ( d) ( h ; p.) 3 Wiener Med. Wocli. 486 DISEASES OF THE PERIPHERAL NERVES. great toe. In the former case it is carried back, gradually narrowed as far as the heel. The leather sole and its covering are lined with fine kid leather. The heel part of the shoe is quite soft, consisting only of satin ; and the shoe is fastened above the ankle by narrow ribbons. Without this preparation the pointed step is impossible." I have met with the affection among violin-players, and within the past year have had a patient under treatment. He had been diligently prac- tising a " run," which involved the necessity of complicated movements of the fingers ; and it was his custom, on arising in the morning, to spend a half hour or so in playing the difficult passage ; and on the day of the con- cert he worked for several hours at the same task, but upon attempting to play in the evening he found it utterly impossible to do so, as his fingers would become rigid and refuse to obey the will. It was some months be- fore he could again play. Onimus, 1 in describing a form of impaired power and consequent mus- cular atrophy, which he calls " professional muscular atrophy," details a case which resembles somewhat the form of functional disease which we are considering. It begins by muscular cramp, and there is subsequent loss of power with wasting. I therefore think we may consider this affec- tion as a connecting link between scrivener's cramp and progressive mus- cular atrophy. He says : " Recently I observed one case which it was most difficult to differentiate from progressive muscular atrophy, as the atrophied muscles were the same as those which are the first affected by this latter affection. They were the muscles of the thenar eminence, and chiefly the adductor pollicis. The patient was an enameller, who had to hold an object all day between his thumb and index finger. He first got cramps in the thumb, which suggested the idea of scrivener's palsy ; then tremor of the thumb, on ac- count of the fibrillary contractions ; and, lastly, atrophy. Under the influence of treatment there was a rapid amendment, which showed that the case was really one of professional muscular atrophy, and not com- mencing progressive atrophy." Causes and Pathology This spasmodic affection follows the con- tinued use of the muscles which are concerned in delicate muscular actions; and is not only produced by writing, but, as I have shown, by other forms of manipulation requiring great delicacy of coordination. The higher and the more complex is the character of these acts, and the more easily the fac- ulty to perform them becomes developed, so much the greater is the danger of the disease. An act which requires at first mental direction of a superior kind, when acquired and executed unconsciously, is much more likely to give rise to this neurosis than one of a grosser kind, or one which is con- stantly performed under the active direction of the will. For this reason writer's cramp is much more rare among those who write and meanwhile compose, than among clerks or copyists who do " machine work." Con- stant use of the pen of this kind is seen to be followed by mischief. Such 1 London Lancet, Jan. 22, 1876. PROFESSIONAL CRAMP. 487 causes as piano-playing or violin-playing are by no means rare. A young lady, sent to me by my friend Dr. D. M. Stimson, owed all her trouble to a bad habit she had contracted of reading novels while she practised her scales. In her case there was extensor paralysis, and some loss of sensa- tion, which remained after a spasmodic stage. The conditions then, with the exception of paralysis, are the result of an over-developed automatism, and are not, I am convinced, connected with any central change, though Mr. Solly 1 is inclined to consider that there is degeneration of the motor cells in the upper part of the cord. In writing a familiar word, or collection of words, the educated indi- vidual does not stop to form every letter, but the pen is unconsciously guided. It is even possible to talk while writing or playing the piano, and equally complex feats are performed while the mind is not engaged. In many of these acts the volition is directed in other channels, or is behind the muscular action. The pen travels in advance of the mind ; and should this state of things be so exaggerated as to become more than a phase of the ordinary automatism which enters into the performance of many of the functions of daily life, there remains a condition of disordered and height- ened activity which is uncontrolled by the will, and is symptomatized by the spasms of which I have spoken. A more advanced condition con- sists in exhaustion of the motor cells at the upper part of the cord, and as a result we find loss of power and occasionally atrophy. Poore 8 does not believe in the central organic origin of the disease ; but Solly, 3 Smith, 4 and Hammond 5 take this view of the case. Among 23 cases which I have seen, the occupation of the individuals was as follows : Clerks . . . .14 Stenographer . . . 1 Engraver ... 1 Musicians .... 2 Lawyers .... 2 Type-setter ... I Clergymen ... 1 Cigar-maker ... 1 As it will be seen, the patients were all men. They were all between the ages of 30 and 60, but I do not believe this latter fact has very much importance. Diagnosis Progressive muscular atrophy may be mistaken for the paralytic form, but when it is remembered that the paralysis precedes the atrophy (should such tissue-change take place), and that progressive muscular atrophy is rarely so limited, there is no reason why the real nature of the trouble should not be recognized. Neuralgia of the cervico- brachial variety is a common symptom, and its real significance may not be detected ; the subsequent element of spasm, tremor, or paralysis will, however, remove any doubt from the mind of the observer. 1 Surgical Experiences, London, 1865, p. 20.5. 2 Practitioner, June, July, and August, 1873. t Op. cit. 4 Lancet, March 27, 18G9. 5 Op. cit., p. 790. 488 DISEASES OF THE PERIPHERAL NERVES. Prognosis If the individual gives up the occupation which has pro- duced the affection, there is no reason why he should not recover, provided the disease has not become confirmed, and even in this form Jaccoud 1 speaks of a rare temporary amelioration. It has been my experience tlmt, if taken in hand promptly, the patient may be cured. Sixteen of tli -< cases were absolutely cured, and continued so as long as they refrained from their work. Two were improved, but upon beginning the pursuit of their calling had relapses. The remainder were of the paralytic variety, and are now under treatment. Treatment Rest and electricity are the means at our command. A galvanic current is found to be the most beneficial, and the electrodes should be so small as to include but one muscle at a time in the circuit. The current must be mild, or it will only aggravate the disease. Besides this application to special muscles, one pole may be placed at the nape of the neck, and the other to the muscles of the hand and forearm. A. W., aged 38. The patient had followed the occupation of clerk for several years, and had assiduously worked at his desk for many hours in the day. Two weeks before I saw him he noticed an impairment in his writing power, and this consisted in an inability to write without the occurrence of a convulsive contraction of the extensors of his right forearm, by which the pen flew from the paper. This did not occur at the moment of writing, but after a few words had been finished. He tried to keep the hand steady by the influence of the will, but all his efforts were ineffectual. When he attempted to hold the point of any small ob- ject, such as a stick or pencil, against the surface, the same spasm would occur. There was no wasting of the muscles, pain, or other symptom. I determined to try galvanism combined with manual exercise, and the internal application of strychnia in doses of g^th of a grain. Galvani/a- tion of the flexors of the forearm and of the small muscles of the hand was made, and, at the same time, the positive |x>le was held for a few minutes at the najxi of the neck. He was directed to procure the round of a chair with which to exercise. Galvanization was persevered in, although the progress was very slow. At first he could not write more than two words (almost illegibly) ; but as he grew better, these spasms disappeared. Three seances a week kept up for a period of about three months effected such an improved condition that he was finally discharged at the end of that time. Strychnia and iron, or conium (FF. 8, 9, 10, 48, 51, 72, 82), are remedies which may IK- used in conjunction. The ether spray apparatus does great good, and I have occasionally benefited my patients by fasten- ing the hand in an immovable apparatus or splint. Absolute cessation of the particular work which gave rise to the malady is to be insisted upon, and no benefit will result from any form of treatment unless this command of the physician is re*j)ected. When the patient attempts writing anew he should provide himself with a pen having a cork holder, and this may be purchased from any 1 Op. cit., p. 302. PROFESSIONAL CRAMP. 489 good stationer. He should change his system of penmanship and acquire the so-called free hand style, in which the fingers are engaged only in holding the pen, and the other motions are performed by the muscles of the forearm. The attempt at " shading" the lines should not be made, but he should endeavor to adopt the round hand and avoid "pot hooks" and " up and down" strokes as much as possible. Sea air. salt baths, and a change of habits and scene are all fraught with benefit. I do not consider tenotomy advisable except in extreme instances. FOKMULJ1. (ADULT DOSES.) 1. R. Tr. aconit. rad. 3j-3ij; Sodii bromidi 3iss; Aquae menth. pip. ad giv M. Sig- 5j t. i. d. 2. R. Tr. digital. 5 iij ; Syr. papav., Elixir cura9oa, aa |ij M. Sig- 3j at a dose. 3. R. Chloral, hydrat. gj ; Ess. menth. pip. q. s. ; Syr. tolutan., Mucil. aoac., aa 3ij M. Sig. 3j at a dose, well diluted. 4. R. Chloral, hydrat., Calcii bromidi, aa 3j > Syr. limonis ^ij ; Aquas ad ^iv M. Sig. Jj at a dose. 5. R. Dragee ergotin (Bonjean), (gr. v.), no. xx. Sig. One at a dose. FORMULA. 491 6. R. Fl. ext. ergotae ij ; Sodii bromidi iss ; Aquas camphorae ad Jfiv. M. Sig. A teaspoonful every 4 hours. 7. R. Acidi hydrocyanic! dil. n^ xx-xxxvj ; Aq. ext. ergotse 3J M. Ft. massa et divid. in capsul. no. xij. Sig. One every 3 hours. R. Stryeh. sulph. gr. ss-j ; Cinchonas sulph. 5j 5 Tr. ferri chlor. 3 V > Acidi phosph. dil., Syr. limonis, aa Jij M. Sig. A teaspoonful in water at a dose. 9. Hammond's Solution. R. Stryeh. sulph. gr. ss-j ; Quiniae sulph., Ferri pyrophos., aa 3j 5 Acidi phos. dil., Syr. zingib., aa % ij M. Sig. A teaspoonful in water at a close. 10. R. Ext. nucis vom. gr. viij ; Quin. sulph. 3j '> Ferri redacti gr. xxx M. Ft. massa et divid. in pil. no. xxx. Sig. One after eating. 11. R. Sol. strych. sulph. (gr. j-Jij) gij Ferri dialysat. Jiss; Aquae flor. aurantii ad s'\v M. Sig. A teaspoonful at a dose. FORMULAE. 12. R. Ferri carbonat. sacch. 5'j ; Cinchon. sulph. gr. xxiv. M. Divid. in chart, no. xij. Sig. One t. i. d. 13. R. Zinci oxidi 5J ; Confectio. rossB q. s M. Ft. massa et divid. in pil. no. xxx. Sig. One t. i. d. 14. R. Sol. potass, arsenitis 5ij ; Quinism sulph. 5$s ; Acidi sulph. aromat. q. s. ; Aqua? anisi ^iv M. Sig. A teaspoonful every 4 hours. 15. R. Sol. acidi hydrobromici, Elixir simplicis, aa 3ij M. Sig. A teaspoonful before each meal. 16. R. Quinine sulph. 5.) Sol. acidi hydrobromici ^iij ; Aquae campliorae ad iv M. Sig. A teaspoonful three times a day, in a tumblerful of water. 17. R. Potass, iodidi 5'j ; Potass, nit rat. 5 v j 5 Syr. scillje 3j ; Spts. ai union, acetat. ad Jiv M. Sig. A teaspoonful every 4 hours. 18. R. Potass, acetat. 5 v j ; Infus. digitalis Jviij M. Sig. A dessertspoonful three times a day. FORMULAE. 493 19. Bayhy's Pill R. Pil. hydi-arg. massae, Pulv. scilhe, Pulv. digital., aa gr. xxiv. M. Ft. massa et divid. in pil. no. xxiv. 20. R . Hydrarg. bichlor. gr. ss ; Potass, iodid. 3J ; Tr. cinch, co. Jiv M. Sig. A teaspoonful three times a day. 21. R. Tr. ferri chlor., Tr. digitalis, aa ^ss M. Sig. Ten to twenty drops, in water, three times a day. 22. R. Elaterii gr. iv ; Ext. nucis vom. gr. iij ; Confectio. rosae q. s M. Ft. massa et divid. in pil. no. xij. 23. R. Sodii bromidi, Ammon. bromidi, aa 3ss; Chloral, hydrat. 3YJ ; Tr. aconiti rad. Jiss ; Aquae menth. pip. ad iv M. Sig. A teaspoonful three times a day, or ot'tnicr it' required. 24. R . Phosphori gr. ij ; Ol. amygdala? dulc. 3j '> Ess. menth. pip. q. s. ; Mucil. acac. vj M. ,. Sig. A teaspoonful after eating. 494 FORMULAE. 25. Thompson's Solution. R. Phosphor! gr. ss-iss ; Alcohol absol. q. s. ut dis. ; Ess. menth. pip. q. s. ; Glycerin* ad Jiv __ M. Sig. A teaspoonful after eating. 26. R. Phosphori gr. ss-j ; Sevi gr. c M. Divid. in pil. no. xxv. Sig. One after eating. 27. R. Zinc, phosphidi gr. iv ; Confectio. rosae gr. xxiv. M. Ft. massa et divid. in pil. no. xij. Sig. One after eating. 28. R. Strych. sulph. gr. ss-j ; Acidi muriatici dil. Jvj ; Aquae ad giv M. Sig. 3j t. i. d. 29. R. Strych. sulph. gr. ss-j ; Acidi phosph. dil. ^ij ; Syr. simplicis ad siv. M. Sig. 3j t. i. d. 30. JJartholow's Injection for Hypodermic use. R. Strych. sulph. gr. ij ; Aq. destil. vel aquae cerasi 3J M. 81. R. Pepsini sacch. 3 v j 5 Acidi muriatici dil., Tr. nucis vom., aa ss ; Aquae cinnamomi ad ^iv __ M. Sig. A teaspoonful after each meal. FORMULAE. 495 32. R. Ol. morrhuae, Ext. malti (Loeflund), aa |iv M. Sig. A tablespoonful three times daily. 33. R. Bismuth, subcarb., Pepsini sacch., aa ^ss ; Pulv. aromatici ad iv M. Divid. in chart, no. xxiv. Sig. One t. i. d. after eating. 34. R. Pepsini sacch., Pulv. carb. ligni, aa Jss M. Divid. in chart, no. xxiv. Sig. One three times a day after eating. R. Antimon. tartrat gr. j ; Aquas ^iv. M. If emesis is desired, give one tablespoonful every half hour till vomiting is produced ; or, if continued depressing effect is desired, a teaspoonful every hour or two. 36. R. Tr. verat. virid. 3iJ ss > Aq. menth. pip. ad iv M. Sig. One teaspoonful every two hours, or oftener if needed. 37. R. Phosphori gr. j ; Ol. morrhuas Oj M. Sig. A tablespoonful at a dose. 38. R. Sodii bromidi ^iss ; Aquae camphorae, Tr. lupulin., aa 3U- M. Sig. A teaspoonful at a dose. 496 FORMULAE. 39. R. Tr. cannabis indicae 5U Aq. flor. aurantii ad sij. M. Sig. A teaspoonful at a dose. 40. R. Ferri et ammon. citratis 3$s ; Tr. cinch, co., Tr. gentianae co., aa 3y 5 Aquae ad Jviij M. Sig. A dessertspoonful ter in die. 41. R. Magnes. sulph. ^j 5 Infus. senna? giv ; Int'us. caffeae 3ij M. Sig. A wineglassful to be taken every morning, or oftener if required. 42. R. Syr. ferri iodid. 5vj ; Syr. glycyrrhizaa Jiv M. Sig. Half to a full tejispoonful after eating. 43. R. Acidi arsenici gr. j ; Pulv. nigr. pip., Ferri redacti, aa gr. xx ; Ext. gentianae q. s. M. Ft. massa et divid. in pil. no. xx. Sig. One three times a day. 44. R. Ext. belladonnas gr. iij vj ; Zinci oxidi gr. xlviij ; Syr. simplicis q. s M. Ft. massa et divid. in pil. no. xlviij. Sig. One thrice daily. FORMULA. 497 45. R. Potass, ioclidi iss ; Vini sem. colchici 3ijss ; Potass, nitrat. 5"j ; Aquae ^viij M. Sig. A tablespoonful three times a day. 46. R. Sodas bicarb., Sulph. lot., aa %ss M. Divid. in chart, no. xx. Sig. One three times a day. 47. R. Croton-chloral. 3y ss Aquae rosaa ^viij M. Sig. A tablespoonful at a dose. 48. R. Protagon. Syr. aurantii cort., aa ^j. M. Sig. Thirty drops to a teaspoonful three times a day. 49. R . lodoformi gr. xxiv ; Confectio. rosas q. s M. Ft. raassa et divid. in pil. no. xxiv. Sig. One thrice daily, or oftener if required. 50. R. Fl. ext. gelsemium semperv. 3iJ ss > Elixir simplicis ad Jiv M. Sig. One to two teaspoonsful at a dose. 51. R. Ext. conii fl. (Squibb) gss ; Soclii bromidi 3 j ; Aquas cam phone ad ^iv. M. Sig. Teaspoonful at a dose. 32 FORMULA. 52. R. Tr. moschi, Tr. lobelias, aa 3ij > Spts. etheris comp. ad 'ij M. Sig. A teaspoonful at a dose. 53 (Tanner.) R. Tr. assafoetidae 3U > Spts. ammon. aromatici 3'ij Tinct. chirata? 3 v y M- Sig. GO drops in a wineglassful of water every two or three hours. 54. R. Elix. ammonia? valerianat. Jfiij ; Chloroformae 3*ss ; Aquae camphorae ad ^iv M. Sig. 3J every 3 or 4 hours. 55. R. Zinci valerianat., Ext. hyoscyami, aa 3j M- Ft. pil. no. xl. Sig. One at a dose. 56. R. Ext. physostig. venenos. gr. xij. Divid. in pil. no. xxxvi. Sig. One every 4 hours. 57. R. Syr. calei lactophosph., Ext. malti, au 3ij M. Sig. A teaspoonful every 4 hours. 58. R. Ferri bromidi 5'j ; Syr. lat'tucarii Jiv M. Sig. Half to one teaspoonf ul every 3 or 4 hours. FORMULA. 499 59. Hypodermic Injection. R. Atropias sulph. gr. j ; Sol. Magendie 5J M. Filter, n^v-x. 60 __ (Bartholow.) R . Ext. ergotin. aq. 5j > Glycerine 3J ; Aquae Svij M. Filter. Tn,viij = gr. j. 61. R. Atropiag sulph. gr. j ; Aqua? 3j ; Acid, salicylic! q. s M. Filter. n\,x = gr. ? y 62. R. Tr. belladonnas ss ; Glycerinaj 3J ; Linim. sapon. iij. M. Ft. linimentum. 63. R. Tr. aconiti rad. Sij ; Linim. camph. comp. ad iv M. Ft. linimentum. 64. R. Tr. aconiti fol., Chloroformaa, Tr. capsici, a a Sss ; Linim. saponis ad ^iv. M. Ft. linimentum. 65. R. Unguent, veratriae j ; Rad. aconiti pulv. 5j M - Use externally (with care). 500 FORMULA. 66 (Turnbull.) R. Aconitiae gr. ij ; Spt. rectificati gtt. vj } Adipis prep. Jj M. Rub a small part on the track of the painful nerve. 67. R. Chloral-hydrat., Camphorae, aa 3\j ; Adipis ^ss M. Use locally. 68 (Tanner.) R. Camphorae 3j 5 Ext. belladonnas gr. iv ; Ext. conii gr. xlviij M. Ft. massa et divid. in pil. no. xlviij. Sig. One, thrice a day. 69. R. Emulsio pancreatin. 5i-3 ss after eating. 70. R. Ext. belladonnas gr. iv ; Ext. opii, Ext. hyoscyami, aa gr. xij M. Ft. massa et divid. in pil. no. xij. Sig. One at a dose. 71. R. Ext. hyoscyami, Ext. conii, aa gr. xxiv M. Ft. massa et divid. in pil. no xij. Sig. One or two at a dose. 72. R. Strychniae sulph. gr. j ; "Acid phosphates" (Horsford), Tinct. cimicifugte rac., aa 5ij M. Sig. Teaspoonful at a dose. FORMULA. 501 73. R. Syrupi phosphati comp. (calcis, ferri, etc.). Sig. Teaspoonful at a dose. 74. R. Tr. belladonnas, Potass, iodidi, aa Jij ; Aquaa menth. pip. |iv M. Sig. 5j t. i. d. 75. R. Tr. ferri perchloridi ^ss ; Glycerina3 Jj ; Tr. calumbae ad iv M. Sig. 3J t. i. d. 76. R. Ext. belladonna? gr. iv ; Ext. ergotce aq. 3j > Ferri sulph. exsiccat. Jss M. Ft. massa et divid. in capsul. no. xij. Sig. One every 4 hours. 77. R. Argenti nitrat. gr. vj-viij ; Confectio. rosas q. s M. Ft. massa et divid. in pil. no. xxiv. Sig. One after each meal. 78. R. Argenti nitrat., Ext. belladonnas, aa gr. vj-viij ; Ext. gentianae q. s M. Divid. in pil. no. xxiv. Sig. One after each meal. 79. R. Argenti nitrat. gr. vj-viij ; Ext. nucis vom. gr. xij M. Divid. in pil.*no. xxiv. Sis. One after each meal. 502 FORMULA. 80. R. Argenti phosphat. (tribasic.) gr. viij ; Ext. quassia? q. s M. Ft. massa et divid. in pil. no. xxiv. Sig. One after each meal. 81. R. Ext. belladonna? gr. iv ; Ol. terebinth. 3ij ; Buytri cacao q. s M. Divid. in capsul. no. xij. Sig. One t. i. d. 82. R. Tr. physostig. venenos. n^v-x ; Glycerine 5.) Aq. rosa? ^iij M. Sig. At a dose. 83. R. Tr. aconiti rad. n^v ; Chloroform n^x; Syr. papav. Jss. M. Sig. At a dose. 84. R. Ammon. bromidi, Sodii bromidi, au 3j M. Divid. in chart, no. xlviij. Put in waxed paper. Sig. Two at night, and one in the morning. 85. R. Amyl nitriti 3".j ; Alcohol, absol. ad ^ij M. The patient should be directed to provide himself with a small homa-o- jwitliic bottle, into which he is to put 3 SS f the mixture. When he has an aura of sufficient length, he may quickly empty the contents of the bottle in his handkerchief, and apply it to the nostrils. FORMULA. 503 86. R. Tri-nitro. glycerini 3ss ; Alcohol, absol. 5vj M. Sig. 8-10 drops three times a day. 87. 4 R. Camphorae monobromidi 5ss-3j ; Confectio. rosae q. s M. Divid. in capsul. no. xij. Sig. One every hour until the effect is produced. R. Tr. cannab. Ind., Tr. hyoscyami, a a 5 V 5 Tr. conii 3i ss -5'ij 5 Syr. lactucarii ad ^iv M. Sig. Teaspoonful at dose. 89. R. Tr. nucis vomicae 3 V > Spts. ammon. aromatici, Tr. capsici, aa 3 V J 5 Aquaa cam phone ad ^iv. M. Sig. Teaspoonful at a dose, in the morning. R. Tr. digitalis 3 V J ! Ferri dialysat. 3j ; Elixir Chartreuse alb. ad |iv M. Sig. 3J * i- d. in water. 91 __ Burmann's Hypodermic Solution. R. Conioe 3iij, Acidi acetic, fort. 3J5 Spts. vini rect. 3.) '> Aquae destil. ad ij. M. Sig' "l v = ^j coniaj. Begin witli one drop. 504 FORMULAE. 92. Hypodermic Injection. R. Daturiae gr. j ; Ac. acetici fort. q. s. ; Glycerine 3U ; Aqua? destil. ad ^j. M. Sijj. Bejnn with three minims. 93. R. Ammon. muriat. 3ij ; Pulv. aromatici, Jj. M. Divid. in chart, no. vj. Sig. One every hour. 94. R. Pulv. paullinas sorbilis 3j. Divid. in chart, no. xxiv. Sig. One to three every hour till relieved. 95. R. Fructus belladonna? iv ; Spts. vini rect. ^viij M. Ft. linimentum. The fresh berries should be obtained ; but, if this is impossible, the leaves, either fresh or dried, in the same quantity may be used. In either case the liniment should not be used for several days. Battery Fluid (for zinc-carbon batteries). R. Potass, bichrom. pulv. ^viij; Aqiue bullientis Ov ; "When cold, add Acidi sulpli. o v U- M INDEX. ABSENCE of blood in cutaneous vessel in hysteria, 373 of " tendon reflex" in locomotor ataxia, 277 Abstinence from food in hysteria, 377 Abuse of bromides in epilepsy, 329 Active cerebral hyperaemia, 69 Acute alcoholism, 351 cerebral anaemia, 113 cerebritis, 149 myelitis, 233 softening, 149 Adult spinal paralysis, 247 JEsthesiometer, the, 22 Sieveking's, 22 Affections of the organs of speech in chorea, 394 Agraphia, 165 Aitken on prognosis of softening, 161 Alalia, 161 Alcohol in urine, means of detecting, 358 in ventricular fluid, 357 Alcoholism, 351 acute, 352 causes of, 355 chronic, 354 definition of, 351 dingnosis of, 359 hallucination in, 353 morbid anatomy and pathology of, 356 prognosis of, 358 symptoms of, 352 treatment of, 359 Anosmia, cerebral, 113 spinal, 227 Anaesthesia, 448 auditory, 448 causes of, 449 diagnosis and prognosis of, 450 of fifth nerve, 449 hysterical, 372 of radial nerve, 449 symptoms of, 448 treatment of, 450 Aneurism of brain, 196 miliary, 198 Antero-lateral amyotrophic sclerosis, 289 causes of, 29'2 dingnosis of, 293 morbid anatomy of, 292 prognosis of, 293 symptoms of, 289 synonyms of, 289 treatment of, 293 Antero-epinal paralysis of adults, 247 causes of, 252 definition of, 247 diagnosis of, 252 morbid anatomy and pa- thology of, 252 prognosis of, 254 symptoms of, 249 synonyms of, 247 treatment of, 254 of infancy, 239 causes of, 243 definition of, 239 deformities in, 239 diagnosis of, 246 electricity in, 246 morbid anatomy and pa- thology of, 243 muscular tissue, changes in, 245 prognosis of, 246 Sinkler's case of, 239 symptoms of, 239 synonyms of, 239 treatment of, 246 Aphasia, 161 definition of, 161 diagnosis of, 175 history of, 162 infantile, 174 location of speech centre in, 168 Lordat on, 164 medico-legal study of, 177 pathology of, 167 synonyms of, 161 treatment of, 178 trephining in, 179 with left sided paralysis, 171 without lesion, 170 \poplexy, 83 Apparatus, electrical, 30 for the treatment of nervous diseases, 30 Van Bibber's, 30 Arcus senilis, the, 94 Arrangement of nerve-roots in posterior columns, 285 Arthropathies in cerebral hemorrhage, 91 Asemasia, 161 Asthenic cerebral hypersemia, 69 Atheromatous changes iu vessels, 97 Athetosis, 92 Atrophy, partial facial, 266 causes of, 268 506 INDEX. Atrophy, partial facial (continued). diagnosis of, 268 Draper's case of, 267 pathology of, 268 prognosis of, 268 synonyms of, 266 symptoms of, 266 treatment of, 269 progressive muscular, 255 with cerebral sclerosis, 183 Auditory vertigo, 124 causes of, 126 definition of, 124 diagnosis of, 128 pathology of, 12'> _ synonyms of, 124 treatment of, 128 Automatic man, the, 314 BASEDOW'S disease, 412 Basilar meningitis, 66 Bed-sores, treatment of, 238 Bell's paralysis, 453 Bloodletting in apoplexy, 108 Blue line, the, 475 Bone changes in posterior spinal sclerosis, 283 Bony growths, 198 Brain lesions. 97 tumors, 185 choked disk a symptom of, 188 diagnosis of, 199 localization of, 200 morbid anatomy of, 189 prognosis of, 202 symptoms of, 185 treatment of, 202 varieties of, 189 Brittleness of bones in locomotor ataxiii. 283 Broca on location of speech centre, 168 Brown-Se'qunrd's theory of auditory con- vulsions, 127 Bulbar diseases. 308 paralysis, 336 causes of, 339 condition of tongue in, 337 diagnosis of, 340 morbid anatomy and pathology of, 340 prognosis of, 342 progressive variety of, 339 reflex variety of, 339 stationary vnriety of, 339 symptoms of, 336 synonyms of, 336 treatment of, 342 Burrowes' experiments, 145 nAXCEROUS growths in hrain, 190 \J Case of cerehellar tremor, 194 Case of hsEmatomn, 42 of post-paralytic chorea, 93 Case (continued). of spinal tumor, with persistent reflex sensibility, 215 Catalepsy, 389 causes of, 390 definition of, 389 diagnosis of, 391 flexibilitas cerea in, 389 induced in animals, 391 malarial, 390 morbid anatomy and pathology of, 391 prognosis of, 392 symptoms of, 389 treatment of, 392 Cauteries, 32 author's, 32 glass rod, 32 fiuerard'p, 33 Pncquelin's, 33 Central neuritis, 91 spinal hemorrhage, 220 Cerebellar hemorrhage, 112 tumor, case of, 1 94 Cerebral anaemia, 113 causes of, 116 chronic, 114 definition of, 113 infantile, 115 morbid anatomy and pathology of, 118 prognosis of, 121 symptoms of, 114 synonyms of, 113 treatment of, 121 congestion, 72 hemorrhage, 83 attacks of, without loss of con- sciousness, 87 causes of, 94 condition of eyes in, 86 conjugate deviation of eyes in, 86 definition of, 83 diagnosis of, 100 morbid anatomy and pathology of, 96 post- paralytic states in, 91 prodromata of, 83 prognosis of, 104 psychical disturbance in, 85 residual paralysis in, 88 respiratory disturbance in, 86 seat of, 99 symptoms of, 83 time of attack of, 95 treatment of, 83 byperoemia, 69 causes of, 73 definition of, 69 diagnosis of, 78 influence of occupation in, 73 local, 79 morbid anatomy of, 77 pathology of, 75 INDEX. 507 Cerebral hyperaemia (continued). prognosis of, 80 symptoms of, 70 synonyms of, 69 treatment of, 80 meninges, diseases of, 35 meningitis, acute, 44 causes of, 45 diagnosis of, 46 pathology and morbid an- atomy of. 46 prognosis of, 49 symptoms of, 44 treatment of, 49 chronic, 65 treatment of, 68 pacliymeningitis, 35 acute, symptoms of, 35 chronic, causes of, 39 morbid anatomy and patho- logy of, 39 osseous plates in, 39 prognosis of, 39 (symptoms of, 37 treatment of, 40 with haematoma, 40 case of, 42 causes of, 41 formation of cysts in, 4t morbid anatomy and pa- thology of, 41 prognosis of, 44 symptoms of, 40 treatment of, 44 rheumatism, 51 sclerosis, 179 causes of, 182 'definition of, 179 diffused, 180 diagnosis of, 184 prognosis of, 184 symptoms of, 180 synonyms of, 179 treatment of, 184 softening, 148 acute, 149 causes of, 151 diagnosis of, 153 morbid anatomy and pa- thology of, 151 prognosis of, 153 symptoms of, 149 treatment of, 153 chronic, 154 causes of, 156 definition of, 154 diagnosis of, 159 morbid anatomy and pa- thology of, 157 prognosis of, 160 symptoms of, 154 treatment of, 161 classification of, 148 definition of, 148 tumors, Grasset's classification of, 190 Cerebritis, 149 Cerebro-spinal diseases, 343 meningitis, 343 retraction of head in, 344 Cerebrum and cerebellum, diseases of, 69 Cervical pachymeningitis, 204 Cervico-brachial neuralgia, 427 Cervico-occipital neumlgia, 426 Character of the deposit in so-called tubercular meningitis 59 Charcot on reduced temperature in bys- tero-epilepsy, 389 Chloral-bromide treatment in epilepsy, 333 Choked disk, 187 Chorea, 393 adult, 398 among*6chool children, 400 case of, 396 causes of, 399 definition of, 393 dependent upon tapeworm, 396 diagnosis of, 404 embolic theory of, 403 epidemic, 393 ether spray in treatment of, 405 heart lesions of, 401 malarial, 400 morbid anatomy and pathology of, 401 of pregnancy, 397 post-paralytic, 92 prognosis of, 404 symptoms of, 393 synonyms of, 393 treatment, 405 with eczema, 399 Chronic cerebral pachymeningitis with haematoma, 40 myelitis, 236 Clavus hystericus, 371 Collateral circulation, 159 Condition of organs of generation in hys- teria, 370 Congestion, cerebral, 70 spinal, 223 Congestive pernicious fever, its resem- blance to cerebro spinal meningitis, 345 Constriction band, the, 235 Contractions, fibrillary, 256 Contractures in antero-lateral sclerosis, 289 in hemiplegia, 01 in infantile paralysis, 240 paralytic, 91 Contusions and punctured wounds as causes of paralysis, 460 Convulsion as a symptom of brain tumor, 185 Convulsive cerebral congestion, 71 Coordination, 284 Corpuscles, Gluge's, 157 Cramp, dancer's, 484 telegrapher's, 484 writer's, 484 508 INDEX. Cramp (continued). professional. 484 causes of, 486 diagnosis of, 487 pathology of, 486 "Crises gastriques," 281 Cross paralysis, 89 Crum- Brown's experiments, 124 Cutaneous eruptions in locomotor ataxia, 278 DA COSTA on cerehrnl rheumatism, 51 Decuhitus paralysis, 46*2 Delayed transmission of impressions, 236 Delirium tremens, 352 Depraved appetite in hysteria, 372 Diathetic growths, 202 Diplopia, 70 Diseases of cerebral meninges, 35 of cerebrum and cerebellum, 69 Dislocation as a cause of paralysis, 461 Division of a nerve trunk as a cause of paralysis, 460 Douleureux, tic, 420 Dreams of movement, 404 Duration of life of hard drinkers, 358 Dynamometer, 25 Mathicu's, 25 the author's, 25 ECHOLALIA, 176 Eczema with chorea, 399 Education of right side of the brain, 178 Electrical apparatus, 30 Embolic theory of chorea, 403 Embolism, 129 of the cerebral vessels, 137 causes of, 141 diagnosis of, 142 morbid anatomy and pa- thology of, 145 prognosis of, 147 symptoms of, 138 treatment of, 147 Emprosthotonos, 296 Endemic tetanus, 299 Epidemic chorea, 393 Epilepsy, 308 aborted. 313 abuse of bromides in, 329 age in causation of, 316 auditory, 321 Brown-S6quard's experiments in, 320 causes of, 316 chloral- bromide treatment of, 333 definition of, 808 diagnosis of, 325 dislocation of bones in, 312 experimental production of, 321 grave attacks of, 309 heredity in, 317 history of 308 hystero, 384 induration of cornua ammonis, 819 irregular attacks of, 313 Epilepsy (continued). Jackson on, 322 light attacks of, 312 masked, 315 morbid anatomy and pathology of, 318 nocturnal, 311 prognosis of, 325 resembling hydrophobia, 369 responsibility in, 315 symptoms of, 309 synonyms of, 308 syphilitic, 325 temperature influences in, 317 treatment of, 326 warnings in, 309 Epileptiform tic, 425 Equilibrium, sense of, the, 124 Ergot in pachymeningitis, 212 Eruptions with neuralgia, 420 Essential paralysis, 239 Etat crible, the, 78 Examination of patient, 17 post-mortem, 18 Exhaustion simulating acute tubercular meningitis, 64 Exopthalmic goitre, 412 causes of, 417 definition of, 412 diagnosis of, 417 morbid anatomy and pathology of, 417 prognosis of, 417 symptoms of, 412 synonyms of, 412 treatment of, 418 unilateral, 414 Experimental production of epilepsy, 321 Extravasation of blood in neuralgia, 421 FACIAL neuralgia, 421 paralysis, 455 causes of, 454 diagnosis of. 457 electricity in, 458 pathology of, 456 prognosis of, 5 Lead poisoning, 470 causes of, 472 diagnosis of, 475 from tea drinking, 474 morbid anatomy and pathology of, 475 prognosis of, 476 synonyms of, 470 treatment of, 476 Local paralysis, 453 Localization of tumors, 200 Locomotor ataxia, 267 hysterical, 281 spurious, 281 Loring's experiments, 78 Lyssaphobia, 361 MALE hysteria, 378 Mastodynia, 431 Mdniere's disease, 124 Meningeal hemorrhage, 219 Meningitis, acute and chronic spinal, 204 symptoms of, 204 granular, 52 cerebro-spinal, 343 causes of, 344 definition of, 343 diagnosis of, 345 morbid anatomy and pathology of, 345 prognosis of, 346 symptoms of, 343 synonyms of, 343 treatment of, 346 chronic cerebral, 65 causes of, 68 diagnosis of, 68 morbid anatomy and pa- thology of, 68 prognosis of, h8 symptoms of, 65 treatment of, 68 connected with cardiac disease, 51 of the aged, 52 rheumatic, 50 senile, 52 tubercular (granular), 52 basal, 53 causes of, 58 development of, 62 diagnosis of, 53 morbid anatomy and pathology of, 59 prognosis of, 62 symptoms of, 53 treatment of, 64 tubercular deposits in, 61 vertical, 53 vital signs in, 55 510 INDEX. Meningo-cerebritis, 149 Mental changes in looomotor ataxia, 279 Migraine, 4*21 Miliary aneurisms, 98 Mimetic chorea, 400 Morbid impulses in hysteria, 372 Mortality in tubercular meningitis, 58 Mottled skin in pseudo-bypertrophic paralysis, 273 Multiple embolism, 139 Myelitis, 236 causes of, 236 cbronic, 236 diagnosis of, 237 morbid anatomy and pathology of, 237 symptoms of, 236 treatment of, 238 troubles in, 235 NERVES, tumors of, 451 Neuralgia, age and sex in causation of, 434 association with epilepsy, 432 bad teeth as a cause of, 434 causes of, 432 cervico-occipital, 426 circulatory disturbances in, 420 clavus, 423 coarse nnd fine varieties of, 439 connection with pulmonary disease, 432 crural, 4 definition of, 419 diagnosis of, 436 electricity in treatment of, 442 excision of supra-orbital in, 424 facial, 421 influence of temperature in, 435 intercostal, 428 inveterate case of, an, 437 morbid anatomy of, 436 nerve areas in, 441 uerve section in, 432 of testis, 424 ovarian, 431 pain of, 419 prognosis of, 436 renal, 431 sciatic, 428 syphilitic, 422 treatment of, 438 trigcminal, 421 trophic disturbances in, 420 urethra), 431 visceral, 430 Neuritis, 444 causes of, 446 morbid anatomy and pathology of, 446 nerve section in, 447 stretching in, 447 prognosis of, 447 symptoms of, 444 treatment of, 447 Neuritis (continued). trophic changes in, 445 Neuromata, sarcomatous, 402 treatment of, 452 Nystagmus, 189 OCCLUSION of intracranial vessels, 129 Occupation, and its relation to cere- bral hyperaemia, 73 Oculnr trouble with brain tumor, 187 Ophthalmoscope, the, 28 Opisthotonos, 296 Organs of speech, affection of in chorea, 394 DACHYMENINGITIS as a result of in- 1. jury, 35 spinal, causes of, 207 diagnosis of, 211 morbid anatomy and pathology of, 208 prognosis of, 210 symptoms of, 206 treatment of, 211 Painters' colic, 470 Palsy, Scrivener's, 486 shaking, 406 wasting, 255 Paralysis, adult spinal, 247 after dislocation, 461 agitans, 406 case of, 408 causes of, 408 diagnosis of, 410 morbid anatontfj^nind pathology of, 409 prognosis of, 411 symptoms of, 407 synonyms of, 406 treatment of, 411 nntero-spinal, of infancy, 239 bulbar, 336 cross, 89 Cruveilhier's, 256 diphtheritic, 466 case of, 467 causes of, 468 diagnosis of, 469 morbid anatomy and pathology of, 468 prognosis of, 469 symptoms of, 467 treatment of, 4(i9 facial, 453 from pressure of forceps, 462 heat in the treatment of, 111 hysterical, 375 local, 453 of cranial nerves, 277 of sphincters, 235 pseudo-hypertrophic, 269 residual, 88 temporary spinal, 251 traumatic, 453 Paralytic chorea, 395 INDEX. ' 511 Paraplegia, 234 hysterical, 375 Parkinson's disease, 406 Partial cerebral anaemia, 113 Passive cerebral hyperaemia, 69 Pathology of spasm, 483 Perivascular spaces, the, 75 Petrina on localization, 200 Piesmeter, the, 26 Pleurodynia, 428 Pleurosthotonos, 296 Poisoning, lead, 470 Posterior spinal sclerosis, 276 ascending and descending, 277 bladder complication in, 277 causes of, 281 diagnosis of, 286 morbid anatomy and pa- thology of, 282 neuralgia in, 276 prognosis of, 287 state of mind in, 277 symptoms of, 276 synonyms of, 276 treatment of, 287 Post-hemiplegic disorders of movement, 92 Post-paralytic chorea, 92 Primary and compensatory contractions in paralysis, 240 Prodromata of infantile palsy, 239 Professional cramp, 484 muscular atrophy, 486 Progressive muscular atrophy, 255 causes of, 268 definition of, 255 diagnosis of, 363 history of, 255 morb'nl anatomy and pa- thology of, 259 prognosis of, 265 resembling lead palsy, 263 symptoms of, 255 synonyms of, 255 treatment of, 255 Pseudo-hypertrophic muscular paralysis, 269 cases of, 271 causes of, 273 diagnosis of, 275 heredity in, 273 lordosis in, 272 pathology and morbid an- atomy of, 274 prognosis of, 275 symptoms of, 269 synonyms of, 269 treatment of, 275 Puerperal embolism, 142 hysteria, 379 RABIES canina, 361 Reflex spasm, 481 Retraction of head in cerebro-spinal meningitis, 344 Rigor, 35 Risus sardonicus, 295 Rombergon delayed transmission of pain- ful impressions, 236 Rubber muscle, the, 32 SCIATICA, 428 Sclerosis, antero-lateral, 289 cerebral, 179 cerebro-spinal, 343 causes of, 350 diagnosis of, 351 morbid anatomy and pathology of, 350 prognosis of, 851 resembling paralysis agitans, 351 stages of, 346 symptoms of, 346 synonyms of, 346 treatment of, 351 lateral, 293 posterior-spinal, 276 Scle"rose en plaques, 346 Scrivener's palsy, 486 Seat of cerebral hemorrhage, 99 Senile meningitis, 52 Seventh nerve, paralysis of, 457 Shaking palsy, 406 Sieveking's oesthe.siometer, 22 Simple apoplexy, 83 Sleep not necessarily due to cerebral anaemia, 120 Softening after vascular plugging, 134 cerebral, 148 not necessarily an inflammatory pro- cess, 148 of posterior columns in tetanus, 303 Spaces, the perivascular, 75 Spasm, facial, without pain, 482 from genital irritation, 481 functional, 479 with voluntary movements, 480 pathology of, 483 reflex, 481 treatment of, 483 Spinal anaemia, so-called, 227 Gribney on traumatic causation of, 226 Griffin on, 227 . congestion, 223 symptoms of, 223 hemorrhage, 218 causes of, 219 diagnosis of, 221 morbid anatomy and pathology of, 220 prognosis of, 221 symptoms of, 219 synonyms, 218 treatment of, 222 hypersemia, subacute, 224 causes of, 224 diagnosis of, 226 morbid anatomy and patho- logy of, 225 512 INDEX. Spinal hypersemia, snbacute (continued). prognosis of, 226 symptoms of, 224 treatment of, 226 irritation, 227 causes of, 229 diagnosis of, 231 morbid anatomy and pathology of, 230 prognosis of, 231 symptoms of, 227 treatment of, 231 meninges, diseases of, 204 meningitis, acute and chronic, 204 pachymeningitis, 206 causes of, 207 symptoms of, 206 paralysis, temporary, 251 tumor, 213 causes of, 217 diagnosis of, 218 morbid anatomy and pathology of, 218 prognosis of, 218 symptoms of, 213 treatment of, 218 varieties of, 213 Spurious locomotor ataxia, 281 Staining solutions, 21 Sthenic cerebral hyperseraia, 69 Stomachic vertigo, 123 St. Vitus' dance, 393 Syncope, 113 Syphilis of the brain, 192 Syphilitic epilepsy, 325 pachymeningitis, 37 rTABES dorsalis, 276 1 Tin-lie carebrale, 56 Tarantism, 393 Temporary spinal paralysis, 251 Tetanus, 303 allied to strychnia poisoning, 303 causes of, 298 curare in, S07 definition of, 295 diagnosis of, 305 endemic, 299 morbid anatomy and pathology of, 302 nascentium, 297 pleurosthotonos in, 296 prognosis of, 305 risus sardonicus in, 295 softening of posterior column in, 303 statistics, 305 Tetanus (continued). symptoms of, 295 synonyms of, 295 treatment of, 306 urine in, 297 Tetany, 480 The epileptic zone, 322 Theory of sleep, 120 Thermometer, the, 22 Thrombosis, 129 of cerebral arteries, 129 case of, 130 causes of, 133 diagnosis of, 135 morbid anatomy and pa- thology of, 133 treatment of, 135 of sinuses and veins, 135 after aural disease, 1 35 Tic douleureux, 420 epileptiform, 425 Torticollis, 483 Traumatic paralysis, 463 diagnosis of, 463 prognosis of, 463 treatment of, 464 Treatment of bed-sores, 238 of spasm, 483 Tremor, 409 functional, 410 Trismus nascentium, 297 Trophic changes in traumatic paralysis, 460 Tubercular deposit in motor centre, 61 Tumors of brain, 185 of nerves, 451 spinal, 213 TTNILATERAL tremor as a result of U localized meningitis, 46 Unreliability of post-mortem appearances in hydrophobia, 867 Urine in tetanus, 297 VARIATIONS of temperature in cere- bral hemorrhage, 86 Vertigo, 123 W r IRE hook in treatment of facial paralysis, 458 Writers' cramp, 484 r / ONE, the epileptic, 321 (LATE LEA * BLANCHARD'S) OF MEDICAL AND SUEGICAL PUBLICATIONS, In asking the attention of the profession to the works advertised in the follow pages, the publisher would state that no pains are "spared to secure a c g f the confidence earned for the publication^' the hoie by 5he ^ca * f StToa'and accuracy and finish ot execution. The printed prices are those at which books can generally be supplied by booksellers throughout the United .States, who can readily procure for their customers an works not kept in stock. Where access to bookstores is not convenient, books will be by mail post-paid on receipt of the price, but no risks are assumed either on the money or the books, and no publications hut my own are supplied. Gentlemen will theretore in most cases find it more convenient to deal with the nearest bookseller An ILLUSTRATED OATAT.OOUK, of (H octavo pages, handsomely printed wilf be for warded by mail, post-paid, on receipt of ten cents. Nos. 706 and'708 SANSOM ST., PHILADELPHIA, June. 1878. ADDITIONAL INDUCEMENT FOR SUBSCRIBERS TO THE AMERICAN JOIIRNAL_OF^THE MEDICAL SCIENCES. THREE MEDICAL JOURNALS, containing over 2000 LARGE PAGES, Free of Postage, for SIX DOLLARS Per Annum, TERMS FOR 1878: The AMERICAN JOURNAL OF THK MEDICAL SCIENCES and 1 Five Dollars per annum, The MKDICAL NEWS AND LIBRARY, both free of postage, } in advance. O.R THK AMERICAN JOURNAL OF THK MEDICAL SCIENCES, published quar- ~) . n terly (HoO pages per annum), with ollars, The MEDICAL NEWS AND LIBRARY, monthly (384 pp. perannum), and j- per annum, TH MONTHLY ABSTRACT OF MEDICAL SCIKNCK (592 pages per I annum). j in advance. ** Advance paying subscribers can obtain at the close of the year cloth covers, gilt-lettered, for each volume of the Journal (two annually), and of the Abstract (one annually), free by mail, by remitting ten cents for each cover. SKI'AltATE Sr/lSCRlI'TJOXS TO THE AMERICAN JOURNAL OF THK MEDICAL SCIENCES, when not paid for in advance, Five Dollars. THK MEDICAL NEWS AND LIBRARY, free of postage, in advance, One Dollar. THE MONTHLY ABSTRACT OK MKDICAL SCIENCE, free of postage, in advance, Two Dollars and a Half. In commencing a new half century in the career of the "AMERICAN JOURNAL OF THE MKDICAL SCIENCES," the publisher has much pleasure in assuring its wide circle of readers that, at no former period has it had the prospect of a more extended sphere of usefulness. Sustained as it is by the profession of the whole United States, and with a circulation extending to every country in which the English language is read, the efforts of the editors will be directed, as heretofore, to render it in every way worthy of its reputation, and of the universal favor with which it is received. With its attendant periodicals, the "MKDICAL NEWS AND LIBRARY'' and the "MONTHLY AB- STRACT OF MEDICAL SCIENCE," it combines the advantages of the elaborate preparation which can be given to a quarterly, and the prompt conveyance of intelligence by the monthly, while the whole, being under a single editorial supervision, the subscriber is secured against the duplication of matter inevitable under other circumstunr< >. These efforts the publisher seeks to second by offering these periodicals at a price unprecedentedly low a price which places them within the reach of every practitioner, arid gives the equivalent of three large octavo volumes for the comparatively trifling ("For THE OBSTKTRICAL, JOURNAL," see p. 23 ) 2 HENRY C. LEX'S PUBLICATIONS (Am. Journ. Med. Sciences). cost of Six DOLLARS per annum. The three periodicals thus offered are universally known for their high professional fttaudiug in their several spheres. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, EDITKDBT ISAAC HAYS, M.D., AITD I. MINIS HAYS, M.D., is published Quarterly, on the first of January. April. July, and October. Each num- ber contains nearly three hundred larpe octavo pages, appropriately illustrated wher- ever necessary. It has now been issued regularly tor over FIKTY years, during the whole of which time it has been under the control of the present senior editor. Through- oat this long period, it ha* maintained its position in the highest rank of medical peri- odicals both at home and abroad, and has received the cordial support of the entire profession in this country. Among its Collaborators will be found a large cumber of the most distinguished names of the profession in every section of the United States, rendering its original department a truly national exponent of American medicine.* Following this is the ''RgriRW DRPARTMBNT," containing extended and impartial reviews of important new works, together with numerous elaborate "ANALYTICAL AND BIBLIOGRAPHICAL NOTIOKS" giving a complete survey of medical literature.. This is followed by the "QUARTERLY SUMMARY OF IMPROVEMENTS AND DISCOTKRIE? IN THE MEDICAL SCIENCES," classified and arranged under different heads, presenting a very complete digest of medical progress abroad as well as at home. Thus, during the year 1877, the "JOURNAL" furnished to its subscribers 101 Original Communications, 1H5 Reviews and Bibliographical Notices, and 227 articles in the Quarterly Summaries, making a total of FOUR HTNDKED AND SIXTY-THKER articles illustrated with 64 maps and wood engravings, emanating from the best professional minds in America and Europe. That the efforts thus made to maintain the high reputation of the "JOURNAL" are fuccessful, is shown by the position accorded to it in both America and Europe as a leading organ of medical progress : This i* universally acknowledged as tbe leading! The Philadelphia Medical and Physical Journal American Journal, H ml has been conducted by Or ! issued its first number in 1S20, and after a brilliant Hays alone until I860, when his son was associated 'career, was succeeded in 1>;7 by the American with him. We quite agree with tbe critic, that this 'Journal of tbe Medical Sciences, a periodical of journal is second to none in the language, and cheer- world-wide reputation; the ablest and u<- of the fully accord toil tbe first place, for uowhere shall ! oldest periodicals in the world a journal which baa we find more able and more impartial criticism, and nowhere such a rep-rtory of able original articles Indeed, now that the "British and Foreign Medic><- Chirnrgical Review" ban terminated it career, the American Journal Maud* without a rival. London Md. Times and Gazette, Mov. 24, 1877. The present number of the American Journal Is an exceedingly good on. and gives every promise of maintaining the well-earned repntalin< f the re view Our venerable contemporary bag our best wishes, and we can only expre-s the hope that it may con- tinue its work with as much vigor and excellence for the next flf y years ax it has exhibited in the past. an nnsullied record. Ctrosa'y Uiatury of A.mtricu.n Jft-d. LUf.ratv.rf., 187. It is universally acknowledged to be tbe leading American medical journal, and, iu oar opinion, is second to none in tne language Bosttn Med. nmi Stirg. Journal, Oct. 1^77 This is the medical journal of onr country to which the American physician abroad will point witli tlin greatest sati faction, as reflecting the state of iiiedivaj culture iu bis country. For a great mauy years it hat been the medium tlirongh which onr ablest writ- ers have made kuowu their 8 and observa- tions AMrf.es of L. P Yrrn'teU. M.D., before Inter- London Lnnctt, Nov. 24, 1877. i national Mtd. Congrut, fcept. 1670. And that it was specifically included in the award of a medal of merit to the Publisher in the Vienna Exhibition in 1873. The subscription price of the AMERICAN JOURNAL OF THE MEDICAL SCIENCES" has never been raised during its long career. It is still FIVE DOLLARS per annum ; and when paid for in advance, the subscriber receives in addition tbe " MEDICAL NKWS AM> LIBRARY," making in all about 1500 large octavo pages per annum, free of postage. II. THE MEDICAL NEWS AND LIBRAKY is a monthly periodical of Thirty-two large octavo pages, making 384 pages per annum. Its '-LIBRARY DEPARTMENT" is devoted to publishing standard works on the various branches of medical science, paged separately, so that they can be detached for binding, when complete. In this manner subscribers have received, without ex- pense, such works as WATSON'B PRACTICE," "WEST ON CHILDREN." "MALOAKJNE'S SUROKRY," "STOKKS ON FEVER," and many other volumes of the highest reputation and usefulness. GOSSELIN'S " CLINICAL LECTURES ON SUROERY," having been com- pleted in the number for June, 1878, with July will be commenced the publication of -LECTURES ON THK D SBASES OK THE NERVOUS SXSTBM," by J. M. CHARCOT, Professor to the Faculty of Medicine of Paris, translated from the French by (J.EOROB SIGERSON. * Communications are invited from gentlemen in all parts of the country. Elaborate articles inserted by the EJUr are paid for by tbe Publisher. ( HENRY C. LEA'S PUBLICATIONS (/1m. Journ. .Med. Sciences). 3 M D.. M.Ch., Lecturer on Biolopy, etc., Catholic Univ. of I relate] (see p 16) thus rendering this date a valuable and convenient time to comnn nee subscriptions Ihe "NKWs DEPARTMENT" of the "MEDICAL NEWS AND LIBRARY" presents the current information of the month, with Clinical Lectures and Hospital Gleaning A new and attractive feature of this will be found in an I'laborate series of ORIOINAL AMERICAN CLINICAL LKCTURKS, specially contributed to the News by gentlemen of ihe highest reputation in the profession throughout the United States. The amuse- ments for this are not as yet completed, but already the co-operation bus be~en secured of the following: S. 1). GROSS. M.D , Prof, of Surgery. Jefferson Med Coll . Philada. ROBERTS BAKTHOLOW. M.D.. Prof. Theory and Practice of Med.. M ;d. Coll. of Ohio T. G. RICHARDSON, M IX. Prof. Genl. arid Clin. Surg., Univ. of La., New Orleans WILLIAM GOODEI.L. M.D.. Prof. Clin. Gyncecolosy, Univ. of Penna. FORDYCK BARKKR. M.I).. Prof. Clin. Midwiiery, Ac.. Bellevue Hosp. Med. Coll NY N. S. DAVIS, M.D., Prof. Prin and Prac. of Med.. Chicago Med. Coll. L. A. DCHRI.VO. M.D.. Clia. Prof, of Diseases of the Skin, Univ. of Penna. J. P. WHITE, M. D.. Prof, of Obstetrics. c., Univ. of Buffalo. JOHN ASHHURST. Jr., M D , Prof, of Clin. Surg.. Univ. of Penna. D. WARREN BRICKKLL. M.D.. Prof. Obstetrics. c., Charity Hosp. Med Coll. N. WILLIAM PKPPKR. M.D.. Prof. Clin. Medicine. Univ. of Penna. J. LEWIS SMITH, M..D., Cliu. Lee. on Die. of Chil., Bellevue Hosp Med. Coll., N. Y. WILLIAM F. NORKIS. Ml)., Clin. Prof, of Diseases of the Kye. Univ. of Penna. P. S. CONNER. M.D.. Prof, of Anat. and Clin. Surgery, Med. Coll. of Ohio, Uin. THOMAS G. MORTOX. M. I)., Surgeon to Penna. Hospital, Philad.i. F. J. BUMSTKAD. MD.. late Prof, of Venereal Dia., Coll. Phys. and Surg., N. Y. J. Fl. HUTCHINSOX, M D., Physician to Penna. Hospital. F. PKYRK PORCH ER, M.D . Prof of Mat. Med. and Cliu. Medicine, Med. Coll. of S.C. CHRISTOPHER JOHNSON. M.D., Prof, of Surgery, Univ. of MJ., Baltimore. S. W. GROSS. M.D.. rinrg. to Philada. Hospital. WILLIAM THOMSON, M D., Lecturer on Ophthalmology, Jeff. Med. Coll., Philada. With contributors such as these, representing every portion of the United States the publisher feels safe in promising to the subscriber a series of practical lectures unsurpassed in variety, interest, and value. As stated above, the subscription .>rice of the "MKDICAL NEWS AND LIBRARY" is ONE DOLLAR per annum in advance; and it is furnished without charge to all advance- paying subscribers to the "AMERICAN JOURNAL OF THE MEDICAL .SOIKXCKS." III. THE MONTHLY ABSTRACT OF MEDICAL SCIKNCE is issued on the first of every month, each number containing forty-eight large octavo pages, thus furnishing in the course of the year about six hundred pages. The aim of the ' ABSTRACT" is to present without, duplicating the matter in the " JOURNAL" and ' NEWS" a careful condensation of all that is new and important in the medical journalism of the world, and all the prominent professional periodicals of both hemi- spheres are at the disposal of the Editors. To show the manner in which this plan has been carried out it is sufficient to state that during the year 1877 it contained .?? Art'n-lcs mi An"tnmff <*'( P///vo/oj7//. X? " < Mut'-i-iti Maiicti .v CONSKRVA- TITE MEIMCINR" (see p. 15), or of "STUROKS'S CUMOAI. MKDICINK" (see p. 14), or of the new edition of "SWAYNK'S OBSTKTRIC APHORISMS" (see p. 22). or of "TANNKR'S CLINICAL MANUAL" (see p. 5), or of "CMAMBKRS'S RESTORATIVK MRDICINK" (see p. 18), or of "\VEST ON NERVOUS DISORDERS OF CHILDREN'' (see p. 21). * * (jientlemen desiring to avail themselves of the advantages thus offered will do well to forward their subscriptions at an early day, in order to insure the receipt of complete sets for the year 1878. ^g" The safest mode of remittance is by bank check or postal money order, drawn to the order of the undersigned. Where these are not accessible, remittanves for the "JOURNAL" may be made at the risk of the publisher, by forwarding in RKOISTKKKD letters. Address, 1I1.NRY C. LEA, Nos. 706 and 708 SANSOM ST., PHILADELPHIA, PA. riUNOLISON (ROBLEY), M.D., "^ Late Professor of Ingt itutts of Medicine in Jefferson Medical College, Philadelphia. MEDICAL LEXICON; A DICTIONARY OF MEDICAL SCIENCE: Con- taining a concise explanation of the various Subject? and Terms of Anatomy, Physioloj y. Pathology, Hygiene, Therapeutics. Pharmacology, Pharmacy, Surgery, Obstetrics, Medic n I Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters; Formulae f< T Officinal, Empirical, and Dietetic Preparations ; with the Accentuation and Etymology c f the Terms, and the French and other Synonymes ; so as to constitute a French as well as English Medical Lexicon. A New Edition. Thoroughly Revised, and very greatly Mod- ified and Augmented. By RICHARD J. I'UNGLISON, M.D. In one very large and hand- some royal octavo volume of over 1100 pages. Cloth, $6 50; leather, raised bands, $7 50. (Just Issued.) The ohject of the author from the outset has not been to make the work a mere lexicon or dictionary of terms, but to afford, under each, a condensed view of its various medical relations, and thus to render the work an epitome of the existing condition of medical science. Starting with this view, the immense demand which has existed for the work has enabled him, in repeated revisions, to augment its completeness and usefulness, until at length it has attained the position of a recognized and standard authority wherever the language is spoken. Special pains have been taken in the preparation of the present edition to maintain this en viablereputntion. Puringthe t n years which have elapsed since the last revision, the additior s to the nomenclature of the medical sciences have been greater than perhaps in any similar period of the past, nnd up to the time of his death the author labored assiduously to incorporate every- thing requiring the attention of the student or practitioner. Since then, the editor has been equally industrious, so that the additions to the vocabulary are more numerous than in any pre- vious revision. Especial attention hap been bestowed on the accentuation, which will be found marked on every word. The typ -graphical arrangement has been much improved, rendering reference much more easy, nnd evsry care hns been taken with the mechanical execution. The work has been printed on new type, small but exceedingly clear, with an enlarged pnge, so that lie additions have been incorporated with an increase of but little over a hundred pages, and the volume now contains the matter of at least four ordinary octavos. A book well known to our reader*, and of which .j Cory of technical terms is simply a rinf qua non. In a every American ought to lit- proud. A'heu thu learned .i-icnre HO extensive, and with such collaterals H* nirdi- author of the work pact-oil nway. probably all of us line, It is as much n necessity also to the practising feared lest th honk should n< t maintain its place physician. To meet the wants of students and most in the advancing science wlme terms it defines. Knr- physicians, the dictionary rnufct be condensed while tunately, Dr. Kichnrd J. Dunirlison. having assisted hie futher in the revision of several editions of the work, and having been, therefore, trnined in the met hods and omprehensive, and practical while perspicacious. Jt *ras because Dunglison's met these indications that it became at once the dictionary of general use wherever imbued with the spirit of the book, has been able to medicine was studied in the Knclish language. In edit it. not in the patchwork manner so dear to the I former revision have the alterations and additions heart of book editors, so repulsive to the taste of intel- ligent book readers, but to edit it us a work, of the kind should be edited to carry it on steadily, without jar or interruption, along the grooves of thought it has travelled during its li r e!inie. To show the magnitude of the task which Dr Dunuli^on has acstimed and car- ried throiiL-h.it is only necessary to t-taie that more great. More than six thousand new subjects and terms nave been added. The chief terms have been set in black 'etter, while the derivatives follow in small caps; an arrangement whicb greatly facilitates reference. We may safely confirm the hope ventured by the editor " that tlie work, which possesses for him a filial as well ' an Individual interest, will be found worthy a con- than six thousand new subjects have been added in the | 'immure of the position so long accorded to it as a present edition. I'/nla. Mrit. Tinitt, Jan. 3, 1874. "tandard authoritv." CHncintmti Clinic, Jan. 10, 1874. About the first book purchased by the medical stu ' It has the rare merit that it certainly has no ri al dent is the Medical Dictionary. The lexicon explana- in the English language for accuracy and extent .-i' 1 references. London Medical Gatette. HENRY C. LEA'S PUBLICATIONS (Manuals). A CENTURY OF AMERICAN MEDICIXE. ITTii-lBTG. Bv Doctors E H Clarke, H. J. Bigelow, S. D. Gross, T. G. Thomas, and J. S. Billings. In one very hand' some 12tno. volume of about 350 pages : cloth, $2 25. (Just Ready.) This work has appeared in the pages of the American Journal of Medical Sciences during the year 1876. A? a detailed account of the development of medical science in America, by gentle- men of the highest authority in their respective departments, the profession will no' doubt wel- come it in a form adapted for preservation and reference. JJOBLYN (RICHARD D.), M.D. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. Revised, with numerous additions, by ISAAC HATS, M.D., Editor of the "American Journal of the Medical Sciences." In one large royal 12mo. volume of over 500 double-columned pages ; cloth, $1 50 ; leather, $2 00. Tt is the best book of definitions we have, and ought always to be nponthe cttfdnt'i tabl*. Southern M-.-1. . volume, of about one thousand pages, with 374 wood cuts, cloth, $4; strongly bound in leather, with raised bands, $4 75. TJARTSHORNE (HENRF), M. Z>., ** Professor of Hygiene in the University of Pennsylvania. A CONSPECTUS OF THE MEDICAL SCIENCES; containing Handbooks on Anatomy, Physylogy, Chemistry, Materia Medica, Practical Medicine, Surgery, and Obstetrics. Second Edition, thoroughly revised and improved. In one large royal 12mo. volume of more than 1000 closely printed pages, with 477 illustrations on wood. Cioth, $4 25 ; leather, $5 00. (Lately Itstitd.) We cau say with the strictest truth that it is the liest work of the kind with whicli we are acquainted It embodies iua condensed form all recent coutribu- deots, but to many others who may desire to refresh their memories with the smallest possible expendi- ture of time. S. Y. Wed. Journal, Sept. l>7i. tious to praciica.1 mediclo*, nd is therefore useful j The student will find tbiMhe most convenient and lo every busy practitioner throughout oar country, , age f u i book of the kind on which he can lay his besides being admirably adapted to the use of stn j band. Pacific Jfr.d awl tiurg. Journ., Aug 1S74 deuts of mediciue. The hook is faithfully acd ably executed Charleston Med. Journ , April, \-'-< The work is intruded as an aid to the medical stu This is the best book of its kind that we have ever fxamined. It is an honest, accurate, and conci;-* comppiul of medical sciences, as fairly an possible dent, aud as such appears to admirably fulfil its ob- | representing their present condition. The chances ent, aud as such appears to admirably fulti! its ob- ; re |irHseuting their present condition. Tl eel byitsexcellent arrangement, thefullcompilalioo- 1 aB( j tne additions have beensojudiciousan of ficts the perspicuity a.,d terseness of language, , pd the clear and instructive illustrations in" . nut- parts of the work American Jonrn. of Pharmacy, Philadelphia, July, 1S74. The volume will be found useful, not only to stu | nd th as to render it. so far a* it goes, entirely trustworthy, [f students mast have ft conspectus, they will be wise to procure that of Dr Hurtshorne. Detroit Stv. of Med anil Ptiarm., Aug 1S74. T UDLOW(J.L.), M.D. A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics To which is added a Medical Formulary. Third edition, thoroughly revised and greatly extended and enlarged. With 370 illustrations. In one handsome roysl 12mo volume of 816 large pages, cloth, $3 25 ; leather, $3 75. The arrangement of this volume in the form of question and answer renders especially suit- able for the office examination of students, and for those preparing for gradu fTANNER (THOMAS HA WKES), M. D., &c. 1 A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAO- NOSIS. Third American from the Second London Edition. Revised and TILBURY Fox, M. D., Physician to the Skin Department in University College Hospital, Ac. In one neat volume small 12mo., of about 375 pages, cloth, $1 *** On page 4, it will be seen that this work is offered as a premium for procuring new subscribers to the " AMERICAN JOCRNAL or THIS MEDICAL SCIENCES. HXNUY C. LA'S PrjBLiOATiorfs (Anatomy). QRAY (HENRY), F.R.S., Ltcturtr on Anatomy at St. Oeorge't Hospital, London. ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by H. V. CARTER, M.D., and Dr WESTHACOTT. The Disfections jointly r>y the AtfTHOnand DR. CARTER. With nn Introduction on General Antinomy and Development >>j T HOJ.MKH, M.A.. Surgeon to St. George's Ho.pi'al. A new American, from the eighth enlargec and improved London edition To which i added " LAMIMARKN. MEDICAI, AII> STHGICAL," by LIITIIBR HUI.DEK. F.R C.S.. author of" Human Osteology," " A Manual of Dissections," etc. In one map rificent imperial octavo volume of nearly 1070 pages, with 622 large and elaborate engravings on w^ood. (Nrrly Rtady.) The author has endeavored in thin work to cover a more extended range ol subject* than is eu>* txnary in the ordinary text-books, by giving not only the details necessary for the student, but also the application of those details in the practice of medicine and surgery, thns rendering it both guide for the learner, and an admirable work of reference for the active practitioner. The en- gravings form a special feature in the work, many of them being the sire of nature, nearly nl) original, and having the names of the various parts printed on the body of the cut, in place of figures of reference, with descriptions at the foot. They thns form a complete and splendid series, which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve tc refresh the memory of those who may find in the exigencies of practice the necessity of recalling the details of the dissecting room ; while combining, as it does, a complete A tins of Anatomy, with a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of essentinl use to all physicians who receive students in their office*, relieving both preceptor nml pupil of much labor in laying the groundwork of a thorough medicnl education. Since the appenrnnee of the last Ainericnn Edition, the work has received three revisioss nt the hands of its accomplished editor, Mr. Holmes, who has sedulously introduced whatever has seemed requisite to maintain its reputation as a complete and authoritative standard text-book and work of reference. Still further to increase its usefulness, there has been appended to it the recent work by the distinguished anatomist, Mr. Luther Holden "Landmarks. Medicnl and Surgical'' which gives in a clear, condensed, and systematic way, all the information by which the prac- titioner can determine from the external surface of the body the position of internal parts. Thus complete, the work, it is believed, will furnish all .the assistance that, can be rendered by typeand illustration in anatomical stndy. No pnins have been spared in the typographical execution of the volume, which will be found in all respects superior to former issues. Notwithstanding the increase of size, amounting to over TOO pages and 57 illustrations, it will be kept, as heretofore, at a price rendering it one of the cheapest works ever offered to the American profession. ALSO FOR SALE SEPARATE TJOLDEN (LUTHER), F.R.C.S., Surge tn tt fit. B irthtlotnew 8 and the Fwwlling HnpfMtd.andSvrg.r. 1S78. '1'iiii little work is a inont valuable collection of plain, simple, and practical dints; it contains in- struction which will be invaluable to the busy prac- titioner as well BJ to the wludvnt of medicine, and w heartily commend It to our readers. Canadn Stud. and Sitry. /<>rn., April, 1.S7S. QMITH (HENRY H.), M.D., and UORNER ( WILLIAM E.), M.D., Pro/. .), -^*- Proffgxnr of Comparative Anatomy and PhysioUtgy in th. Univ. of Pa. A SYSTEM OF HUMAN ANATOMY: INCLUDING ITS MEDICAL and Surgical Relations. For the Use of Practitioners and Students of Medicine. With nn Introductory Chapter on Histology. By E. 0. SHAKESPKAUE, M D , Ophthalmologist to the Phila. IIosp. In one large and handsome quarto volume, with several hundred original illustrations on lithographic plates, and numerous wood-cuts in the test. (Preparing.) In this elaborate work, which has been in active preparation for several years, the author hag sought to give, not only the details of descriptive anatomy in a clear nnd condensed form, but also the practical applications of the science to medicine and surgery. The work thus has claims upon the attention of the general practitioner, as well as of the student, enabling him not only to re- fresh his recollections of the dissecting room, but also to recognize the significance of all varia- tions from normal conditions. The marked utility of the object thus sought by the author is self-evident, and his long experience and assiduous devotion to its thorough development are a sufficient guarantee of the manner in which his aims have been carried out. No pains have been spured with the illustrations. Those of normal anatomy are from original dissecti jns, drawn on stone by Mr. Hermann Faber, with the name of every part clearly engraved upon the figure, after the manner of " Holden" and "Gray" and in every typographical detail it will be the effort of the publisher to render the volume worthy of the very distinguished position which id aaticipated for it. .XTILSON (ERASMUS}, F.R.S. A SYSTEM OF HUMAN ANATOMY, General and Special. Edited by W. H. ftocHKCHT, M. D., Professor of General and Surgical Anatomy in the Medical Col- lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In one large and handsome octavo volume, of over 600 large pages ; cloth, $4 j leather, $5. TIE A TH (CHRISTOPHER), F. R. . S., *-*. Teacher of Operative Surgery in University College, London. PRACTICAL ANATOMY: A Manual of Dissections. From tbe Second revised and improved London edition. Edited, with additions, by W. W. KEEN. M. D., Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphia In one handsome royal 12ino. volume of 578 pages, with 247 illustrations. Cloth $3 50 ; DELLAMF(E.), F. R, C.& THE STUDENT'S GUIDE TO SURGICAL ANATOMY: A Text- Book for Students preparing for their Pass Examination. With engravings on wood. In one handsome royal 12mo. volume. Cloth. $2 25. (Lately Published.) We welcome Mr. Bellamy s work, as a contribu- tion to the study of regional anatomy, of equal value to the student and the surgeon. It is written in a clear and concise style, and its practical suggestions idd largely to theinterest attaching to its technical details Chicago Mtd. Examiner, MarcL 1, 1674. C 'LELAND (JOHN), M.D., Professor of Anatomy and Physiology in Queen's College, Galwntf. A DIRECTORY FOR THE DISSECTION OF THE HUMAN BODY. In one small volume, royal 12mo. of 182 pages : cloth, $1 25. (Just Issued.) This is a plain, convenient, dissecting guide, to be I in common use, bat merely supplements them and -serf over tbe subject As such, it will command it I prppan* the dissector (or many pracncal dilliculnes "elf to tb student by the lucid composition and dis- | thatare apt to perplex t , inexperienced. &e 1 1 IV l ii-c ovw<3n j i ironion r !?* fur cu rrvlntr 1 11 t ha n.trkal Mini Oi,m tinct directions of the author. Jfed. and. Surg Rf.porter, Feb. 1S77. This volume does not interfere with the text-books coureiiientHize for carrying iu the pocket, and should be iu liie possession of every student of medicine. - K. Y. Mud. Journ., March, 1877 QCHAFER (EDWARD ALBERT), M.D., O Assistant Prof etsor of Physiology in University Ootloge, London. A COURSE OF PRACTICAL HISTOLOGY: Being an Introduction to the Use of the Microscope. In one handsome royal 12mo. volume of 304 pages, with numerous illustrations : cloth, $2 00. (Jnst Issued.) We are very mr bp,^ f ^he^ u ,b^ h^ha^s^^^ Jhe ^^h^^ the^tU, ss^ microscopic anatomy of the tissues and W* <> '* ' ' ir ecfion or pa.ag.aph from any one else. Even absolutely necessary .^^L^S^S^M, \ w hen de^cribingso.ne of the,,,, ones, process,.. * it is the way in which it takes thstu eiit ^ ' ' 6UOWb , uch ft practical familiarity with the, as it were, showing him what to do, and *P' m "^ s to give his description the flavor of originality. In simply, but thoroughly, how to do it.-Oost nMed.an* , ^^ W(j cau i ondde ntly .ecommend ibeWk Surg. Journ., April, 1S7/. as t))e mo(jt U!ieful ,,, a nual f.ir the practical hisiol.j- As a whole, the book is an admirable one. 1 , Rist w , t h which we are acqua nted. Chicago .V->1. descriptions are brief, but they are clear and de'i j ourn . and Exam., Sept. 1377. ed The author has learned the art of stopping when HBNBY C. LEA'S PUBLICATIONS (Physiology). riARP ENTER (WILLIAM B.), M.D., F.R.S.,,F.G.S., F.L.S., v SepMrar to Univtrtity of London, etc. PRINCIPLES OF HUMAN PHYSIOLOGY; Edited hy II KXKY TOWER, M.B. Lond., P R.C.S., Examiner in Natural Science*, University of Oxford. A new American from the Eighth Revised and Enlarged English Edition, with Jiotes and Addi- tions, by FRANCIS Q. SMITH, M. D., Professor of thelLstitntescf Medicine in the Univer- sity of Pennsylvania, etc. In one very large and handsome octa^ volume, of 1083 pages, with U opiates and 373 engravings on wood; cloth, $5 60; leather, $6 50. (Just Istiitd.) The great work, the crowning labor of the distinguished nnthnr. and through which so many generations of students have acquired their knowledge of Physiology, has been almost met:imor phosed in the effort to at opt it thoroughly to the requirements oi modern science. appearance of the last American edition, it has had several revisions at the experienced hiind of Mr. Power, who has modified and enlarged it o as to introduce all that is importnnt in the investigations and discoveries of England, France, and Germany, resulting in an enlargement of about one-fourth in the text. The series of illustrations has undergone a like revision, a large proportion of the former ones having been rejected, and the total number increased to nearly four hundred. The thorough revision which the work has so recently received in England, hag rendered unnecessary any elaborate additions in this country but the American Editor, Pro- fessor Smith, has introduced such matters as his long experience has shown him to be requisite for the student. Every cure has, been taken with the typographical execution, and the work is presented, with its thousand closely, but clearly printed pages, as emphatically the text-bonk for the student and practitioner of medicine the one in which, as heretofore, especial care is directed to show the applications of phy. iology in the various practical branches of medical science. Notwithstanding its very great enlargement, the price has not bet n increased, rendering this one of the cheapest works now before the profession. We hare been agreeably surprised to find the vol- ume so complete in regard to the structure and func- tions of the nervous system in all its relations, a btibject that, in many respects, isoueof the most diffi- cult of all, in the wh.'le range of physiology, upon which to produce a fall and satisfactory treatise of the class to which the one before us belongs. The additions by the American editor give to the work as it is a couiderble value beyond that of thi list English edition. In conclusion, we can give our cor- dial recommendation to the work us it now appears. The editors have, with their additions to the only work on physiology in our language that, in the full- est M-u-e of the word, la the production of a philoso- pher as well as a physiologist, brought it up as fully as could be expected, if nut desired, to the standard of onr knowledge of its subject at the present day. It will deservedly maintain the place it his always bad in the favor of the medical profession. Journ. of Nervous and Mental Di>tane, April, 1877. (iood wine neds no bush" says the proverb, and an old and faithful servant like tlie big" Carpenter, as carefully brought down at) this edition lias ben by Mr. Henry Power, needs little or no commendation by us. Such onoruious advances have recently been made in our l'hvsi'.l"i;iral knowledge, th.-it what was perfectly new a year or two ago. looks now as if it had been a received nd established fnct for years. In this encyclopa-dic way it is unrivalled. Here, iv it seems to us, is the great value of the book: one is safe In sending a student to it for information on almost any given subject, per- fectly certain of the fulness of Information it will con- vey, and well satisfied of the accuracy with which it will there be found stated. London Med. Times antl Feb. 17, 1870. Th UK fully ore treated the strncture and functions of all thi) important organs of tht; body, while there are chap- ters on sleep and somnambulism; chapterson ethnology . a full section on (jeneraiion. and abundant references to the curiosities of physiology, as the evolution of light, heat, electricity, etc. In short, this new edition penter i-i, as we have said at the start, a very encyclo- pedia of modern physiology. The Clinic, Feb. 24, 1K77. The merits of "Carpenter's Physiology are so widely known and appreciated that we need only allude lini-tly to the fact that inthelatest edi ion will be found a com- prehensive embodiment of the results of recent phytio- lonical investigation. Care has been tukeu to preserve the practical character of the original work. In fact the entire work has been brought up to date, and evidence of the amount of labor that has been bestowed upon it by its distinguished i-litor. Mr Henry Power. The American editor has made the latest additions, in order fully to cover the time that has elapsed since the last English edition. JV. Y Mr.d Journal, Jan. Ih77. A more thorough work on physiology could not be found. In this all th facts discovered by the late re- searches are noiiced. and neither student nor practi- tioner should be without this exhaustive treatise on an rn.. rt:int elementary branch of medicine. Atlanta Med. anil Surg. Journal, Dec. 1876. ITIRKES (WILLIAM SENHOUSE), M.D. A MANUAL OF PHYSIOLOGY. Edited by W. MORRANT BAKER, M.D., F.R.C.8. A new American from the eighth and improved London edition. With about two hundred and fifty illustrations. In one large and handsome royal 12mo. vol- ume. Cloth, $3 25; leather, $3 75. (Lately issued.) Kirkes' Physiology has long been known as a concise and exceedingly convenient text-book, presenting within a narrow compass all that is important for the student. The rapidity with which successive editions have followed each other in England has enabled the editor to keep it thoroughly on a level with the changes and new discoveries made in the science, and the eighth edition, of which the present is a reprint, has appeared so recently that it muy be regarded as the latest accessible exposition of the subject. On the whole, there is very little in the book the hands of students. Boston Med. and 8ura. which eltherthe student or practitioner will notflnd Journ., April 10 18T3 of practical value and consistent with onr prexeut , . knowledge of th.srapidly changing science; and we . ^ ts enlarged form it is, in onr op nion, s til the have no hesitation in expressing our opinion that best book on phyiol,.gy, most useful to the student, this eighth edition is one of the best handbooks on ~P Mla - **<* Time*, Aug. 30, 1873. physiology which we have in onr language. If. T. This is undoubtedly the best work for students of JTed. Record, April 15, 1873. physiology extant. Cincinnati Mid. Sews, Sept. '73. The book is admirably adapted to be placed In fJARTSHORNE (HENRY), M.D., **- Professor of Hygiene, etc , in the Univ. ofPenna. HANDBOOK OF ANATOMY AND PHYSIOLOGY. Second Edi- tion, revised. In one ro.yal 12mo. volume, with 220 wood-cuts : cloth, $1 75. (Juit Issuid.) HKNB.Y C. LEA'S PUBLICATIONS (Physiology). 9 n ALTON (J. C.}, M. D., *-' Professor of Physiology in the College of Physicians and Surgeons, Ntw> York, Ac. A TREATISE ON HUMAN PHYSIOLOGY. Designed for the use of Students and Practitioners of Medicine. Sixth edition, thoroughly revised and enlarped, with three hurired and sixteen illustrations on wood. In one very beautiful octavo vol- ume, of over 800 pages. Cloth, $5 50 ; leather, $6 50. (Just Itsitcd.) From the Prefa-te to the Sixth Edition. In the present edition of this book, while every part hns received a careful revision, the ori- ginal flan of arrangement has been changed. only so far as was necessary for the introduction of new material. The additions and alterations in the text, requisite to present concisely the growth of positive physiological knowledge, have resulted in spite of the author's earnest efforts at condensation, in an increase of fully fifty per cent, in the matter of the work. A change, however, in the ty- pographical arrangement has accommodated these additions without undue enlargement in the bulk of the volume. The new chemical notation an r l nomenclature are introduced into the present edition, ss hav- ing now so generally taken the place of the old, that no confusion need result from the change. The centigrade system of measurements for length, volume, and weight, is also adopted, these measurements being at present almost universally employed in original physiological investiga- tions and their published accounts. Temperatures are given in degrees of the centigrade scale, usually accompanied by the corresponding degrees of Fahrenheit's scale, inclosed in brackets. MEW YORK, September, lS7.i. Durinjr the pst fe- years several new works on pby-' This popular tcx'-book on physiology comes to us in Ijtions of old works, have appeared, its sixth edition with the addition of about fifty percent, competing for the lavorof.tii* raeilkal student, but none of new matter, chiefly iu the departments of patho- wi!l rival this IK-W edition of Daltnn. As now enlarged, logical chemistry and the nervous system, where the it will he found aJso to be. in general, a satisfactory work principal advances have been re.nli/d. With so tho- of refereooe for the practitioner. Chieayo Jled.'jwarn. , rough revision and addi'ious. thxt keep the work well nrf Etui miner. .Ian. < : up to the times, its continued popularity may he ennfi ^^^.^^3^1 H^S^l^^Ssi"' 1 ' fairness, a fulness. a,Kl a oon<-iy exist in the minds of observers themselves as only pro- ' th Professor of Physiolojy in the University of I., ni.-i- babilities. that none of his readers need he led into ana. as by all competent teacher* in the United State* p-ave error- white makitg them a study. The iMical , !ln(1 wherever the RngHxb language is read, this book Recoi-rf. Feb 19 1876 has been appreciated. The present edition, with it* 3l l^erevisionof ,hi ? r r twork has bro ug ht it forward | ^&^^^^ f^ with th phys^U^al advancesof tb day. and renders ^ ffm psrwptiblv in.-reaswl.-A'w Orleuns todical tt, as it ba^ver leen. the fii^st wovk for studen< S ex- j , Surreal J".t. Mnreh. 1876. Unt. Aa,<*ttWc Jrtarn. n/Mflrf. .l.-. anil to cai-b element 'ts more important compounds used in uifdi- cineor pharmacy nreiiiven, together with both syntheti- cal ami nnalyrim) reactions. The systematic analysis of componn Unit States Pharmacopoeia, is prepared under the sinllmr supervision >tnn Journal of Cfirniitry. NOT |s76. A-lmirably adapted to the use of medical students. Atlanta M#l. J77>.,Oct. 1376. pt^WNES (GEORGE), Pk.D. A MANUAL OF ELEMENTARY CHEMISTRY; Theoretics] and Practical. Revised and corrected by HKURT WATTS, B.A., F R.S., anthor of " A Diction- ary of Chemistry," etc. With a colored plnte, and one hundred and seventy-seven illus- trations. A new American, from thf twelfth nnd enla-gel London edition. Edited by ROBICRT BRIDGES, M.D. In one larpe royal 12ino. volume, of over IftOO pages. (Nearly Ready.) Two careful revisions by Mr. Wnfts, since the appearance of the !.>*. American edition of " Fownes," have so enlarged the work that in England it has been divided into two volumes In reprinting it, by tbe use of a small and exceedingly clear type, cunt for the porp- se, it has been found possible to comprise the whole, without omission, in one volume, not, unh.tndy fir study sml reference. The enlargement of the work has induced the American Editor to confine his :i Editions to the narrowest compass, and be bus accordingly inserted only such discoveries iis h.-ive been an- nounced since the very recent nppesmnee of the work in England, and has adder the standards in popular use to the Decimal and Centigrade systems employed in the origir.nl. ' Among the additions to this edition will he found a very handsome colored plnte, representing a number of spectra in the spectroscope. Every care has been taken in the typographical execn lion to render the volume worthy in every respect of its high reputation nnd extended use, nnd though it hns been enlarged by more thnn one hundred nnd fifty p:tges, its verv moderate price will still maintain it as one of the cheapest volumes accessible to'th chemical student. T>OWMAN (JOHN E.), M. D. PRACTICAL HANDBOOK OP MBDICAL CHEMISTRY. Edited by C. L. BI.OXAM, Professor of Practical Chemistry in King's College, London. Sixth American, from the fourth and revised English Edition. In one neat volume, royal 12mo. , pp. 351, with numerous illustrations: oloth, S3 25. gl' TUK SAMB AUTHOR. (Laf-ly lnont-d.) INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANALYSIS. Sixth American, from the sixth and revised London edition. With numer- ous illustrations. In one neat vol., royal 12mo., oloth, $2 25. KSiPP'S TECHNOLOGY ; or ChemiBtry Applied te I rry handsome octavo voloroes, with 500 wood the Arts, and to MannfactnreB. With American I engravings, cloth $6 00. additions by Prof. WALTER R. JOHNSON, la two I HENRY C. LEA'S PUBLICATIONS (Chemistry). 11 J2LOXAM (C. ,.), Pri>fe.s*rmly clearaud logical The author seldom overstrains a, theory, and in several cas n s, as for instance, in his remtrks on atomicity (p. 81, et f>eq.\ points out difficulties which are too often over- looked. He has made many things easy of compre- hension, which are generally very difficult, and al- together his book will be real treasure to earnest students. London Land, Aug. IS77. This volume is devoted to the principlea upon which the theoretical structure of modern i-hemi try is hused. and as sur-h it is a very valuable addition to our litera- ture, insomuch a. it discu-scs. in a c'ear and corn 1 re- hensive manner, the various laws {jivernlnsr chemical combination and decomposition, and the various theo- ries wlii.'h have hei-n advanced for explaining an- nounced fct. In our opinior. the work will prove to b' a valuable a : d to the chemical student who would familiarize himsulf with the ili-ories nf the science that hr. Parrish's great work on pharmacy It only an honored place on our owu bookshelves. Dublin remains to be said thai the editor has accomplished Jfeit. Prens ami Circular, Aug. 12, I>7 J. bi work so well as to maintain in this fourth edi- We expre88ed our opinion of a furiuer edition i. tion, the high standard of excellence which it had terms of Qualified praise, and we are in >o oo4 attained in previous editions, under the editorship of , o delrae , fr<>m , na , ..piuion in rflerenee to the pre- Its accomplished anthor This ban not been aeconr ^^ ^5,^,,,, tllfi pre ,x,ration of which has fallen into pllshedwJthont much labor, and many additions and competent hands. It is a book with which no pbarma- lmproveraenti<,involvingchaDgesin the arrangement e}Hl ean dispense, and from which uo physician can of the several part* of the work, and the addition of fai , to deriTe mnch j n r orn>a ,5 on ()f Tli)ue , o him j, much new matter. With the modifications thus ei- prHct i ee ._ Pacific Jftd andSurg.Jvun., June, '74. fectfd it constitutes, as now presented, a compendium of the science and art indispensable to the pharma- With these few remarks we heartily commend th cist, and of the utmost value to every practitioner work, and have no doubt that it will maintain its of medicine desirous of familiarizing himself with old reputation as a text-book for the student, aud a the pharmaceutical preparation of the article* which work of reference for the more experienced pbysi- h P prescribes for his patients. Chicago Uttd.Journ., cin and pharmacist . Chicago lied. Kzttmhter, July, 1874. June 1J, 1874. The work Is eminently practical, and hag the rare I Perhaps one, if not the most important book npo merit of being readable and interesting, while it pre- pharmacy which has appeared iu the English laa- ger ves a strict ly scieniificcharaeter. The whole work gunge has emanated from the transatlantic press, reflects the greatest credit on author, editor, and pub- " Parrisb's Pharmacy" is a well-knowu work on thii Usher I twill convey some idea of the liberality which side of thewater.and the fact shows us that a really has been bestowed upon itsprodnction when we meu- useful work never becomes merely local in its fame, tion thatthereare nolessihan 280carefully executed Thanks to the judicious editing of Mr. Wiegaud, the illustrations. In conclusion, we heartily recommend posthumous edition of "Parrish" has been saved to the work, not only to pharmacists, but also to the the public with all the mature experience of its au- multitnde of medical practitioners who are obliged thor. anpulation. Phil- eoncerning remedial agents, Dr. Still^'s is "par rx- atielphta Mtd. Times, Dec. 12, IS74. cellf.nce" the work. The work being out of print, by The rapid exhaustion of three editions and the uni- IheexhMnstiouofforraereditions.theanthorhaslaid T eral favor with which the work has been r- the profession under renewed obligations, by the by the medical profo^lon, are sufficient proof of its earefnl revigion, important additions, and timely re- excellence as a repertory of practical and mefnl in- ; a work not exactly supplemented by any furioat i on f or tbe physician. The edition before us other in the hnglUh language, if in any language, fully sustains this verdict, asthe work has been care- The mechanical execution handsomely sustains tue ful)y ^^^^ HIld in 80me j>rtiong rewritten, briug- well-known skill and good taste of tho publisher in/? it , the pre ^ en , tinle j,y the admission of St. Louis Jfett. and Sura. Journal, Dec 1874. chloral and croton chloral, nitrite of ainyl, bichl.,- The prominent feature of Dr. StllK s great work ride of methylene, methylic ether, lithium cook- ig sound good sense. It is lexrned. but it learning pounds, gelseminnm, and other reuueilits. At*. In of inferior value compared with the discriminating Journ. of Pharmacy, Feb. l->7.~>. judgment which is shown by its anthor inthedis- We can hardly admit that it bas a rival in the cussion of his subjects, aud which renders it a trust- mnltitnde of it citation" and the fulness of Its re- worthy guide iu the sick-room. Am. Practitioner, gearoh lntl) clinical histories, and we must assign it Jan. 1875. a piac* in the physician's library; not, indfed, as From the publication of the first edition "StlH^'s fully ri'|>r>--.'iiiin^ th>- prcst-ut >iate of knowledge iu Therapeutics" has been one of the classics; its ab- pharmacodynamics, but as by far the most complete eence from our libraries would create a vacuum treatise upon the clinical and practical side of the which conld be filled by no other work in the Ian- question. Sontun Mtd. und. Surg. Jvurnul, Uov.c, guage, and its presence supplies, in the two volume* 1874. HENRY C. LEA'S PUBLICATIONS (Mat. Med. and Therapeutics). 1 3 UTILLE (ALFRED). M.I), LL.D., and \fAlSCH (JOHN M.}. Ph.D., Pr v !'f. Tfl f f r " r y'<" f ' i Practice of Clinical 1 Pro/, of Mat. ifrA. ,,,1 R,,t in PMla. Med. in UK.IV. of Pa. c, t n. Pharmacy. S-.oj. t; tht. American Plinrmace.ut icrtl X .we ii'.t ion THE NATIONAL DISPENSATORY: Embracing the Chemistry, Botany, Materia Medina, Pharmacy, Pharmacodynainics, and Therapeutics of the Pharmaco- poeias of the United St.ites and Great Britain. For the Use of Physician? and Pharma- ceutists. In one hanlsome octavo volume, with numerous illustrations. (In Press.) The want has long been felt and expressed of a work which, within a moderate compass, should give to the physician and pharmaceutist an authoritative exposition of the Pharmaco- poeias from the existing standpoint of medic il and pharm iceutical science. For several years the authors have been earnestly engaged in the preparation of the present volume, with the hope of satisfying this w:\nt, and their labors are now sufficiently advanced to enable the pub- lisher to promise its appearance during the, coming season. Their distinguished reputation in their respective departments is a guarantee that the work will fulfil all reasonable expectation as a guiile in the selection, compounding, dispensing, and medicinal uses of drugs, complete in all respects, while convenient in size, and carefully divested of all unnecessary and obsolete (tatter. J?ARQ.DHARSON (RODKRT). J/./>.. r.trturnr rm 3Intr.rin Mniiiffr fit St. Mary'* Hospital Medical School. A GUIDE TO THERAPEUTICS. Edited, with Additions, embracing the U. S. Pharmacopoeia. By FKANK WOODBUHV, M.D. In one neat volume, rojal 12mo. volume of over 400 pages : cloth, $2. (Now Ready.) The object of the author has been to present in a compact and compendious form the the- rapeutics of the Materia Medica, unincumbered by botanical and pharmaceutical details. The volume is thus emphatically a work for the medical student, to aid in hij acquiring a clear and connected view of the subjtct in its most modern aspects; and for the busy practitioner who may wish to refresh his meinorv. Under each article, in parallel columns, are given its phy- siological and therapeutical actions, thus enabling the reader to take in at a glance the essential facts with respect to each remedy, and numerous formulae are given as examples of their prac- tical use. Considerable additions have been introduced by Dr. Woodbury, who has made numerous changes to oda.pt the work to the wants of the American student, introducing all the preparations of the U. S. Pharmacopoeia, and many of the newer remedies. This little volume is an earnest effort to advance manner, that it deserves cnreful study by every stu- the i)t<>ie.sts of intelligent therapeutics. In a mode- dfut and young practitioner. Cincinnati Clinic, rate compass we find 'he established facts concerning Jan. 12, 1S7S. th physK,l<, g ical and therapeutical actions of reme- Many peraon8 who learned thcra p entic . s before , S " * ft **vto****t* f threat remedies the physiological action of remedies was taught to ia health and disease are pre-eatcd in parallel col- KtU(lents find it difficalt to discorer tue bearing of un.as. This arrangement impresses ns very favor- ,, h y8ioloical action on therapeutic employnfent Hbiy, as both convenient and etiolated to stamp from ordinary text-books. Dr. Farquharsou hasmost the facts upon the memory. We d J not know of an i Dge niously shown it by printing the two in parallel equal number of pages in one work that con ains for co i urans and corresponding paragraphs, so that, by the n<*ds f ttM student anything near as valuable running the eye down the left-hand side of a page we an account ot these subsUnces. We can cordially et the physiological actions of a drug, and on the commend this work to the medical stnd-nta*- the best ri gl)t-hand rhe therapeutical uses, while, bv running introduction to th study of larger and more elabo- it stl . aiif | )t acrO88 tne pagt) w<> at once perceive the rated treaties Detroit Lancet, Jan. 18/S. j re | H ,i,, U s of the one to the other. On this account, the An excellent feature of r>r Farquharsou's Guide, work is likely to be useful, not only to students pre- and oue which trill commend it to all earnest stu- \ piringfor their examinations, hut to those medical dents, is the arrangement, in tabular form, of the va- ' men, also, who are well acquainted with larger rious officinal preparations and their dose, so that ' books on the same subject, but experience the diffl- they may be readily committed to memory This ctilty, already mentioned, of seeing the relations handbook is so well arranged, aud presents the well between the actions and use of remedies. The established facts of therapeutics in so impressive a Lnndeu>a- ble, and it is hardly It^s essential to th practition.-r who compounds his own medicines. Much of what is contained in the introduction might to be em- mitted to memory by every student of medicine. As a help to phy.-U'htus it will be found Invaluable and doubtless vrill make its way into lilir.iries not already supplied with a sU'nlard work of the kind . The American Practitioner, Louisville, July, '74. HENRY C. LEA'S PUBLICATIONS (Pathology, &c.}. (V.), AND ftANVIER (A.). v Prf. in the Faculty of Iff tl , Hirix. Prof in the College of Frnur, . MANUAL OF PATHOLOGICAL HISTOLOGY. Translate.!, witli Notes nnd Additions, by E. 0. bBAKr.spKAKE, M.D , Ptithnlogi^t and Ophthalmic Surgeon to Pbilnda Hospitnl, Lecturer on Refrrciion and Operntive Ophthalmic Surgery in I'niv. of Penna. In one very handsome octavo volume of about 600 pnges, with over 300 illus- trations (Preparing.) So much hns been done of lute years in the elueidntion of pathology by means of the micro- Kcope, and this subject now occupies so prominenta position ns one of the most important l>r:uiche. of me'dical science, that the American profession cannot fail to welcome a translation of the pre- sent work, which, through its own merits nnd through the well-known reputation of its distin- guished authors, is regarded in Europe as the standard text-book and work of reference in its department Such investigations and discoveries as hpve been made since its nppe;irnnce will be introduced by the translator, nnd the work is confidently expected to assume in this country the same position which has been so universally accorded to it abroad. JfENWlCK (SAMUEL), M.D., * Asftftnnt Physician to the London Hospital. THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. From the Third Revised and Enlarged English Edition. With eighty-four illustrations on wood. In one very handsome volume, royal 12mo., cloth, $2 25. (Just Issued ) Of the in uy guide-books on medical diagnosis, claimed to be written for the special instruction of students, this, is the bent. The anthor i evidently well-read and accomplished physician. and he knows how to teach practical medicine. The charm of sim- plicity is not the least int resting feature in the man- ner in which Dr. Fenwickcunveys instruction. There are few books of this size on practical medicine that contain KO ranch and convey it so well as the volume before as I' is a book we can sincerely recommend to the student f >r direct instruction, and to the prac- titioner as a ready and useful aid to hr memory. Am. Journ. of Syphilography, Jan. 1874. It covers the ground of medical diagnosis in a con- cise, practical manner, well calculated to astittt |ii Htndeut in forming a correct, thorough, and system- atic method of examination aud diagnosis of disei.-e. The illustrations are numerous, and finely executed. Those illustrative of the microscopic appearsuce of morbid tissue, &e., are especially clear and distinct. Vhictigo Xed. Examiner, Mov. U7S. riREEN (T. HENRY), M.D., Lecturer on Pathology and Morbid Anatomy at Oharing-Oroft Hospital Medical School. PATHOLOGY AND MORBID ANATOMY. Second American, from the Third and Enlarged English Edition With numerous illustrations on wood. In one very handsome octavo volume of over 300 pages, cloth $2 75 (Just Issued.) Th.>se not acquainted with this text book ought to be. We have always thought that for Ihn average doctor this work wa^ much more nsef ill than the larger irealixe-i. liitoit is condensed such knuwl dgeto^Hin which, elsewhere, would require great labor ami wide reading. For student* and practitioners full of cares, it i particularly v ilua^le. In this edition the goneral h'gh chancterof the work is maintained, the newcolH are fully np to the standard of those ijsfil before, which w-re excellent, the execution of the work at the hands of the publisher is f.mliles* Ohicngo Mul Journ attti Krnm., Feb 1877. Altogether. thislR the best short manual of morbid anatotnyin the English language, aud we regret that onr space and the character of our contents forbids * more extended notice The arrangement and choice ofsnbjects, the olearness and romparxlire thonmgh- ues of its statements make it very satisfactory WBth|iOKH*n language. It may he safely anrt hen rti!y ci > in mended t snideols, especially of morhtd ana- lomy. Joiim. of tfervitis an't Mental Hiftatt, Oct. 1S7B. D AVIS (NATHAN ). Prof, of Principfe* nnd PraHice of Mffiicinr., fie., in dhir-ngo 3Tfd. College. CLINICAL LECTURES OX VARIOUS IMPORTANT DISEASES; being a collection of the Clinical Lectures delivered in the Medical Wards of Mercy Hoc- pita), Chicago. Edited by FRANK H. DAVIS, M D. Second edition, enlarged. In one handsome royal 12mo. volume. Cloth, $1 75. (Lately Issued.) tical Relations. ID two large and handsome octavo volnroes of nearly 1500 pages, cloth. $7 00. HOLLAND'S MEDICAL NOTES AND REFLEC- TIONS. ) vol Svo., pp. SftO, cloth. $S .*iO. BARLOW'S MANUAL OP TBE PRACTICE O XEDICIKB. With Addition by D. F. ConBlE, M r> 1 TO! Svo.. pr- 0o OHHISTISON'B DISPRN8ATOKY. With copious ad Hltlou* "tsd 5'3 lrr wno<-on'rn's Uy R B u,KsrBLn cloth. *4 00. CARPENTBR'8 PRIKB BS8AT OH THK D8B O> ALCOHOLIC LIODOEU m HEALIH AND PISKAS.B. Xev edition, with a Preface by D. F. OO*DIE. M D., anr explanationaof seientiAc word. In one neat 12nu . volnine, pp. 17S, cloth. 60 cents OLDGB'8 ATLAS OF PATHOLOGICAL HISTOLOGY Translated, with Notes and Additions, by JO-JRPH LBIDT, M. D. In one volume, very large Imperial quarto, with 320 copper-plate figures, plain and colored, cloth. *l OO. L4. ROOHS 0V TELLOW FEVER, considered in lt Historical, Pathological, Etiological, andTherapeo- srrRf?Ks-s ixTRonrmox TO TFIE .srrnv OF (T.IMCAT, MEHiriXE. Being a Gnu?" to the In- vestigation of PispHse. In OPP handsome 7-ino. volume, cloth, J 2."i (Lntrhf twerf.) STORES' LErTt'KKS ON FEVER Fdited by Jonx WIM.'AM MI>ORK, M. D.. Assistant Physician to the Cork S're.'t Fere'- Hosr.jtal. In one neat Svo. volume, cloth, $2 00. (Juxt Jgx-utd ) . LEA'S PUBLICATIONS (Practice of 15 FLINT (AUSTIN], M.D., * Professor of the. Principle* and Practice of Hfedicine in Bellewte Mvd. Collage, K. Y A TREATISE ON THE PRINCIPLES AND PRACTICE OF MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fourth edition, revised and enlarged. In one large and closely printed octavo volume of about 1100 pp. ; cloth, $6 00 ; or strongly bound in leather, with raised bands, $7 00. (lately Issued.) By common consent of the English and American medical press, this work has been assigned lo the highest position as a complete and compendionAext-book on the most advanced condition of medical scienc*. At the very moderate price at which "it is offered it will be found one of the sheapest volumes now before the profession. This excellent treatise on medicine has acquired ] dentsand abook nf ready reference for practitioners, tor itself in the rrited States a reputation similart<> ', The force of its logic, its simple and practical teach- th;U enjoyed in England by the admirable lectures ings, have left it without a rival in the field N. . of Sir Thomas Watson. t'may not possess the, saiae ; Med Record, Sept 15, 1874. charm of style, but it h-is like solidity, the fruit of FHnt'sPracticeof Medicine bus become so fixed in long and patient observation, and presents kindred : its position an an American text book that little need moderation and eclecticism. We have referred to , le 8aid beyond the announcement of a nw edition, many of the mostimportantchapters. and find the r extended as many of the standard works oa volume, aud therefore will not * so terrifying to tlie ; p rdel i c p. it still is sufficiently complete for all ordi- student as the bulky volumes which several of our narv reference and we do not know of a tnorecon- Enerlish text-books of medicine have developed into, venient work for the busy eaneral practitioner. British rind Foreign Sfed.-Chir. Ren., Jan. 187t. i Citwinna.ti Lnnr.f.t a-nd O'ttervf.r, Jane, 1878. Itisof eanrsettnoececKary teintrodnoe.or enlogire j Prof. Flint, in the fourth edition of his great work, this now standard treatise All the college* worn- has performed H labor reflecting much credit upon mend it as a text-book, and there are few lihraries . h'm self, a ndeonferringa lasting benefit upon the pro- in which on of its editions is not to be fonnd. The , fession. The whole work showsevidenc* of thorough present edition h-a been enliira^d and revised tobring revi-ion, so that it appears like a new book wiitten it up to theanthor's present level of experipnce and expressly for the times For thegnral practitioner reading His own clinical studies and the latest con- and student of medicine. w cannot recommend the triburiotis to medical literature 'both in tnic country \ book in too strong terms A*. 1' Mr.d.Joitr .Sept '73. and in Karope. have received careful attention, so j t j s ^i Te n to very few men to tread in the steps of that some portions have been entirely rewritten, and i ^ Hg |j o Flint, whos single volume ou medicine, about seventy pages of nw matter have been added i t h ml g^, hereaad there defective, is a imsterpiece'of -Qh.if.nyc, M'd Jovrn., June, 1873. Has never been surpassed s a text-book for sta- Uicid condensation and of general grasp of an enor- mously wide subject Lend. Practitioner, Dec. '73. F THV SAME AUTHOR. ESSAYS ON CONSERVATIVE MEDICINE AND KINDRED TOPICS. In one very handsome royal I2rao. volume. Cloth, $ I 38. (Just 1st td ) fJARTSHORNE (HENRY), M.D., *> Prt)/e*or of Hgytene in tkt University of Pen-mtvl******- ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MED1- CiNE. A haady-book for Students and Praetitionr*. Fourth edition, revised and im- proved. With about one hundred illustrations. In on handsome royal 12mo volume, of about 550 pages, cloth, $2 63; half bound, $2 88. (Lately Ittned.) A a haadboak, which clearly sets forth tlieu^FW- i advances in medicine, is admirably condoned, and d AIS of tliePttl-VCIPI.BS A.VD PRArTtCBflF MBDIOI o not know of its equal. Vn. Hed. Monthly yet sufficiently explicit fur all the purposes-intended, thus maknie it by fur the best work of It* diameter , Ter published. Cincinnati Minic, Oct 24, 1CT4. As a brief, condensed, but comprehensive band- I c . book, it cannot be improved upoJ i.-CMnago M*d \ Without d.-nbt the best book .of thejtlnd publish. , Nov. J5, 1874 The wrk i bj ought fully np with all the rwentf Jnnrn -. N< "- l! i in the English languag. St. Lotii* Mtfl. l.0.,Profeord. Tov.rn , Oct. 14, 1871. The author's rare combination of great scientific attainment* couibined with wonderful forensic eio- nuence has exerted extraordinary Influence over the last two generations of physicians. His clinica de- scriptions of most dUease.shave nevei been equalled : and on this score at least his work will live long in the future. The work will be s-mght by ai appreciate a great book. Amer. Journ. uj SfjMl- ography, July, 1872. 16 HENRY C. LEA'S PUBLICATIONS (Practice of Mt dicinc). r>RISTOWR (JOHN SYEIf), M.D , F.R.C.P., J-S Pfiytiiciiin and Joint Lecturer on ttedicinf, fit. Thoina*'* H"*j'Hn1. A MANUAL ON THE PRACTICE OF MEDICINE. E.lite.l, with Additions, by. JAMES II. Ilu CHINKON, M.D., Physician to the Penn.-i. Hospital. In one handsome octavo volume of over 1100 pages: cloth, $5 50; leather, $6 50. (Just Ready.) In the effort of the author to render this volume a complete and trustworthy guide for the student and practitioner he has covered a wider field than is customary in text-hooks on the Practice of Medicine, and has sedulously %ndeavored to present each sobjeet in the light of the in os i modern developments of observation and treatment. So much has been done of late years to enlarge our knowledge of disease by improved methods of diagnosis, and so many new ngencie* have been called into service in treatment, that n condensed and compendious work, thoroughly on a level with the advance of medical science, can hardly fail to prove of value to the profV Dr. Bris'owe ha" long been before the profession as nn able thinker acd writer on professional sul>- J.TI-. Hi- present work is second to none of its kind, the part on diseases of the nervous system being, perhaps, the most deserving of praise. It is eminently readable, both in matter and print, and fully deserves tbe success it is sure to obtain. Bdin. Jfed. Journ., Oct. 1877. The treatment of the various diseases i admirably summed np, and we pronounce l>r. Brist-iwe's boon to be eminently practical on Ibis subject. A fair space is given to the dietetics of disea-e and we are .Bind tht this subject is receiving more and more attention in the w rks on medicine We give the author our hearty congratulations, and his book onr best commendations and wish it all success. Lond. Med. Time* and ff Ph*ician at tht If)*pital f.ir Kpilep*1c* o-<1 Paralytic*. and at the Vut-l'atient*' Dnpartme.nt of the. Nftv> York H*pitnl. NERVOUS DISEASES; THEIR DESCRIPTION AND TREATMENT. In one handsome octavo volume of 512 pages, with 53 illua. ; cloth, $3 50. (Just Ready.) The object of the author has been to fu.-nish to the student and practitioner in a cle:ir and concise form a guide to the dingnosis and treatment of affections of the nervous system, em- bodying the very great advances made during tbe hist few years in our knowledge of these dis eases. Unusual opportunities in public and pri -ate practice have qualified him for this work, and his desire has been to render it strictly practical, adapting it to the wants not only of the spe- cialist, but of tbe general practitioner. Particular care has therefore b*en devotd to the manage- ment of nervous diseases, ami in an appendix will be found a careful selection of well tried formulae. The thorough manner in which the subject has been treated may be understood from the fol- lowing very condensed SUMMARY OF CONTENTS. ISTRODUCTIOH. Hints in reeard to Examination and Study ; Apparatus for the Treatment of Nervous Disease. Chap I. Diseases of the Cerebral Meninges. Chnp. II. to Chnp VII. Dis- eases of the Cerebrum and Cerebellum Chap. VII Diseases of the Spinal Meningeg. Chap, VIII. to Chap. XII. Diseases of the Spinal Cord. Chap. XII. liultutr Diseases Chap. XIII. to Chap. XV. Cerebro-Spinal Diseases. Chap. XV. Diea>e of the Peripheral Nerves. Chap. XVI. Neuritis. Chap. XVII. Local Paralyses. Chap. XVIII. Lead Poisoning ; Functional Spasm; Professional Cramp : Formulae. rilTARCOT (J. M.). ^ Pr*fe*artn thf. Hinnltyof ifed. Pari, Phy*. fn l,n Salpr'rilrt, ftr. LECTURES ON DISEASES OF THE X ENVOI'S SYSTEM. Trans- lated from the Second Edition by GEORGK SIOERSOX, M.D , M Ch., Lecturer on Biology, etc., Cath. Univ. of Ireland. With illustrations (Publishing in t/i Medical Neus and Library, commencing with the July No. 1878. See page 2 ) JJUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, the Cifi/ nf I,,-,,,!. Hnap , etc. THE PRACTITIONER'S HANDBOOK OF TUKATMKXT; Or. the Principle? of Therapeutics. In one very neat octavo volume of about 550 pages : cloth, $4 00. (Now Ready.) It -nay be said that the scope of this work is not dissimilar to th:it of the well known " Principles of Medicine,'' by Dr J. C. R. Williams, now long out of print, which in its day met with snch unusuul acceptance. More practical in its character, however, it seeks to bring to the aid nnd elucidation of positive therapeutics, the vast accumulation of scientific fnctsand theories made by the present generation, pointing out the measures to be adopted at the bedside and establishing them on firm rational grounds. Such a work, by a first-iate man, and fully up to the advanced condition of science, cannot fail to prove of the utmost service to both student and practitioner. Our friends will find tliis a very readable book: and that it sheds lighi upon e^ery theme it touches, raOFi BIT the practitioi er to fee] more certain of his diagnosis in difficult ca.ses. We confidently commend the work to our renders as one worthy of ca-eful perusal. It liirhis the way o v "r o'scure and difficult raises in medical practice. The chapter on the eirculntion of the blood is tin 1 most exhaustive and instructive to be found. It is a book every practitioner needs, and would have, if be knew bow siitg- stive, and helpful it would be to him. .S'(. /.OKI* Mfd. and Surg.Jnur*., A^rii. 1877. The object is one of the most important wlncn a med- ical writer ran propose to himself, tor therapeutics N the goal of medicine, and the plan is an excellent one. In justice to l>r. Kothergill we ought to say that he has ad- hered to his plan throughout the work with fidelity, ami has accomplished bis object with a rare degree of success. We heartily commend bis book to the medical student ns an honest and intelligent guide through the mazes of therapeutics, and assure the practitioner who has grown gray in the harness that he will derive pleasure and in- struction from its perusal The imperfections and errors which we have noticed are few and unimportant. On the other hand, the excellences are many and patent. A'aluable suggestions and material for thought abound throughout. The chapters on body heat and fever, in- M animation, action and inaction, and the urinary sys- tem are particularly good. The descriptions of patho- logical conditions, and the character of the therapeutic measures advised give evidence of sound clinical obser- vation.- Button Mfd. and Sure Journal. Mar 8. 1^77. The strong good sense, the racy style, the practical volume before us Dr. Fothergill appears in his best mood. Our readers, especially the younger members of the profession, will find this a most suggestive aid use- fulliook. There are tew old practitioners who will not be benefited by its perusal. We commend it to all la--c- t.f readers, with the expression nf belief that those who buy it will be hardly content to clc se it until the lu-t leafis turned over. Cincinnati Clinic. Miir 'A, 1877. It is our Iionest conviction, after a careful perusal of this goodly octavo, that it represents a great amount of earnest thought and painstaking work, and is therefore one of those books which both de.-crve and are likely to survive. This book, although written ostensibly tor the young and inexperienced, may be very profitably studied by those who have been practising their profession more or less empirically for thirty ov forty years. We particularly recommend the chapters on Public and I'rivate Hygiene. Food in Health and lll-Henlth. and the Conclusion the Medical Man at tin- liedside The last is high-toned, and indicate-; much shrewdness of ob- servation. Our space will not admit of furtherquotation. We content ourselves with again recommending the book very cordially E'lin. Med. Jmirn., .Ian lf-77. It isof great advantage to the practitioner to have gen- eral principles to guide him. and that he should not, when confronted with an assemblage f pathological symptoms, be at the mercy of an unreasoned experience of a .-iiiiilar case, or lie obliged to swear in n rha mnyiatri. He will find reasons in this work for not looking upon drugs as grouped in fixed and unalterable categories, but learn when and why he may give opium to cause purgation, and castor oil to check it. We strongly re- cnaractcr of his instruction, are qualities in the author er mrriend it to our readers. T/tt. London Practitioner, which commend him to American physicians. In the .Ian. 1877. By the same Author. THE ANTAGONISM OF THERAPEUTIC AGENTS, AND WHAT IT TEACHES. Being the Fothergillian Prize Essay for 1878. In one neat volume, royal 12mo. of about 200 pages. (Short /y.) It would seem unnecessary to call the attention of the profession to a work on so suggestive a subject by a writer so brilliant as Dr. Fothergill. There is. perhaps, no one who has a better claim to be heard, and no topic more worthy the study and reflection of the practitioner. T INCOLN (D. F.}. M.D., *-' Phiixician t the Department o f !fr.renng DiKf.ase.x, Bfixtnn Dlopf.nsiry, ELECTRO-THERAPEUTICS; 4. Concise Manual of Medical Electri- city. In onevery neatroyal 12mo. volume, cloth, with illustrations, $1 50. (Just Issued.) ROBERTS ( WILLIAM], M. D.. J- ** Lecturer on Medicine, in the Manchester School of Medicine. Ac. A PRACTICAL TREATISE ON URINARY AND RENAL DIS- EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Seo ond American, from the Second Revised and Enlarged London Edition. ID one large and handsome octavo volume of 616 pnges, with a colored plate j cloth, $4 50. (Laie/y Published. ] LECTURES ON THE STUDY OF FEVER. By "A. HUDSON, M.D., M.R.I. A., Physician to the Meath Hospital Inonevol Svo., cloth, #2 50. ' A TREATISE ON FEVER. By ROBERT D Lvo.vg, K C C. In one oc'.avo volnmo of 362 pages, cloth, *2 25. CLIXICAL OBSERVATIONS ON FUNCTIONAL NERVOUS DISORDERS BvC. HAXDPIFI.D JOKES M D., Physician to St. Mary's Hospital, &c. Sec ond American Edition. In one hH ndsome octavo volume of 348 paees. clol OX REN'AL DISEASES: a Clinical Hnide to their Diagno.-iis and Treatment With Illnstm- tions. In one 12mo. vol. of 301 pages, clo'h - 18 HENRY C. LIA'S PUBLICATIONS (Diseases of t!><> 6V* *>*/, FLINT (AUSTIN), M.D., *- Professor of the Principle* and Practice of Medicine in Bellevue Hoxpital Med. College, F. J. PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY. SYMPTOM- ATIC EVENTS AND COMPLICATIONS, FATALITY AND PROGNOSIS, TREAT- MENT, AND PHYSICAL DIAGNOSIS; in a series of Clinical Studies. By ATSTIN FLINT, M.D., Prof, of the Principles and Practice of Medicine in Hcllevue He f|iit;il Med. College, New York. In one handsome octavo volume : $3 50 (Lately Issuni .) This volume, containing the results of the author's extended observation nnd experience on a subject of prime importance, cannot but have a claim upon the attention of every practitioner. This book contains an analysis, in the author'* lucid Mtioner. While the author take? ls*ni> with ninn leading mind* of the day on importaiitquestions arising in the study of ;>htliiMF. the strong testimony of expe- rience and authority will have threat weight with the soekcr after truth As the result ofclinicul Mudy. the work is unequalled. St. Lou.it Med. and Kurg Juurnnl, March, 187. style, of the notes which he hast made in several hun- dred cases in hospital and private practice. We com mend the book to the perusal of all interested in the study of this disease. Boston Med. and Sura. Journal, Feb 10, 1876. The name of the author is a sufficient guarantee that this book iit of practical value to both student and prac- ftY THE SAME AUTHOR. (Just Issued .) A MANUAL OF PERCUSSION AND AUSCULTATION; of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. In one handsome royal 12mo. volume: cloth, $1 75. In this little work the object of the author has been to present in a clear and compact form the existing condition of physical exploration, showing the manner of conducting it and the diagnostic value of the several signs thereby elicited. We can confidently recommend this treatise to all I rightly value lhee modes of exploration of disease, who would leara auscultation aud percussion, and | Briftshund Far. Ifeit.-GMr Rw., July, 1x7. T> r THE ft A ME A UTHOR. A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE HEART. Second revised an,l enlarged edition. In one octavo volume of 550 pages, with a plate, cloth, $4. Dr Flint chose a difficult subject for hU researches, tnd clearest practical treatise on those subject*, and and has shown remarkable powers of observation .honld be in the hands of all practitioner aud stu- tnd reflection as well as great industry, in his treat- lent* It is a credit to American medical literature, meat of it. His book must be considered the fullest , -Amer. Journ. of the Med Sciences, July, 1860. T)Y THE SAME AUTHOR. A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THB RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume of 595 pages, cloth, $4 50. Dr. Flint's 'realise is one of the most trustworthy i >ncy to over-refinement and unnecessary minuteness (aides which we can consult. The ->tyle in clear and j rhich characterize* many work* on tb'<> name *nb- dlstinct, and is also concise, being free from that tend- j*ct. HvMin Medical Press, Feb. 6, 1867. W WILLIAMS (C.J.B.), M.D., Senior ConmiUing Physician tothe Hospital for Consumption. Brompton. PULMONARY CONSUMPTION; Its Nature. Varieties, and Treat- ment. With an Analysis of One Thousand Cases to exemplify its duration. In one neat octavo volume of about 350 pages, cloth, $2 50. (Lately Published.) (CHAMBERS (T. K.), M.D.. vX Consulting PhysiHan to St. Mary's Hospital, London, Ac. A MANUAL OF DIET AND REGIMEN IN HEALTH AND SICK- NESS. In one handsome octavo volume. Cloth, $2 75. (Just Issued.) DIPHTHERIA ; its Nature and Treat iot, with an account of the History of its Prevalence in vart- ons Countries. By D D SI.ADK, M.D. Second and revised edition. In one neat royal 12mo. volume, cloth, 91 -J.V WALSHE ON THE DISEASES OF THE HEART AN) GREAT VESSELS. Third American edition. In 1 nl. STO . 490 ni>.. r1tli *< on FULLER ON DISEASES OF THE LUNOS AND AIR- PASSAGES. Their Pathology, Physical Diagnosis. Symptoms, and Treatment. From 'the second and revised English edition. In one hamlsome octavo volnme of about 500 pages : cloth, $3 .">0. LA ROCHE ON PNEUMONIA. 1 vol. 8vo., cloth, of 500 page* Price $S 00. SMITH ON CONSUMPTION ; ITS EARLY AND RE- MEDIABLE STAGES. 1 vol. 8vo.,pp.254. |2 2fi LECTURES ON THE DISEASES OF THE STOMACH. With nil Introduction on its Anatomy and Physio- logy. By WII.UAM RKIVTOX. M I).. K K S From the second and enlarged Lon Anedition. With 11- 1'iMratinns on wood In one handsome octavo volume of about 300 pages: cloth, *:i I.',. CHAMBERS'S RESTORATIVE MEOKUNE An Har- veian Annual Oration. With Two Se'|iipls Fn one very handsome vol. small 12mo , cl"th, 1 00. PAWS TREAT. SE ON THK FI'N'TION OF DI- iESTMX; it Disorders and their Treatment. From the second London edition. In one hand- some volume, small octavo, cloth, $2 00. PAVY'S TREATISE ON FOOD AND DIETETICS. PbTiologfc*lly and Therapeutically Con^iipred. In one handsome octavo volume of nearly 600 pages, cloth, $4 75. __ HENRY C. LEA'S PUBLICATIONS ( Venereal Digeases, &c.). 19 ftUMSTEAD (FREEMAN J.}, M. /)., *-* Profissor of Venereal Diseases at the Col. of Phys and Surg ffete York Ac THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- EASES. Including the results of recent investigations upon the subject. Third edition, revised and enlarged, with illustrations. In one large and handsome octavo volume of over 700 pages, cloth, $5 00 ; leather, $6 00. In preparing this standard work again for the press, the author has subjected it to a very thorough revision. Many portions have been rewritten, and much new mutter added, in order to bring it completely on a level with the most advanced condition of gyphilography, but by careful compression of the text of previous editions, the work has been increased by only sixty-four pages. The labor thus bestowed upon it. it is hoped, will insure for it a continuance of its position as complete and trustworthy guide for the practitioner. A valuable work on Venereal Diseases, which not venereal diseases, that it may seem almost sKperflu- , , - nnlyhas a wide circulation in Ibis country, and ons to say more of it than that a new edition has been been accepted a the standard, bnt appears tolnve Usued. But the author's industry has rendered this formed the basis. 10 a large extent, of many of the books and article- which have been written on the same subject and . J urn.. Oct. 18 in England. - The Olat- . n w edition virtually a new work and so merits as : much special commendation a* if lt predecessor- baa , D ot been published As a thoroughly practical book .. .. . . ; on a clas ' 8 of d , Reases which for * / / arge Khare o f It is the most complete bonk with which we are ac- nearly every physician's practice, the volume befor* quainted in the language. The latest vi_ews of the ns is by far the best of which we have knowledge. best authorities are put forward, and the information -V r. Jfedteal Gazette. Jan 28. 1871 is well arranged a great point for the student, and u ; 8 rare IQ thp history of me dicine to find any on* BtiiJ more for .he practiUoner. The subjects of vis- brtok wljich con , ain(i , n tha , a practitioner need! to ce.-al syphilis syphilitic affections of the eyes, and know; wllile the j )OSBe(18or ,,f i< nra given as a the most complete and best w^rk ever published. good aicouut of the diseases of which he treats, bul Dominion 3ffd. Journal. May, 1869. j ' O ne has furnished us with sorb a complete serie* This Is a work of master hands on both sides. M : of illustrations of the venereal diseases There i, Cnllerier is scarcely second to, wethink wemay truly , however, an additional interest and valnepog! tay is a peer of the illustrious and venerable Ricord, j by the volume before us ; for it is an A mericau while in this country we do not hesitate to say that : xnd translation of M. Cnllerier'i work, w Pr. Bnmstead, as an authority, is without a rival dental remarks by oneof the most eminent A A:-sunn,c our readers that these illustration.- tell the vph Uographem, Mr. Hnmstend. Brit. < whole, history of venereal disease, from its inception Vff<-n- "M- . Review, July, 1869. 7" EE (HENRY), Prof, of Surgery at the, K^ynl OolJfat of Surgeon* of England, etc. LECTURES ON SYPHILIS AND ON SOME FORMS OF LOCAL DISEASE AFFECTING PRINCIPALLY THE ORGANS OF GENERATION handsome octavo volume: cloth; $2 25. (Late/i/ Published.) moditiririKi!- ol'tti.-r jT<>fe--s.'s in pnti.'ii's preiouily ^vpbi'itic: primnry :in,l M-rnn.inry syphilitic 'i!:ii <\- ( 'b:!i. rtc. Tl"- book i- full of clinical nint.-rin' lllnrtrtHnK tli<-- nal or quoted. Arc/iires "f f>trmallsy. April. ! The work is valuable, as it treats quite fully of sub eets which are not dwelt upon in the systematic works of ot'-r-r Kiislisti authors of tbe present (lay. a* the info ulaWHty of syphilitic blood: f he con. lit dm < nivler which tlii' secretions of primary and secondary syphi'ilic man- ifestMion* mav be inoculated natunillv or artitici.-iHy : the morbid processes produced by such inoculation : the res " fTILL (BERKELEY], Surgeon to the Lock Ho.1tnl. London. OX SYPHILIS AXD LOCAL CONTAGIOUS DISORI one handsome octavo volume ; cloth, $3 25. 20 HENRY C. LEA'S PUBLICATIONS (Diseases of the S*T V , fir.). tfO X (TILnURF),Af.D.,F.R.C.P.,avook is -,. well :ir- geii'-ral character, coinplicalions. nd modifications of ranged that tlie reader will have no difficulty in tindin;; eroption*. totrtberirith th-Ir practical hlnta on the ex- at once exactly tlie Information he mny require A ami tuition of skin diseases, will 1 e of ereat istance csirefully compiled formulary of remedies tor skin 11 (Tee- to the novice in this department of medicine. We know tions and some notes on dirt in skin disease*, ''nsidern- of no other which, in so little space contains so much lily enhance the value of the epitome. London Lancet. reliable information. N. Y. MtJ. Jmirn.. Dec. 1S7. j Nov. 4, 1876. It bus no especial features other than it Is concis- and ' It must be admitted that even those well prcpar'-d fur quite practical. The early chapters, treating of ele- general practice find diseases of the skin dithVult of clas- mentary matters, in the study of sMn diseases, are very sificati >n, and HS difficult of diii^nosis. and that nothing pood, and the list of formulae is excellent. Archives of is more desirable than some work wliic-li. not > htlmritte Clinical Kurge'y, Dec. 1876. i" nature, shall be a useful ordinary puide. :in I is-m-d If doctors neiclect the study of diseases of the skin, it J>y n >> of recognized authority. It b Mfamdthtt ried in the pocket, while the text furnishes briefly, tint clearly, the information tinner. It meets fully a points of the classification, diagnosis, symptoms, and ja. Weekly, Jan. 6, 1877. , This little work cannot fail to acquire a large circle of clearly, the information desired by tlie general practi- readers. In a very small compass all the essential tinner. It meets fully an almost universal want. -4m. TXTILSON (ERASMUS), F.R.S. ON DISEASES OF THE SKIN. With Illustrations on wood. Sev- enth American, from the sixth and enlarged English edition. In one large octavo volume of over 800 pages, $5. A SERIES OF PLATES ILLUSTRATING "WILSON ON DIS- EASES OF THE SKIN;" consisting of twenty beautifully executed plates, of which thir- teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and embracing accurate representations of about one hundred varieties of disease, most of them the size of nature. Price, in extra cloth, $5 60. Also, the Text and Plates, bound in one handsome volume. Cloth, $10. J$Y THE SAME AUTHOR. - THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and DIB- KABES or THE SKIN. In one very handsome royal 12mo. volume. $3 50. (J.MOORE), M.D.,M.R.I.A. ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, with exquisitely colored plates, Ac., presenting about one hundred varieties ot disease. Cloth, $5 50. The diagnosis of eruptive disease, however, under all circumstances, Is very difficult. Nevertheless, Dr. Neligan has certainly, "as far as possible,'' given ft faithful and accurate representation of this class of diseases, and there can be no doubt that these plates will he of great use to the student and practitioner in drawing a diagnosis as to the class, order, and species to which the particular case may belong. While ooking over the "Atlas" we have been induced to es of children, so numerous are the affections con- (iidered either collaterally or directly. We are acquainted with no safer guide to the treatment of children's diseases, and few works give the insight into the physiological and other peculiarities of chil- - arily embrace the consideration of many affections dren that Dr. Smith's book does. Brit. Med, Journ., of which it is a symptom ; and this is excellently well April 8, 1871. dona by Dr. Smith. The book might fairly be de- 1 HENRY C. LEA'S PUBLICATIONS (Diseases of Children). 21 SMITH (J. LE WIS), M. D., *3 Professor of Morbid Anatomy in the Bellevue Hospital Sfed. College, ff. T. A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Third Edition, revised and enlarged. In one handsome octavo volume of 726 pages. Cloth, $5 ; leather, $6. (Just Issued.) The eminent success which this work has achieved has encouraged the author, in preparing this third edition, to render it even more worthy thmi heretofore of the fnvor of the profession. It has been thoroughly revised, and very considerable additions have been made throughout. To accommodate these the volume has been printed in a smaller type, so as to prevent any notable increase in it* size, and it is presented in the hope that it may attain the position of the American text book on this important department of medical science. This work took a stand as an authority from its first edition will confirm and add to its reputation. Having appearance. and everyone imeivste;! in studying the been brought up to the present mark in the rapid ml- diseases of which it treats is desirous of knowing what vauce of medical science, it is the best work in our improvements are apparent in the successive editions, language, on its ran>_'e of topics, for the American prac- The principal additions to which we n fer. mid which titioner. Pacific Mtd. anil Sitrg. Jourti.. Feb. 1-7 f>. rill be the di.stinguishing features of the third eJitiuu. are chapters on diphtheria, cerebro-spinal meningitis, and riirheln. The former disease is considered much Dr. Smith's Diseases of Children is certainly the most valuable work on the subjects treated that the practi- tioner can provide himself with. It is fully abreast more in detail than formerly, and a great amount of witn ever y advance: it should be in the bunds of prac- very practical information is added, and altogether it is tjtj oners generally, while, because of the conciseness one of the most comprehensive and one of the best writ- aM ,| c ] ea rness of style of the writing of the author. every ten chapters of the subject we have thus far read. His p r(l f e! , sor o f diseases of children, if he has not already description of cerebro spinal meningitis, founded also ,| one SO( should adopt this as his text-book Va . Medical for the most part on personal experience, is admirably \fynMy Feb 1876 clear and exhaustive.-'/^ JM. Record, Feb. 19, 1876. ( ^ ^.^ ^^ of ^ ^^ Talu8He wor k is now In presenting this deservedly popular treatise for the i )e f ( , re us- w j| n a hundred pages of additional matter third time to the profession. Dr. Smith ha? given it a ., ; ,i t ,.red si/.e of paue. new illustrations, and nc careful preparation, which will make it of decided su- Q ( - ,i ie jj seases treated of for the first time, we notice periority to either of the former editions. The position rotne i n an j cerebro-spina! fever, which lately prevailed of the author, as physician and consultant to several | j n e pj f i en iic form in some parts of the country. The large children's hospitals in New York City, has fur- art j c | e upon diphtheria, containing the latest develop- ni-hed him with constant occasions to put his treatment nients \ n the pathology and treatment of that dread dis- to the test, and his work has at once that practical and t ,. lM , w |,j,. n so lately ravaged our country, is peculiarly thoughtful tone which is a marked characteristic ot the interesting to every practitioner. We glaitlv welcome be-t productions of the American medical press. Mtd. tllis standard work.'and cheerfully recommend it to our and Surg. Rtporlrr, Feb. IsTiJ. readers as tlie >iest on this subject in the Fnulish larc- The former editions of this book have civen it the guage. SaihrWe Journal of Med. and Surgery, March, highest rank among works of its class, and the present 1876. rtONDIE (D. FRANCIS), M. D. ^ A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely- printed pages, cloth, $5 25 ; leather, $6 25. The present edition, which is the sixth, is fully up I teachers. As a whole however the ^work i ^ the ^*| tothettmesln the discussion of all those polntsiu the | American one that we have, and nits pathology and treatment of infantile diseases which I -.ion to American prHctinoners it ctainly -has no have befn brought forward by the Germau^nd French | ,qual.-Jfe York Md. Record, March 2, 1888. (CHARLES), M. D., Physician to the Hospital for Sick Children, *c. LECTURES ON THE DISEASES OF INFANCY AND CI HOOD. Fifth American from the sixth revised and enlarged English edition. In one large and handsome octavo volume of 678 pages. Cloth, $4 50 ; leather, $5 50. (Latt 'y The continued demand for this work on both sides of the Atlantic, and its translation into Ger- man, French Italian, Danish, Dutch, and Russian, show that it fills satisfactorily a sively felt by the profession. There is probably no man living who can speak itl HJ derived from a more extended experience than Dr. West, and his work now prese: nearly 2000 recorded cases, and 600 post-mortem examinations selected Irom among n cases which have pnssed under his care. In the preparation of the present edition 1 much that appeared of minor importance, in order to find room for the introduction of matter, and the volume, while thoroughly revised, is therefore not increased mater Of all the English writers on the diseases of chil- I living authorities in the difficult ^rartnient of medj 4rea. there is no one so entirely satisfactory to us as I cal scieuce in winch he w most U< T>r. West. For years we have held his opinion as I Boston Med. and Surg. Sou judicial, and have regarded him as one of the highest | D 7 THE SAME AUTHOR. (Lately Issued.) ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD. HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians o don, in March, 1871. In one volume, small 12mo., cloth, $. 22 HKNBY C. LKA'S PUBLICATIONS (Diseases of Women). /THOMAS (T.GAILLARD},M.D., Professor of Obntetrics, Ac., in the College of Physicians and Surgeons, N. r., Ac. A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Fourth edition, enlarged and thoroughly revised. In one large and handsome octavo volume of 800 pages, with 191 illustrations. Cloth, $5 00; leather, $6 00. (Just Issn- The author has taken advantage of the opportunity afforded by the call for another edition of this work to render it worthy a continuance of the very remarkable favor with which it has been received. Every portion has been subjected to a conscientious revision, and no labor h:is been spared to make it a complete treatise on the most advanced condition of its important subject. A work which has readied a fourth edition, mill eiou would remark that, as a teacherofgynaec that. to... in ill.- short spare of five year*, l.as achieved both didacticand clinical, Prof. Thorn* - In- certainly a re|iiii:ition which place* it almost U-yond the reach takeo the lend far ahead of his ennfren.t, au.1 as no of criticism, ami the favorable opinions" which we hnve author he certainly has met with unuMial and mer- already expressed of the former editions g^m to re- Hed success. Am Jnurn. <>f Obstetric.*, Nov. 1874. quire that we should do little more than announce This volume of Prof. Thomas in it* revised form this new issue We cannot re'rain from snyinz that. i s c i as ,ical without being pedantic, full in ihe details as a practical work, this is second to none in the Kn|<- of aDatom '_ and pathology, without ponderous lisb, or. indeed, in any other language. The arrant.'*- translation of pages of Gerrain literature, describes ment of the contents, the admirably clear manner in aiti Dcr |y the details and difficulties of each ouera- whirh the subject of the differential diagnosis of ,j on> w i t hont wearying and nseless minutiie, and is injf litfht and instruction. Dr Tlioma is a man with a very dear I..-:,,! and deride,! view-. ,,,,,l there seems to be nothing which he so much dislikes KS ha/y notions of diagnosis and blind routine and unreasonable thera , . ., (ll Professor Thomas fairly took the Profession of t ani '0. plates, ninth. *3 on WANNER (THOMAS H.), M. D. ON THE SIGNS AND DISEASES OF PREGNANCY. First Arneric.n from the Second and Enlarged English Edition With four colored plates andillustratioi 8 on wood. In one handsome octavo volume of about 500 pages, cloth, $4 25. OBSTETR1CA L JO URNA L. (Free of postage for 1878 ) THE OBSTETRICAL JOURNAL of Great Britain and Ireland; Including MIDWIFERY, nnd the DISEASES OP WOMEN AND INFANTS. With an American Supplement, edited by J. V. IXGHAM, M.D. A monthly of about 915 octavo pages, very handsomely printed. Subscription, Five Dollars per annum. Single Numbers, 60 oents each. Commencing with April, 1873, the Obstetrical Journal consists of Original Papers by Brit- ish and Foreign Contributors ; Transactions of the Obstetrical Societies in England and abroad ; Reports of Hospital Practice; Reviews and Bibliographical Notices; Articles and Notes, Edito- rial, Historical, Forensic, and Miscellaneous; Selections from Journals; Correspondence, Ac. Collecting together the vast amount of material daily accumulating in this important and ra- pidly improving department of medical science, the value of the information which it pre- sents to the subscriber may be estimated from the character of the gentlemen who have already promised their support, including such names as those of Drs. ATT HILL, AVEI.I.NG, ROBERT BARNES, J. HENRT BENNET, NATHAN BOZEMAN, THOMAS CHAMBERS. Fi.EKTWOon CHURCHILL, CHARLES CLAY, JOHV CLAY, MATTHEWS DITNCAN, ARTHUR FARRE, ROBKRT GRKENHALC.H. GR.ULY HEW- ITT, BRAXTON HICKS, ALFRED MEAHOWS, W. LEISHMAN, ALEX. SIMPSON, HEYWOOD SMITH. TYLER SMITH, EDWARD J. TILT, LAWSON TAIT, SPENCER WELLS, &c. 4c. ; in short, the repre- sentative men of British Obstetrics and Gynaecology. In order to render the OBSTETRICAL JOURNAL fully adequate to the wants of the American profession, each number contains a Supplement devoted to the advances made in Obstetrics and Gynzecology on this side of the Atlantic. This portion of the Journal is under the editorial charge of Dr. J. V. INGHAM, to whom editorial communications, exchanges, books lor re- view, Ac., may be addressed, to the care of the publisher. %* Complete sets from the beginning can no longer be furnished, but subscriptions can coir- with January, 1878, or Vol. VI., No. 1, April, 1878. 24 HENRY C. LBA'S PUBLICATIONS (Midwifery). PLA YFAIR ( W. 8.), M.&., F.R.C.P., Pm/etsor of OMt-tric Medicine in King'* College, etc. etc. A TREATISE ON TFIE SCIENCE AND PRACTICE OF MIDWIFERY. Second American, from the Second and Revised English Edition. Edited, with Addi- . ii..i,-. by ROBKUT P. HAIIKIS, M.D. In one handsome octavo volume with numerous illus- trations". (1'rrjmriH.g ) i The rery remarkable success which fans in so short a time exhausted the first editions of this work, in both England and America, shows that the author hag successfully supplied an acknowl- edged want of a work which, within a moderate compass, should serve as a guide to th< recent condition of obstetric art and science. A few notices of the previous edition are appended. Tlie author's reputation was fuflicient to warrant containing the ver> latest Information regard inp the B r eat expecta'ions. when his fo -Incoming work was an- subject of ob-tetrics, full of hints of tin- nn-alf-t prac- nounced. anil it." appearance has caused nodisapp. int- tical value. This work will tind. we predict. :t 'ar^e ami uient It drain in a masterly way wiih many disputed >eady sale The lunik is profusely illti-trate.1 with valu- j'oints. and jrives conclusions which it would be difficult to ftainay. The work is the most valuable acquisition to the subject on which it treats which has been Riven able wood-outs, and is printed in beautiful type. Cin- cinnati Lniirrl unit Oi.t'rvrr. NOT. 1876 This is pre-eminently a work adapted to the wants of the profession in a longtime, and in Haying this we do ; gt udents. and will to more towrd aocompli-hing the not forget the manv admirable treatises which have re pro , ess j on .,, \ H w.w that particular branch ,,1 me.licin,- rently appeared. No practitioner onn afford to be with thftn ,. other work in the field ofob-tetric literature. outitP,ti.niuIarJourn.,>fMrtl., Sept. 1876. ln pr . ljs ,. nf , llis work too much cannot h said in <1- ve:-sc criticism very little \Ve advise every student The hi.'h reputation already won by T)r Playfair in and even graduate to obiain it. and hope, e.re long, to this speci.il 'lepHrtmentof medicine is a sufficient iruar- see it adopted as the principal text boon of ob.stetrie anteo, fur the meritorious clmracterof this work. Kvery mediciue in every co/lece in the. United States. A'oji/i- page is replete with interesting arid instructive matter- ville Mi'd. and Surg. Journ , Oct. 187U. E ODGE (HUGH L.), M. D., Emeritti/t Prnfensnr nf Midwifery, r Parry refer principally to the use of the forceps, lactation, anil t.he puerperal diseases, and are intended to increase the aset'ulne.-s c.-f the work in this country. An entiicly new chapter on diphtheria of puerperal wounds haw been added (Dr. I', has hud unusual experience in this form of puerperal fever), and also a number of illustrations of the principal nl>.-tct> ieal instruments in use in Ame- rica. We have nn hesitation in saying that the work. in its present shape, is a great improvement on its prede- ce~sor. and in recommending it as the one obstetrical text-book which we should advise every Kngli.-h speak- ing practitioner and student to buy. Anwrii-un Jour- nal of Obstetrics, Feb. 1S76. Perhaps the most useful one the student can procure. Some import ant additions have been made by Ibe editor, in order to adapt the work to the profession iu this coun- try, and some new illustrations have been introduced, to represent the obstetrical instruments generally em- ployed in American practice. In its present form, it is an exceedingly valuable book for both the student and practitioner. A'ew York Med. Journal, Jan. 187C. In about two years after the issue of this excellent treatise a second edition has been called for. We regard the treatise as thoroughly sound and practical, and one which may with confidence be consulted in any emtsr-' gency. The London Lancet, Dec. 11, IsTti. -pARRY (JOHN S.), M.D., -*- O'^tttrician to the Philadelphia Hospital, Vice-Prest. of the OWet. S ^ciety of Philadelphia _ EXTRA-UTERINE PREGNANCY: ITS CLINICAL HISTORY, DIAGNOSIS, PROGNOSIS, AND TREATMENT. In one handsome octavo volume. Cloth, $i 60. (Lately Issued.) It is with genuine satisfaction, therefore, that weread the work before us. which is far in advance of any mo- nograph upon the subject in the English language, and exceeding very much, in the number of cases upon which it is based, we believe, any work of the kind ever published. The author has given great care and study to the work, and has handled his statistics with judg- ment: so 'hat. whatever was to be gained from them, he has gained and added to our knowledge on the sub- ject. We owe the author much for giving us a clear, readable book upon this topic. He has, so far a* it is at present possible, removed the obscurity attending certain points nf the subject. He has brought order out of something very like chaos. Philadelphia Mrd. Times, Feb. 19, 1S76. In this work Dr. Parry has added a most valuable contribution to obstetric literature, and one which meets a want long felt by those of the profession who have ever been called upon to deal with this da-* of cases. Boston Med. and Surg. Journ.. March 9, 187B. This work, being as near as possible a collection of the experiences of many persons, will afford a most useful guide, both in diagnosis and treatment, for this most interesting and fatal malady. We think it should be in the hands of all physicians practising midwifery. Cin- cinnati Clinic, Keb.'o, 1876. A SHHURST (JOHN, Jr.), M.D., -* 1 Prof of Clinical Surgery, Univ. of Pa., Surgeon to the Episcopal Hospital, Philadelphia. THE PRINCIPLES AND PRACTICE OF SURGERY. In one .very large and handsome octavo volume-of about 1000 pages, with nearly 550 illustrations, cloth, $6 50; leather, raised bands, $7 50. Its author has evidently tested the writings and experiences of the past and present in the crucible j of a careful, analytic, and honorable mind, and faith- _| fully endeavored to bring his work npto the level of, the highest standard of practical surgery. frank and definite, and gives us opinions, and gene rally sound ones, instead of a m&ierisujne oft! jpinlons of others. He isconservative, but not hide- bound byauthority. His style isclear, elegant, and scholarly. The wr rk is an admirable text-book, and a useful book of reference. It is a credit to American professional literature, and one of the first ripe fruits >f the soil fertilized by the blood of onr late unhappy VHT.N. r. Med. Record, Feb. 1, 1872. SKEY'S OPERATIVE SURGERY. In 1 vol. 8vo, cl., of 650 page* ; withabout lOOwood-cats $3 2! COOPER'S LECTURES ON THE PRINCIPLES AND PRACTICE OF SuRflBRY. Inlvol. 8vo cloth, 750p. $2. GIBSON'S INSTITUTES AND PRACTICE OF SUR- OKRT. Eighth edition, improved and altered. With thirty-four plates. In two handsome oc'.avo vol- nines, abont 1000pp.. leather. ralsdbandf. *" ^. THE PRINCIPLES AND PRACTICE OF SURGERY. By Wn.LttM PIRRIB, F.R S.E., Professorof Surgery in the University of Aberdeen. Edited by JOHN NEILL M.D., Professor of Surgery in the Penna. Medical College, Surgeon to the Pennsylvania Hos- pital, &c. In one very baud-some octavo volume of 780 pages, with 316 illustrations, cloth. MILLER'S PRINCIPLES OK SUKGKKY. Fourth Ame- rican, from the Third Edinburgh Edition. In one large Rvo. vol. of 700 pages, with 340 illustrations cloth, *:J 75. MILLEU'S PRACTICE OF SURGEKY. Fourth Ame- rican, from the last Edinburgh Edition Kevised b; the American editor. In onelarge Svo. vo .of nearly 700 pages, with 3C4 illustrations: cloth, $J 16. 26 HJBNBY C. LEA'S PUBLICATIONS (Surgery'*. S1ROSS (SAMUEL D.), M.D., Professor of Surgery in the Jeffereon Medical College of Philadelphia. A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fifth edition, carefully revised, and improved. In two large and beautifully printed imperial octavo vol- umes of about 2300 pages, strongly bound in leather, with raised bands, $16. (Jnst Issued.) The continued favor, shown by the exhaustion of successive large editions of this great work, proves that it has successfully supplied a want felt by American practitioners and students. In the present revision no pains have been spared by the author to bring it in every respect fully up to the day. To effect this a large part of the work has been rewritten, and the whole enlarged by nearly one fourth, notwithstanding which the price has been kept at its former very moderate rate. By the use of a close, though very legible type, an unusually large amount ol matter ii condensed in its pages, the two volumes containing as much as .four or five ordinary octavos. This, combined with the most careful mechanical execution, and its very durable binding, renders it one of the cheapest works accessible to the profession. Every subject properly belonging to the domain of surgery is treated in detail, so that the student who possesses this work may be aaid to have in it a surgical library. We have now brought our task to a conclusion. Bird have seldom read a work wiih the, practical vi.lue of which we have been more impressed. Kvery chapter is so concisely put together, that the busy practitioner. when in dimi-ulty. can at once find the information he require-. His work. on the eontiary.is cosmopolitan, the surgery of the world being fully represented in it. The work, in fact, is so historically unprejudiced, and so eminently practical, that it i* almost a false compliment to say that we believe it to be destined to occupy a fore- most place asawork of reference, whileasystrm of mr- ftery likethe present system oi'surgery is the practice of surgeons. The printing and bimiing of the work is uii- ' exceptionable; indeed, it contrast-, in the latter re- spect, remarkably with Enitlish medical anrt surgical cloth-bound publications, which are generally so wretch- edly stitched as to require re-binding before they are any time in use. Dul>. Journ. nf M?d. Sci., March, 1874. Dr. Gross's Surgery, a great work, has become still greater, both in sfze and merit, In its most recent form. The difference in actual numberof pages is not more than 130, but. the size of the page having been increased to what we believe is technically termed "elephant." there has been room for considerable additions, which, toge- ther with the alterations, are improvements. Lend. Lancet, Nov. 16,1872. It combines, as perfectly as possible, the qualities of a text-book and work of reference. We think this last edition of Gross's ' Surgery," will confirm his title of ' Primut inter Fares." It is learned, scholar-like, me- thodical, precise, and e-xlian-tnc. We scjircely think any living man could write so complete ami faultless : \ treiitise. or comprehend more solid, instructive matter, in the given number of pages. The labor mu.st have been immense, and the work -rives eviileii'-" powers of mind, and the highe-t order ofinte discipline imd methodical disposition, and arrangement of acquired knowledge and personal experience. A'. 1' Med Journ.. feb 1873 As a whole, we regard the work as the representative "System of Surgery" in the Knglish language. St. Louis Medical and Surg. JVmr/i., Oct. 1 - The two magnificent volumes before us afford a very complete view ot the surgical knowledge of the day. Some years ago we had the pleasure of presenting the first edition of Gross's Surgery to tlie profession a* work of unrivalled excellence; and now we time the result of yearn of experience, labor, and study, all con- densed upon the great work before us And to students or practitioners desirous of enriching their library with a treasure of reference, we can simply commend the purchase of these two volumes of immense research. Cincinnati Lancet and Observer, Sept. l.-7'J. A complete system of surgery nr.t a mere text-book of operalious, but a scientific account uf surgical theory and practiceiuall itsdepurtments. Jirit.und for. MrU.- C/iir. Rev.,Ju. 1873. Y THE SAME AUTHOR. A PRACTICAL TREATISE. ON THE DISEASES, INJURIES, and Malformations of the Urinary Bladder, the Prostate Olnnd, and the Urethra. Third Edition, thoroughly Revised and Condensed, by SAMUEL W. GROSS, M.D., Surgeon to the Philadelphia Hospital. In one handsome octavo volume of 574 pages, with ITU illus- trations: cloth, $4 50. (Just Issued.) The book is fully up to the times, and we know of no monograph on the subject of urinary diseases that is fuller and more complete than the one under notice. Oincin. Lancet and Observer, Dec. Ifc76. It is a valuable and exhaustive treatise on the surgery of the urinary organs, brought fully up to the exiting state of our knowledge. A perusal of its 574 pages will amply repay the investigator. 1'aajlc Med. and Surf Journ, Nov. 1878. Nothing need be raid to commend this standard work to the profession. It has long been considered one of the most valuable from the pen of the distinguished author. The editor bus done his work ably and faith- fully, and several of the chapters, by no means the least i useful ones, are from his pen; as a monograph repre- | senling all the surgery of the parts of which it ire;, is. it has nosuperiorin our tongue Med and Surg He- I porter, Oct. 21, 1876. For reference and general information, the physician or surgeon can find no work that meets their necessities more thoroughly than this, a revised edition uf an ex- cellent treatise, and no medical library should be with- out it. Kepli-te with huud.souie ilhi-iruti us und good ideas, it has the unusual advantage of being e.isily comprehended, by the rca>onuble and practical uinnncY in which the various sul.j.-ci> ure systematized :u.d arranued We heartily recommend it to the pi a a valuable addition to the important literature of dis- eases of the urinary or^aug Atlanta Med Journ., Oct. 1876. It is with pleasure we now again tnke up this old work in a decidedly new dress. Indeed, it must be regarded as a new book in very many of its parts. The chapters on -Hi-eases of the liladder," I'rostate Body, and Lithotomy." are splendid specimens of descriptive wri'.iiiL': while the chapter on "Stricture" is one ul the ni'i-t e.,nci,e and clear tlnil we have ever read A*w York Med. Journ., Nov. 1876. n T TBS SAME AUTHOR. A PRACTICAL TREATISE OX FOREIGN BODIES IN THE AIR-PASSAGES. In 1 vol. 8vo. , with illustration?, pp. 468, cloth, $2 75. D1GELO W (HENRY J.), M L^~ *-* Professor of Surgery in the Mct-tsichusetts 3ftd. College. ON THE MECHANISM OF DISLOCATION AND FRACTURE OF THE HIP. With the Reduction of the Dislocation by the Flexion Method. With numerous original illustrations. In one very handsome octavo volume. Cloth, $250. HENRY C. LEA'S PUBLICATIONS (Surgery). 27 (LEWIS A ). A.M.. M.D., Snrfffon to the Prfs'iyttri-in H"x/'itnl. A MANUAL OF OPERATIVE SURGERY. In one very handsome royal 12mo. volume of about 500 pages, with 332 illustrations ; cloth, $2 50. (Just Ready ) MnnV years having elapsed since the nppenrance in this country of any work devoted exclu- sively to the operations of surgery, and the ordinary surgical text-hooks being too large and unwieldy for ready consultation and reference, the author has thought that a compact manual devoted exclusively to practical operative details, thoroughly illustrated, would fupply a want universally felt. He has accordingly sought to embody in the work a concise account of all the operations practised at the present day, devoting special attention to the newer and less fami- liar ones, copiously illustrated with diagrams and figures, man}- of which are original. The scope of the work can be gathered from the subjoined very condensed OF PART I. THE ACCESSORIES OF AN OPERATION. PART II. LIGATI-RK OF ARTERIES. PART III. AMPUTATION. PAHT IV. EXCISION OF JOINTS AND BONES PART V. NETROTOMV AND TEHOT- OMY. PART VI. PLASTIC OPERATIONS OF i HE FACE. PART VII. SPECIAL OPERATIONS. Chap. I. Operations upon the Eye and its Ajpendages. Chap. II. Operations upon the Ear and its Appendages. Chap III. Operations upon the Mouth and Phaiynx. Cluip. IV. Operations performed upon the Neck. Chap. V Operations performed upon the Thorax. Chap. VI. Ope- rations performed upon the Abdominal Wall, Stomach, and Intestines Chop. I'll Operations upon the Male Genit'o-Urinary Organs Chap. VIII. Operations upon the Genito-Urinary Organs of the Female. Chap. IX. Miscellaneous Operations. H 'OLMES (TIMOTHY], M.D., Surgeon to St. George's Hospital, London. SURGERY, ITS PRINCIPLES AND PRACTICE. some octavo volume of nearly 1000 pages, with 411 illustrations '"" (Just Issued.} In one hand- Cloth, $6; leather, $7. We belie veil to be by far the beet surgical text-booh tbat we have, insomuch asjt is the complete*!, and theonemost thoroughlylironght up to the knowledge of the present day. All who will givelhis book the careful perusal that it deserves and requires, whe- ther student or practitioner, will agree with us, ihst, from the happy waj in which justice is done, both to the priuciples and practice of surgery, from thecare with which its pages are brought up to modern date, from the respect which is paid all along t" the opin- ions of others, it deserves to take the first place among the text-books on surgery. British Med. Journ., Dec. 25, 1875. This is a work which has been looked for on both sides of the Atlantic with much interest. Mr. Holmes is a surgeon of large and varied experience, and one of the best known, and perhaps the most biilliant writer upon surgical snbjecrs in England. I* is a book for students and an admirable one and for the busy general practitioner. It will give a student all the knowledge needed to pass a rigid examina- tion. The book fairly justiflesthe high expectations that were formed of it. Its style is clear and forcible, even brilliant at times, and the conciseness needed to bring it within its proper limits has uol impaired its force and distinctness. A". Y. Md. Record, April 14, 1876. It will be found a most excellent epitome of enr- gery by the general pracliiioner who ha> nut r be time 10 give attention to more in in ate and extended works, and to the medical student, In fact, we know ofuo one we can more cordial y recommend. The author has succeeded well ia giving a plain aud practical a-count of each surgical injury and d s-ase, and of ' the trentment wWch is most commonly advisable. It will no doubt bee > me a popular work in the pro- fession, and especially as a text-book. Cincinnati Med. fftwx, April, 1876. In point of literary structure we have no words but j those of praise to write of Dr. Holmes'* book. His j diction is always graceful and clear, aud he usually wjrks with great conscientiousness. There is much ! independence of thought and a hel thy disposition to j resist the tendency to walk in old tracks simply be- ! cause they are old. On ihe whole, lie has done his work I in a manner for which it would be ungenerous not to i give him very high credit indeed. Dublin Journ rf I Med., Oct. 1876. TJAMILTON (FRANK H.), M.D., Professor of Fractures and Dif locations, Ac., in Bellemie Hasp. Sfed. College, Kev> York. A PRACTICAL TREATISE OX FRACTURES AND DISLOCA- TIONS. Fifth edition, revised and improved. In one large and handsome octavovoluite of nearly 800 pages, with 344 illustrations. Cloth, $5 76: leather, $6 75. (lately Issued.) This work is well known, abroad as well as at home, as the highest authority on its important subject nn authority recognized in the courts as well as in the schools and in practice and again manifested, not only by the demand for a fifth edition, but by arrangements now in pro- gress for the speedy appearance of a translation in Germany. The repeated revisions which the author has thus had the opportunity of making have enabled him to give the inostcareful consid- eration to every portion of the volume, and he has sedulously endeavored in the present issue, to perfect the work by the aid of his own enlarged experience and to incorporate in it whatever of value has been added in this department since the issue of the fourth edition. It will there- fore be found considerably improved in matter, while the most careful attention has been paid to the typographical execution, and the volume is presented to the profession in the confident hope that it will more than maintain its very distinguished reputation. There is no better work on the subject in existence than that of Dr. Hamilton. It should be in the posses sion of every jreneral practitioner and surgeon. The Am. Journ. of Obstetrics. Feb. 187C. The value of a work like this to the practical physi- cian and surgeon can hardly be over-estimated, and the necessity of having such a book revised to the latest dates, not merely on accouut of the practical importance of its teachings, but also by reason of the medico legal bearings of the cases of which it treats, uud which have recently ben the subjectof useful papers l>y 1'r Hamil- ton and others, is sufficiently obvious to every one The present volume seems to amply fill all the requisites. \Ve can safely recommend it as the best of its kind in the English language, and not excelled in any other. Journ. of XeTcous and Mental Disease, Jem 1876. HKNBY C. LEA'S PUBLICATIONS (Surgery). &RICHSEN (JOHN E.), *' Professor of Surgery in University College, London, etc. THE SCIENCE AND ART OF SURGERY; being a Treatise on Sur- gical Injuries, Diseases, and Operations. Carefully revised by the author from the Seventh and enlarged English Edition. Illustrated by eight hundred and sixty two en- gravings on wood. Ir two large and beautiful octavo volumes of nearly 2000 pages: cloth, $8 50 ; leather, $10 50. (Now Ready.) In revising this standard work the author has spared no pains to render it worthy of a continu- ance of the very marked favor which it has so long enjojed, by bringing it thoroughly cm a level with the advance in the science and art of surgery mnde since the nppearnnce of the last edition. To accomplish this has required the addition of about two hundred page" of text, while the illustrations have undergone n mnrked improvement. A hundred and filty adilitionnl wood-cut.* have been inserted, while about fifty other new ones have been substituted for figures which were not deemed satisfactory. In its enlarged nnd improved form it is therefore pre- sented with the confident anticipation that it wilt maintain its position in the front rank of text-bocks for the student, and of works of reference for the practitioner, while its exceedingly moderate price places it within the reach of all. The seventh edition U before tlie world us the last word or surgical science There may.be monographs which excel it upon certain polnix, but :IK a con spectiis upon surgical principles and practice it is unrivalled. It will well reward practitioner* to read it, for it has been a p' ciiliar province of Mr E-ichsen to demonstrate the absolute interdepend- ence of medical and surglcil science We need scarcely add, in conclusion, that w heartily com- mend the work to students that they rosy bo grounded in a sound faith, and to practitioners as an Invaluable guide at tbe bedside Am Practi- tioner, April, 1878. It in no i lie compl ment to say that this is the best edition Mr. Erich-en has ever produced of his well- known book. Besides inheriting the virtues of i'8 predecessors, it possesses excellences quite its own. Having stated that Mr. Erichsen his incorporated into this edition every recent improvement In the science and art of surgery, it would be a supereroga- tion to give a detailed criticism. In short, we un- hesitatingly aver that we know of uo other single work where the student and practitioner can gain at oncesoclear an insight into tli.i principles of surgery, and so complete a knowledge of the exigeucies ot surgical practice. London Lnncft, Feb. 1 I, IsT^ For the past twenty years Erichen's Surgery has maintained its pi ace as the leading lex I- book, not only in this country, but in Great Bri ain. Tint it is able 10 hold Its ground, IK abundanlly proven by ibe tho- roughness wi>h which the pre-eLt dilioii has he -n revised, and by the large amount of valuable mate- rial that has bren addel. Aside from this, i ne hun- dred and fifty new Illustration* have been inserted, including quite a nomber of microscopical appear- ances of pathul .gical processes. So in irked is this change for the better, that tbe work almost appear) as an entirely new one i(l. Re >ded, and many cf the old i ties have been redrawn The author highly appreciates the favor wiih which his work has been received by Ameri- can surgeons, and has endeavored to render bis latest edition more than ever worthy of their approval. That lie has succeeded admirably, musi. we ibink. be the geueral opinion. We heartily recommend the book to both student and practitioner. A". Y. J.'e1 ' 4 LP.CT PART V. DlSK.ASKS OK I UK AKTKTI.ATIOJSg. 7 VI. PHI.KUMO.N, Aii.cKSs, AM> PisTf'i.A. 3 " It will be seen from this brief abstract of the contents that these Lectures treat of ubiectg which are of daily interest to the i ractitioner, while some of them hardly receive in the text books the attention which t>eir importance deserves. E (EDGAR A.}, Suraeon to the. Liverpool Eye an* Vir Infirmary, nnd tr the Dispensary fnr Skin Disuse* HOW TO USE THE OPHTHALMOSCOPE. fiein^ElementaiT In- structions in Ophthalmoscopy, arranged for the Use of.Students. \\Tth thirty-five illustra- tions. In one small volume royal ]2mo. of 120 pages: cloth, $]. (JN 010 Ready.) This capita] little work should be in the hands of i strnment and the suggestions to aid in interpreting ev ry medical student, andwebad almostsaid every whit is seen. D-troit Hed. Jonrn Nov 1877 general practitioner. Its explanation of the optic 1 TKi * principles on which the ophthalmoscope is founded, a , S(1 ,,,! in^ **&** '" T toncise.but we may i.s 80 clear and simple that the most itnpld reade ^J^* 25 mS'il? ,T' ' n " nner : *'"? ' conld scarcely fail of understanding them. Equally &?%? ^^X ' *?' art . " rl nna . 1 "* satisfactory are tire directions for the use of tie in E.^fcd!^ ' ^ ^ ln ' lruaiT (BARTER (R. BRUDEXELL), F.R.C.S Op'ttunliiiic Surgeon to St. George e Hoxpita.1, ttc. A PRACTICAL TREATISE ON DISEASES OF THE EYE. Edit- ed, with test-types and Additions, by JOHN GREEN, M.I), (of St. Louis, Mo.). In one handsome octavo volume of about 500 pages, and 124 illustrations. Cloth, $3 75. (Just Issued. ) Dr. Green, whose reputation and experience in this department are well known, has given this work a very careful revision, and has introduced much matter which will be found of importance to the practitioner. As his system of test-types i.s the one recommended by the author, they have been inserted in the volume in a shape which will admit of their being detached and mounted for convenient office use. These test-types, on a sheet for mounting, can be had separate, price 25 cents. It would be difficult tor Mr. Carer to write an uniu- in view, aud presents the subject in a clear mid conn>e structive book, and impossible for him to write an un- I manner, easy of comprehension, and hence the more interesting one. Kveu on suljects with which he is not valuable. We would especially commend, however, as bound to be familiar, he can di.-course with a raredegree worthy of high praise, the manner in which the thera- ot clearness aud effect. Our readers will therefore not I peutics of disease of the eye is elaborated, for here the be surprised to learn that a work by him on the Llisea.-es author is particularly clear and practical, where other of the Kye makes a very valuable addition to ophthal- writers are unfortunately too often deficient. The nnal mic literature. . . . The book will remain one useful diaper is devoted to a discus-ion ol the uses an.. alike to the general aud the special practitioner. Not tion of spectacles, and is admirably compact, plain, and tlie least valuable result which we expect from it is that useful, especially the parairraj hs on the trealiin it will to suiuecoDMderiihle extent despecialize this bril- pres'iyopia and myopia. In conclusion, our thanks ar liiint department of medicine. London iMnctt. Oct. 30. due the author for many useful hints in the ur^at ,-ub- 1S75. ject of ophthalmic suritery and therapeutics, a field It is with great pleasure that we can endorse the work -'" '" '''" - lrs wu B 1 " b l ".?" -. 1 " ',", as a most valuable contribution to practical ophthnl- wheat trom a u.a.-s ul chatJ -.>ct } ri J// iCU ? 7. mology . Mr. Carter never deviates from the end he has i Uct - **> 1 * 1XTELLS (J. SOELBERG), ' ' Professor of Ophthalmology in King's Vollege Hospital, Ac. A TREATISE ON DISEASES OF THE EYE. Third American, from the Fourth nnd Revised London Edition, with additions ; illustrated with numerous engravings on wood, and six colored plates. Together with selections from the Test-types of Jaeger and Snellen. In one large and very handsome octavo volume. TA URENCE (JOHN Z.), F. R. C. S., Editor of the Ophthalmic Review, &c. A HANDY-BOOK OF OPHTHALMIC SURGERY, for the use o Practitioners. Second Edition, revised and enlarged. With numerous illustrations. In one very handsome octavo volume, cloth, $2 75. TAWSON (GEORGE], F. R. C. S., EngL, U Assistant Surgeon to the. Royal London Ophthalmic Hospital M^orfleldf, Ac. INJURIES OF THE EYE, ORBIT, AXD EYELIDS: their Imme- diate and Remote Effects. With about one hundred illustrations. In one very hand some octavo volume, cloth, $3 50. 30 HENEY C. LBA'S PUBLICATIONS (Medical Jurisprudence). PURNETT (CHARLES //.), M.A , M.D., --* Aurj.1 8urg to the Prztb. hofp., Surgeon-in-iharpeofthrlnJIr for Dig. oftlir Enr, Phi In. TIIK EAR, ITS ANATOMY. PHYSIOLOGY, AND DISK ASKS. A Practical Treatise for the Use of Medical Students and Practitioners. In one h;ind- some octnvo vo'iime of 615 pnges, with eighty-seven illustrations : cloth, $4 50; leather, $5 50. (Jut Ready.) Recent progress in the investigation of the structures o*" the ear, and advances nin'e in the modes of treating its diseases, would seem to render desirable a new wo-k in which nil the re- sources of the molt advanced science should b placed a' the disposal of the practitioner. This it hns been the aim of Dr. Burnett to accomplish, and the advantages which he h.-is enjoyed in the special study of the subject are :i guarantee that the result of hif labors will prove of service to the profession nt large, as well as ti the specialist in this department. As the t'tle of the work indicates, this volume the medical student and general practitioner, ih's treats of the anatomy and physiology of the ear, as well ax of its diseases, and the author has taken special palus to make thin difficult and complicated matter thoroughly clear and intelligible The book i-i designed w| ecially for the use of >tndsnts and general practitioners, snd places at their disposal much valuable material. Such a book as (lie pre- sent one, we think, has long been needed, and we may congratulate the author on his success in fill- lug the gap. Both ir.udent and practitioner can study the work with a grtat deal of benefit. It is prjfu'ely and beautifully illustrated. A. T. Hot- pital Gatf.it f, Oct 15. lf-77. The medical student and general practitioner have long felt the need of abook ol thit characteron an oigaa so litlle understood and yet so important as the ear The author ha presented in it e volume clearly but concisely the great ad ranc. s which have been made of laie yearsln otology aud hasitdirated the direction in which further researches can be moat profitably carried on The work is divided iuto twop.tr s. In 1'art I. the nnatoinv and physiol- ogy of the ear ar* minutely, yet explicitly, detailed in a manner not 10 be found in auy of the ordinary text-bjoks. In Part II the diseases and treatment of the ear are fully and pracli.-ally presented. To work is indi-pensablfl, and will not he found void of interest !> the specialist Mar^lund Mtd. . Nov 1S77 The appearance of this book Is another proof of the rapidly increasing amount of honest, valual that is now heing done in the various brai medical science in this country. Dr. Burnett commended for having wiitieu the be?i book on the subject in the English language, anl esp- '.i-iily for the care and attention be lias given to rh - ..-antic side of the subject. N. Y. Med Jmirn., Do. There is probably no other book of the kind in the Eng'ish language which contains so < -incise and yet so complete an account of the numer -us dis- eases to which the >ar is liab'e. We can safely pre- dict that every intelligent medical man who takes the trouble to make himself f miliar with (he. load- ing fact* concerning this class of disease, as given by Dr. Kurnett, will not only admit that the lima thus employed was far from being wattled, but that the earnest labors of Otologists withiu the last few years have taken away the sting oi reproach con- tained ia the hackneyed phrse that ' nothing can be got out of the ear but fees aud wax.'' Mvi. nnd Sury. Jotirn., Nov. i - /TAYLOR (ALFRED S.), M.D., *- Lecturer on Med. Jurittp. and Chemistry in Ghty't Hospital. POISONS IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. Third American, from the Third and Revised English Edition. In one large octavo volume of 850 pages ; cloth, $5 50 ; leather, $6 50. (Just Jss/ifit.) The present is based upon the two previous edi- being described which give rise, to i g> ct, pr.-l>;illy fur be.yo id what any other living auliionty on toxicol- ogy could have amassed or utilized. H Has luily SUM. lined his refutation by the conrniiiiiiHte skill aud legal acumen be has displayed in ti.e an align- ment of tbe subject-mailer, aud the result i.s n work on Poisons whicti will b indispensable to evei y .-i u- dent or practitioner in lawaud medicine Ttte Du't- ImJourH. / M &i He ., Oct. Ia7.~>. B ] THE SAME AUTHOR. undertake to speak of the merit of Chilly's Plead ings. Ch'cifft, Lf.gnl ffrtct, Oct. 16, 187.1. It is beyond question tbe m >t attractive as well MEDICAL JURISPRUDENCE. Seventh American Edition. Edited by JOHN J. RKESK, M.D., Prcf. of Med. Jurisp. in the Univ. of Penn. In oue large octavo volume of nearly 900 pages. Cloth, $5 00; leather, $6 00. (Lately Ism- -/.) To the members of the legal and medical profession, . best authority on this specialty in our language. On it Is unnecessary to say anything commendatory of | this point, however, we will -ay that we cuMLANDFORD (G. FIELDING^. D,, f\R. C. P., Lecturer on Psychological Medicine at the. School / St. George's Hospital, Ac INSANITY AND ITS TREATMENT: Lectures on the Treatment, Medicul and Legal, of Insane Patients. With a Summary of the Laws in force in the United Suites on the Confinement of the Insane. By ISAAC RAY, M. D. In one very handsome octavo volume of 471 pages; cloth, $3 25. It satisfies know of no single work wmcu contains, in ou | interesting phases of human society and progress. . . mall a compass, so much illustrative of the strangest I The fulness aud breadth with which he has carried operations of the human mind. Foot-notes give ihe i out his comparative survey ol this repulsive field of authority for each statement, showing vast research history [Torture], are such as to preclude our doing and wonderful industry. We advise our confi erts justice to the work within our present limits, ttui t read this book aud ponder its teachings Chicago here, as throughout the volume, there will be found Mtd. Journal, Aug. 1870. | a wealth of illustration aud a critical gntsp ol the As a work of curious inquiry on certain outlying philosophical import of lacu which will render Mi. points of obsolete law, "Superstition and Force'' ii Lea 8 labors , overling value to the historical olu . Sne of the most remarkable books we have met with. : deat.-London Saturday Sweu,, Oct. s, 16,0. London Athenceum, Nov. 3, 1866. Ag a i, 00 ij o f rea dy reference on the subject, it is of He has throwna great deal of lightupon whatmust the highest value. Westminster Review, Oct. 1S67. be regarded as one of the most instructive as well as | 75 r THE SAME AUTHOR, (late y Published.) STUDIES IN CHURCH HISTORY THE RISE OF THE TEM- PORAL POWKR BENEFIT OF CLERGY EXCOMMUNICATION. In one large royal 12ino. volume of 516 pp.; oloth ; $2 75. The story was never told more calmly or with , literary phenomenon that the head of one of the firl greater learning or wiser thought. We doubt, indeed, ' American houses is also the writer of some of its most if any other study of this field can be compared with original books. London Athenceum, Jan. 7, 1S71. Mr. Lea has done great honor to himself and thit country by the admirable works be has written on ecclesiologicaland cognate subjects. We have already this for clearness, accuracy, and power. Chicago Examiner, Dec. 1870. Jlr. Lea's latest work, "StndiesinChurch History,'' ,__ fully sustains the promise of the first. It deals with had occasion to commend his "Superstition aud three subjects the Temporal Power, Benefit of Force" and his " History of Sacerdotal Celibacy." Clergy, and Excommunication, the record of which \ The present volume is fully as admirable in its me- has a peculiar importance for the English student, and j thodof dealing with topics and in the thoroughn Is a chapter on Ancien; Law likely to be regarded as a quality BO frequently lacking in American au fiaal. We cau hardly pass from our mention of such with which they are investigated. A". Y. Journal rf works as these with which that on "Sacerdotal Psychol Medicine, July, 1870. Telibacy" should be included without noting the 1 32 HENRY C. LEA'S PUBLICATIONS. INDEX TO CATALOGUE American Journal of tbe Medical Sciences Abstract, Monthly, of tbe Med. Science* . Allen's Auatomy Anatomical Atlas, by Smith and Homer . Ashton on the Kectuui and Anns . . . Attfleld's Chemistry Ashwell on Diseases of Females . Ashhnr.-'t's Surgery Browne ou Ophthalmoscope .... Burnett on the Ear Barues on Diseases of Women . . . Bellamy's Surgical Anatomy Bryauts Practical Surgery .... Bloxam's Chemistry Blandford on insanity Brtslmuj on Keual Diseases .... Brinton n the Stomach .... Bigelow on the Hip .... Barlow'b Practice of Medicine Bowinan'8 (John E.) Practical Chemistry . Bowman's (John E.) Medical Chemistry Brlslowe's Practice Hamatead on Venereal Bu instead and Cullerier's Atlas of Venereal Carpenter's Human Physiology . Carpenter on the Use and Abuse of Alcohol Cornil and Ranvier , Carter on the ty ft Clelaud's Dissector Clowes' Chemistry ....'. Century of American Medicine 'Chadwick on Diseases of Women . Charcot on the Nervous System Chambers on Diet aud Regimen . Chambers'!) Restorative Medicine . . Christlson and Griffith's Dispensatory Churchill's System of Midwifery. Ch archill on Puerperal Fever Condie on Diseases of Children . Cooper's (B. B ) Lectures on Surgery . . Cullerier'n Atlas of Venereal Diseases Cyclopedia of Practical Medicine. Dalton's Human Physiology . . l>iv,s - Clinical Lectures .... Uewees on Diseases of Females . Druttt'a Modern Snrgery DangliHon's Medical Dictionary . Qunglison's Hnman Physiology . Erichsen's System of Surgery F.riuharsns Therapeutics .... Fenwick'8 Diagnosis -. . Flint ou Respiratory Organs . Flint on the Heart Flint's Practice of Medicine . Flint's Essays Flint on Phthtsi Flint on Percu**i,.n FothergiU's Handbook ofTreafment . '; -' ; Fothergill's Antagonism of Therapeutic Agents Pownuit's Elementary Chemistry . Fox on Diseases of the Skin . . '.'-'.' Puller on the Lungs. 4c Green's Pathology and Morbid Anatomy . Gibson's Snrgery G luge's Pathological Histology, by Leidy . Gray's Anatomy Griffith's (R. E.) Universal Formulary Gross on Urinary Organs . . ' . Gross on Foreign Bodies in Air-Passages . Gross's Principles and Practice of Snrgery . Oosselln's Clinical Lectures on Snrgery Hamilton on Dislocations and Fractures Bartshorne's Essentials of Medicine . Hartsnorne's Conspectus of the Medical Selena Hart-home's Anatomy and Physiology Hamilton on Nervous Diseases Heath's Practical Anatomy . . ~ .' ;'*' Hoblyn's Medical Dictionary ,'* ''' V : Hodge on Women .' . . - .' v .-'. o Hodge's Obstetrics . . . . ,'#* s--J<->> Hodge's Practical Dissections . . . Holland's Medical Notes and Reflections . P.V.I: . 1 . 3 7 Ho'mes's Snrgery Hnlilra s Landmarks .... iorner's Anatomy and Histology Hudson on Fever rlill on Venereal Diseases .... iillier's Handbook of Skin Diseases fones (C. Haudtield) on Nervous Disorders Kirkeh' Physiology Knapp's Chemical Technnlogy Lea's Superstition and Force Lea's Studies in Church History . Lee on Syphilis Lincoln ou Electro-Therapeutics . Leishman's Midwifery ..... La Roche on Yellow Ferer .... La Roche on Pneumonia, &c. Laurence and Moon's Ophthalmic Surgery . Lawson ou the Eye Lehmann's Physiological Chemistry, 2 rols. Lehmann's Chemical Physiology . Ludlow's Manual of Examinations 18 .M.Mical News and Library 1;l Mnigs on Puerperal Fever s Miller's Practice of Surgery l ;i Miller's Principles of Surgery . H Montgomery on Pregnancy . 29 Neill and Smith's Compendium of Med. Science 7 N'eligan's Atlas of Diseases of the Skin 11 i >b.stetrical Journal ' Parry on Extra-Uterine Pregnancy !-' ! Pavy on Digestion I'iivy on Food s Parrish's Practical Pharmncy . is pj vrie's System of Surgery l ; j Playfair's Midwifery '' } Qnain and Sharpey's Anatomy, by Leidy . 2- Roberts on Urinary Diseases '\ I Ramsbotham on Parturition -"' Remsen's Principlesof Chemistry 9 Rigby's Midwifery Rod well's Dictionary of Science . s.imson's Operative Snigery Swayne's Obstetric Aphorisms . ' . Sargent's Minor Surgery Sharpey and Qnain's Anatomy, by Leidy Skey's Operative Surgery ! ' Slade on Diphtheria hiifer's Histology li Smith (J. L.) on Children .... 1 4 Smith (H. H.) and Homer's Anatomical Atlas 1 s Plinth (Edward) on Consumption . l v Smith on Wasting Diseases in Children !"' Mille's Therapeutics ]"' S;ill6 4 Maisch'g Dispensatory Sturges on Clinical Medicine . Stokes on Fever Tanner's Manual of Clinical Medicine . Tanner on Pregnancy ie 17 17 1 [Taylor's Medical Jurisprudence I Taylor's Principles and Practice of Med Jnrisp. 1 s Fa> lor on Poisons . . . . 1 Take on the Influence of the Mind '-"> Thomas ou Diseases of Females . . . 14 Thompson on Urinary Organs . 8 Thompson on Stricture :; Tli.iinpson on tbe Prostate ;ti |Todd on Acute Diseases (i Walshe on the Heart (i Watson's Practice of Physic 1' Wells on th Eye : West on Diseases of Females ; 1" West on Diseases of Children ' West on Nervous Disorders of Children 8 What to Observe in Medical Canes I 6 Williams on Consumption 7 Wilson's Human Anatomy 4 Wilson on Diseases of the Skin .... - Wilson's Plates on Diseases of the Skin 21 Wilson's Handbook of Cutaneous Medicine " W. .liter's Organic Chemistry . 14 Winckel on Childbed a 17 19 ._,,, 17 8 n .;i 31 17 J.', 14 9 B 6 17 M 24 .'i 90 la i- 17 H 11 24 .'. 17 22 2* 2ft 18 7 21 I is 20 VI M 14 14 r, 28 n .so M 31 ?2 n 30 ?0 14 18 1.5 29 23 21 14 18 7 20 20 20 11 32 For "Tut OBSTETRICAL JOURNAL," FIVE DOLLARS a year, see p. 23. University of California SOUTHERN tSS&UL UBRA 405 Hligard Avenue, Lo. Anoele* Return thto material to the n *ry from which tt wa borrowed. UC SOUTHERN REGIONAL LIBRARY FACILITY A 000 453 092 9 WL100 H21?n 18?8 Hamilton. Nervous diseases IIPI PP.M IIRRARY University of Califor Southern Regional Library Facility ^