Google
This is a digital copy of a book that was preserved for generations on library shelves before it was carefully scanned by Google as part of a project
to make the world’s books discoverable online.
It has survived long enough for the copyright to expire and the book to enter the public domain. A public domain book is one that was never subject
to copyright or whose legal copyright term has expired. Whether a book is in the public domain may vary country to country. Public domain books
are our gateways to the past, representing a wealth of history, culture and knowledge that’s often difficult to discover.
Marks, notations and other marginalia present in the original volume will appear in this file - a reminder of this book’s long journey from the
publisher to a library and finally to you.
Usage guidelines
Google is proud to partner with libraries to digitize public domain materials and make them widely accessible. Public domain books belong to the
public and we are merely their custodians. Nevertheless, this work is expensive, so in order to keep providing this resource, we have taken steps to
prevent abuse by commercial parties, including placing technical restrictions on automated querying.
We also ask that you:
+ Make non-commercial use of the files We designed Google Book Search for use by individuals, and we request that you use these files for
personal, non-commercial purposes.
+ Refrain from automated querying Do not send automated queries of any sort to Google’s system: If you are conducting research on machine
translation, optical character recognition or other areas where access to a large amount of text is helpful, please contact us. We encourage the
use of public domain materials for these purposes and may be able to help.
+ Maintain attribution The Google “watermark” you see on each file is essential for informing people about this project and helping them find
additional materials through Google Book Search. Please do not remove it.
+ Keep it legal Whatever your use, remember that you are responsible for ensuring that what you are doing is legal. Do not assume that just
because we believe a book is in the public domain for users in the United States, that the work is also in the public domain for users in other
countries. Whether a book is still in copyright varies from country to country, and we can’t offer guidance on whether any specific use of
any specific book is allowed. Please do not assume that a book’s appearance in Google Book Search means it can be used in any manner
anywhere in the world. Copyright infringement liability can be quite severe.
About Google Book Search
Google’s mission is to organize the world’s information and to make it universally accessible and useful. Google Book Search helps readers
discover the world’s books while helping authors and publishers reach new audiences. You can search through the full text of this book on the web
TU
24503407298
NERVOUS DISEASES: |
THEIR
DESCRIPTION AND TREATMENT.
BY
ALLAN McLANE HAMILTON, M.D.,
FELLOW OF THE NEW YORK ACADEMY OF MEDICINE;
ONE OF THE ATTENDING PHYSIOIANS AT THE EPILEPTIC AND PARALYTIC HOSPITAL,
BLACKWELL'S ISLAND, NEW YORE CITY;
ARD AT THE OUT-PATIENT DEPARTMENT OF THE KEW YORK HOSPITAL ;
MEMBER OF THE AMERICAN NEUROLOGICAL ASSOCIATION,
BTC. ETC, BTC,
WITH FIFTY-THREE ILLUSTRATIONS.
PHILADELPHIA:
HENRY O. LEA.
Entered according to Act of Congress, in the year 1878,
HENRY C. LEA,
in the Office of the Librarian of Congress. All rights reserved.
PHILADELPRIA:
COLLINS, PRINTER,
705 Jayne Street,
$78
TO MY FRIENDS
FORDYCE BARKER, M.D.,
AND
JOHN T. METCALFE, M.D.
PREFACE.
Ir has been my object to produce a concise, practical book ; and
should the satisfaction be ever accorded me of knowing that I have
made the subjects of Diagnosis and Treatment of Nervous Diseases
more simple to my readers than I think they now are, I will be
amply rewarded for the task I have undertaken.
I have not considered Insanity, because I believe that this subject
deserves much more extended notice than it could possibly receive in
a book of this size and kind.
T have deemed it advisable to include a short article upon Cerebro-
Spinal Meningitis, though, by many authorities, it is not regarded,
strictly speaking, as a nervous disease. I think, if for no other
reason, its interesting diagnostic relations entitle it to consideration.
In conclusion, I wish to thank Drs. Loring, Janeway, Mason,
Shakespeare, my resident physicians, Drs. Meyer, Naylor, Ryan, and
Baldwin, and Mr. F. 0. C. Darley, for valuable assistance in the
preparation of this volume.
ALLAN McLANE HAMILTON.
2 East 33p St., New York,
May Ist, 1878.
1*
CONTENTS.
INTRODUCTION.
PAGE
I. Hints 1n REGARD TO METHODS OF EXAMINATION AND Stupy—Ex-
amination of the patient, symptomatology, etc.—Autopsical and microsco-
pical examinations . . . * ‘ . . . é. + 17-21
II. INsTRUMENTS USED FOR THE DIAGNOSIS AND TREATMENT OF NER-
vous Diseases—The Thermometer, Esthesiometer, Barezsthesiometer,
Dynamometer, Ophthalmoscope—APPARATUS FOR THE TREATMENT OF
Nervous Diszase—Electrical, rubber muscles, cauteries, etc. . + 22-84
CHAPTER I.
DISEASES OF THE CEREBRAL MENINGES.
Cerebral Pachymeningitis—Acute, chronic—Chronic pachymeningitis with
hematoma—Acute Cerebral Meningitis—Rheumatic Meningitis—Menin-
gitis of the Aged—Acute Granular (Tubercular) Mfeningitis—Acute
granular meningitis of the convexity—Chronic Cerebral Meningitis . 385-68
CHAPTER II.
DISEASES OF THE CEREBRUM AND CEREBELLUM.
Cerebral Hyperamia—Cerebral Hemorrhage—Cerebellar Hemorrhage 69-112
‘CHAPTER III.
DISEASES OF THE CEREBRUM AND CEREBELLUM (CONTINUED).
Cerebral Anemia (acute, chronic, infantile)—Stomachic Vertigo—Auditory
Vertigo 2 5 . : . a 5 e ‘4 . + 118-128
CHAPTER IV.
DISEASES OF THE CEREBRUM AND CEREBELLUM (CONTINUED).
Occiusion OF INTRA-CRANIAL VESSELS—THROMBOSIS—EMBOLISM—
Thrombosis of the Cerebral Arteries—Thrombosis of Sinuses and Veins—
Embolism of the Cerebral Vessels . ; . a » 129-147
viii CONTENTS.
CHAPTER V.
DISEASES OF THE CEREBRUM AND CEREBELLUM (CONTINUED).
PAGE
Cerebral Softening—Acute, chronic—Asemasia (aphasia)—Cerebral Scle-
rosis—Diffused Cerebral Sclerosis . . . . . . + 148-184
CHAPTER VI.
DISEASES OF THE CEREBRUM AND CEREBELLUM (CONCLUDED).
Brain Tumors . . . ® 7 6 ‘ 7 a _ + 184-203
CHAPTER VII.
DISEASES OF THE 8PINAL MENINGES.
Spinal Meningitis (acute pachymeningitis)— Acute and Chronic Spinal Me-
ningitis—Spinal pachymeningitis—Spinal 7 ee Hemorrhage
(Meningeal, Central) . r z s m . & + 204-222
CHAPTER VIII.
DISEASES OF THE SPINAL CORD.
Spinal Hyperemia (Spinal er curaeak Subacute iia Hyperemia)—
Spinal irritation . : : + 223-282
CHAPTER IX.
DISEASES OF THE SPINAL CORD (CONTINUED).
Inflammation of the Spinal Cord—Myelitis— Acute, chronic—Antero-Spinal
Paralysis of Infancy—Of Adults . a . . - + 283-254
CHAPTER X.
DISEASES OF TIIE SPINAL CORD (CONTINUED).
Progressive Muscular Atrophy—Partial Facial ai a ing Sh
trophic Muscular Paralysis . . . : . : + 255-275
CHAPTER XI.
DISEASES OF THE SPINAL CORD (CONCLUDED).
Posterior Spinal Sclerosis (Locomotor Ataxia)—Antero-Lateral Amyotro-
phic Sclerosis—Lateral Sclerosis of the Spinal Cord—Yetanus . 276-307
CHAPTER XII.
BULBAR DISEASES.
Epilepsy—(The grave attack, the lie attack, dei id Rinepasamies ed
Paralysis . . . + 808-342
CONTENTS. ix
CHAPTER XIII.
CEREBRO-SPINAL DISEASES.
PAGR
Cerebro-Spinal Meningitis—Cerebro-Spinal Sclerosis—Alcoholism—Acute
—Chronic—Hydrophobia—Hysteria—Hystero-Epilepsy—Catalepsy 343-39
CHAPTER XIV.
CEREBRO-SPINAL DISEASES (CONCLUDED).
Chorea—Paralysis Agitans—Exophthalmic Goitre . . 7 + 893-412
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—Anesthesia—Tumors of Nerves . . . . « 444-452
CHAPTER XVII.
DISEASES OF THE PERIPHERAL NERVES (CONTINUED).
Locat Paratysis—Facial paralysis—Traumatic paralysis—Diphtheritic
paralysis 2. ewe ee 458-469
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. ete. . . . . . . - « 470-489
Formutz . . . e . a . . 3 % - 490-505
LIST OF ILLUSTRATIONS.
Dr. Seguin’s surface thermometer
. Sieveking’s sesthesiometer
- Diagram for making records
. Beard and Rockwell’s piesmeter
. Mathieu’s dynamometer
. The author’s dynamometer
- Loring’s ophthalmoscope
. The author’s gas cautery .
Osteoma of dura mater . . . + (Lancereaux)
. Tuberculous matter about a vessel + (Cornil and Ranvier)
. Distended perivascular spaces with atrophy . . (Fothergill)
. The topography of lesions . . . . .
. Miliary aneurisms .
. Multiple lesions with tongue atrophy .
. Instrument for applying heat and cold
. Tissue changes in softening . . 2 : .
. Handwriting of an agraphic patient . P - (Bourneville)
- Handwriting of agraphia and cerebro-spinal sclerosis . . ,
. Location of island of Reil . . . (Bateman)
. External indication of island of Reil . . + (after Turner)
- Choked disk . 5 . : ry (after Leibreich)
. Tubercular deposit 2 iu : a .
. Sarcoma : >
. Gumma
. Psammoma
- Encephaloid
. Glioma : . .
. Cerebellar aneurism . 7 (Bristowe)
. Deformity of hand in cervical aly meningitis @ (heres)
. The consequences of spinal section
. Changes in muscular tissue in anteré-spinal paralysi sis of infaney
(Duchenne)
. Changes in muscular tissue i in antero-spinal paralysis of infaney
(Duchenne)
. Changes in muscular tissue in anteropin paris of infaney
(Duchenne)
PAGE
22
23
52
26
26
27
28
383
39
60
78
97
98
102
M1
158
166
166
168
179
188
191
191
191
191
192
192
197
206 ©
214
245
245
245
LIST OF ILLUSTRATIONS.
FIG.
$4. Changes in muscular tissue in antero-spinal Se of infancy
(Duchenne) F ;
§. Antero-spinal paralysis of adults . 3 (Seguin)
386. ‘*Main en griffe”’ . . . . 4 (Roberts)
87. Atrophy of left shoulder A 4 $
88. Partial facial atrophy .
89. The spinal curve in pseudo-hypertrophie peraly, 8i8
40. Appearance of muscular tissue in aed ea paralysis
(Charcot)
41, Appearance of trophic one-chunges i in » Jason btie ataxia (Chareot)
42. The course of posterior nerve-roots . ; (Clarke)
48. Pathological changes in locomotor ataxia ua antero-lateral sclerosis
(after Charcot) . . é ‘
44. Lateral sclerosed patches i Es . (Charcot)
45. Region of endemic tetanus on Long Island 7 :
46. The pathology of hysteria
47. Hystero-epilepsy . ‘ m ‘
48. Dr. Yeo’s case of exophthalmic goitre . @ + (Yeo)
49. Chart for the application of electricity F . (after Henle)
50. Trophic change of the skin a é 5 F
51. Sarcomatous neuroma . ‘ t (Foucault)
52.
. Wire hook for the treatment of facial paralysis
. Reflex spasm from genital irritation 7
PAGE
245
248
256
258
267
272
274
283
285
292
294
801
882
386
413
440
445
452
458
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.
SympromMATOLOGy.—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 gencral, increased or controlled by will, “fine” or
“coarse ;” time of day, continuous or at intervals; subsidence or continu-
ance during sleep.
IxcoorpinaTion 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 anesthesia; dysssthesia or hyperes-
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.
Disorpers oF Oraans or 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).
Psycuicat Disorper.—Illusion, hallucination, delirium, mania, me-
lancholia, delusions, loss of memory, loss of consciousness, imbecility, idiocy,
excitability, dementia.
MisceLLANeovs.—Character of cutaneous surface, changes in tempera-
ture, variation in salivary secretions, changes in pigmentation and appear-
ance of hair, perspiration, etc.
Excitine Cause; Diacnosis; 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 post-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,
as well as the condition of the diploé; 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
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 :—
BR. 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
razor 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, 15 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. Thisis 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
|
'S USED FOR THE DIAGNOSIS OF NERVOUS
DISEASE.
INTRODUCTION,
tis 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
4M 1. such variations as may occur in the patient’s condition,
‘Those I propose to describe ave intended for examinations
of temperature and sensory changes, and for the detection of
altered motility.
Tne Turrmomerer.—There are several instruments
made for the purpose of determining variations in tempe-
rature, and though some are of extreme delicacy, 1 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 instrament 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
UA ia tube is spirally coiled upon itself and inclosed in a circular
Thermeme:er. box. This form has the merit of being unaffected by other
than the body temperature.
’s disks IT have found to possess extreme delicacy, and if pro-
perly 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-cleetric
current which is generated.
COR een re ern aren ry ea)
The AEstuesiomeren 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 instrament of
ll
THE ZSTHESIOMETER. 23
Sieveking, which is also used and recommended by Brown-Séquard. It
ia made of brass or steel, and very closely resembles a shoemaker’s mea-
Fig. 2.
G.TIEMAN&CO,
Bleveking's Asthesiometer.
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 sesthesiometers 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 xsthesiometer has one advantage. The points are bifurcated, one
arm ending in a bulb, while the other is sharp, so that analgesia as well as
anzsthesia 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 ssthesiometer 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 a3 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 hyperwsthesia they may be much more
nearly approximated and distinguished as two than in the anesthetic
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 . . a . : F é . $line.
Red surface of lips. zg a . a : Fi + 2 lines.
Palmar surface of third aa = * : + 1iine.
Tip of nose : Os é : - 8 lines.
Metacarpal bone of thumb * * 4
Skin of cheek . % s pelle
Mucous membrane of hard ‘palate is . 6 &
Dorsal surface of first finger 3 . a ESS
Dorsum of hand over headg of metacarpal bones y 6B 4
Mucous membrane of gums o 7 . 3 o. ose
Lower part of forehead. e . ‘ - lo
Lower part of popes . er, Ait Ae Swe - 12%
Back of hand. . . . 5 és é o 1 4
Neck under lower j jaw’ . . . . fe . » 15
Vertex . . . . . . . . - 15 *
Skin over the patella a . . a é : - 16 %
Skin over the sacrum . . . . 3 ‘ - 18 ‘*
Skin over the sternum . . . . . . + 20 «
Skin over cervical vertebrae é : 5 - . 24
Skin over middle of back 7 . 2 - 80 *
Skin over middle of the arm. . . Z ‘ - 80 *
Skin over middle of the leg . . . . : . 80
Certain precautions must be taken when using the e«sthesiometer, 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
8TH ESIOMETER—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.
Diagram for making reeords.—Roman numerals show anesthetic indications, the others nor-
mal sensibility.
The Bar.esTHESIOMETER of Eulenburg, modified by Beard & Rock-
well, has been used asa means for the determination of the individual
sense of application of weight which is lost in various forms of’ paralysis
and anesthesia. It consists of a sp.ing 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 DynamoueTER.—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.
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 along glass tube (2) which dips into a small
bottle filled with mereury, 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 seale
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
Easaenencveus force of fifteen pounds’ pressure brought to bear upon
the bulb would be required to press the column of mer-
eury 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,
8. The action of the muscles is the same at different times. The same
group of museles 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 aceurate 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-
leas invention, as the results obtained must be of the clumsiest kind. In
fact no instrument bot the myograph, of which there are several forms,
‘is of any use for delicate observation.
INTRODUCTION.
28 INTRODUCTION,
Tae Orntaatmoscore.—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.
Loring’s Ophthalmoscope.
Tp 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
ophthalmoseope a number of lenses are held in a revolving disk behind
the mirror.
For more specific directions the reader is referred to Dr. Loring’s ad-
mirable little work.
To examine the eyes of a patient properly, the observer may follow the
concise directions laid down by Hutehinson.*
' Determination of Errors of Refraction with the Ophthalmoscope, E. G,
Loring. Wm. Wood & Co., N. Y.
* Jonathan Hutchinson. Clinical Reports of London Hospital 1867-8, p. 182.
pied xl ccanebaslion ef tie Zaudun vevesls choked dlakiandl uote paxttiae
but I will speak more fully in regard to this subject when we come to the
APPARATUS FOR THE TREATMENT OF NERVOUS
_ DISEASE.
Ex.xerricat.—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
ee eee me. ‘This last apparatus is rarely
Sisad teed cx ost ob the form I first deseribed constitutes a simple bat-
' Am. Psychological Journal, Noy, 1876.
2 West Riding Reports, vol. v. p. 148.
* 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 cireu-
} 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 su
E catmot but think that the former alternative is the more rational, and from
that very Palaearteees in eve ohestons Says cnt @ foro er
Sa awk tepecially mental diseases, are concerned, that there never will be,
any more than there now is, uny art to read the mind's construction in the eye. »
* Du Diagnostic des Maladies du System Nerveux par l'Ophthalmoscope.
Paris, 1876.
* La France Médicale, Feb. 26, 1876.
© Med, Times and Gaz., vol. i., p. 495, and seq.
7 Diseases of the Nervous System. New York, 1876.
* Phil. Med, Times, May 8, 1875.
al
32 INTRODUCTION.
paralysis. The instruments of the two firms I have mentioned, besides
those of Drescher 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.
Russer Muscues, 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 fur 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.
Tue Hyropermic Syrince, ETHER Spray Apparatvs, and SpinaL
and CranraL Ice Baas, should be procured by every physician who has
occasion to treat this class of diseases.
Cavtertes.—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 clamp (B, 4), so that, by a simple movement, the dome can be
removed and replaced by another. About the lower edge of the pla-
tinum, is a small collar of wire gauze, expanded at its lower end, which
prevents the escape of any return flame (2).
From the two stopcocks pass rubber tubes, one to the gas-burner, the
other toa 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.
34 INTRODUCTION.
The cauteries of Pacquelin and Guérard, of Paris, are both good. In
them the vapor of benzine (which should be very pure) is forced with air
upon a piece of hot platinum. These are exccllent substitutes for the
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 PACHYMENINGITIS8. 35
CHAPTER I.
DISEASES OF THE CEREBRAL MENINGES.
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 has 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 ofthe
disease we may divide these neuroses as follows :—
Cerebral pachymeningitis, seit
(Inflammation of the dura mater), Chronic,
Chronic, with hematoma.
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 discase, or old age.
ACUTE PACHYMENINGITIS.
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 106° 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
86 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, eapecially
if the inflammation extends to the base, the head may be drawn backwards
and downwards,
Ramskill' 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 as 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 car disease or abscesses in other
bony cavities. These latter cases are not uncommon, if we may accept
the experience of aurists and surgeons. Abercrombie’s’ 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® mentions a case which closely resembles this one, and another
quoted by Abercrombie, and seen by Prathernon, was also of idiopathic
origin. Abercrombie’s 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. Bauduy® another which followed scarlet
fever, and many of the same kind may be found mentioned by other
authorities,
' Russell Reynolds’ System of Medicine, vol. ii. page 325.
® Abercrombie on the Brain, page 21.
3 Journal de Médecine, tom. ii., New Series, page 523.
‘ Transactions New York Pathological Society, 1876.
5 St. Louis Clinical Record, March, 1876.
38 DISEASES OF THE CEREBRAL MENINGES.
sents 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 progressed
from a few points until it had become general, being most profuse on the
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 dict.
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 size 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
a 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 parietal
bone and the eruption.
A small opening was found communicating between them, perforating
the cranial walls, and looking very much like 9 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 Jiij of pus. The
other organs were healthy.
42 DISEASES OF THE CEREBRAL MENINGES.
narrow 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 hamatoma 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., 60, widower, N. 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. is
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 off and on, inercased by approaching a fire. He cannot appreciate
the ticking of a watch pressed to his left car. 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.
24th. 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. 6, 1875. To-day, while patient was sitting in a chair, he had a
convulsion, and then became comatose. Urine albuminous. Ordered ol.
tiglii miv, 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. Tle is unable to walk or stand
without being supported, as the right leg gives way; complains of con-
46 DISEASES OF 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-bath. The patient,
after bathing, sat for some time with uncovered head upon the beach ex-
posed to the heat of a noonday sun. Haeddeus!' 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 deli-
rium, headache, and disorders of motility are much less marked in cerebritis
than in acute meningitis, and it must be remembered that the pulse in the
latter disease is much more rapid and full, and the temperature much
higher.
Typhoid fever is symptomatized by elevation of evening temperature,
diarrhea, abdominal tenderness and tympanitis, muttering delirium, and
the presence of petechie. Delirium tremens may be occasionally con-
founded with the disease under discussion, but it must be remembered
that the history of alcoholism—peculiar delusions and alcoholic delirium,
the absence of headache and the condition of the skin, are all evidences of
delirium tremens, which are not to be mistaken.
Pathology and Morbid Anatomy.—When the pia mater and
arachnoid become the seat of inflammation, we may roughly group the
lesions and consequent symptoms into two classes, one indicative of basal
trouble and the other of vertical. In the former, cranial nerve-trunks
will be injured or diseased ; while in the latter, the investing membranes
of the cerebrum will be the seat of morbid action, and the functions of the
cortex must be consequently destroyed, so that the symptoms will be more
of a psychical character than when the base is involved.
The recent investigations and contributed cases of Landouzy,* of which
104 are presented by this author, demonstrate the connection between cer-
tain symptoms and lesions of the description to be hereafter mentioned, in-
volving those portions of the cortex containing the centres of Hitzig? and
Fritsch. These prove very clearly that violence of the inflammatory pro-
cess in certain places may be attended by certain paralyses or contrac-
tions of limbs which are innervated from these centres. A case which
recently came under my observation is one of this kind, and possesses
great pathological interest.
E. B., aged thirty-six, born in Ireland, by occupation a blacksmith, is
a stout, well-made man of nervous temperament, and up to the commence-
ment of his present trouble had enjoyed uninterrupted good health. He
has not had syphilis, and his habits have been good. His mother and
father are dead, the former having died of old age and the latter of phthi-
sis. There is no family history of insanity, epilepsy, paralysis, nor of any
1 Berliner Klin. Woch. 1869, p. 564.
2 Contribution a I’ étude des Convulsions et Paralysis liées aux Meningo-enceph-
litis fronto-pariétales. Paris, 1876.
* Reichert and Du Bois Reymond's Archives, 1870, Heft 3.
I improbable. If
tzig and Ferrier, we shall
‘ich is “situated on the
_ ape heygenageey increase in cerebral A iis ~ years
menin; contact depressed portion ¢, Which probably
does not impinge upon the cranial contents at ordinary times,
1 Functions of the Brain, page 307.
| ® Journal of Anatomy and Physiology, vols. xiii., xiv., November, 1873, Muy,
1874. : '
delirium 5 ‘and elaterium (F. 22),
La Ppa onion piaranershen im Blisters applied behind
the ears and to the neck are excellent adjuvants. Should the patient's
| pra sodegtiiss Vai-trpimgeci Sips oye
stimulants, nourishing food, such as milk, egg-nog, beef-broths, and nutri-
tious but digestible food, are of great importance. In the other forms
presently to be alluded to, we should be governed by the existence of rheu-
-matism, or the advanced age of the patient, and for the former
alkalies, colchicum, aud other remedies of the same nature, and for the latter
a generous diet and a liberal use of stimulants. (KF, 17, F. 45.)
RHEUMATIC MENINGITIS,
A form of inflammation of the meninges may be connected with, or
oceur during the course of acute articular rheumatism, or again it may be
found without any coexisting joint trouble.
‘Trousseau" has described three forms of cerebral rheumatism. One of
these he calls apoplectic, and it is symptomatized by coma without paraly-
sis; a second form, first described by Gosset, is that in which delirium
is followed by coma; and there is a third in which delirium makes
its appearance in the course of inflammatory rheumatism. Its co-
existence with joint-trouble is by no means the rule, though the majority
of cases reported have been of this character. Posner* reports a case in
which the inflammation left the joints and attacked the meninges. Pain
in the head, delirium, and slow pulse were the prominent features of the
patient’s illness, and recovery took place in about two weeks. The
symptoms of an attack of metastatic rheumatic meningitis are these:
Fither during an attack of acute rheumatism, or afterwards, the patient
may become dull and stupid, and delirium makes its appearance. This
delirium is of a violent character, and during its existenee the patient
may have delusions and hallucinations of sight and hearing, In a case
reported by Meznet® the delusions of persecution were a prominent fea-
ture, but there is no regularity in their mode of expression, There is
nétally but a slight rise of temperature, though it may sometimes attain
an elevation of 106°, or thereabouts, and the pulse at the same time be-
comes very rapid and full, Headache of a severe variety, such as I have
described when speaking of the other forms of ucute meningitis, may be
'! Rheumatismus Cerebralis, Schmidt's Juhresbericht, vol. 118, p. 25.
* Encephalopathia Rheumatica, Ibid., vol. 104, p. 167.
® Archives Générales, June, 1856.
DISEASES OF THE CEREBRAL MENINGES.
aie Si eles deregile’ fiers Boe 110 se
him much worse; his excited condition being supplanted by one
lity. He does not recognize those in the room, and is utterly
nt to the kind attentions of his mother or nurse. When the
is drawn across the skin it leaves a vivid red mark, which has been
considered one of the strong pathognomonic signs, The pulse is greatly
accelerated, and perhaps reaches 170, while the temperature may be found.
fo 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
Tall’ tersely describes this last stage as follows: The third stage is
denoted by coma and its concomitant diminution of the sentient and vyolun-
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 stil/ 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. Zemperature.—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°. 1t 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. Pu/se.—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 eannot
' Op. cit., p. 93
' meningitis occurring in tubercular
tr deta nh flee as fund i the Td er
‘but not inthe brain. = *
the senses, of which tem were males and six females there was t-
SS edee tan Yous al pe, eva lactose. sat eo soanig aah
between twenty and thirty; four were in the fourth decade, and one in
the fifth and sixth. Se ee Cee ee
it was found that of fifty-four examined, nearly four-fifths
the number were below twenty-five years. SS eae ee
tuberculous deposits, both in the brain and other organs.
‘The seat of the granular deposit seems to be chiefly the arachnoid and
pia mater, thongh 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
Tuberculous Matter about the Vessels. (Cornil and Ranvier.)—A. Tubereulous deposit,
B. White blood-corpuseles. (€. Granular contents of vessel.
The membranes are all more or less congested and dotted with opaque
spots or patches, The cortex is hyperemic and the ventricles distended
by fluid. Their ependyma is toughened and rough, and presents agranu- _
lar appearance which may be likened to that of a piece of white shark's
ekin,
Softening of various parts of the brain, the nerve trunks and optic
! St. George’s Hosp. Reports, vol. vii. p. 35.
62 DISEASES OF THE CEREBRAL MENINGES.
There the tubercular granulations were very numerous, and formed a sort
of tumor. The pia mater, 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 leas absolute; and to explain
this paralysis no other lesion than the tubercular meningitis in the region
ot the motor centre of the arm.”!
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 Médicale 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. 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, ete.
E. Other forms of meningitis.
F. Exhaustion.
A, Typhoid, in some of its forms, or typho-pneumonia, may resemble
tubercular meningitis, either of the primary or secondary forms. This is
especially the case when typhoid symptoms are added tv those of phthisis.
The irregular varieties of typhoid are attended by absence of diarrhaa,
tympanites, and other abdominal symptoms. The eruption of typhoid may
also resemble the tache cérébrale of this form of meningitis, but it is
usually confined to the chest and abdomen, and is an early symptom.
Typho-pneumonia may bear a close resemblance to secondary tubercular
meningitis, and this is particularly the case if moist rales can be heard all
over the chest, and there is some dulness at the apex. Certain points are
' London Med. Record, July 15, 1876. Abstract from Le Progrés Médical,
April 22, 1876.
2 Gazette Médicale, 1871, 412.
3 Deutsche Klinik, 1878, 184.
a
68 DISKASES OF THE CEREBRAL MENINGES.
ee ee ee
Behe Aiatos soca 1) Ws tvs aah, lee" TS
disease is ordinarily one of adult life. It is connected oftentimes with the
tuberculous diathesis, and is not rarely dependent upon constitutional
syphilis; it may be seemingly idiopathic, or result from head injury, ex-
posure to the sun, intemperance, the ucute zymotic fevers, and the other
causes of meningitis.
Morbid Anatomy and Pathology.—The cerebral meninges have
been found to be thickened, adherent to each other, or to the inner surface
of the cranial bones, with effusions beneath, which have undergone
eepua sometimes gummy exudation of syphilitic origin will be
found scattered over the surface of the brain, or calcareous plates of per-
haps an inch in diameter will be found in the dura mater, such as I have
already spoken of in chronic pachymeningitis. If the disease has involved
the cortical substance of the brain, we may discover patches of softening
of variable extent and depth, and perhaps superficial abscesses, At the
hase of the brain the meningitis is not generally so diffuse, but occurs in
circumscribed spots, the eranial nerve trunks being generally softened and
bound down by bands of new tissue.
Diagnosis.—The form of meningitis of the convexity presents so
many symptoms that are common to other brain diseases, that the matter
of diagnosis is often very difficult, and it is impossible at times to deter-
mine the nature of the patient's disease until after death. Meningitis of
the base, however, is much more easily diagnosed. There are nearly
always ophthalmoscopic appearances, which is not the case in the other
form of disease, and some one, or all of the cranial nerves are paralyzed.
The symptoms of tumor may counterfeit those of chronic basilar menin-
gitis, but perhaps are more severe. If the disease be of a syphilitic char-
acter, the question of diagnosis is a puzzling one; for in some respects
4 condition which favors the formation of syphilitic tumor and chronic
meningitis is the same, and occasionally these two diseases are found to
coexist.
Prognosis.—Shonld the disease be syphilitic, the prognosis is nearly
always favorable, but, if it be the result of injury, recovery is less likely
to take place; should it follow the acute exanthematous fevers, there is very
little hope.
Treatment.—Our main reliance is in the free use of large doses of
jodide of potassium, or in the employment of mercurials. Active eounter-
irritation and the use of blisters and cauterization may afford a great deal
of relief. A saturated solution of the iodide of potassium may be ordered,
and the patient should be directed to begin with a dose of ten drops three
times a day, and gradually increase one drop with each dose until he takes
a hundred drops ar more during the twenty-four hours.
13 DISEASES OF THE CEREBRUM AND CEREBELLUM.
which has been called by various writers “I'Etat crible.” This consists
of a peculiar spongy worm-eaten appearance. Arndt says that when these
lymph-spaces are dilated they are filled with effete material from the
brain resembling amyloid substance or leucin, called by him hyaline, The
perivascular spaces are very large, and openings of some size are found at
points where vessels have been cut across. ‘These are due to the abnormal
Fig. 11.
Distonded Porlrascular Spaces, with Atrophy. (Fothergill.)
pressure made by the distended vessel and the destruction of adjacent
nervous tissue. Calmeil, Van der Kolk, Durand-Fardel, and lately Arndt,’
have accounted for them as the result of cedema of the perivascular space.
This appearance is a* constant one in all brains where there has been
continued hyperamia, and especially in the brains of drunkards. The
bloodvessels, when not destroyed, will be found to be tortuous and varicose,
and coated oftentimes by a granular shining deposit, The pia mater is
thickened, and its vessels present the appearance just described perhaps
better than any other tissue,
Diagnosis.—The condition in its early stages may be mistaken for _
the opposite state, cerebral anwmia; in fact, the diagnosis is always full
of difficulties.
An inspection of the following table may, however, furnish us with
hints so that we may be enabled to separate cerebral congestion from
cerebral anwmia, It will be observed that some of the symptoms are
closely allied.
' Virchow's Archiv, Lxiii. p. 24.
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,’ 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 edema.”
CONDITION OF THE EYES,
Prevost,? 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,s we are enabled to study systematically the
variations of temperature. He divides the cases into four groups: 1.
1 Op. cit., p. 548. 2 Gazette Hebdom., Oct. 18, 1865.
3 Etudes cliniques et thermometriques sur les Maladies du Syst}me nerveux,
Paris, 1872.
92 DISEASES OF THE CEREBRUM AND OEREBELLUM.
pheral 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.
Tremor
Coarse.
( Regular (continuous, or on movement)
Certain, regular move-
ments due to interus-
Quick, clonic spasm, of sei, pronators, etc.
intermitting typo;
Choreold Continuous
spasin, or
Regular (continuous, or on movement) inco-ordl-
nation of
Jerking movement.
f Continuons =‘ Athetosis’”
Slow, mobile spasm, of 1
remitting type On movement = slow, oramp-Itke Inco- ]
ordination “Spastic contracture” of
hemiplegic children.
Tonic spasm, varying —[" Of interossel, conspicuous
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 rarely the face, and the movements are quite coarse, and may be
associated with a certain amount of hemi-anesthesia. 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-
' These 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 Charcott and Paynet another. In
acase 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 case the hemiplegia followed embolism,
and a branch of a spinal artery (rami medullx spinales, of Riidinger) was found
obstructed by a plug. Pressure had been made on the spinal ganglion from
which one of the branches of the sciatic originates.
£ Med. Chir. Trans., vol. lix.
* Journ. of Cutaneous Med., Oct. 1868, p. 69 ; quoted by Charcot.
{ Op. cit., p. 72. + Br. Med. Journ., Aug. 1871.
Teens ia nie of cerebral en
leads to the oceurrence of faker beats: a ‘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 tho. left rentisialey cian
i as
~ 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,
T 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 capilleries 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, 1 fully agree with Hughlings Jackson, that the only heritage trans-
mitted from father to son is the liability to arterial degeneration, gout, ete.
This exception to the general rule is somewhat conspicuous, for the here-
dition of mauy convulsive and neuralgic, as well as the trophie diseases,
is a well-established fact, and has long been recognized as an important
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, anemia, etc. And now regarding
the predisposing states which favor the rupture of a vessel. An hypertro-
plied heart, enlarged by overwork in foreing the overloaded blood which
must be formed when the kidneys do not properly act as climinants, 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 1 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,
ua
apeeeer ihe Kocalaston of stones aha wo
Bee cliglnd cxperians of Broea and Brown-Séquard, and
gnal. He was suddenly deprived of power, and fell to the gro
After an hour or two, when sufficiently revived by the vain, he ¢
mnaelbaig reds He was zed on the left side.
* Berliner Klin, Woch., April 26, 1875.
98 DISEASES OF THE CEREBRUM AND OEREBELLUM.
degeneration” of Gull and Sutton which is found in other localities.*
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 Aneariems,
I 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.
' 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-Fardelt found that of 32 cases the arteries were only healthy in 9
cases, while in 21 they were thickened, and in 2 ossified.
Andralt found that of 32 cases the arteries were apparently healthy in but 4.
* Brit. Med. Journal, April 7, 1877, p> 362.
t Traité, clinique et pratique, des Maladies des Vieillards, Paris, 1854, p. 228.
t Clinique Méd., vol. v.
pagans Hapa pa lipo
. -seram | ;
amass; finally the clot contracts, becomes yellow, and assumes the appear-
ance I have alluded to, ite zage that on dos i ania ee
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 _ There may be a eyst filled with thick-
ened blood, which is indicative of an effusion of recent occurrence, and
there may be others of smuller size, in different stages of resolution. Small
aveurismal 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® has
written an exhaustive paper upon this subject, in which 49 cases are
given, proving most conclusively its connection with diseased kidney and
heart. Of these 49 eases, 30 were due to renal disease, and
six had nncomplicated 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 acenracy 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 thalamus will present the same phenomena, only that the
temperature is higher in the paralyzed limb than in the preceding form.
A lesion in one crus 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. Hemianwesthesia is quite marked; and
| the third and seventh nerves are paralyzed, so that ptosis and profound
' Arch. de Tocologie, 1875.
* Guy's Hosp. Rep., vol. xxi. p. 181.
® Holmes’s System of Surgery, 1870.
102 DISEASES OF THE CEREBRUM AND CEREBELLUM.
facial muscles, <a slight contraction of those of right side when he
opens 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 protraded
the tip points to the right side, no t tactile loss of sensation as de-
termined by the esthesiometer. Saliyn 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 14; some difficulty of speech, especially with the letter r,
pronouncing “righteous” “eightshus;” the left leg he drags slightly when
he walks. Six months ago he lept 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,
We are to diagnose the symptoms of cerebral hemorrhage in its different
stages from those of the following diseases: Actual attack from uremia,
drunkenness, opium poisoning, tumor, epilepsy, compression or concussion
from injury, embolism, and thrombosis. There are certain general ap-
pearances which symptomatize the uremic condition, and can hardly be
{ The internal cause of the hemorrhage is always important, whether it be
_ produced by an abscess, tumor, or other intracranial diseased states ; and
_ these things are to be taken into account. The antecedent history of the
‘patient, the presence of pain of «localized character,
pean peas acl disease and kindred conditions should all be ascertained.
Serous apoplexy, as it has been called, when an immense effusion of serum
fakes place either ern the investing ee ns the ventricles,
or throughout the brain substance, is usually of ;
pendent npon the collection of fluid which takes: ihe pac of spied
brain substance or attenuated vessels.
_ Prognosis 0: all cheecvers t¥ inom exceedingly difficult
mutter 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 tobe 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-
pora striata, or into the crura or pons are then 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-
vhage. 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 oecurrence of inflammatory action about
the clot, or whether there be urwmic trouble or softening, We may angur
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
line pierce oust ea pene pk Tf in this
ying in a comatose state upon the floor, he is to be
warm by contact with bottles ith hot water, ae
darkened, and his collar and shirt collar band should | ma ot eee
Bee aa oa a el ae
is essential to keep him perfectly quiet ; so loud talking is to be
and officious friends kept away. Tn 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 la ery aot tp Meee
afresh by any such measure. If, however, the pulse be full, strong, and
hounding, 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 Cae
he given in a wafer, or applied to the tongue if he is unable to swallow; it
is udvisable 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, 56), 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
ata time, and after an interval of four hours, another dose, if the pulse
has not decreased in yolume or frequency. The medical attendant should
not forget to draw the patient’s urine frequently, I have known a negleet
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 perbaps 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 injudicions in the extreme; so it will not do to give large doses.
Should there be a condition of prostration, a tablespoonful or two of milk
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
j 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
110 DISEASES OF THE CEREBRUM AND —
Seite teat is tt eee a
th, anda ol wer lim!
sein imental faculties teat obseured, and ey an uneasy
ion of the eyes. bout a after the receipt ens in-
jury, while working one day tthe baa, toad on :
After remaining in bed some time, muscular power and pact
sibility slowly came back. He was able 10 walk wilh
Geek icdlatines + tive musica of both the leg and arm were 0 om ee
and I determined to use faradism.
The constant use of the very mild current for several weeks
was ai some degree, the seleraal contour of the Lege deer forget,
was able to progress wit! a cane, but his speech remai te
the treatment he had repeated premonitory signs of a new attack.
Fonte was resorted to to arte baa hi its good effects were
Ge eatperery ox thos % vidi ootoatn
Tn connection with this vsinnin va ney ised
iodide of potassium, strychnine, or ergot.
Jodide of Potassium.—Should there be a syphilitic history, I think we
may begin at once with this remedy. If there be no such dyserasia, 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 eases
the patient’s tendency to recovery was hastened more by rest, good food,
and fresh sir, than by any other form of medication. It is perhaps of
value in old cases.
Phosphorus.—Fither 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 zine (I*, 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,
perhaps excepting electricity. When the exaggerated electro-muscular
irritability subsides, we may give it in doses of y'y of a grain three
times a day (F. 29), but before this time its use is attended with
danger.
=
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,!
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 aymp-
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. (zeneral sensibility is unaltered even when hemiplegia
exists; we barely observe a slight anesthesia in a few rare cases; hyperms-
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.”
1 Abstracted in Chicago Journal of N. Disease. vol. ii. p. 621.
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 Curonic CeresraL An&MIA.—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 anesthesia, 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 tind 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 edema of the legs and ankles, and sometimes
albuminuria. Feebleness and muscular want of power, of a light grade,
ones earn brain, “and with thie facs in view, {6-8 aawiBe
how any modification of circulation will result in im-
coger Heart disease generally in sonalecorier a anal
ail seen that. spilden exnetious not only blanch the face; ‘bat au’woll jalodilea’
faintness. Various modifications of the functions of the liver may be as-
sociated with states of cerebral pnwmin 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-
vies; and Schrader Van der Kélk 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 fanetional de-
rangement of the liver without affvetion 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
IP elation of spirits whieh follows a free movement of the bowels after con-
tinued torpidity of the liver. The extension of the cerebral vaso-motor
and the involyement 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
anemia 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
128 DISEASES OF THE CEREBRUM AND CEREBELLUM.
recling, dizziness, nausea, and other symptoms with which we are already
familiar.
Diagnosis.—Gowers,' 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 mal, from apoplectic warnings,
and from general cerebral anemia. 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 Charcot’s’ 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, 1876.
® Legons sur les Maladies du Syst. Nerv. No. 4, p. 321.
or unnsual density of the blood, congulation oceurs,
terfered with, 7 yard ot tbeala a Geprlved at Moedond
iVie das be Sus nas enuses, there may be an
ry action from without in the manner T bare dee
1 Virchow’s Archiv, Band Ixii., Heft 1, Nov. 1874.
* Verhandlung dur Wurz., p. Med. Geselschaft, viii, 179,
* Path. Anat. of the Nervous Centres, p, 32,
- an ned rear yci s n cao
: iH vee er a were all pes) tae ing
®
Steen Sound hy many. obeervers. Lancoreaux eotimates that teealy.
‘of all the cases are thus complicated. T have sven one, case. where
1 Bastian, Common Forms of Paralysis, ete.,
nd ae
148 DISEASES OF THE CEREBRUM AND CEREBELLUM.
CHAPTER V.
DISEASES OF THE CEREBRUM AND CEREBELLUM (Contixurn).
CEREBRAL SOFTENING.
Synonyms.—Ramollissement (rouge, blanc, jaune). Encephalitis
aigue, chronique (Fr.). Mollities cerebri, Encephalitis, Softening of the
Brain (chronic, acute), Inflammation of the Brain.
Definition.—A discase 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 has
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, us 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, iy Diffused Cerebritia.
+ Meningo-Cerebritis.
ff : 3
(Inflammatory) l Purulent Cerebritis.
2. Chronic Softening, (Primary Softening.
(Non-inflammatory), (Secondary Softening.
1. Under the first head we may place the variety described by Elam,'
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.
' Cerebria, and other Diseases of the Brain, London, 1872.
lected by Aitkin,’ be found that the duration
disease was the following, which also proves that
the acute than the chronic form of the disease.
166 DISEASES OF THE CEREBRUM AND CEREBELLUM
ble us to see whether the inability to write is due to this cause, or is really
the “agraphie” condition. Reading, singing, and the power of gesticu-
Fig. 17.
lating are lost cither separately or together, A person who canno! speak
is sometimes able to sing. So, too, in reading. He may read mechani-
Fig, 18.
Handwriting of two pationte: "A" boing affected with agraphia, and “BB with cerobro-
spinal selorosie, The fret specimen ts lateoded for ** Possible to soe you on Tuesday.” The
second, * Dieu ot mon Droit."
cally without appreciating the sense, or may drop his words or substitute
others, and perhaps is unconscious of his mistake, He may be unable to
read, but may show by signs that he knows what such and such a pieture
may be. The power of gesticulation may be, and often is, lost. He may
make attempts to describe the figure of some object, bat cannot do so,
Trousseau related the exse of a person who was told to imitate the playing
of a clarionet, but when he attempted to do so beat instead an imaginary
tambourine. He is sometimes able to count figures which are before him,
or pieces 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 go in a peculiarly automatic way. After this, when
some thought is required to make combinations, the effort is unsuccessful.
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 under
Fig. 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,
FF, slightly tortoous 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 superior division are very tortuous and yery
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
superciliary arch, whence they are reflected, to be continuous with convo-
lutions of the inferior division, and terminate behind in the frontal trans-
verse convolution, F, F, which all the three enter. They are called Jirst
(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 u second orders it
178 DISEASES OF THE CEREBRUM AND CEREBELLUM.
Prognosis.—The view we are to take of our patient’s condition is to
be governed entirely by the question whether there is or not a primary
organic disease, its importance and the character of the aphasia.’ 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.
60) speaks 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’ ia quite good, but a serious indication of grave cere-
bral trouble. Aphasia with paralyais 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 be evidenced of arterial degeneration, or valvular deposits,
the case 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 disease, and sometimes we are able to better the patient’s condition
to a great deg Should there be hemiplegia, contractures, or other evi-
denees suggestive of degencration of the cerebral tissue, we will find our-
selves powerless to help our patient materially. It is only when aphasia
exists a3 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 Topographie Cranio-Cérébrale,’”? described experi-
ments made by him to determine the relation of the cranial bones with
underlying parts; and Turnei*? has made additional observations, and
given rules for determining this relation, Figure 20 is taken from Tur-
ner’s article, and I have slightly modified it so that the point where the
trephine may be 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. 20.—* Diagram showing the relations of the convolutions to the
skull. R. ‘The fissure of Rolando, which separates the frontal from the
1 In one case reported by Bateman, the patient recovered almost entirely, and
he could pronounce every word distinetly, with the exception of those containing
the letter P.
# Revue d’ Anthropologie, tome v. No. 2, 1876. .
3 Journal of’ Anatomy and Physiology, vols. xii., xiv., 1873, 1874.
‘188 © DINRAsES oF THE Pakanctaeee CEREBELLUM,
that the optic nerve shall be implicated either at its origin or in its course.
Another fact is of importance, 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
is, in substance, the following. The disk may be seen to be prominent,
Fig, 21.
Choked Disk. (After Leibreieh.)
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! says not more
than 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”
appearance. The central radiating appearance resembles very much a
scintillating body, while the retinal veins are distended and tortuons, are
quite serpentine in their course, and they may even be varicose.
T cannot agree with Albutt, who considers the recognition of any prom-
inence of the disk a difficult matter, and I think that this is the opinion
of the majority of ophthalmologists.
Speech is generally involved at some time or other, and psychical trou-
bles of all kinds, but more frequently the asthenie forms, make their
appearance, There is often a condition of hebetude and stupidity whieh
is supposed to symptomatize a tumor in the posterior lobes, or there may
be mental decay of a most grave character. Delusions, loss of
change of temper, suicidal tendencies, and various perversions of intelli
gence may occur in any case.
' The Ophthalmoscope, ete., 1871, p. 55.
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. Gulvaniam I believe to be useless. Ligature of the carotid
haa been employed by Coe for aneurigmal 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 MENINGES.
CHAPTER VII.
DISEASES OF THE SPINAL MENINGES.
SPINAL MENINGITIS.
ACUTE PACHYMENINGITIS.
Tne 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' has given the name external pachymeningitis to the form
which results from pressure made by diseased vertebra, and coexisting
with Pott’s disease, while other varieties have been described as internal
hemorrhagic pachymeningitis (Meyer?) and cervical hypertrophic pachy-
meningitis (Charcot’). 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.—Thie disorder, which commonly involves all three mem-
branes, is generally ushered in by a chill, followed by elevation of tem-
perature; a hard, full pulse; and exeruciating pain. This pain is increased
by any movement the patient may make. He tries to relieve his suffering
by changing his position 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. Hyperesthesia 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
' Sur la Méningite, ete. Thdse, Paris, 1871.
® Des Pachymeningitide, ete. Bonne, 1861.
® Legons sur les Fonctions du Sys. Nerveux, fas. 1, part 2, p. 248, etc.
223 DISEASES OF THE SPINAL MENINGES.
has reported recoveries which have taken place in cases which were of
traumatic origin; so the prognosis is perhaps not so bad, after all.
Treatment.—tThe 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.
230 DISEASES OF THE SPINAL CORD.
causes play an important part in its production; care, worry, and over-
work being among these. Various debilitating diseases, childbirth, and
had habits, may be enumerated as additional causes.
Morbid Anatomy and Pathology.—Spinal irritation being a
functional disease, it is impossible to find any* post-mortem indications,
unless they, perhaps, are foci of low inflammatory action, such as thicken-
ing of the neuroglia, or simple atrophy.
As to its pathology, I have already expressed my views in regard to
the probability of both hyperwmic and anemic conditions as pathological
factors. It is impossible, I am convinced, to locate the point of irritation
in either of the columns, and any attempt to do so is an unwarranted and
impossible refinement of diagnosis. We may approximate its seat by the
region of tenderness, and the predominance of special groups of symp-
toms; and this is all that I believe to be possible. Spinal irritation may
undoubtedly result from—1, reflected irritation; mpoverished_ blood-
supply; 3, local changes dependent upon disease of adjacent tissues.
The labors of Brown-Séquard, Bernard, and lately Lauder Brunton.
have proved most satisfactorily the intimate relation between the sympa-
thetic and cerebro-spinal systems; and the observations of the former are
especially valuable because of their pathological bearing. Not only may
distant organs xend irritating impressions to the cord, to be followed by
yaso-motor stimulation, contraction, and subsequent relaxation of the
vessels, but the intra-spinal circulation of impure blood may produce local
irritation, imperfect nutrition of the nerve-cells, shrinkage of the nervous
tissue, and odema of the perivascular spaces. The chain of inhibitory
ganglia, deseribed in such a beautiful manner by Brunton, places in close
relation the different parts of the cerebro-spinal axis, so that there ix
nearly always a disturbance of several organs when the harmony is af-
fected.
The vascular cramp of Nothnagel will account for various ischaemic
conditions in certain parts, while circulation in neighboring distriets may
be perfectly normal. Bidder! has also shown that complete alteration of
vascular calibre is impossible, so that at best there is contraction but at
a certain point, while the other part of the vessel may be dilated.
Bidder’s experiments also demonstrated that excitement or exaggera-
tion of function may exist with depressed function at the same time, in a
compound organ,
It is therefore reasonable enough to consider that spinal irritation is not
altogether dependent upon spinal anamia.
The production of special symptoms is explained by the involvement
of sympathetic, cranial, or spinal nerve-roots. The headache may result
trom cerebral anemia, as may also the mental and hysterical symptoms ;
while the visceral disturbances arise from sympathetic derangement of the
' Die Reflexe sines der sensiblen Nerven du Herzen auf die motarische du
Blutgefiisse.
232 ° DISEASES OF THE SPINAL CORD
diate and excellent. External counter-irritation, either by the actual
cautery applied on the painful points, a blister, or some irritating oint-
ment, is advised, and if vomiting be present, a blister on the epigastrium,
subsequently dusted with morphia, allays the irritability of the stomach. I
have used with success, and would recommend, galvanism (the descending
current), the positive pole being placed upon the nucha, and the negative
in the groin. Five-minute séances every day, or every other day, are
sufficient.
Galvanization of the cervical sympathetic is an important form of auxil-
iary treatment. Heat and cold alternately applied to the spine are followed
by excellent results; or Chapman’s ice-bags, filled with hot water, and
placed in contact with the spine for fifteen or twenty minutes daily, are
beneficial.
Open-air exercise, Turkish baths, massage, all help the patient ; and
Mitchell’s rest-treatment, already described, is one of our best modes of
treatment in confirmed cases.
234 DISEASES OF THE SPINAL CORD.
manner. Hyperesthesia is an exceptional feature, but it may form one of
the initial symptoms in conjunction with trembling of the limbs. After
the paralysis takes place, the temperature is lowered several degrees, and
circulation is very defective. At the end of a week there may be indica-
tions of the upward extension of the spinal inflammation if it be progres-
sive, and it is sometimes recognized by the tendency to priapism and the
distress in breathing, and with these there may be hiccough and hurried re-
aspirations, their number perhaps reaching 48 in the minute. Bedsores form
over the sacrum, and there is every appearance of approaching dissolution.
The skin becomes clammy, and there may be rigors; while the pulse grows
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 portion 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 ax—
1. Paraplegia of sudden or gradual origin, attended by anesthe
and analgesia, but usually preceded by dyswsthesia of various kinds, or
actual hyperwsthesin. [t may be accompanied in the beginning, accord-
ing to Radeliffe,’ 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 amesthesia being
absent when the anterior columns are alone partially affected. Again, in
other cases one lez may be paralyzed and the other anesthetic. The
onset of the paraplegia may be very sudden, and the disease prove rapidly
fatal. Jaceond? 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 sphineters will be paralyzed ; if the myelitis
extends so that the dorsal portion and the e/lio-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
portion 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.
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 myclitis.
Prognosis.—In every case much depends upon the nature of the
cause, and the extent of the cord involved. If there be a traumatism, of
course this gives the disease a serious character, and death may occur in
afew days. If the myelitis result from pressure from diseased and dis-
placed vertebrie, 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
carly 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 preter the use of ergot in half-drachm doses thrice daily; or we may
use the bromides (I. 44).
The sesquichloride of iron (F. 75) seems to have enjoyed deserved
popularity in England, and it is preferred by Radeliffe to the iodide of
potassium. In one ease 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 chronie 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 from the spine. Brown-Séuard 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
240 DISEASES OF THE SPINAL CORD.
6. Gradual development, perhaps limping at first, and afterwards com-
plete paralysis, but no acute symptoms.
In this exceedingly valuable lecture, Sinkler throws much light upon
the symptomatology of the disease, and gives the details of a classical
case.
The paralysis may take the form of hemiplegia, or it may affect the
voluntary muscles of all four extremities, and some of those of the trunk;
but the facial muscles, as a rule, escape. After a short time there isa
return of power in many of those at first involved, and but a small number
of muscles (notably the anterior tibial, peroneal, and others of the leg and
thigh) remain powerless.
The temperature of the paralyzed muscles is much lowered, and Ham-
mond has seen a difference of from eight to ten degrees between the
affected and normal sides. The bladder and bowels escape the paralysis,
and their functions are consequently unimpaired.
Muscular contractility is lost with the commencement of the paralysis.
and the faradic current will rarely produce contractions. Such, however,
is not the case with the galvanic, except in extreme instances, or when
the case is one of long standing. So far there are rarely any evidences of
atrophy or contractures of the paralyzed muscles, but it will be found now
that certain muscles at first affected begin to regain their lost functions,
while others become atrophied and utterly useless, Even the galvanic
current fails to stimulate them ; and at this period, which may vary from
four to five weeks to six months from the beginning of the disease, there
may be deformities and muscular contractures, which may result either
trom the weight of the body upon the affected limb, or from the antagonism
of non-paralyzed muscles; but Volekmann! considers that this incapacity of
the limb to support the superimposed load is of much greater importance
as a cause of deformity than the mere antagonisin of the unatiected muscles.
These deformities may take place as lateral curvature of the spine, tali-
pes, and other distortions which appear as various muscles are paralyzed,
or, if there be shortening of the limb (which is by no means uncommon).
as a consequence of reduction in the length and size of bones which have
become atrophied. The deformities that may result from the disease under
consideration are of a primary, and of i
The primary forms are those which are seen as talipes of both kinds, and
result from loss of sustaining power of the muscles. The compensatory
consist in spinal curvatures, such as lordosis or scoliosis.? The skin is
usually blue and livid, and the temperature is much below that of the
healthy limb. These deformiti »pear, but continue through
life, which is in no way shortened by the disease. The following cases
may be presented to illustrate the appearance and behavior of the disease.
The first case is somewhat anomalous, as there were two forms of para-
secondary or compensatory nature,
s rarely dis
? Sammlung Klinischer Vortriige, Hett 1, 1870.
* Produced by attempts to restore disturbed equilibrium.
e of the nerve-cells, Somiauantang we
ier ero
SSLTAh ce soon. 40 be tho. sons of hot dateyr Sct eoSURa Ee
‘The sarcolemma and nerves were not altered. In the striated muscles,
instead of the single normal cell-nncleus, there were seen three er four
granular cell-noclei, which seemed to be at the same g
contained two or three, or even more nucleoli, ‘The contractile material
aipeerpepepeerogepee
it. are pation ilerdinernpe eee: jel
these nerves were found to be thin, shrunken, and “et
irc hoses’ sad anaslea peshad ‘epheacinack ehich’deag aie
resting than those of the cord. ~ tn i
The muscular fibres are at first found to be reduced in size, and subse~
quently the transverse strie gradnally disappear, while the
fibres become more marked. There is n 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, chow thé: changes aia taiat
The bloodvessels running to the atrophied museles sre 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 Gaz. Méd. de Paris, 1871. 1 Thid., 1864, p. 290.
® Med.-Chir. Trans., vol. ii. 1869, p. 249.
ag * Quoted by Bos op ity 290,
«Jahre fir Kinderheilkunde, 1871, more 1.
254 DISEASES OF THE SPINAL COORD.
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 16 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 clectricity 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. 76). Seguin recommends leeching and dry cups,
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. 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 moseles of the right thenar eminence show extreme degeneration.
Tn left thenar eminence the joner 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, aud they contain small cysts.
8.—Progressive muscular atrophy may be mistaken for seve-
tal 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 # case in which there appeared to be lead paralysis, but
which subsequently turned out to be progressive muscular atrophy.
Several months ago Mr. N., a2 Cuban gentleman, came to me with a
letter from his medieal 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 te or three occasions, at some years’ interval, rheumatic pains and
neuralgia in the arm and shoulder of the lefi 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,
sueh 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 canae,
The disease continued to progress (notwithstanding treatment), the por-
PROGRESSIVE MUSCULAR ATROPITY. 265
tility, and the limited field of the paralysis, excladed 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 be was a man of leisure, there was no trade
or ocenpation 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 griffe. None of the muscles of the back were
affected, and the deltoids were of good volume and power. The fact that
others in bis 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 anomalons case. I call it anomalous, becanse I have been taught, and
my Own experience convinces me, that this is a very rare seat of progres-
sive muscular atrophy. Protean us is the malady, I have not seen para-
lysis of the extensors, as a primary symptom, in any one of the twenty-
tight cases of the affection I have met with from time to time.
To 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-
puired 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 atrophy of groups of muscles which are sup-
ported by a common trunk, as well as loss of electric contractility and
secondary atrophy.
.—Ovceasionally the disease may be arrested or cured en-
tively, and this fact seems almost ineredible 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
had prognosis. The majority of cases, however, go on to an unfavorable
termination, and perhaps one reason is, that patients delay so long to seck
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;
* Art. Wasting Palsy, Reynolds's System of Medicine, vol. ii, p. $49.
—_—_
hie Bone Changes In Locomotor Ataxia, (Chareot.)
mes interrupted by patches of degeneration.
periphery first, and extends to the centre, and
point of origin of the nerve and progress towards
¢ disk is nearly always found to be atrophied and
to be no change in the size of the retinal vyes-
298 DISEASES OF THE SPINAL OORD.
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’ 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 :—
Deaths fr
Place. | Period. | Total deaths. | RA" L0™ | Proportion.
London... |_--1850-8-4 224,515 73 1 in 3075
Ireland... | 1831-1851 | 1,187,374 238 1 in 4987
New York » | 1819-1834 83,783 112 1 in 748
Bombay ; 1851-1858 | 42,651 912 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 :—
1 Legons Orales, tome ii. pp. 599-612.
316 BULBAR DISEABEB.
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, but, 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 scen at various times, the ages at which the disease appeared were
as follows :—
Male. Female. Total.
Under 10 years. . ‘ F 16 10 26
Between 10 and 20 years . : 23 48 7
Between 20 and 30‘ . 2 27 14 Al
Between 80 and 50 ‘* : : 29 11 40
Over 50 es . . 4! 1 5
99 84 183
Reynolds and Iammond 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-
lepey 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 Sf es Herpin, ee . + 27
“ 83 4 “é Maisonneuve, there were - 46
“© 306 ve Alegre, bes + 105
“106 & at Leuret, ae - 42
“© 930 66 ae Moreau, “ - 76
Be MSS te tt Dunaut, ae « 26
fe GQ st ag Delasianve, ge ‘417
Made tt Ze Dussart, st - 40
It will therefore be seen that nearly half of all the cases begin before the
twentieth year. Bean collected 273 cases, 43 of which began between the
6th and 12th years; 49 between the 12th and 16th years; and 17 be-
tween the 16th and 20th years.
The attacks of early life are exceedingly irregular, and may begin as
poorly developed 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 sex, it may be said that Beaumés, 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.
1 In two of these cases there was an indication of syphilis.
* Récherches sur les Causes de |’Epilepsie, etc., Paris, 1876.
330 BULBAR DISEASES.
Analysis of Eleven Cases of Epilepsy.
8. B.—Sodic bromide. P. B.—Potassic bromide.
“ei | | |
S Average
§ | No. i
S| Sexand |Doration of} attacks | Maximum , Minimum | Diminu- Remarks.
3 uge. disease. before duse. | duse. tion.
% ; treatment. lL
\- i
Malo, 15 |Sineo birth ‘1-2 weekly | a B. gr. xx.8.5. gr. xv. ‘2 in 8 weeks Weak intellect.
2| Mule, 22 |Two years '1-2 weekly | ‘spe A XV ve Aa 20 w'ke Disease followed
sunstroke; treat-
ment ed three
months.
3| Male, 25 /One year !1 or more SB. xxv., 8.B. gr. ij. None in 8 |Hard drinker,
in week, , P.B. gr. weeks feeble intellect:
| symetimes ' xxx. tl otassium salt
many in a. | inert.
) day | \
4| Female, 2/18 months ‘1-2 weekly,'Very small ............|None in 8 |Fits followed den-
sometimes | doses 1 | weeks tition ; rickety
| Sin aday | constitntion.
3 | Female, 18 One year | Iu week 18-B. grxxxGr. xx. |None in 4 ‘Tuberealons dis-
weeks ease.
6 Male, 18 Five years “4m week |8.B. gr. xv. = None from 5No affection of
| i :weekx — | intellect.
7 Female, 11 'Five yours ‘og in week 8.B. gr. xx. 9.B. gr. xv. a in 5 w'ks |Followed a blow :
| 1 | : subject to head.
| e.
8 Female,17'Several Sometimes None after bitten tongue
months | 4-3 dally treatment
9 Male, 20)19years (2-3 weesly ,9.B. gr. x1. 8.B. gr. xv. No fits for |No aura,
i \ 2 weeks
10 , Male, 13 |Twoyoars 3 weekly |3.B. gr.xxv3.B, gr. xv.1in3 w'ks |Well developed
; dinease, facies
1 | | eplleptica well
marked.
++ lin Sw'ks 'No fits nince be-
| ginning of treat-
| | | ment.
t
11: Male, 25 \11 years
: |
‘ 1
1 in 2 weeks|S.B. gr. xx,
By this table it will be seen that from fifteen to twenty grains of the
sodie salt were required to immediately decrease the number of attacks.
Below 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 been exhausted.
Even 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
as 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. Bromism oecurred in
spite of all I coud do in most of them, though it was a mild form and
under control. The patients were oll 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.
331
EPILEPSY.
*popyisea seas neo #14 Jo
wopywod ogy ways OWRD
J0 Wop esses oE;poUTINY twnd
+07n JO uojesvAcsayUN odn
quepusdep Aiporqnopan omy y moqy
“Huy ;
aro-s0a0 fq poraxe syonnye !
PRoq Go Molq pavodduw suet
{ysoms0a0 UNG wRONINg fg JNOQY
1
\
*aqTqned) aupiain wawek
ou {ywoqsoysdy :Xpnax 2909, ¥ INOW
sup qzo opyand
-oypy Lrnoaedde : vaytdyouyo
pus Wauereura jraviod
Uy Pople ous ‘xquoaed yuoH
“e1Ny : pourspuos yous !
Naeq a ydoyide oq yng! sawot A
smo *
easvugo
dopun
Power |
SMUV RY
'
! riwek Lpeaon0d
yraent 9 40) ! ormasse “eoqd
‘yRapnyeor “ppg a 0700] “ake
aa" feu, | sqvaour | -ywoay onyseyn
TPOXIN JO ‘KoNd-eyae]) fF uOqY {pty} "xXx “44 “4a ‘sl
|
110 294q]-poa
akekoa vow mivok ' Wao
[BunWON “pyy xx-xX ap | Moqy 3 “xx “13 “Ig “8
|
! rr)
i sjunopeddy yd
cone py cy ead
seymour ' “axx ‘oprmoaq
oxi] Pryx 3p! BL WMogy|>Pow ‘T}O JaAzi-PO,))
|
aaea quoting:
| Wye 4y FT
d1a ‘aoay ‘oynoele
yore WWMyREIs
WAT a@ opywiosq = aqquom: =, Azeyyixuw Sp “y "9
Qh OL sf) Ofpow WAN XX-X Gg WMogy/"Mvsq pow “KAT 0,
, aMemywag) | mom |
‘onnomp | yuoubexqny | neds
"Jo Maye. ponayju0,) | eapar Jo | 1930 ‘osop ofvi0ay
nopwng
|
‘WeU I Ned—"W ‘d
‘630 $1 fae pur'doyw
#pojied yenaywuont
PLSL ‘OR «18 emo | AP QVTON
os -3aNP sg aNOGW 0} WIgD om:
o euod Powweso0} JOM S41quneur
od PZUEL P| a xx aH ay *
| '
Pinvay sama | an
“eqiaen 2 ay ¢ quod
wad {Lay qaqa xx as ay gg Lieaa zo | vawodg
, “eq NOU g 1xeu
ny 1 ‘xqiuow Fixed | i
ar | ‘qamour yxou |
Ul % Woe CANT
uy L wq—an % yxeu
uy g§ ‘yoo HO “ak
wawokz Oye -ag ‘y ‘wad xx sayy !Spqoom Zor | BALZT “A -6
‘K of
sauom
eyinou 9 3xem 40y
AUep OT
sured £1,008
wawok GUYZ fc KYINOU E Wag Og F NOGH “UL “Hy <IROLOL CA ‘CL
i 1 yWamzRes, go>
sawoh “ynamyeouy enjoq, ‘wp & 3
wag soyy Bupmp wyouye-oy | soaps oy |
‘ wang , |
\ : |
“sa puwp— Wt
‘apimoag, 21pog ay) fo sasog, aywsspoyy ynin Redazidy fo sang anog fo siskpuy
r
t
BULBAB DISEASE
332
“OIeT p¥g
qe peg
suo} wo}[du09 junaysuaR
*yeo20994
ssarequnisyyy
“WyNoW of § O10.M ByZEIWT “3g “gs JOPUN TOG
“dy1oysaRoK
*Poswoso0) syp—q3KOU | 40J “4g “]] WONT] VET
SMUT
eqjyaom ¢
sqjuour 9 |
sqyuow »
sqjnom +
eqiuom 9
sqyuoM g
sqimoa 9 !
sqquodt F |
qyuem | |
sqjuour 9
qyaoul |
suyjuout 9
“yuourywor
quoaoad Jo
uopwing
“pba ax ag ’s
p44 ee all agg
“Pd OXx u's
419004 | | 41 y)00u1 g | wivok 3
wqmou guy | d]yjaourg , wawak 1%
“Ppa ax aS ug ‘qd | syyuoutz oT | 4iqiaomy = sxawod gz
“pha cap P-ma0 “xe “a AQQuoa 7 | Ayqqucug = wavol p
k pop ax af ag ‘a Ayyaow [A yqquom 4 | saved g
Sato Auep xp a ag sa £1ya0m g | Stqauow 1g srvod oF
+970 ‘Jes0149 ‘Py ox ag ‘s 4yep xp a3 -ag‘a | syvomg UT | Ayqiuow g | wawad 61
\
“ad | $ pep txx wag ss | Ayymom , £yyuoury | savas g
\
4g ‘8 | ‘pp axa ‘d “ppt xx a8 ag cd | Ayywuow | | Apy nour F | sav0d FT
i 1
see * (qyucut 1 205) .084g 41x00 ¢ | L1yQUOUT gy: waved 0%
“pep ap Lad Ayqiaow |; Ayqraow g | wavod Zt
j pyy eax aged | cp Pa exx cat agea | equaoarg opt dtynomy | eawosor | 3z | 1
¢ ers *qmemnyresd t
yuowywels Bu: | -awounwes | ojaq -oavontp! '
domsog | jo osop wamyayyg | “Bnzp Jo OP WANT | sainp wyow~ ae a ‘ody “ON
JOON aFYOAY gy | voNMING i
| ! ‘ \
! o8uiasy H
“prov onwosqoipAy]—"1g “HH
‘aplmoiq oIssuIOg — "1g “dd
Asdapidy amosyy fo sasn) sapary fo sishjuy
sapymoig d1pog—ag ‘g
334 BULBAR DISEASES.
.
Where there is on 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 necded 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 seeins
to be a “habit” (if I may use the expression) or tendency to periodicity.
Amy] 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 status
epilepticus. Ilia patient had had a great succession of fits, and was at
the point of death; the pupils were contracted to an intense degree, pulse
116, 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' draws the following conclusions in regard to the action
of this drug in epilepsy :—
“Tt exerts an important influence where the epilepsy is due to or con-
nected with cerebral anemia, for the reason that it ‘anticipates the attack
when there are prodromata; cuts off the attack when it appears; relieves
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 hyperemia, for the reason that they
last longer and become more frequent, and when cither maniacal or con-
vulsive, increase in intensity.
My own experience with amyl nitrite has clearly settled in my mind
the fact that it has 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 eases; 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 oecur 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 hy Chicago Journal of Nervous and Mental Disease, April,
1874, p. 260.
336 BULBAB DISEASES.
As a 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 drags
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 ([lammond) ; Glosso-
laryngeal paralysis (‘Trousseau).
In the year 1841 Duchenne’ first called attention to a peculiar group of
symptoms which were connected with progressive degeneration of the
medulla oblongata; and some years later Trousseau’ noticed it in his admi-
rable lectures, and presented several cases reported by Davaine,* long
before Duchenne’s observations were published, but which were before
considered to be examples of double facial palsy. Hughlings Jackson,‘
Dumesnil,’ Charcot,’ and Joffroy, Hammond,’ and lately Dowse,* 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 sclerosis,
which affects 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. cit., 2me edit.
® Lectures on Clinical Medicine, trans., vol. i. p. 908.
% Quoted by Trousseau, vol. i. p. 909.
‘ Philosophical Transactions, part i., 1868.
5 Gaz. Hebdomadaire, Juin, 1859, p. 390.
§ Archiy. de Physiol., tom. iii., 1870, p. 247.
7 Diseases of Nervous System, p. 502 et seq.
® Brit. Med. Journ., Nov. 4 and 11, 1876.
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 has been injected hypodermically in
doses of one grain.
Offenberg’ 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 # concise defini-
tion of this most protean of nervous affections, for it simulates a multitude
of organic and functional diseases so pertectly, 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 with contractures which seem to be the
result of organic disease, so permanent and intractable do they appear.
Convulsions, anesthesia, 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. Contining 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-
rial, and visceral. Sensorial symptoms are of three kinds: hyperesthetic,
anesthetic, and mental. Hyperasthesia, though much more common than
anesthesia, is not so marked. Large areas of hyperwsthesia 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.? Coition is impossible, and one patient
1 Wien. Med. Presse, 1876, No. 1.
2 T 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.
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 may be 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, troths 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. Pomme! 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,” extension of the upper limbs is quite rare. The
lower limb is extended, so that the foot presents the appearance of talipes
equinus, the toes having a claw-like appearance. The thigh is extended
on the pelvis, and the whole limb is adducted.
Ilysterical contractures of a permanent character may affect the body,
1 Traité des Affections Vaporeu
* Des Contractures, Paris, 1875.
3876 CEREBRO-SPINAL DISEASES.
ous, and there is never atrophy or any of the peculiar tissue changes or
neuritis which generally follow hemiplegia froin cerebral diseases. Para-
plegia of the hysterical variety is rarely attended by any urinary or
rectal troubles, and never by incontinence, and the muscles are well nour-
ished and respond to electric stimulation. Some voluntary motion is
possible in the recumbent position, and it is only when the patient walks
that she shows her loss of power. Reynolds states that a peculiarity of the
disease is the fact that no amount of help can keep the patient from stag-
gering or falling; she may be supported by strong arms, but she sinks to
the ground, not, however, falling entirely, but regaining her position by a
voluntary effort.
The visceral troubles are a host in themselves. Not only may the
patient complain of unbearable pains situated in the liver, stomach, and
other organs, but there may be urinary affections of considerable impor-
tance. Two varieties of hysterical urinary derangement are spoken of by
Charcot, one being ischuria, and the other a complete suppression, which
he has called oligurie. In both cases the urinary passages are perfectly
normal; in the first there is simple retention of urine in the bladder;
and for a long time (amounting even to months or years) it will be found
necessary to use a catheter.
Laycock’ has called attention to this state of affairs, which lasts
sometimes twenty-four or thirty-six hours, during the menstrual epoch.
Charcot has found the condition to last even longer—sometimes for several
days. This suppression of urine is occasionally accompanied by vomit-
ing, and the presence of urea has actually been discovered in the vomited
substances. This has been explained by the experiment of Brown-
Séquard, who found that after certain forms of mutilation carbonate of
ammonia or free urea was found in the intestines of animals, which settled
the fact that there was a “supplementary elimination.” This same con-
dition of affairs is not unusual in renal disease, and the odor of ,the
breath and sweat is decidedly uriniferous. Vomiting of fecal matter is a
rare symptom. There is in the majority of cases a decided increase
in the amount of urine yoided. It is of a very light color, quite limpid,
and of low specific gravity, and is sometimes discharged during the con-
vulsive seizure. Digestive disturbances, accompanied by eructations of
wind, borborygmi, epigastric pain, and loss of appetite, are present in
Most cases.
Abstinence from food and continued unconsciousness need hardly be
alluded to in this chapter. Cases of this kind derive sensational impor-
tance from newspaper description, and from their very hysterical nature
suggest fraud and deception. The case of Louise Lateau, as well as
others, has been cleverly investigated, and is doubtless familiar to my
readers. The history of this class of cases furnishes us with many exam-
ples, some of which are quite ancient,
' Treatise on the Nervous Diseases of Women, London, 1840, p. 229.
378 CEREBRO-SPINAL DISEASES.
cles might be accompanied by spasm of the involuntary muscles also, or
the latter might form the chief phenomena of the paroxysm, consisting in
hiccup, eructations, sighs, and borborygmi. During the whole of the at-
tack the hyperasthesia of the skin was exceasive, especially at the fore-
head, epigastric region, and sternum; there was no loss of consciousness.
The attack ended either with a copious flow of limpid urine, or a discharge
of tears. There was never any pain or sensation referable to the genera-
tive organs, nor anything whatever in the history or the symptoms indica-
tive of their implication in any way whatever. The same absence of any
pathological condition of the organs of generation has been observed in
cases of male hysteria observed by others.
Causes.—Hysteria is most decidedly an affection of women, and is
connected in many instances with some sexual or uterine derangement.
Among men hysteria is far less rare, I think, than it is supposed to be,
but with them the hysterical trouble is of a lighter grade, and it is unusual
for examples either of anasthesia, convulsions, or contractures to be wit-
nessed, As a rule, the hysterical man possesses a smooth face, slender
figure, soft falsetto voice, large thyroid cartilages, small hands, and taper-
ing fingers, and sometimes large mamma. His genital organs are poorly
developed, and his manners are mincing and effeminate. Hysterical
phenomena are, however, not uncommonly presented by stalwart men.
Among women this approach to the appearance and behavior of the other
sex is inconsistent with the development of hysteria. Women with bushy
eyebrows, coarse hair, perhaps a slight moustache, angular build, narrow
hips, and coarse voices are seldom hysterical. They are “ strong-minded,”
rarely emotional, and inclined to look upon the hysterical trouble of their
weak sisters with something like contempt.
Reynolds aptly says: “Some women are as little likely to become
hysterical as sume men are to fall pregnant.” Ht might be added: and as
their chances to conceive are diminished. Hysteria is of much more com-
mon appearance among spinsters and single women, and is far from being
rare among old maids who marry late in life. A case of this kind fell
under my observation some years ago. An examination revealed an un-
developed uterus; and from the nuptial night dated a series of nervous
symptoms of a grave hysterical character. The uterine irritability which
is connected with the pregnant state between the ages of thirty and forty
is apt to produc a profound impression upon the nervous system. Among
married women with impotent husbands, or among those who have, on the
other hand, suffered through the lust, inconsideration, and brutality of
husbands of another kind, the disease is not uncommon, The puerperal
state, lactation, and the cessation of the catamenia favor its development.
T have lately treated a number of cases of a class which I am sure is
familiar to most medical men, especially to those who devote the greater
part of their time to the study of nervous disease. I allude to certain ill-
defined hysterical conditions that are connected with or follow the puer-
peral state. These cases do not come under the head of puerperal mania,
which is 8 common and well-recognized form of insanity, but are difficult
382 CEREBRO-SPINAL DISEASES.
diminished. The relative size of the communicating tracts also under-
goes modification. Though this explanation is decidedly rough and super-
ficial, I trust it will give the reader a better idea of the pathology of this
affection than would any extended written description.
Fig. 46.
The Pathology of Hysteria.
Diagnosis.—As hysteria may counterfeit nearly every known symp-
tom, it will be seen that the task of making a diagnosis is not always an
easy matter. If, however, we consider that the symptoms are generally
presented in a group, which is decidedly irregular and inharmonious, and
that the patient is on the alert in regard to all that goes on about her;
that she has a fear of severe treatment; that the use of chloroform will
certainly overcome the contractures; and that the cure is generally sudden,
there is not much chance for mistake. Besides, there is never any evidence
of gross organic change, the muscles only losing their fulness from inaction.
Prognosis.—If the individual has suffered tor a great length of time,
and especially if there be confirmed uterine disease, the chances of entire
recovery will be extremely bad. The disease is not only discouraging
in the way of treatment, but annoying to the friends, and far more disa-
greeable to the physician, who receives yery little for his pains but abuse
and want of appreciation. Some cases may be easily cured, and these
ure among young people. Much, however, depends upon treatment.
Treatment.—The history of the treatment of hysteria is curious in
the extreme. Going back to the middle ages we find numerous examples
of miraculous cures, which were undoubtedly of an hysterical character.
Schele de Vere, in his little work entitled “ Modern Magic,” thus speaks
of a favorite mode of treatment which has been followed by the Zouave
Jacob and many others in modern times :—
884 CEREBRO-SPINAL DISEASES.
remedies which I know of, the latter being employed in its induced form,
and the electric brush applied upon a dry surface. General treatment of
a tonic character should be used when it is possible; and iron, in combina-
tion with phosphorus or phosphoric acid, cod-liver oil, and sea-baths
(FF. 8, 9, 10, 12, 24, 57, 32), together with local treatment. Local dis-
ease should be promptly eradicated if possible, uterine versions or flexions
righted, and the menstrual function restored to its regular character.
In those bed-ridden cases which are so discouraging and trying, we may
use Weir Mitchell’s treatment. A patient may lie in bed leading a very
irregular life, and doing just about what she chooses, without improving
in the least; while, if her room be darkened, her diet changed, and her
muscular tone kept up, a cure may be often wrought.
HYSTERO-EPILEPSY.
This interesting variety of hysterical trouble has received a great deal
of attention from Charcot,' Dunant, Dubois, and Bourneville, as well as
from many other writers, some of whom did not recognize its distinct
character until after Charcot’s valuable investigations had been announced.
Tissot* says that “the hysterical attack sometimes resembles epilepsy,
so much so as to have received the name epileptiform hysteria, but the
attack nevertheless does not possess the true character of epilepsy.”
Others, among whom are Briquet,‘ Landouzy, and Saunders, have also
described the condition.
Upon the authority of Charcot,5 the combinations of epilepsy and hys-
teria take place under the following different circumstances :—
1. a. Epilepsy being the primary disease, upon which hysteria is en-
grafted, under the influence of emotional causes or at the time of puberty.
b. After marriage (vide Landouzy’s Case), the epilepsy having always
existed. After connection, the hysterical feature of the attack is developed.
In this case the hysterical character of the epilepsy subsided when sexual
excitement was interrupted by pregnancy.
2. The hysteria being primary, the epilepsy is added thereto. A rare
condition.
8. Convulsive hysteria coexisting with petit-mal.
4. An epileptic attack, followed by hysterical contractures, anesthesia,
ete.
I have observed a form which slightly differs from any of the above.
The patient, an epileptic, was seized occasionally with hystero-epileptic
attacks during the menstrual periods, and at other times there was un-
complicated epilepsy. She has had epilepsy since the fifth year, when
she was frightened by her mother, who threatened to beat her.
1 Legons sur les Maladies du Syst8me Nerveux, part i., Paris, 1872.
2 De I’ Hystéro-épilepsie. 3 Maladies des Nerfs, quoted by Charcot.
* Op. cit. 5 Op. cit., p. 324.
392 CEREBRO-8SPINAL DISEASES.
mental influence, and strong cutaneous revulsives are recommended should
we suspect malingering.
Prognosis.—When the cause is emotional, or when there is a mala-
rial influence, the individual’s chances are remarkably good. It is only
when the disease appears in a subject of very marked nervous tempera-
ment that there is any reason to give a bad prognosis, and such cases are
chronic. A fatal termination is a very remote possibility.
Treatment. —Electricity in its induced form seems to be indicated for
the abortion or relief of the paroxysm, and amyl nitrite may be recom-
mended for the same purpose. Should there be malarial influences, qui-
nine, arsenic, or iron is of course in order. Curare, bleeding, and many
other forms of treatment have been useless. In the transitory affection
(catalepsie passagére) cold water douches, or diffusible stimulants, are
resorted to.
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,! which is instructive, as it exhibits changes in the nerve-
trunks; and Ogle,’ Kirkes,? Hughes,‘ and Romberg’ 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,
ay st cs «with old thickening, one,
Recent vegetations on mitral and aortic valves, . + one.
Recent vegetations on mitral and aortic valves, with peri-
cardial adhesions, < a A « . two.
Recent vegetations on mitral and tricuspid valves, =. one.
Recent vegetations on mitral and mioleng valves, with
pericardial adhesions, — . one,
Recent vegetations on mitral and aortic valves, with
recent pericarditis, : : two.
Recent vegetations on mitral valves with old pericardial
adhesions, ‘ : . 5 3 F é - 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 appeayances 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 hamatine mingled
with indefinite débris, probably of nervous origin, swelling the canals
around arteries which still remained distended with blood.
1 Archiv f fir Path. Anat., ete., t. Ixi.
® Brit. and For. Med.-Chir. Review, 1868; Med. Times and Gaz., 1866.
3 London Med. ette, 1850; Med. ‘Times and Gaz., 1863.
“ Guy’s Hospital Reports, vol. iv., 1846. 5 Op. cit.
26
404 CEREBRO-SPINAL DISEASES.
rated white corpuscles, and that the location of the lesion is in the corpus
striatum.
Dickinson is disposed to regard the chorea as the result of rheumatism
rather than of endocarditis, and considers the central condition one of
hyperemia 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 other
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 perivascular change are widely scattered throughout that
large region which lies inferiorly 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 diaputed. Iam
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 choreic 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 the jerk, while the tremor of
the other affection is rhythmical and usually fine, and varies under certain
cireumstances. The rapid recovery should also be an element in the
diagnos
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. Choreie 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 pregnaney.
412 CEREBRO-SPINAL DISEASES.
EXOPHTHALMIC GOITRE.
Synonyms.—Basedow’s disease; Graves’ disease; Exophthalmie
eachectique ; Cardiogmus strumosus.
This interesting disease has received 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 hideous
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 hyperamia 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 carly 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 al impaired, and there may be some diarrhoea
or attacks of vomiting; while sleep ia troubled, and the patient suffers
greatly for want of rest.
Ilis appearance 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 exophthalmos of the left eve 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 (phthisieal) so evi-
dent in the other patient. But she ia especially interesting now, as being
1 March 17, 1877.
414 CEREBRO-SPINAL DISEASES.
her periods. She says her throat was much more enlarged nine months
ago than it is now.
There may be double exophthalmos or single, but the double affection of
the eyes is the rule in the great proportion of cases.
The eyeball may be pressed back, as the vascular cushion behind is
soft and yielding; and a peculiar thrill is to be felt. An ‘‘arcus senilis”
has repeatedly been observed: by Bartholow,' who first called attention
to this change, and by others, among them Thomas.? Irritability of
temper, hysteria, laryngeal trouble, and difficulty of breathing are symp-
toms which are to be noticed, and towards the end this respiratory em-
barrassment becomes quite distressing.
The patient is generally badly nourished, and we may have added to
the symptoms already described many of those of general anemia.
The skin of the whole body may sometimes be of a much darker hue
than it is in a condition of health, and some discoloration of that covering
the forehead is often noticed. This discoloration resembles a brown stain,
and it has been spoken of as “bronze skin” by some writers. Raynaud*
has called attention to the connection between this stain, or vitiligo, and
exophthalmic goitre. He gives “five cases of exophthalmic goitre, culled
from varions sources, in the course of which patches of vitiligo appeared
on various parts of the body. Beyond the observation that vitiligo is
more common in men than in women, except when congenital, that it
attacks by preference persona of dark complexion, that it is sometimes,
though rarely, hereditary, and has a certain analogy to Addison’s disease,
viewed as an imperfeet vitiligo, little has been made out with regard to
its pathology. Mr. Iutchinson has pointed out that although no known
cachexia appears to set up a predisposition to the affection, the symmetry
of the cutaneous patches is suggestive of some pre-existing general fault
of the circulatory or nervous systems, and is opposed to the hypothesis of
a parasitic origin, Without offering any explanation of the coexistence
i igo with exophthalmic goitre, Dr. Raynaud thinks that the coinci-
dence should not be allowed to pass unnoticed.”
Roth‘ reports a case of exophthalmic goitre, the patient being a woman
fifty years of age, her menopause having taken place six years before.
She became debilitated, suffered from palpitation and sweating at night.
and afterwards there was gradual enlargement of the thyroid gland and
protrusion of the eyeballs. The pulse was 120, and the temperature
normal. It was impossible for her to close her eyelids, The exoph-
thalmos was greater on the left side, and the thyroid was more enlarged
on the opposite side,
Galvanism was used, the positive pole being placed on the upper part
of the sternum and the negative on the superior cervical ganglion. On
' Chicago Journal of Nervous and Mental Diseases, July, 1875.
2 Richmond and Louisville Med. Journ., Nov. 1876.
3 Archiy. Gén., June, 1875; and London Med. Record, Sept. 15, 1875.
4 Wien. Med. Presse, 1875, No. 30.
418 CEREBRO-SPINAL DISEASES.
who a'so reported a death. Bartholow' has cured three patients; Ham-
mond? four, und reports one death. Dr. J. P. Thomas,’ of Kentucky,
details a very interesting case which ended fatally in five years. Very
little can be said in regard to the character 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
Corlieut 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
Bartholow has cured three cases by this agent. Chalybeate preparations,
digitalis, ergot, and cod-liver oil are all excellent remedies (FF. 6, 8, 21,
46). If galvanism be used, we should bring the sympathetic nerve under
its influence by placing one pole (the positive) at the angle of the lower
jaw, and apply the negative over the epigastrium.
' Op. cit. £ Op. cit., p. 797.
. * Richmond and Louisville Med. Journal, 1877.
* Rep. by Jaccoud, vol. i., p. 672, 2d edition.
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 gen-
tleman who consulted me some time ago presented this indication of facial
neuralgia, there being several hyperwsthetic 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 pulsc 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-
roxysins, 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 Weir
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.’ 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 spasm. In a form of facial neuralgia which has been known as tie
epileptiform or tic douloureux, tonic spasm of the eyclid 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
son, of New York, is an example of a neurosis of this kind.
NEURALGIA. 421
of the muscles of the thorax. Mitchell’ “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 supergictal 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. us “bladder.
4. és “rectum.
5. fe “ testis.
6. Hepatic neuralgia.
7. Neuralgia of the heart.
8. sf “¢ stomach.
9. Laryngeal and pharyngeal neuralgia.
Among the first group the most important is neuralgia of the fifth nerve,
which may also exist with a motor complication, as tie epileptiform, or
with gastric complications, as migraine or * sick headache.’
FACIAL NEURALGIA.
Synonyms.—Face-ache ; Fothergill’s face-ache; Prosopalgia; Tri-
geminal neuralgia; Tic doulourcux; 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,” presenta the following features: The
attack may be preceded by some chilliness, pallor, and uncasiness, and is
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; the
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 « 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 was
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 PLEURODYNIA.
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 hyperis-
thetic, and this is particularly the case if the neuralgia be attended by
herpetic patches. ‘The painful points are chiefly over the inter-vertebral
foramen, and where the nerve pierces the muscles anteriorly. The rectus
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. Cutancous hyperasthesia, 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”
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
engratting of the pulmonary trouble upon the neurotic stock. Epilepsy
enters extensively into the causation of many forms of neuralgia, especially
epileptiform tic; and not only may these other neuroses have appeared
among the progenitors of the individual, but they actually exist with the
neuralgia.
Blandford! 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 aleo-
holism is associated with a variety of ncuralgic 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 periosteal disease, but through the condition of mal-nutrition and
enfeeblement of thegnervous 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.
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 the
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, and
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.! Neuromata
very frequently give rise to neuralgia. Such neuromata sometimes follow
amputation or gross nerve-wounds, and the ncuralgia 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 tecth 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 varicty, 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 10 years, 2 6 _ 8
ab * 10 to 20 ‘ 22 19 14 55
tad “20 to 80“ 68 ad 40 108
$8 * 30 to 40 ‘ 67 33 39 139
bt “ 40to 50‘ 64 23 29 116
vf “ 50to 60 ‘ 47 14 14 15
Le “* 60to70 ‘* 21 6 9 36
ae “* 70 to 80 ** 5 _ 1 6
296 101 146 543
1 Huebner, Ziemssen’s Encyclopedia, vol. xii.
440
DISEASES OF THE PERIPHERAL NERVES.
Fig. 49.
ry
—~ [8
ant.cut,
Jatercostit
Be
n
at
NEURALGIA. 443
remedies. . I have spoken of quinine. I may add that when given con-
tinuously, either in combination or alone, it cannot fail todo 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.
464 DISEASES OF THE PERIPHERAL NERVES.
the muscle-changes which follow separation from the cord. His conclu-
sions may be thus summed up :— é
~ If aspinal nerve be cut through at any point between the spinal gan-
glion and the periphery, the nerve-tibres 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
“chistopathic change,” ¢. 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 the
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. Ifthe 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 it 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' 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 inet 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 anesthesia, 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 :?? “ Always select the current which
produces the most muscular contractions, with the least amount of’ pain.”
Pain and over-tatigue, which follow the use of a strong current, are very
' Des Paralyses Peripheriques, Paris, 1876, p. 45.
2 Phila. Med. Times, Feb. 20, 1875.
468 DISEASES OF THE PERIPHERAL SERVES.
reading. In three weeks my voice. then at times unimelbgitde. grew sed-
denly better. and in four or five days was restored. The difficulry in ewal-
lowing alse soon disappeared. The loss of motion and sensaden im both
anus aod legs increased. In walking I «emed w be on velvet: there was
a sensation of coldness in my feet, and at first the circulation wa: retarded.
The general loss of power was progressive until February la. Jt was
then impossible for me to stand alune even when lifted up. w raise myself
an inch from the chair by my arm. to bring my thumb and forefinger
together, or to exercise my strength in any yart. The toes Lung 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 furadic current. The fingers were drawn up when the hand was at
rest, but only by great effort could be straightened cut again. The mus-
cles of the arms were much weakened. but with those of the thigh retained
more power than the They were also the last to lose and the fins 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 litt 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 Ist I walked
al 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 12th faradism to the muscles every day until
February 15th, afterwards three times a week for three weeks. Tincture
of mux vomica 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
museles every morning for one hour.”
Causes.—Morbid Anatomy and Pathology.—Dowse' quotes
Balthazar Foster, who has stated that * 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.
See case nog by Dr. A.W. Foot, Dublin Quarterly Journal, Sept.
1872, p. 176, of * Locomotor Ataxia subsequent to Diphtheria.” This was evi-
dently the ataxic form of Brenner.
DIPHTHERITIC PARALYSIS, 469
Labadie Lagrave, Andral, and others have called attention to the blood-
changes in this disease, viz., diminished fibrine and an increased number
of white corpuscles. Sauné has found that the red corpuscles are de-
stroyed, and that there is a great increase in the amount of débris 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 nced not be mistaken for any
other affection, though occasionally, in its ataxic form, it is confounded
with pgsterior 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 (Concrupep).
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' considers a species of neuralgia of the
mesenteric plexuses. ‘Tanquerel® 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 anesthesia or hyperesthesia, but the latter is more common. The
skin is exquisitely sensitive in parts, such as the scalp, the groin, the bend
of the clbow, 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
! Op. cit., vol. ii. p 132.
® Traités des Maladies de Plomb. on Saturnines, 1839.
472 DISEASES OF THE PERIPHERAL NERVES.
pital 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.
Hand.'\—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.—Electricity 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 applics 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,’ 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. Ilere 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, 15.
® Graduation Thesis, Harvard Medical School—Boston Med. and Surg. Journ.,
Oct. 4, 1877...
Having been carried to a neighboring shed, the buckles are placed over
pyreligneous 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-
filized 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
hy 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 polverized, 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
clonds 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 absarp-
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 selerotic coat is yellowish. Their motions
are far from energetic, and in some eases 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,
8. After grinding lead with oil has only the blue line.
12m
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,' in an admirable paper, calls attention to the
resemblance between ‘wrist drop” duc 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,’ 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. Richardson’s case (Joc. 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 eyent 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 bé so supported that
the muscles shall be relaxed. Dr. H. C. Wood,‘ of Philadelphia, has
t Am. Psych. Journal, Nov. 1875, p. 31.
? Report of the Board of Health, 1872.
% Very large doses seem to increase the symptoms.
4 Phila. Med. Times, Feb. 20, 1875.
480 DISEASES OF THE PERIPHERAL NERVES.
I. TETANY.
A light form of attack arising generally from diarrhea, 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 apasm, trismus, or vesical spasm are examples of more violent
action. The spasms scem 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. Pet/t-mal sometimes resembles this condition, but there is
always some loss of consciousness.
II, FUNCTIONAL SPASM WITH VOLUNTARY MOVEMENTS.
Mitchell! 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 with great regularity.
Bamberger? reports a case which resembled spasm of another kind, of
which I shall presently speak. Whenever the child was held in the stand-
' Am. Journ, Med. Sciences, Oct. 1876.
* Quoted by Handfield Jones, Functional Nervous Disorders.
PROFESSIONAL ORAMP. 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 sir, salt baths, and a change of habits and scene are all fraught
with benefit.
I do not consider tenotomy advisable except in extreme instances.
Sig.
Sig.
FORMULA.
(ADULT DOSES.)
1.
Tr. aconit. rad. 3j-3ij;
Sodii bromidi Ziss ;
Aque menth. pip. ad Ziv.—M.
Bj tied.
2.
Tr. digital. Siij ;
Syr. papav.,
Elixir curagoa, aa 3ij—M.
3j at a dose.
3.
Chloral. hydrat. 3};
Ess. menth. pip. q. 8. ;
Syr. tolutan.,
Muceil. acac., ia 3ij.—M.
. 5j at a dose, well diluted.
4,
Chloral. hydrat.,
Caleii bromidi, 4% 3j;
Syr. limonis 3ij ;
Aque ad Ziv.—M.
. 3j at a dose.
5.
Dragée ergotin (Bonjean), (gr. v.), no. xx.
. One at a dose.
FORMULA. 491
6.
RB. Fi. ext. ergote 3ij ;
Sodii bromidi 3iss ;
Aque camphore ad Ziv.—M.
Sig. A teaspoonful every 4 hours.
7.
BR. Acidi hydrocyanici dil. m xx-xxxvj;
Aq. ext. ergote 3j.—M.
Ft. massa et divid. in capsul. no. xij.
Sig. One every 3 hours.
8.
RB. Strych. sulph. gr. sj;
Cinchone sulph. 5j ;
Tr. ferri chlor. 5v ;
Acidi phosph. dil.,
Syr. limonis, 44 3ij.—_M.
Sig. A teaspoonful in water at a dose.
9.
Hammond's Solution.
RB. Strych. sulph. gr. ss—j;
Quiniw sulph.,
Ferri pyrophos., i 3j;
Acidi phos. dil.,
Syr. zingib., ai 3ij—M.
Sig. A teaspoonful in water at a dose.
10.
RB. 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.
B. Sol. strych. sulph. (gr. j-3ij) Zij;
Ferri dialysat. Ziss ;
Aque flor. aurantii ad Ziv.—M.
Sig. A teaspoonful at a dose.
492 FORMULA.
12.
BR. Ferri carbonat. sacch. 3ij;
Cinchon. sulph. gr. xxiv.—M.
Divid. in chart. no. xij.
Sig. One t. i. d.
13.
RB. Zinci oxidi 3j;
Confectio. rose q. s.—M.
Ft. massa et divid. in pil. no, xxx.
Sig. One t. i. d.
14.
B. Sol. potass. arsenitis 5ij ;
Quinie sulph. 338 ;
Acidi sulph. aromat. q. 8.5
Aque anisi Ziv.—M.
Sig. A teaspoonful every 4 hours.
15.
R. Sol. acidi hydrobromici,
Sig. A teaspoonful before each meal.
16.
RB. Quiniz sulph. 3);
Sol. acidi hydrobromici 3iij ;
Aqux camphor ad Ziv.—M.
Sig. A teaspoonful three times a day, in a tumblerful
of water.
17.
B. Potass. iodidi 5ij;
Potass. nitrat. 5vj;
Syr. seilleu 3);
Spts. ammon. acetat. ad Ziv.—M.
Sig. A teaspoonful every 4 hours.
18.
BR. Potass. acetat. 5vj;
Infus. digitalis 3 viij—_M.
Sig. A dessertspoonful three times a day.
FORMULA. 498
19.
Bayley’s Pill.
R. Pil. hydrarg. masse,
Pulv. scille,
Pulv. digital., aa gr. xxiv.—M.
Ft. massa et divid. in pil. no. xxiv.
20.
RB. Hydrarg. bichlor. gr. ss ;
Potass. iodid. 3) ;
Tr. cinch. co. Ziv.—M.
Sig. A teaspoonful three times a day.
21.
RB. Tr. ferri chlor.,
Tr. digitalis, a4 3ss.—M.
Sig. Ten to twenty drops, in water, three times a day.
22.
B. Elaterii gr. iv;
Ext. nucis vom. gr. iij;
Confectio. rose q. s.—M.
Ft. massa et divid. in pil. no. xij.
23,
B. Sodii bromidi,
Ammon. bromidi, 44 38s ;
Chloral. hydrat. 3.vj ;
Tr. aconiti rad. 3iss ;
Aque menth. pip. ad Ziv.—M.
Sig. A teaspoonful three times a day, or oftener if
required.
24,
B. Phosphori gr. ij;
Ol. amygdale dule. 3j;
Ess. menth. pip. q. 8.5
Mucil. acac. 3vj.—M.
Sig. A teaspoonful after eating.
494
FORMULA.
25.
Thompson's Solution.
B. Phosphori gr. ss—iss ;
Alcohol absol. q. 8. ut dis. ;
Ess. menth. pip. q. 8.5
Glycerine ad Ziv.—M.
Sig. A teaspoonful after eating.
26.
B. Phosphori gr. ss-j;
Sevi gr. c.—M.
Divid. in pil. no. xxv.
Sig. One after eating.
27.
R. Zine. phosphidi gr. iv ;
Confectio. rose gr. xxiv.—M.
Ft. massa et divid. in pil. no. xij.
Sig. One after eating.
28.
R. Strych. sulph. gr. ss—j;
Acidi inuriatici dil. 3 vj;
Aquz ad Ziv.—M.
Sig. 3j t. i. d.
29.
BR. Strych. sulph. gr. ss—j;
Acidi phosph. dil. 3ij;
Syr. simplicis ad Siv.—M.
Sig. 3j t. i. d.
30.
Bartholow’s Injection for Hypodermic use.
BR. Strych. sulph. gr. ij;
Ag. destil. vel aque cerasi 3j.—M.
mv = gr. gs
31.
RK. Pepsini saceh. 3vj;
Acidi muriatici dil.,
Tr. nucis vom., a 3x8;
Aque cinnamomi ad Ziv.—M.
Sig. A teaspoonful after each meal.
FORMULA. 495
82,
B. OL. morrhue,
Ext. malti (Loeflund), aa Ziv.—M.
Sig. A tablespoonful three times daily.
33.
B. Bismuth. subcarb.,
Pepsini sacch., a 3ss ;
Pulv. aromatici ad Ziv.—M.
Divid. in chart. no. xxiv.
Sig. One t. i. d. after eating.
34.
B. Pepsini sacch.,
Pulv. carb. ligni, a 3ss.—M.
Divid. in chart. no. xxiv.
Sig. One three times a day after eating.
35.
RB. Antimon. tartrat gr. j;
Aqua Ziv.—M.
Tf 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.
RB. Tr. verat. virid. Zijss ;
Aq. menth. pip. ad Ziv.—M.
Sig. One teaspoonful every two hours, or oftener if
needed.
387.
B. Phosphori gr. j;
Ol. morrhue Oj.—M.
Sig. A tablespoonful at a dose.
38.
BR. Sodii bromidi Ziss ;
Aquz camphore,
Tr. lupulin., a 3ij.—M.
Sig. A teaspoonful at a dose.
496 FORMULA.
389.
R. Tr. cannabis indice 3ij;
Aq. flor. aurantii ad 3ij—M.
Sig. A teaspoonful at a dose.
40.
BR. Ferri et ammon. citratis 3ss ;
Tr. cinch. co.,
Tr. gentiane co., a& 3ij ;
Aque ad 3viij—M.
Sig. A dessertspoonful ter in die.
41,
B. Magnes. sulph. 3j;
Infus. senne Ziv ;
Infus. caffe 3ij.—M.
Sig. A wineglassful to be taken every morning, or
oftener if required.
42,
R. Syr. ferri iodid. 3vj;
Syr. glycyrrhize Ziv.—M.
Sig. Half to a full teaspoonful after eating.
43.
R. Acidi arsenici gr. j;
Pulv. nigr. pip.,
Ferri redacti, ai gr. xx 5
Ext. gentiane q. s.—M.
Ft. massa et divid. in pil. no. xx.
Sig. One three times a day.
44,
BR. Ext. belladonne gr. iij
Zinci oxidi gr. xlviij ;
Syr. simplicis q. s—M.
Ft. massa et divid. in pil. no. xlviij.
Sig. One thrice daily.
32
FORMULA. 497
45.
B. Potass. iodidi Jiss ;
Vini sem. colchici Zijss ;
Potass. nitrat. 3iij ;
Aque 3viij.—M.
Sig. A tablespoonful three times a day.
46.
RB. Sode bicarb.,
Sulph. lot., a4 3ss.—M.
Divid. in chart. no. xx.
Sig. One three times a day.
47.
RB. Croton-chloral. Zijss ;
Aquee rose 3viij._M.
Sig. A tablespoonful at a dose.
48.
BR. Protagon.
Syr. aurantii cort., aa 3j.—M.
Sig. Thirty drops to a teaspoonful three times a day.
49.
BR. Iodoformi gr. xxiv ;
Confectio. rosa q. s.—M.
Ft. massa et divid. in pil. no. xxiv.
Sig. One thrice daily, or oftener if required.
50.
RB. FI. ext. gelsemium semperv. 3ijes ;
Elixir simplicis ad Ziv.—M.
Sig. One to two teaspoonsful at a dose.
51.
R. Ext. conii fl. (Squibb) 3s ;
Sodii bromidi 3j;
Aqux camphore ad Ziv.—M.
Sig. Teaspoontul at dose.
498 FORMULA.
52.
RB. Tr. moschi,
Tr. lobelise, a 3 ij;
Spts. etheris comp. ad 3ij.—_M.
Sig. A teaspoonful at a dose.
53.—( Tanner.)
B. Tr. assafoctidie ij ;
Spts. ammon. aromatici 3iij ;
Tinet. chirate 3 vij.—M.
Sig. 60 drops in a wineglassful of water every two or
three hours.
' 54.
B. Elix. ammonite valerianat. Ziij ;
Chloroforme 3ss ;
Aque camphore ad Ziv.—M.
Sig. 3j every 3 or 4 hours.
55.
R. Zinci valerianat.,
Ext. hyoseyami, a 3j.—M.
Ft. pil. no. x1.
Sig. One at a dose.
56.
R. Ext. physostig. venenos. gr. xij.
Divid. in pil. no. xxxvi.
Sig. One every 4 hours.
BR. Syr. calei lactophosph.,
Ext. malti, aa 3ij—M.
Sig. A teaspoonful every + hours.
58.
RB. Ferri bromidi 5ij
Syr. lactucarii —M.
Sig. Half to one teaspoontul every 3 or 4 hours.
FORMULZ. 499
59.
Hypodermic Injection.
R. Atropiz sulph. gr. j;
Sol. Magendie 3j.—M.
Filter. = mv—x.
60.—(Bartholow.)
BR. Ext. ergotin. aq. 3j;
Glycerine 3);
Aque 3vij.—M.
Filter. mviij = gr. j.
61.
BR. <Atropiw sulph. gr. j ;
Aque 3);
Acid. salicylici q. s.—M.
Filter. mx—=gr. gy.
62.
BR. Tr. belladonnex 3ss ;
Glycerine 3);
Linim. sapon. 3iij—M.
Ft. linimentum.
63.
R. Tr. aconiti rad. 3ij;
Linim. camph. comp. ad Ziv.—M.
Ft. linimentum.
64.
B. Tr. aconiti fol.,
Chloroforme,
Tr. capsici, 4 3ss 5
Linim. saponis ad Ziv.—M.
Ft. linimentum.
65.
BR. Unguent. veratrie 3j ;
Rad. aconiti puly. 3j.—M.
Use externally (with care).
500 FORMUL.
66.—( Turnbull.)
BR. <Aconitie gr. ij;
Spt. rectificati gtt. vj;
Adipis prep. 3j.—M.
Rub a small part on the track of the painful nerve.
67.
RB. Chloral-hydrat.,
Camphore, aa 3ij ;
Adipis 3ss.—M.
Use locally.
68.—( Tanner.)
R. Camphoree 3j;
Ext. belladonne gr. iv ;
Ext. conii gr. xlviij.—M.
Ft. massa et divid. in pil. no. xlviij.
Sig. One, thrice a day.
69.
R. Enmulsio pancreatin. 3i—-3ss after eating.
70,
R. Ext. belladonne gr. iv;
Ext. opii,
Ext. hyoseyami, a gr. xij.—M.
Ft. massa et divid. in pil. no. xij.
Sig. One at a dose.
71.
B. Ext. hyoseyami,
Ext. conii, a& gr. xxiv.—M.
Ft, massa et divid. in pil. no xij.
Sig. One or two at a dose.
72.
B. Strychnia sulph. gr. j;
“ Acid phosphates” (Horsford),
Tinct. cimicifuge rac., 4% 3ij.—_M.
Sig. Teaspoonful at a dose.
FORMULA.
738.
B. Syrupi phosphati comp. (calcis, ferri, ete.).
Sig. Teaspoonful at a dose.
7A.
RB. Tr. belladonne,
Potass. iodidi, 44 Bij ;
Aqux menth. pip. Ziv.—M.
Sig. 3j t. i. d.
75.
BR. Tr. ferri perchloridi 3ss ;
Glycerine 3) ;
Tr. calumbe ad Jiv.—M.
Sig. 3j t. i. d.
RB. Ext. belladonne gr. iv 5
Ext. ergota: aq. 3j 5
Ferri sulph. exsiceat. 338.—M.
Ft. massa et divid. in capsul. no. xij.
Sig. One every 4 hours.
77.
R. Argenti nitrat. gr. vj ;
Contectio. rose q. s—M.
Ft. massa et di in pil. no. xxiv.
Sig. One after cach meal.
73.
R. Argenti nitrat.,
Ext. belladonna, aa gr. vj—viij 5
Ext. gentiane q. 3—M.
Divid. in pil. no. xxiv.
Sig. One after cach meal.
79.
R. Argenti nitrat. gr. vj-v
Ext. nucis vom. gr. xij.—M.
Divid. in pil. no. xxiv.
Sig. One after cach meal.
501
502
FORMULA.
80.
RB. Argenti phosphat. (tribasic.) gr. viij;
Ext. quassiw q. s.—M.
Ft. massa et divid. in pil. no. xxiv.
Sig. One after each meal.
81.
R. Ext. belladonne 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. mv—x;
Glycerine 3j;
Aq. rose Ziij.—M.
Sig. At a dose.
83.
R. Tr. aconiti rad. mv;
Chloroforma: mx ;
Syr. papav. 3ss—M.
Sig. At a dose.
84.
B. Ammon. bromidi,
Sodii bromidi, 44 3j.—M.
Divid. in chart. no. xlviij. Put in waxed paper.
Sig. Two at night, and one in the morning.
85.
RB. Amyl nitriti Ziij ;
Alcohol. absol. ad 3ij.—M.
The patient should be direeted to provide himself with a small homeco-
pathic bottle, into which he is to put 3ss of 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.
RB. Tri-nitro. glycerini 38s ;
Alcohol. absol. 3vj.—M.
Sig. 8-10 drops three times a day.
87.
R. Camphore monobromidi 3ss-3j;
Confectio. ross q. s.—M.
Divid. in capsul. no. xij.
Sig. One every hour until the effect is produced.
88.
BR. Tr. cannab. Ind.,
Tr. hyoscyami, a3 5v;
Tr. conii Jiss—Jiij ;
Syr. lactucarii ad JZiv.—M.
Sig. Teaspoonful at dose.
89.
R. Tr. nucis vomice 3v;
Spts. ammon. aromatici,
Tr. capsici, && Zvj;
Aque camphor ad Ziv.—M.
Sig. Teaspoonful at a dose, in the morning.
90.
RB. Tr. digitalis 3vj;
Ferri dialysat. 3) ;
Elixir Chartreuse alb. ad Ziv.—M.
Sig. 3j t. i. d. in water.
91.—Burmann’s Hypodermic Solution.
RB. Coniw 3iij, mxij;
Acidi acetic. fort. 3iij, m xij ;
Spts. vini rect. 3);
Aquee destil. ad 3ij.—M.
Sig. mv = mj conix. Begin with one drop.
504 FORMULA.
92.
Hypodermic Injection.
R. Daturie gr. j;
Ae. acetici fort. q. 8.;
Glycerin: 3ij;
Aqua destil. ad 3j.—M.
Sig. Begin with three minims.
93.
RB. Ammon. muriat. 3ij ;
Pulv. aromatici, 3j.—M.
Divid. in chart. no. yj.
Sig. One every hour.
94.
R. Puly. paulline sorbilis 3).
Divid. in chart. no. xxiv.
Sig. One to three every hour till relieved.
95.
RB. Fructus belladonna Ziv;
Spts. vini rect. 3 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. 3 viij ;
Aqui bullientis Ov ;
When cold, add—
Acidi sulph. 3vij.—M.
INDEX. ‘
BSENCE of blood in cutaneous vessels
in hysteria, 373
“tendon reflex” in locomotor
ataxia, 277
Abstinence from food in hysteria, 377
Abuse of bromides in epilepsy, 329
Active cerebral hyperwmia, 69
Acute alcoholism, 851
cerebral anwmia, 113
cerebritis, 149
myelitis, 283
softening, 149
Adult spinal paralysis, 247
Esthesiometer, 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, 858
in ventricular fluid, 867
Alcoholism, 851
acute, 862
causes of, 855
chronic, 864
definition of, 851
diagnosis of, 859
hallucination in, 853
morbid anatomy and pathology of,
856
prognosis of, 858
symptoms of, 852
treatment of, 359
Anemia, cerebral, 113
epinal, 227
Anssthesia, 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, 196
Antero-lateral amyotrophic sclerosis, 289
causes of, 292
diagnosis of, 298
morbid anatomy of, 292
prognosis of, 293
symptoms of, 289
synonyms of, 289
of
Antero-spinal paralysis of adults, 247
causes of, 252
definition of, 247
diagnosis of, 252
morbid anatomy
thology of, 252
prognosis of, 254
symptoms of, 249
synonyms of, 247
treatment of, 254
of infancy, 289
causes of, 248
definition of, 289
deformities in, 289
diagnosis of, 246
electricity in, 246
morbid anatomy and pa-
thology of, 248
muscular tissue, changes in,
245
prognosis of, 246
BSinkler’s case of, 239
symptoms of, 239
synonyms of, 289
treatment of, 246
and pa-
Aphasia, 161
definition of, 161
diagnosis of, 176
history of, 162
infantile, 174
location of speech centre in, 168
Lordat on, 164
medico-legal study of, 177
pathology of, 167
synonyme of, 161
treatment of, 178
trephining in, 179
with left sided paralysis, 171
without lesion, 170
Apoplexy, 83
; Apparatus, electrical, 80
for the treatment of nervous diseases,
80
Van Bibber’s, 80
Arcus senilis, the, 94
Arrangement of nerve-roots in posterior
columns, 285
Artbropathies in cerebral hemorrhage,
91
Asemasia, 161
Asthenic cerebral hyperemia, 69
Atheromatous changes in vessels, 97
Athetosis, 92
Atrophy, partial facial, 266
treatment of, 293
causes of, 268
506
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, 2
with cerebral sclerosis, 183
Auditory vertigo, 124
causes of, 126
definition of, 124
diagnosis of, 128
pathology of, 126
synonyms of, 124
treatment of, 128
Automatic man, the, 314
ASEDOW’S disense, 412
Basilar meningitis. 66
Bed-sores, treatment of, 288
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 ataxia, |
283
Broca on location of speech centre, 168 :
Brown-Séquard’s theory of auditory con-
vulsions, 127
Bulbar diseases, 308
paralysis, 336
causes of, 339
condition of tongue in, 837
diagnosis of, 340
morbid anatomy ond pathology |
of, 340
prognosis of, 342
progressive variety of, 339
reflex variety of, 339
stationary variety of, 339
Burrowes’ experiments, 145
ANCEROUS growths in brain, 190
Case of cerebellar tremor, 194
Case of hematoma, 42
of post-paralytic choren, 93
Case (continued).
of spinal tumor, with persistent reflex
sensibility, 216
, Catalepsy, 889
causes of, 390
definition of, 389
diagnosis of, 891
flexibilitas cerea in, 889
induced in animals, 891
malarial, 890
morbid anatomy and pathology of,
891
prognosis of, 892
symptoms of, 889
treatment of, 392
; Canteries, 82
author’s, 82
glass rod, 82
Guérard’s, 83
Pacquelin’s, 33
; Central neuritis, 91
spinal hemorrhage, 220
| Cerebellar hemorrhage, 112
tumor, case of, 194
, Cerebral anemia, 113
causes of, 116
chronic, 114
definition of, 118
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
cnuses of, 94
condition of eyes in, 86
conjugate deviation of eyes in,
a6
definition of, 83
dingnosis 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
hypermmia, 69
cnuses of, 73
definition of, 69
dingnosis of, 78
influence of occupation in, 73
local, 79
morbid anatomy of, 77
pathology of, 75
508
Cramp (continued).
professional, 484
cnuses of, 486
dingnosis of, 487
pathology of, 486
«Crises gastriques,” 281
Cross paralysis, 89
Cram-Brown’s experiments, 124
Cutaneous eruptions in locomotor ataxia,
278
A COSTA-on cerebral rheumatism, 51
Decubitus paralysis, 462
Delayed transmission of impressions, 236
Delirium tremens, 852
Depraved appetite in hysteria, 372
Diathetic growths, 202
Diplopia, 70
Disenses of cerebral meninges, 35
of cerebrum and cerebellum, 69
Dislocation ns a cause of paralysis, 461
Division of a nerve trunk as o cause of
paralysis, 460
Douleurenx, tic, 420
Dreams of movement, 404
Durntion of life of hard drinkers, 858
Dynamometer, \25
Mathieu's, 25
the author's, 26
CHOLALIA, 176
Eczemn with choren, 399
Education of right side of the brain, 178
Electrical apparatus, 30
Embolic theory of choren, 403
Embolism, 129
of the cerebral vessels, 137
causes of, 141
dingnosis of, 142
morbid anatomy
thology of, 145
prognosis of, 147
symptoms of, 138
treatment of, 147
Emprosthotonos, 26
Endemic tetanus, 20%
Epidemic chorea, 393
Epilepsy, 308
aborted, 313
abuse of bromides in, 829
age in causation of, 316
auditory, 321
Brown-Séquard’s experiments in, 320
causes of, 316
chloral- bromide treatment of, 333
definition of,
dingnosis of, 825
dislocation of bones in, 312
experimental production of, 321
grave altucks of, 309
heredity in, 317
history of 308
hystero, 384
induration of cornua ammonis, 319
irregulur attucks of, 313
and pa-
INDEX.
Epilepsy (continued).
Jackson on, 822
light attacks of, 312
masked, 815
morhid anatomy and pathology of, .
nocturnal, 811
prognosis of, 825
resembling hydrophobia, 869
responsibility in, 315
symptoms of, 809
synonyms of, 308
syphilitic, 326
temperature influences in, 317
treatment of, 326 i
warnings io, 309
Epileptiform tic, 425 ~
Equilibrium, sense of, the, 124
Ergot in pachymeningitia, 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
cnuses of, 417
definition of, 412
diagnosis of, 417
morbid anatomy and pathology
of, 417
prognosis of, 417
| symptoms of, 412
synenyms of, 412
treatment of, 418
| unilateral, 414
; Experimental production of epilepsy, 821
Extravasation of. blood in neuralgia, 421
i
| pegae neuralgia, 421
. parulysis, 455
‘ causes of, 454
diagnosis of, 457
electricity in, 458
pathology of, 456
prognosis of, 457
symptoms of, 453
) synonyms of, 453
{ treatment of, 468
i wire hook in treatment of, 458
spasm without pnin, 482
Faradic apparatus, 31
Fatty degeneration of muscles, 261
Fibrillary contractions, 256
Flexibilitas cerea, 389
Formule, 490
Functional locomotor ataxia, 281
spasm, 479
‘G ALVANIC batteries, 31
‘AT Gibney on traumntic causation of
| spinal irritation, 226
Glass rod cautery, 32
, Gliomata of brain, 194
INDEX.
Globus bystericas, the, 37
Gluge’s corpuscles, 157
Goitre, exopthalmic, 412
Grasset’s classification of brain tamors,
190
Graves’ disease, 412
Griffin on spinal irritation, 227
qe on gait in lateral sclerosis,
By
Hardening fluids, 20
Hemiplegia, 88
hysterical, 375
Hemorrhage, cerebral, 88
meningeal, 40
spinal, 218
Herbert Major on structure of insula,
178
High temperature in tetanus, 296
Hints in regard to methods of examina-
tion and study, 17
Holland on anal leeching, 47
Hydrobromic acid, 80
Hydrocephaloid, 113
Hydrophobia, 261
causes of, 866
curare in, 369
diagnosis of, 868
Dr. Hadden’e case of, 362
morbid anatomy and pathology of,
367
prognosis of, 369
symptoms of, 361
synonyms of, 361
treatment of, 369
Hysteria, 310
causes of, 878
definition of, 370
dingnosis of, 382
morbid anatomy and pathology of,
381
prognosis of, 382
symptoms of, 370
treatment of, 382
Hysterical ansesthesia, 872
artbropathies, 371
paraplegia, 375
tremor, 375
Hystero-epilepsy, 384
cases of, 885
symptoms of, 885
NEANTILE hemiplegia, 174
paralysis, 239
Inflammation of spinal cord, 233
Instruments used for the diagnosis of
nervous diseases, 22
Intra-vesical troubles in myelitis, 235
A ee on epilepsy, 822
‘
1
509
ATERAL sclerosis of the epinal cord, 298
diagnosis of, 295
morbid anatomy of, 294
symptoms of,
syconyme of,
treatment of, 295
Lead poisoning, 470
causes of, 472
diagnosis of, 475
from tea drinking, 474
morbid anatomy and pathology
of, 475
prognosis of, 476
xynonyms of, 470
treatment of, 476
Local paralysis, 453
Localization of tumors, 200
J 276
spurious, -
Loring’s experiments, 78
Lyssaphobia, 861
\ ALE hysteria, 378
Ms Mastodynia, 431
1 Ménitre’s disease, 124
Meningeal hemorrhage, 219
Meningitis, acute and chronic spinal, 204
symptoms of, 204
granular, 52
cerebro-epinal, 343
causes of, 344
definition of, 343
diagnosis of, 345
morbid auatomy 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, 68
eymptoms of, 65
treatment of, 68
connected with cardiac disease, 51
of the aged, 52
rheumatic, 50
senile, 62
tubercular (granular), 52
basal, 63
causes of, 58
development of, 62
diagnosis of, 53
morbid anatomy and patholo
of, 59 F id
prognosis of, 62
symptoms of, 58
treatment of, 64
tubercular deposits in, 61
vertical, 58
vital signs in, 55
510 IND
Meningo-cerebritis, 149
Mental changes in locomotor ataxia, 279
Migraine, 421
Miliary aneurisms, 98
Mimetic chorea, 400
Morbid impulses in hysteria, 872 '
Mortality in tubercular meningitis, 58
Mottled skin in pseudo-hypertrophic ;
paralysis, 273
Multiple embolism, 139
Myelitis, 286 :
causes of, 236 i
chronic, 236
diagnosis of, 237
morbid anatomy and pathology of, |
237
symptoms of, 236
treatment of, 238
vesical troubles in, 235
EX.
Neuritis (continued).
trophic changes in, 445
Neuromata, sarcomnatous, 452
treatment of, 452
Nystagmus, 189
CCLUSION of intracranial vessels, 129
Occupation, and its relation to cere-
bral hyperemia, 78
Ocular trouble with brain tumor, 187
Ophthalmoscope, the, 28
Opisthotonos, 296
Organs of speech, affection of in chores,
804
ACHYMENINGITIS as a result of in-
jury, 85
spinal, causes of, 207
dingnosis of, 211
morbid anatomy and pathology
ERVES, tumors of, 451
Neuralgia, age ond sex in causation |
of, 434 j
association with epilepsy, 482
bad teeth as a cause of, 434 H
causes of, 432
cervico-occipital, 426 1
circulatory disturbances in, 420
clavus, 423
coarse and fine varieties of, 439
connection with pulmonary disease,
482
crural, 4
definition of, 419 |
diagnosis of, 436 ‘i
electricity in treatment of, 442 i
excision of supra-orbital in, 424
facial, 421
influence of temperature in, 485
intercostal, 428
inveterate cnse of, an, 437
morbid anntomy of, 436
nerve arens in, 441
nerve section in, 482
of testis, 424
ovarian, 431 '
pain of, 419
proguosis of, 486
renal, 431 1
sciatic, 428
syphilitic, 422
treatment of, 438
trigeminal, 421
trophic disturbances in, 420
urethral, 331
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 1
of, 208
prognosis of, 210
symptoms of, 206
treatment of, 211
Painters’ colic, 470
Palsy, Scrivener’s, 486
shaking, 406
wasting, 265
Paralysis, adult spinal, 247
after dislocation, 461
agitans, 406
case of, 408
causes of, 408
diagnosis of, 410
morbid anatomy and pathology
of, 409
prognosis of, 411
symptoms of, 407
synonyms of, 406
treatment of, 411
antero-spinal, of infancy, 239
bulbar, 836
cross, 89
Cruveilhier’s, 256
dipbtheritic, 466
case of, 467
causes of, 468
diagnosis of, 469
morbid anatomy and pathology
of, 468
prognosis of, 469
symptoms of, 467
treatment of, 469
facial, 453
from pressure of forceps, 462
heat in the treatment of, 111
hysterical, 875
local, 458
of cranial nerves, 277
of sphincters, 235
pseudo-hypertrophic, 269
residual, 88
temporary spinal, 251
trnumatic, 453
Paralytic chorea, 895
512
Spinal hypersemia, subacute (continued).
prognosis of, 226
symptoms of, 224
trentment of, 226
irritation, 227
causes of, 229
diagnosis of, 281
morbid anatomy and pathology
of, 230
prognosis of, 231
symptoms of, 227
treatment of, 281
meninges, disenses of, 204
meningitis, acute and chronic, 204
pachymeningitis, 206
causes of, 207
symptoms of, 206
paralysis, temporary, 251
tumor, 213
causes of, 217
dingnosis of, 218
morbid anatomy and pathology
of, 218
prognosis of, 218
symptoms of, 213
treatment of, 218
varieties of, 218
Spurious locomotor ataxia, 281
Staining solutions, 21
Sthenic cerebral hyperemia, 69
Stomachic vertigo, 1238
St. Vitus’ dance, 893
Syncope, 113
Syphilis of the brain, 192
Syphilitic epilepsy, 825
pachymeningitis, 37
ABES dorsalis, 276
Tache carebrale, 56
Tarantism, 393
Temporary spinal paralysis, 251
Tetanus, 803
allied to strychnia poisoning, 303
causes of, 298
curare in, 807
definition of, 295
diagnosis of, 305
endemic, 299
morbid anatomy and pathology of,
302
nascentium, 297
pleurosthotonos in, 296 i
prognosis of, 305
risus sardonicus in, 295 :
softening of posterior column in, 803
Statistics, 805
INDEX.
Tetanus (continued).
symptoms of, 295
synonyms of, 296
treatment of, 806
urine in, 297
Tetany, 480
The epileptic zone, 822
Theory of sleep, 120
Thermometer, the, 22
Thrombosis, 129
of cerebral arteries, 129
case of, 180
causes of, 188
diagnosis of, 185
morbid anatomy and pa-
thology of, 183
treatment of, 185
of sinuses and veins, 135
after aural disease, 185
Tic douleureux, 420
epileptiform, 425
Torticollis, 488
Traumatic paralysis, 463
diagnosis of, 468
prognosis of, 463
trentment of, 464
Treatment of bed-sores, 288
of spasm, 488
Tremor, 409
functional, 410
Trismus nascentium, 297
Sraphie changes in traumatic paralysis,
6
Tubercular deposit in motor centre, 61
Tumors of brain, 185
of nerves, 451
spinal, 213
NILATERAL tremor as o result of
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
Wits hook in treatment of facial
paralysis, 458
Writers’ cramp, 484
[= the epileptic, 321
Live Music Archive
Librivox Free Audio
Metropolitan Museum
Cleveland Museum of Art
Internet Arcade
Console Living Room
Books to Borrow
Open Library
TV News
Understanding 9/11